A National Study of Assisted Living for the Frail Elderly: Final Summary Report. Different Models of Assisted Living


The information provided by administrators identified two significant variations among the ALFs that are worth noting. One group of ALFs identified or described themselves as ALFs. Another much smaller group provided the same basic services but identified themselves by some other designation, such as adult congregate living, residential care, or community residential facility. Another significant variation was between ALFs that were free-standing and ALFs located on a campus that offered multiple levels of care. Such “multi-level” campuses typically housed an ALF and a nursing home or some other type of residential care, such as congregate apartments or independent living facilities.

Self-Described ALFs. Seven out of ten (72 percent) of the administrators represented or described the facility as being an “assisted living facility or residence.” Twenty-eight percent of the administrators did not describe the facility as assisted living; however, the facility still met study eligibility criteria. Despite the differences in how the administrators characterized the facilities, the two groups of facilities were remarkably similar in terms of their size, the services they offered, their nurse staffing, most admission and retention criteria, and the basic characteristics of their residents. Self-described ALFs, however, tended to have lower occupancy rates, had been in business for a shorter period of time, were more likely to offer apartments and private units, and were more likely to admit and retain residents who used a wheelchair or received help with locomotion. They also tended, on average, to have higher monthly prices.

Free-Standing ALFs Compared to ALFs Located on a Multi-Level Campus. The majority of ALFs (55 percent) were free-standing, while 45 percent were located on a campus housing multiple facilities or residential settings offering different levels of care. ALFs on a multi-level campus had higher occupancy rates and tended to have higher monthly prices than free-standing ALFs. They were also more likely to have private units and apartments and to provide or arrange more services for residents, most notably nursing care and therapies. ALFs on multi-level campuses also tended to have higher levels of nurse staffing than free-standing ALFs. In addition, they were more likely to admit and retain residents who needed nursing care and residents who used a wheelchair. Despite this, the administrators did not report having a “heavier care” resident case mix than the free-standing ALFs.

Categorization of ALFs by Combined Levels of Service and Privacy. Any attempt to understand assisted living and its role in providing long-term care to the frail elderly is hindered by the lack of a common definition of “assisted living.” Currently, places known as ALFs differ widely in ownership, auspice, size, services, staffing, accommodations, and price. Thus, analyzing data on facilities and reaching conclusions about “assisted living” as a whole involves comparing “apples to oranges.” As a result, project staff developed a classification that divided the universe of ALFs into distinct categories or types of facilities, representing their mix of services and privacy. The four types the study identified represent reasonably homogeneous groups of facilities. Moreover, the data revealed significant differences among groups.

Definitions of high, low and minimal privacy. “High privacy” meant that at least 80 percent of the resident units were private. A total of 31 percent of the facilities met this definition of high privacy. Twenty-eight percent of the ALFs offered “minimal privacy” because they had one or more rooms that housed at least three residents. The remainder of the ALFs (41 percent) fell between these two types of facilities in a “low privacy” category.

Definitions of high, low and minimal services. “High services” was defined as having a full-time RN on staff and providing nursing care, as needed, with facility staff, as well as providing help with at least two ADLs, 24-hour staff, housekeeping, and at least two meals a day. Thirty-one percent of the ALFs met this criterion. Five percent of the ALFs did not offer help with even two ADLs and were thus defined as providing “minimal” services. The remaining ALFs (65 percent)9 were categorized as “low service,” although some that did not provide nursing care with their own staff were willing to arrange a higher level of services through an outside provider, such as a home health agency.10

Combining the mix of services and privacy revealed four basic types. The first type of ALF combined facilities in the “minimal” group of ALFs (i.e., the 32 percent with either minimal privacy or minimal services) and facilities offering low privacy and low service (i.e., 27 percent of the ALFs). The facilities classified as “minimal” had either at least one room shared by three or more unrelated individuals (i.e., minimal privacy) or did not provide basic services, such as assistance with ADLs (i.e., minimal services).

TABLE ES.2: Distribution of ALFs by Categories
Category National Estimate
1a. Low Privacy & Low Service 27%
1b. Minimal Privacy or Service 32%
2. High Privacy & Low Service 18%
3. High Service & Low Privacy 12%
4. High Privacy & High Service 11%

The combined low/minimal privacy and services group was the most common type of ALF, comprising 59 percent of all the ALFs. This type of ALF cannot be easily distinguished from the traditional concept of board and care homes. A significant proportion of resident rooms were shared rather than private, and such facilities offered little beyond assistance with medications, bathing, or dressing. In two of five (41 percent) ALFs described by this model, there was at least one room shared by three or more people. ALFs of this type not only represented the majority of all ALFs nationwide, they also constituted 58 percent of all the facilities that described themselves as “assisted living.”

Another ALF type offered a high degree of privacy in accommodations but low services, a sort of “cruise ship” model of assisted living. In this type of ALF, more than 80 percent of the accommodations were private. However, these facilities would have had a difficult time helping residents age in place, since they had no RN on staff and most were unwilling or unable to provide or arrange any nursing care for residents. Only 19 percent of the ALFs in this model would provide or arrange nursing care and retain a resident who needed such care. This ALF type comprised 18 percent of all ALFs nationwide.

A third type of ALF was one described as high service/low privacy. In such facilities, two-thirds of the accommodations were in single rooms rather than apartments, and fewer than 80 percent of the rooms were private. However, all such facilities had a full-time RN on staff. About half (53 percent) of the ALFs of this type were willing to provide or arrange nursing care, as needed, and retain residents who needed such care. This was also the type of ALF that had the most expansive admission and retention criteria and the highest resident acuity. For example, such facilities were more likely to retain residents who needed assistance with transfers and to retain residents who needed nursing care. Compared to the other ALF types, the high service/low privacy type also had a much higher proportion (35 percent) of residents who received assistance with three or more ADLs, such as help with locomotion or using the toilet, as well as bathing and dressing. An estimated 12 percent of the ALFs across the country were in this category.

A fourth type of ALF offered high service and high privacy. Only 11 percent of all ALFs fell into this category. While resident accommodations were almost evenly split between rooms and apartments, nearly all of the accommodations were private. In addition, 41 percent of the high service/high privacy ALFs offered to arrange or provide nursing care and retain residents who needed such care. All had an RN on staff.

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