A National Study of Assisted Living for the Frail Elderly: Final Summary Report. B. Results


Our best estimates from this national sample indicate that in 1998 approximately 24 percent of residents left an ALF over the course of 12 months. The results indicate that roughly one-third of the residents who left a study ALF between baseline and follow-up (roughly 8 percent of all residents on a yearly basis) either died in the ALF or elsewhere prior to follow-up contact. Most of the remainder who left went to a nursing home or some other residential care setting (e.g., another ALF or personal care home). On an annualized basis, 8 percent of all residents went to a nursing home and 4 percent of all residents moved to some other residential care setting. The need for more care was the most commonly cited reason by respondents for leaving an ALF. Very few (9 percent) of the respondents indicated that they or their family member left the original ALF because they could no longer afford to remain in the facility.

We estimated that roughly one-quarter of ALF residents left their facility over 12 months.

The most common reason given for leaving an ALF was the need for more care.

Those who left a study ALF were most likely to have died or entered a nursing home.

This research also provided some previously unavailable information on the characteristics of residents and facilities that affect individuals’ exit from an ALF. In the multi-variate analyses that controlled for both individual and also facility characteristics, older age and marital status were associated with a resident’s increased likelihood of death prior to follow-up. Although only a small percentage of ALF residents were married, they were twice as likely as unmarried residents to die prior to the follow-up interview. The only individual characteristic or resident-level variable that affected an individual’s likelihood of entering a nursing home was the resident’s cognitive status. Residents who had moderate to severe cognitive impairment were more likely to enter a nursing home.

Both individual-level and facility-level factors determined where residents went when they left their ALF.

Residents in ALFs without a full-time RN involved in direct care were twice as likely to leave their ALF and go to a nursing home or some other care setting than were similar residents in ALFs that had a full-time RN.

Residents in not-for-profit ALFs were significantly less likely than similar residents in for-profit ALFs to move to a different ALF or other residential care facility.

In the multi-variate models, facility characteristics also had an impact. No facility characteristics had a significant impact on a resident’s likelihood of death. However, residence in a for-profit ALF was highly associated with movement into another residential care setting other than a nursing home. Also, residing in an ALF with a full-time RN who provided care to residents reduced a resident’s likelihood of going to a nursing home or to some other setting by roughly half.

These results have a number of relatively interesting policy implications. For policy-makers interested in developing an assisted living industry that can delay nursing home use, creating incentives for facilities to provide a higher level of service could be productive. However, such a policy stance would mean encouraging the development of higher cost ALFs. Yet how to develop ALFs that are affordable for individuals with low or moderate income is also a significant issue. In addition, if higher cost ALFs are encouraged, then the specific amount of delay in nursing home use (i.e., the number of person months) that results from these increased costs become a critical parameter for policy discussions. In addition, one must consider any additional home health, ambulatory care, medications, or acute care use that are required during the delay and might have been avoided by earlier placement in a nursing home.

For consumers intent on avoiding or delaying nursing home placement, seeking out ALFs that have full-time RNs and provide nursing care with their in-house staff may represent a good choice in an ALF. Also, for consumers interested in aging in place, being in a facility with a full-time RN active in direct care may significantly reduce the likelihood that one will move to some other ALF or another care setting other than a nursing home.14

Most people entering an ALF are not as disabled as those entering a nursing home. This means that the choice to enter an ALF with a full-time RN active in direct care may only be important to more impaired residents or to residents over the course of time as they age in place. Thus, many consumers might end up paying “at the front-end” for services that will only be important to them later, if they stay in the same facility.

One must also remember that this analysis focused on facilities that chose at a specific point in the evolution of the industry to have a full-time RN and provide direct care with in-house nursing staff. These services seem to have had a direct impact on resident outcomes. However, the effect of these services in facilities that add them as a marketing tool, in response to a reimbursement incentive, or because of regulatory mandates may differ from the effects we observed in ALFs that voluntarily chose their particular staffing and service pattern.

The finding that cognitive impairment has such an important impact on discharge to a nursing home may also have substantial policy implications. To the degree that the industry is encouraged to care for more severely cognitively impaired residents, then savings in nursing home costs may accrue. However, the industry’s ability to provide appropriate care to this population is unproven. Moreover, the overall effect on total long-term care costs cannot be predicted.

As the discussion above indicates, the policy issues here are complex, and our knowledge base is limited. This is, after all, a single study. Even though it is based on a nationally representative sample of higher service or higher privacy ALFs, an appropriate measure of caution should be used when considering these results in the policy-making process.

Residents Leaving Assisted Living: Descriptive and Analytic Results From a National Survey
AUTHORS: Charles D. Phillips, Catherine Hawes, Kathleen Spry and Miriam Rose
DATE: June 2000
     Executive Summary (http://aspe.hhs.gov/daltcp/reports/alresdes.htm)
     Full Report (http://aspe.hhs.gov/daltcp/reports/alresid.htm)

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