Attending to Assisted Living Medical and Mental Health Care Needs

Assisted living (AL) is the largest provider of residential long-term care in the U.S., and the number of residents in these communities is only increasing as more and more Baby Boomers require some level of care services. A recent study about assisted living communities, led by researchers from the Center for Health Services Research at the University of North Carolina (UNC) at Chapel Hill, examined an important question: What medical and mental health care services should assisted living communities be providing to their residents?

What is assisted living?

According to the latest figures from the Centers for Disease Control and Prevention (CDC), there are nearly 29,000 assisted living communities in the U.S., which are home to over 900,000 residents.

Assisted living communities typically serve people who need help with activities of daily living (ADLs) — such as bathing, toileting, dressing, or eating — and/or instrumental activities of daily living (IADLs) — such as meal preparation, transportation, housekeeping, or medication management.

Such communities provide residents with room and board, at least two meals a day, around-the-clock supervision, personal care assistance, and also can provide some healthcare services to residents, but they do not offer 24-hour skilled nursing care services for extended periods of time. Assisted living is not intended to be a healthcare setting in the way a nursing home/skilled nursing facility is.

These assisted living communities offer an important blend of care, companionship, independence, privacy, and safety in a residential, home-like setting. Assisted living communities strive to deliver “person-centered” care and services to each resident — meeting each individual’s specific needs and preferences.

Are assisted living services meeting residents’ comprehensive care needs?

While nearly all assisted living communities provide similar help with ADLs and IADLs, data from the National Center for Assisted Living (NCAL), the branch of the American Health Care Association that represents assisted living communities, shows that the medical and mental health care services provided by communities is not consistent across the board. For example, they found the following:

4 percent of assisted living communities provide therapy services (physical, occupational, or speech)
7 percent have hospice care
1 percent offer skilled nursing care
0 percent provide mental health or counseling services
1 percent have social work services

At the same time, today’s assisted living resident is older, has increased medical condition acuity, and often has more complex care needs. According to the UNC researchers’ report:

53 percent of assisted living residents are 85 years old or older (compared with 42 percent of nursing home residents).
More than half of assisted living residents need help with mobility.
A majority have a chronic health issue like hypertension, arthritis, cognitive impairment, and/or depression, and one-third or more have a condition like osteoporosis, chronic obstructive pulmonary disease, diabetes, heart disease, and/or chronic kidney disease.
The average length of a stay in an assisted living community is 22 months, and eventually 60 percent of residents will need to transition to a nursing home where they can receive a higher level of around-the-clock skilled nursing care services.

The UNC researchers note some of the potential issues surrounding these demographics and trends:

“As residents’ acuity has increased, there has been growing concern about their medical and mental health needs, in part because most regulations do not require nursing or medical staff; more so, fewer than 7 percent of the 28 900 AL communities are on the same campus as a nursing home, with presumed access to nursing home staff. Concerns are numerous, among them under-prescribing or over-prescribing medication, insufficient communication when problems arise, and regulations that restrict nursing services.”

The experts weigh in on assisted living care needs

It’s for this reason that the UNC researchers gathered a nationwide panel of 19 experts in the medical, nursing, and mental health needs of and care for older adults; dementia care; and assisted living and long-term care management, advocacy, regulation, and education, to collect their insights and offer better, more consistent guidance to inform assisted living communities on the types of medical and mental health care they should consider providing to their residents.

The expert panelists identified 43 recommendations that were highly pragmatic to implement. Among the top recommendations in five key areas were:

Staff and staff training
- Training for all staff on person-centered care
- Care worker-to-resident ratio
Nursing and related services
- Provision of routine toenail care on-site
Resident assessment and care planning
- Resident present during assessment/care planning
Policies and practices
- Has a policy/procedure regarding aggressive or other behaviors
- Informs a responsible party when an emergency department visit occurs
- Discussions about advance directives occur for all residents and are documented
Medical and mental health clinicians and care
- All off-site medical or mental health visits include post-visit notes with findings

You can see a chart with all 43 of the expert panel’s recommendations here.

A holistic care plan for assisted living residents

Assisted living can be a wonderful solution for people who need a little extra help with certain activities but are not in need of the skilled nursing care services provided by a nursing home. As more and more seniors opt to live in an assisted living community, it has highlighted not only our nation’s caregiver shortage but also the broad spectrum of needs of this population of seniors. Some assisted living residents only need help with two or three ADLs or IADLs, whereas other residents are on the verge of requiring a move to a skilled nursing facility.

While the philosophy behind assisted living is to provide each resident with individualized care tailored to their specific needs, oftentimes medical and mental health care services are not a part of these communities’ service offerings. As highlighted by the UNC researchers and their expert panelists, assisted living communities must take an even more individualized and holistic look at each person to ensure that, in addition to ADLs and IADLs, residents’ medical and mental health needs also are addressed.

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