A National Study of Assisted Living for the Frail Elderly: Final Summary Report. Differences Among ALFs That Provided High Services or High Privacy


Resident Case Mix and Hospital Use. The analyses conducted of data from the site visits to those facilities that offered high privacy or high services (or both) also revealed some differences in the distribution of resident characteristics and care needs across the three types of ALFs. ALFs classified as low privacy/high service served a resident population with significantly higher levels of cognitive impairment than one would expect, given the distribution in the ALF resident population as a whole. More that one-third (36 percent) of the residents in the high service/low privacy facilities had moderate or severe cognitive impairment, in comparison to only about one-quarter in the high privacy/high service and high privacy/low service ALFs. There were no statistically significant differences across the three facility types in the proportion of residents needing ADL assistance. The low privacy/high service facilities did serve a population with a somewhat higher proportion of individuals who needed help with two or more ADLs; however the difference was not statistically significant. Similarly, residents in ALFs offering the combination of high privacy and low service did have somewhat higher hospitalization rates than the whole population (i.e., 37 percent vs. 32 percent), although the difference was not statistically significant.15

Facility Effects on Resident Discharges and Exits from ALFs. The data on resident discharges from assisted living also revealed significant differences among facilities. Residents in the low service ALFs, which did not have a full-time RN and did not offer nursing care with their own staff, were twice as likely to enter a nursing home between baseline and follow-up.16

In addition, the analysis demonstrated that residence in a for-profit ALF was highly associated with movement into another residential care facility. Since the most common reason for leaving a facility was the need for more care, this finding suggests that the for-profit sector of the industry may be less committed to, or capable of, meeting the increasing needs of residents.

Facility Characteristics and the Philosophy of Assisted Living. We also examined a series of indicators associated with the philosophy of assisted living. These included aspects of privacy and environmental autonomy; service-related features, such as the willingness of the facility to meet scheduled and unscheduled needs and resident reports of unmet needs for assistance; the ability of residents to age in place, based on retention policies; and affordability.

High Privacy/Low Service vs. High Privacy/High Service. There were few statistically significant differences between the two groups of facilities that offered high privacy but provided differing levels of service (i.e., high privacy/high service and high privacy/low service). The only significant difference between such facilities came in a service-related indicator -- their willingness to meet residents’ unscheduled care needs. Scheduled care needs are those that can be performed at set times, such as receiving medications and bathing. Unscheduled needs are those that arise more randomly throughout the day, such as the need for assistance using the toilet. Analysis demonstrated that the high privacy/high service ALFs were significantly more willing than high privacy/low service ALFs to meet individual residents’ needs for assistance in toileting, locomotion, and transfer.

The analysis based on information provided by administrators in the telephone survey also suggested that these high privacy/low service facilities had much more restrictive admission and discharge policies. In general, they were less willing to admit or retain residents with moderate to severe cognitive impairment, residents who needed any nursing care or monitoring (even temporary), residents with behavioral symptoms or urinary incontinence, or those who needed help with transfers.

High Service/Low Privacy vs. High Service/High Privacy. The two groups of ALFs that offered high service but differed on privacy exhibited statistically significant differences for two of the six indicators. These differences were, as one would expect, in the areas of privacy and environmental autonomy. The high privacy/high service ALFs offered more private resident accommodations and more of the environmental features associated with autonomy (e.g., ability to control the temperature in the room or apartment, access to personal applicances for cooking, a refrigerator in the resident’s unit, and the ability to lock the door of the room or apartment.

TABLE ES.3: Summary of Differences Based on Facility Types
Performance Indicator Comparisons Among Facility Types
Low Privacy/
High Service vs.
High Privacy/
Low Service
Low Privacy/
High Service vs.
High Privacy/
High Service
High Privacy/
Low Service vs.
High Privacy/
High Service
Privacy Significant Difference Significant Difference  
Environmental Autonomy   Significant Difference  
Unmet Personal Care Needs Significant Difference    
Affordability for Low Income Elderly      
Retention Policies Significant Difference    
Meet Scheduled and Unscheduled Needs     Significant Difference
Significant Difference = statistically significant at p>.01

Low Privacy/High Service vs. High Privacy/Low Service. Comparisons between ALFs that differed in both privacy and services also exhibited significant differences in privacy, unmet need for assistance, and policies on retention. As one might expect, residents in ALFs classified as high privacy had significantly greater environmental autonomy. Higher service ALFs had more liberal retention policies and were less likely to have residents with unmet care needs, compared to ALFs that offered high privacy but lower services.

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