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Correspondence: Rosemary Chapin,1, PhD, School of Social Welfare, Office of Aging and Long Term Care, University of Kansas, Lawrence, KS 66045. E-mail: rchapin{at}ukans.edu.
Laurence G. Branch, PhD
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Key Words: Assisted living • Aging in place • Long-term care • Admission and discharge criteria • Resident discharge
Assisted living is becoming an increasingly important component of the long-term care system, both for the traditional private-pay consumer and for federal and state government agencies seeking more economical and noninstitutional ways to care for low-income, frail older people. Assisted living has been referred to as "housing for the elderly with supportive services in a homelike environment" (Lewin-VHI 1996
, p. 1–2). Most definitions emphasize a residential setting with services on a 24-hr (or unscheduled) basis and a high degree of consumer choice and control (Kane and Wilson 1993; Zimmerman and Sloane 1999). Some researchers have suggested that it is this availability of unscheduled services that distinguishes assisted living from services delivered in individual homes (Mollica 1998). Definitions of assisted living vary on major issues such as type of setting (apartment or room), range of services (e.g., activity of daily living [ADL] assistance to skilled nursing), level of privacy (shared or private), and degree of autonomy (e.g., locked door, right to refuse services; Wilson 1996).
Assisted living has evolved largely in response to market demand and has been shaped by a variety of local conditions and special interests. A projected 14 million elderly Americans needing long-term care over the next 20 years will fuel continued demand for assisted living (U.S. General Accounting Office 1999). Citro and Hermanson 1999 projected that assisted living will be the fastest growing type of senior housing in the United States, with an estimated 15–20% annual growth rate over the last few years.
Central to the philosophy of assisted living is greater resident control of his or her environment, including what services are received, when, and how. This philosophy is in contrast to the more medically oriented model, where the resident is a patient, being cared for according to an institutional schedule. Assisted living is "a more consumer focused model that organizes the setting and the delivery of service around the resident rather than the facility" (Mollica 1998, p. 1).
Aging in place has been an integral component of the philosophy and promise of the assisted living industry nationally (Assisted Living Federation of America [ALFA], 1998). The key to an aging-in-place philosophy is for a facility to adjust its service provision and level of care criteria to meet residents' changing needs and to avoid having to discharge individuals to a higher level of care prematurely. The facility that adopts an aging-in-place philosophy will allow for the provision of routine nursing care and medication assistance. This aging-in-place philosophy means residents will have to relocate to a new setting less often. One practice that facilitates a resident's aging in place is "managed" or "negotiated" risk. This practice allows facilities to negotiate a written agreement with a resident who prefers to receive services in a nonstandard way, so long as it does not place others' health and safety at risk.
Aging in place benefits states as well. Several studies have concluded that care in assisted living facilities, when targeted to appropriate clients, can be substantially less costly compared with that in nursing facilities (Kane and Wilson 1993; Leon and Moyer 1999; Lewin-VHI 1996; Manard 1992; U.S. General Accounting Office 1997). Although, on average, nursing facility residents are much more impaired than assisted living residents, earlier research in Kansas found approximately the same percentage of older adults with two to three ADL impairments in assisted living facilities and nursing facilities (Chapin, Dobbs, Moore, and Waltner 1999). The longer this particular subset of older adults can age in place and remain in assisted living facilities, the greater the cost savings will be to states (Mollica and Snow 1996).
Our purpose in this article is to delineate the parameters within which one state's (Kansas) assisted living facilities have allowed residents to age in place. In this state, university researchers and state policymakers collaborate on an ongoing basis to examine program and policy outcomes for older adults. As is the case in most states, state regulatory structures allow for extensive service provision and a relatively high level of care needs in assisted living settings. Owners and operators still can restrict their retention policies to care for less impaired residents than the rules make possible. In this paper, we compare Kansas facility admission and retention policies with national facility admission and retention policies. Implications for increasing seniors' ability to age in place in assisted living settings are discussed.
Attention to aging in place is particularly important now, because the demand for assisted living is escalating and the supply of assisted living facilities is increasing. Mitchell and Kemp 2000 found a 37% increase in assisted living facilities (also referred to as residential care homes) from 1990 to 1998, with services in assisted living facilities in 1998 provided to approximately 500,000 older adults. The American Seniors Housing Association (ASHA) identified 55,273 senior housing units in its 1998 study, which included 6,085 assisted living units in freestanding facilities, 21,273 congregate housing units, and 27,915 continuing care retirement community housing units (ASHA 1999). Recent studies have reported assisted living national occupancy rates varying from 84% to 93.7% of full capacity (ASHA 1999; Hawes, Rose, and Phillips 1999).
Although people are entering assisted living in unprecedented numbers, it appears they are only staying for an average of 30.8 months (2.6 years), according to a recent national study conducted by the National Investment Conference (NIC; 1998). A more recent national study found an even lower average length of stay of 18 months (ASHA 1999). These findings take on added significance in light of the person-environment fit theory, which suggests that an element of successful aging is a person's ability to age in place in a stable living environment (Hooyman and Kiyak 1999; Kahana 1975). When older adults have control over the decision to move and choose assisted living, it is typically with the intention of being able to age in place and not having to relocate (U.S. General Accounting Office 1999). Once an older adult is too frail physically and cognitively to make the decision to move, control over the decision of where to move is often assumed by family (Dobbs 1998). The loss of control over the decision to move can affect older adults' satisfaction with services as well as their emotional well-being (Reinardy 1992, Reinardy 1995).
Relocation can cause stress, isolation, grieving, and an overall decline in physical and psychological functioning in older adults (Staveley 1997). Studies have indicated that relocation, particularly to a nursing facility, places frail older adults at risk for developing depression and suicide ideation (Haight, Michel, and Hendrix 1998). Physical problems such as weight loss have been found in older adults after relocation to an institutional facility (Lander, Brazill, and Ladrigan 1997). In addition, relocation is financially burdensome to older adults, especially for those with lower incomes (Thomasma, Yeaworth, and McCabe 1990). Furthermore, the social consequences of moving from place to place have also been documented (Bartlett 1993). Some of those consequences include the loss of social relationships with staff and residents, the need to form new social relationships, changes in an established daily routine, and loss of continuity of care. If older adults have to move from an assisted living facility to a nursing facility, they are usually faced with having to limit their personal possessions because of reduced personal space in the nursing facility (Regnier, Hamilton, and Yatabe 1995). This can be emotionally problematic for older adults because the stripping of personal possessions strips older persons of their self-identity (Goffman 1961). Given these findings, it is important for owners and operators of assisted living facilities to develop policies that allow residents in assisted living facilities to age in place as long as their needs can be safely met in that environment.
Proponents of assisted living have argued that assisted living can meet the needs of less impaired residents currently being served in nursing facilities (Wilson 1996). If less impaired older adults who are receiving state subsidies can be served in assisted living, then states can potentially reduce reliance on expensive institutional care, while allowing older adults to age in place in an environment that is more homelike, private, and respectful of individual differences (Wilson 1996). The extent to which a person can age in place in assisted living settings before having to go to a higher level of care is determined, in part, by a state's admission and retention policies. Mollica 1998 cited Kansas as one of nine states with the broadest parameters for admission and retention policies. Kansas adult care home statutes permit the provision of skilled nursing services in assisted living settings (Kansas Adult Care Home Regulations, 1997). The statute stipulates that services shall be "provided on an intermittent or limited-term basis or, if limited in scope, on a regular basis." However, Kansas permits individuals to remain in the facility so long as provisions can be made to meet their needs. Examination of state regulations suggests that the Kansas policy of allowing more health care services to be delivered in assisted living settings facilitates aging in place.
Much research has been published that profiles assisted living both nationally and at the state level. However, little empirical work has been published about outcomes in assisted living settings. This research, designed to examine admission and retention policies, provided the university research team an opportunity to look at whether admission and retention policies in Kansas's assisted living facilities support or inhibit aging-in-place. In addition, we examined the reasons for resident discharge as well as the discharge destination.
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any place or facility caring for six or more individuals not related within the third degree of relationship to the administrator, operator or owner by blood or marriage and who, by choice or due to functional impairments, may need personal care and may need supervised nursing care to compensate for activities of daily living limitations ... and in which the place or facility includes apartments for residents and provides or coordinates a range of services including personal care or supervised nursing care available 24 hours, seven days a week for the support of resident independence [skilled nursing services are not prohibited]. Generally, the skilled services provided in an assisted living facility shall be provided on an intermittent or limited term basis, or if limited in scope, a regular basis.
At a minimum, both assisted living and residential health care facilities have to include a toilet; bathing facilities; sleeping, living, and storage areas; and a lockable door. In addition, assisted living facilities are required to have kitchens for residents. For the purpose of this study, results for both assisted living and residential health care facilities were combined and reported as assisted living facilities following the model of the NIC (1998) study. Using similar definitions allows for valid comparisons between Kansas's facilities and the NIC study findings.
Facility Sample
There were 141 facilities in Kansas represented in this study. At the time of the study, the total occupancy capacity for these facilities was 5,110 and the current resident census was 3,579. The median occupancy rate was 75%. The capacity size ranged from 6 units to 227 units, with a median size of 56 units. Approximately 14% of facilities included in this research were located in rural towns (populations of less than 10,000); 54% were located in midsized cities (10,000 or greater but not designated as metropolitan); and 32% were located in metropolitan statistical areas as listed by the U.S. Bureau of the Census (1998).
Data Collection
The university research team, in collaboration with the Kansas Department on Aging, collected data to examine facility admission and retention policies. At the time of data collection (February 1999), there were 169 facilities in Kansas. We received an 83% response rate (N = 141). We gathered information about the following facility characteristics: admission and retention policies, reasons for resident discharge, discharge destinations, and average length of resident stay. Facilities had a choice of completing a survey by mail or telephone.
Measurement
Facility administrators were asked if they would admit or retain residents with various conditions. We selected conditions for our admission and retention criteria section that have been documented in the literature on the health status of assisted living residents (Kane and Wilson 1993; Mollica 1998; NIC 1998) and resident conditions that were allowed in Kansas's licensed assisted living and residential health care facilities (Kansas Adult Care Home Regulations, 1997).
To determine the most common reasons for resident discharge, we gave facility administrators a list of five common reasons for resident discharge and an "other" category. We asked facility administrators to rank their top three reasons for resident discharge. The reasons for resident discharge used in the survey instrument included (a) care needs became too great, (b) behavior problems, (c) functioning improved, (d) not enough funds, (e) spouse died or moved, and (f) other (please explain). Responses were assigned scores ranging from 0 to 3. The reason ranked first was assigned a score of 3, the reason ranked second was assigned a score of 2, the reason ranked third was assigned a score of 1, and those reasons not ranked were assigned a score of 0. An average score was computed for each reason.
To determine the most common discharge destinations, we asked facility administrators to rank the top three discharge destinations. The same scoring method that was used for the reasons for resident discharge was used for scoring the discharge destinations. The discharge destinations included in the survey instrument included (a) death in the setting, did not move out; (b) nursing facility, (c) hospital, (d) another assisted living facility, and (e) other (please explain). In addition, we asked facility administrators to estimate the average resident's length of stay.
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). Those comparisons are displayed in Table 2 . The comparisons in Table 2 indicate that Kansas facilities' admission and retention policies were generally more stringent than facilities nationally on those policies examined in both studies. However, there were some exceptions. There was a higher percentage of Kansas facilities that would admit someone who used a catheter or ostomy, used oxygen, or was mildly confused. The percentages of Kansas's facilities that would admit someone who was incontinent of bladder or bowel were markedly lower than the national figures reported from NIC (1998). In the NIC study, incontinence was divided into two categories: someone who was incontinent of bladder or bowel but self-managed, and someone who was incontinent but required assistance.
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in four geographically representative states (Florida, California, Ohio, and Oregon) found that only 42% of facilities in Florida, 27% of facilities in Ohio, and 28% of facilities in California received some public subsidy to pay for care for some of their residents. In contrast, 86% of Oregon facilities accepted persons receiving Medicaid-waivered services. A National Center for Assisted Living 1998 study reported that 35% of assisted living facilities nationally accepted state reimbursement for low-income residents who qualified. Kansas's payment structure for assisted living has provided an incentive for facilities to participate in the Medicaid HCBS/FE program, thus providing increased access to low-income older adults and the potential to age in place. Kansas uses Medicaid HCBS/FE funds to pay for services provided in assisted living facilities, and Medicaid HCBS/FE recipients use whatever source of income they have to pay for room and board charges in assisted living facilities. The Kansas policy is considered to be more flexible than that of other states, where the amount that can be charged for room and board to Medicaid recipients is limited to the Supplemental Security Income (SSI) payment. This limitation may create disincentives for facilities with higher room and board costs to participate in the Medicaid HCBS/FE program. The higher room and board costs could be paid by Medicaid residents who have incomes that are higher than the SSI cash benefit amount and qualify for Medicaid in some states under a guideline referred to as 300% medically eligible (which is 300% above the SSI allotted cash benefit).
Resident Discharge
We asked administrators to rank the top three reasons for resident discharge. Of the 141 assisted living administrators who responded to our survey, 137 responded to this question. Reasons for resident discharge are reported in Table 3 . The primary reason reported by administrators was that residents' health care needs became too great. This finding indicates that when residents needed a higher level of care, assisted living settings were not always able to meet these changing needs. The reason ranked second for resident discharge was resident behavior problems. In follow-up telephone interviews with administrators, the most common behavior problems reported were elopement risk and wandering.
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). However, ASHA reported a lower average resident length of stay of 1.5 years (ASHA 1999). |
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, p. 46). Our data indicate that Kansas assisted living facilities fill a niche in the long-term care continuum for older adults from relative independence to limited nursing care. On the one hand, Kansas's assisted living facilities have some admission and retention policies that support aging in place. Residents who were able to age in place longer because of more flexible admission criteria included residents who were not ambulatory; who had self-managed incontinence; who had mild forms of dementia; and who had special nursing care needs, such as assistance with oxygen, catheterization, ostomies, medication monitoring, or medication administration. These policy findings indicate that some needs that are typically being met in nursing facilities could also be met in assisted living facilities for a period of time. The fact that facilities strive to retain residents whose needs become greater in some cases (as indicated by the percentage increases from "will admit" to "will retain") is another indication that facilities are serving residents with higher need levels. To provide adequate care for residents with increased care needs, concomitant increases in staffing and resources are necessary.
On the other hand, facilities are limiting admission and retention through facility policies. Residents who find their options limited by admission and retention policies include residents who have severe cognitive impairments, residents who cannot cooperate with staff in managing their own incontinence, and residents who are an elopement risk. When facilities do admit residents with significant health care needs, it is usually contingent on the resident being able to self-manage the problem (e.g., incontinence, wheeling self) or having someone come in and assist the resident (with ADLs, oxygen, catheter, or ostomy).
The findings on admission and retention policies regarding physical and cognitive care needs suggest that assisted living is serving as part of a continuum of care rather than a setting where residents can age in place and remain until death. A small number of residents do return to independent living or die in the setting as suggested by the reason for discharge findings. However, most administrators report that nursing facility placement and hospitalization (often followed by nursing facility placement) are the most common outcomes for those who leave the facility.
By comparing the implementation of one state's assisted living policies to assisted living policies nationally, we can conclude that the role assisted living plays in the long-term care continuum definitely differs from state to state. For example, in some states (e.g., Florida) assisted living serves a range of care needs up to and including higher acuity nursing facility level of care (Vinton, Crook, and LeMaster 1997). However, in informal interviews with Kansas assisted living providers, we found that their rationale for serving a less impaired physical and cognitive population is that they strive to meet the preferences of most residents and provide them with the kind of noninstitutional care environment they desire.
Hawes and associates 1999(p. 66) highlighted a variety of forces that "militate against assisted living facilities serving as an alternative to nursing homes." These forces include residents that prefer settings that do not look at all like nursing facilities, concerns of state regulators that assisted living will become too highly regulated like nursing facilities, political influence of the nursing home lobby, and perceptions of assisted living owners and administrators about the niche they fill in the long-term care continuum (Hawes et al. 1999).
The estimated average length of stay in assisted living facilities reported by facility administrators in Kansas of 2.36 years implies that the capacity to age in place in Kansas is limited for many residents. Some experts in the long-term care field suggest that assisted living in Kansas is still a rather new phenomenon compared with other states and that older adults will begin to utilize assisted living at a much greater rate for longer periods of time in the coming years (Kansas Department of Health and Environment, personal communication, P. Maben, March 1999).
Study Limitations
The study had some limitations that should be considered. First, there was potential reporting error in the administrators' responses to the questions asking whether they would admit or retain residents who were mildly confused and significantly cognitively impaired. Although the categories were initially chosen from the familiar codes used in the national Resident Assessment Instrument, MDS Version 2.0, under cognitive skills for daily decision making (U.S. Department of Health and Human Services 1996, p. 94), a bias may have resulted from the administrators' not having a formal definition of these criteria.
We collected an estimated average length of stay from assisted living facility administrators and did not collect exact resident length of stay (from admission to discharge for a resident sample) and, therefore, cannot determine exactly how long residents are aging in place in assisted living settings. As suggested by our facility admission and retention policy findings, resident functional, cognitive, and health conditions are factors in determining resident length of stay. In a current longitudinal study we are conducting that focuses on the capacity for residents to age in place in assisted living facilities, we are collecting resident functional, cognitive, and health information from admission to discharge to determine exact length of stay and the factors that influence length of stay.
Areas for Future Research
The examination of the relationship between additional facility characteristics and resident length of stay is an area for future study. As mentioned previously, we are currently conducting a longitudinal analysis of resident length of stay and how facility factors are associated with increased lengths of stay in assisted living settings. The factors that are included in the study are size, cost, services offered, staffing patterns, geographic location, and admission and retention policies. This project will allow us to determine what types of assisted living facilities are more successful than others in implementing an aging-in-place philosophy.
Additionally, current research has not fully explored how important it is to older adults that assisted living provide the opportunity to age in place rather than function as an intermediate step in the long-term care continuum. Some older adults may prefer a care environment with residents who have mild levels of impairment and who look similar to them in other ways (e.g., socially, physically, and cognitively), knowing that if their condition deteriorates, there is a strong possibility that they will have to relocate to a place that serves a higher level of care. In contrast, other older adults may prefer to live in a care environment where their needs can be met until the end of life and do not object to a resident population that has a broad range of impairments. The preferences of older adults in this regard need to be explored. Implications for educating older adults to become informed about the extent to which a facility will allow them to age in place prior to admission need to be considered.
Conclusion
The findings of this study suggest that, overall, Kansas assisted living facilities are functioning as an intermediate step in the long-term care continuum. Our findings suggest that less restrictive assisted living admission and retention policies, given adequate staffing and funding, could increase opportunities for aging in place. These findings have implications for policymakers nationwide who are interested in more fully supporting aging in place.
State long-term care policymakers need to consider how facility practices reflect existing state policies. Even though the Kansas regulatory structure allows for residents with a broad range of care needs to age in place in assisted living settings, we found that this is not happening because facility practices do not fully reflect existing state policies. Nationwide, we found that assisted living facilities are admitting and retaining people with a wider range of care needs, compared with Kansas assisted living facilities.
If elderly persons across the United States are to have increased opportunity to age in place in assisted living settings, then many facilities will need to consider expanding some of their admission and retention policies. For example, admitting and retaining residents with incontinence problems (realizing that staffing needs to be appropriate to assist with incontinence problems) would allow residents to age in place longer. Admitting and retaining residents with severe cognitive impairments would also create an avenue for a vulnerable elderly population to age in place. In our Kansas study we did find a smaller proportion of Alzheimer's disease units and dementia-only facilities than was found in the national NIC study. It is likely that these specialized accommodations will become increasingly popular residential alternatives nationwide. Facilities that decide to increase flexibility in admitting and retaining the more severely cognitively impaired population will need specialized training and resources for staff to help them deal with older adults who have severe cognitive impairments. Also, flexible payment structures offered by some states provide an incentive for facilities to accept low-income older adults receiving or pending Medicaid HCBS/FE, thus allowing opportunities for Medicaid HCBS/FE recipients to age in place in assisted living settings.
Studies have indicated that there is overlap in the population that is at the higher acuity end of assisted living and the lower acuity end of nursing facilities (e.g., the population that needs assistance with two to three ADLs; Chapin et al. 1999; Hawes et al. 1999). More empirical research is needed to determine how similar the assisted living and nursing facility population needing assistance with two to three ADLs may be and whether this subset of older adults in nursing facilities, with adequate staffing and resources, could potentially be served in assisted living settings.
As the aging population grows in number and the average life expectancy increases, assisted living as a long-term care alternative will be more in demand. Some professionals have argued that assisted living can provide a cost-effective alternative for a subset of older adults needing long-term care, while still maintaining their autonomy and dignity (Citro and Hermanson 1999; Wilson 1996). Although assisted living settings as a long-term care option have become increasingly popular with older adults, it is essential for policymakers to continue to track changes in admission and retention policies in assisted living settings and to consider the implications of these policies for older adults and their families.
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Received for publication March 24, 2000. Accepted for publication July 27, 2000.
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