Assisted living and nursing homes: Apples and oranges? Based upon the work of: Sheryl Zimmerman, MSW, PhD, Professor at the University of North Carolina, Chapel Hill School of Social Work Developed by Ashlie D. West, MSW Student Research to Teaching Initiative Chen, & Konrad copyright 2003 1
Why did we move away from skilled nursing facilities? Combined impact of the growing numbers of older adults, A shortage of nursing beds, Increasing costs of nursing care, The better overall health of new cohorts of older adults, and The dissatisfaction with nursing home (NH) care (Bishop, 1999; Borra, 1986; Korock, 1987) 2
Filling the gap Congregate housing first attempt; failed Continuing care retirement communities and NHs learned from congregate housing s mistake and broadened their continuum of care Assisted living (AL) facilities provided an invisible support system in a residential setting (Sullivan, 1998) 3
The assisted living debate NHs are threatened by their increasing market share ALs are not subject to the same licensing restrictions and guidelines as NHs There is no single accepted definition of AL nor guidelines for how to operationally distinguish it from other forms of care (Lewin-VHI, Inc., 1996) The lack of longstanding AL state regulations and federal oversight has allowed significant variability in the characteristics of the facilities and residents served (Assisted Living Quality Coalition, 1998; Frytak et al., 2001; Hawes, Lux, et al., 1995; Mitchell & Kemp, 2000; Wilson, 1996) 4
Current study goals To describe the current state of AL care and residents in comparison with NH care and residents; To identify differences between different types of AL care and residents; and To consider how differences in AL case-mix reflect differences in care provision and/or consumer preference 5
Sample Data used from a multistage cluster sample of residential care/assisted living (RC/AL) facilities and NHs in Florida, Maryland, New Jersey, and North Carolina 233 long-term care facilities and 2,078 AL residents participated in the Collaborative Studies of Long- Term Care (CS-LTC) spanning across the spectrum of licensed AL and NH care 3 types of RC/AL facilities 1) fewer than 16 beds; 2) facilities with 16 or more bed of the traditional board-and-care type; and 3) new model facilities Nursing homes were also included 6
Facilities across the states State RC/AL Beds New-model Beds Florida 49,800 14,314 Maryland 4,708 1,858 North Carolina 15,012 5,514 Total of 2,500 facilities 1,216 (49%) are small, 877 (35%) are traditional, and 407 (16%) are new-model 7
Sampling region for each state Each region must contain at least 15% of the state s RC/AL facilities of each type; Each region must include both urban and rural areas; When compared with the entire state, the region must fall within 30% of the state mean on 8 measures that characterize the county population by race, age, income, and employment status, and prevalence of primary care physicians, hospitals, and NH beds A total of 233 facilities were recruited from October 1997 to November 1998 (113 small, and 40 from each of the other 3 types) 8
Differences between participating and nonparticipating facilities Nonparticipating RC/AL facilities have more owners working more hours in the facility, more rate levels, and a slightly less impaired resident population. No differences in reference to proprietary status; affiliation with other long-term care facilities; facility size, age, or occupancy rate; and resident age, race, or ethnicity. Nonparticipating NHs have a higher occupancy rate than participating NHs and less resident impairment. 9
Facility-level measures Demographic facility size, age, and profit status 6 measures from the Policy and Program Information Form of the Multiphasic Environmental Assessment Procedure (Moos & Lemke, 1996) 4 measures that summarize admission policies and estimate the range of available services These 10 process of care measures are organized by the following domains: Requirements for the residents, Individual freedom and institutional order, and Provision of services and activities. 10
Resident-level measures Resident demographics age, race, gender, marital status, and medical conditions Minimum Data Set ADL Self-Performance Index (MDS-ADL; Morris, Fries, & Morris, 1999) need for assistance in ADLs Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) Minimum Data Set Cognition Scale (MDS-COGS; Hartmaier, Sloane, Guess, & Koch, 1994) Cohen-Mansfield Agitation Inventory (Cohen- Mansfield, 1986) 11
Analyses Descriptive statistics across facility type Multivariate analyses examined differences in 10 process of care measures between RC/AL facilities with less than 16 beds; traditional RC/AL with 16 or more beds; new model RC/AL; and NHs Generalized estimating equation models determined differences in resident case-mix across RC/AL facilities using data for 2,078 residents 12
Results Description of facilities Characteristic Bed size Mean (SD) Facility age Mean (SD) Small RC/AL (n=113) Traditional (n=40) New-model (n=40) 8.9 (3.6) 45.8 (36.7) 65.1 (43.1) 12.8 (13.4) NH (n=40) 115.8 (50.8) 23.0 (16.4) * 5.3 (3.0) 24.1 (15.1) For-profit 92% 67% 73% 58% * One facility had been in operation for 148 years and was excluded from the calculation; the facility in operation for the next longest time had been open n for 80 years 13
Requirements for residents Characterist ic Acceptanc e of Problem Behaviors Admission Policies (ADLs) Admission Policies (all) Small RC/AL (n=113) Traditional (n=40) New-model (n=40) NH (n=40) 30.6 41.8 34.9 42.3 61.4 51.9 72.5 100.0 72.5 70.0 75.1 94.7 Note: All range from 0 100. 14
Individual freedom and institutional order Characterist ic Policy Choice Small RC/AL (n=113) Tradition al (n=40) Newmodel (n=40) NH (n=40) 44.7 52.8 63.4 51.3 Policy Clarity 47.9 69.9 78.1 81.7 Provision of Privacy Resident Control 47.9 64.3 74.9 41.7 21.3 37.6 38.6 41.6 Note: All range from 0 100. 15
Provision of services and activities Characteris tic Health Services Social / Recreation al Services Services (All) Small RC/AL (n=113) Traditional (n=40) New-model (n=40) NH (n=40) 51.2 75.1 77.1 86.4 41.4 61.4 66.7 72.3 51.0 68.3 69.1 77.2 Note: All range from 0 100. 16
Description of residents (Percent) Characteristic Small RC/AL (n=665) Traditional (n=648) New-model (n=765) NH Age 85+ 46 57 52 49 White 85 92 95 89 Female 76 77 75 72 Married 10 10 14 17 Heart Condition 38 48 49 48 ADL Impaired 37 15 25 83 Cognitive Impaired 42 23 35 51 Behavioral Imp. 49 37 39 30 17
Case-mix of RC/AL residents by facility characteristics 1. Residents in traditional facilities differed significantly from those in smaller facilities Race (92% White, compared with 83% White), Percentage with a heart condition (48% vs. 38%), Functional impairment (mean MDS-ADL score 3.0 vs. 6.1), and Cognitive impairment (mean MDS-COGS score 2.1 vs. 3.2) 18
Case-mix of RC/AL residents by facility characteristics (cont.) 2. Residents in facilities that provided more privacy are more often: White (94% vs. 84%); Female (79% vs. 72%); Older (85.2 years vs. 82.7 years) With a heart condition (50% vs. 39%); and Scored lower in functional, cognitive, and behavioral impairments. 19
Discussion New-model facilities score higher than small facilities across all domains of individual freedom and institutional order. Smaller homes are outperformed by larger homes on many objective measures of structure and process. NHs score significantly lower on the provision of privacy than all RC/AL facility types and lower on policy choice than do new-model facilities. New-model facilities score higher than traditional facilities in both privacy and policy choice. 20
Discussion (cont.) Residents in RC/AL facilities are functionally impaired, however less so than those in NHs; cognitive impairment is also less than in NHs. Behavioral problems are more prevalent in RC/AL than in NHs (as reported in this study). ADL, cognitive and behavioral impairments are highest in younger facilities (less than 5 yrs old) and those that are for-profit. Facilities with higher rates of resident impairment have more lenient admission policies, provide less privacy, and less resident control. 21
Discussion (cont.) In only one instance (NH admission policies) are 100% of items endorsed, and within the individual freedom and institutional order domain, only 21-78% of items within any area are endorsed. Among all CS-LTC facilities under study, nonprofit facilities score higher than for-profit facilities in reference to policy choice, clarity, and provision of privacy, and they have more restricted admission policies. 22
Final revelations NHs do not differ from traditional and new-model RC/AL facilities in the provision of social/recreational services, policy clarity, and resident control. NHs are significantly different from smaller RC/AL facilities in these same 3 areas, and in all cases score higher than smaller RC/AL facilities. Overall, it appears that RC/AL and NH populations are becoming increasingly similar (Hawes, Mor, et al., 1995). Given the similarities in case-mix and service provision, the degree to which RC/AL differentiates itself from NH care requires that conditions allow for differences. The degree to which RC/AL substitutes for NH care is in large part dependent on both the degree to which Medicaid programs will pay for RC/AL as an alternative to NH care and the extent to which research demonstrates differences in outcomes between the two settings (Zimmerman, Sloane, & Eckert, 2001). 23
References Zimmerman, S., Gruber-Baldini, A.L., Sloane, P.D., Eckert, J.K., Hebel, J.R., Morgan, L.A., Stearns, S.C., Wildfire, J., Magaziner, J., Chen, C., & Konrad, T.R. (2003). Assisted living and nursing homes: Apples and oranges? The Gerontologist, 43 (2), 107-117. Additional references cited in the article and this presentation: Assisted Living Quality Coalition (1998). Assisted living quality initiative. Building a structure that promotes quality. Washington, DC: Public Policy Institute, American Associations of Retired Persons. Bishop, C.E. (1999). Where are the missing elders? The decline in nursing home use, 1985 and 1995. Health Affairs, 18, 146-155. Borra, P.C. (1986). Assisted living a timely alternative. Provider, 12, 14, 16-17. Cohen-Mansfield, J. (1986). Agitated behaviors in the elderly, II. Preliminary results in the cognitive deteriorated. Journal of the American Geriatrics Society, 34, 722-727. Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). Mini-mental state: A practical method for grading cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. 24
References Frytak, J.R., Kane, R.A., Finch, M.D., Kane, R.L., & Maude-Griffin, R. (2001). Outcome trajectories for assisted living and nursing facility residents in Oregon. Health Services Research, 36, 91-111. Hartmaier, S., Sloane, P.D., Guess, H., & Koch, G. (1994). The MDS Cognition Scale: A valid instrument for identifying and staging nursing home residents with dementia using the Minimum Data Set. Journal of the American Geriatrics Society, 42, 1173-1179. Hawes, C., Lux, L., Wildfire, J., Green, R., Mor, V., Green, A., et al., (1995). A description of board and are facilities, operators, and residents. Report to the Office of the Assistant Secretary of Planning and Evaluation. Research Triangle Park, NC: US Department of Health and Human Services, Research Triangle Institute and Brown University. Korcok, M. (1987). Assisted Living : Developing an alternative to nursing homes. Canadian Medical Association Journal, 137, 843-845. Lewin-VHI, Inc. (1996). National study of assisted living for the frail elderly. Literature Review Update. Contract No. HHS-1-94-0024. Mitchell, J.M., & Kemp, B.J. (2000). Quality of life in assisted living homes. Journal of Gerontology: Psychological Sciences, 55B, P117-P127. 25
References (cont.) Moos, R.H., & Lemke, S. (Eds.) (1996). Evaluating residential facilities: The multiphasic environmental assessment procedure. Thousand Oaks, CA: Sage Publications, Inc. Morris, J.N., Fries, B.E., & Morris, S.A. (1999). Scaling ADLs within the MDS. Journal of Gerontology: Medical Sciences, 54, M546-M553. Sullivan, J.G. (1998). Redefining long term care. Contemporary Long-Term Care, 21, 60-64. Wilson, K.B. (1996). Assisted living. Reconceptualizing regulation to meet consumers needs and preferences. Washington, DC: Public Policy Institute, American Association of Retired Persons. Zimmerman, S., Sloane, P.D., & Eckert, J.K. (2001). Emerging issues in residential care/assisted living. In S. Zimmerman, P.D. Sloane, & J.K. Eckert (Eds.), Assisted living: Needs, policies, and practices in residential care for the elderly. Baltimore, MD: The Johns Hopkins University Press. 26