A National Study of Assisted Living for the Frail Elderly: Final Summary Report. Facilities, Administrators, and Staffing


ALFs were almost equally likely to be operated by for-profit as by not-for-profit entities. However, the vast majority (79 percent) of organizations that owned or operated the high service or high privacy ALFs were involved in the operation of other types of supportive housing for the elderly, such as nursing homes and congregate apartments. Almost two-thirds (64 percent) of the not-for-profit ALFs, for example, were located on a multi-level campus that housed various types of supportive housing for the elderly, including a nursing home. Indeed, nearly half (49 percent) the owners of all of the high service or high privacy ALFs owned or operated nursing homes, and nearly half (46 percent) of these ALFs were part of a multi-facility system or “chain” of ALFs.

Facilities showed some variation in the level of functional limitations and cognitive status among their residents. In most ALFs, relatively few residents had significant functional limitations and care needs. In most ALFs, assistance with medications was the only area in which they reported most residents needing and receiving help. However, approximately 15 percent of ALFs seemed to have a substantial proportion of residents with somewhat heavier physical care needs, such as need for help with transfers and other middle-range and late-loss ADLs. Administrators also reported fairly high “turnover” rates among residents, with an average annual rate of 41 percent of the residents each year.

Staffing across facilities varied considerably. On first shift, one-quarter of the ALFs had direct care staff to resident ratios of 8-to-1 or lower, and another quarter had ratios of 16-to-1 or greater. While staffing ratios varied considerably, there was some consistency across ALFs in the types of staff used. For example, the sampled ALFs that were site-visited almost universally utilized some licensed nursing services. Staff turnover was lowest among licensed nursing staff, but administrators estimated that roughly one-quarter of all direct care staff turnover during the course of a year.

High Privacy or High Service Facilities

  • Half were for-profit businesses and half were not-for-profit entities
  • Most owners provided some other type of long-term care
  • Considerable variation in staffing
  • Median price was $1,800 per month
  • Wide variation in which services were included in base rate

The most common monthly charge for living in an ALF was approximately $1,800. However, because of the diversity among ALFs in what was included in that base rate, one is not quite sure what that sum purchased. For example, relatively few facilities (36 percent) provided temporary nursing care as part of their base monthly rate, while a substantial majority (80 percent) provided planned recreational activities. For those residents who exhausted their funds paying at this level, many facilities were willing to accept payments from alternative sources (e.g., charity, Supplemental Security Income, Medicaid). Policy in a substantial proportion of facilities (45 percent), however, simply called for the discharge of those who exhausted their private financial resources.

View full report


"finales.pdf" (pdf, 907.67Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®