Seven Challenges Assisted Living Must Get Right

      The assisted living industry is fascinating, and opportunities abound to improve the lives of the fragile elderly. In this unique social setting, a diverse group of individuals is united by their need for assistance with managing their health care. This compels them to make enormous life changes as they embrace a new concept of “home.”
      A formidable challenge confronting this social model is the need to simultaneously implement two opposite and contradictory management approaches:
      • 1.
        Synchronized care, where certain aspects of daily life, such as meals, activities, and transportation, must run on a more-or-less fixed schedule
      • 2.
        Person-centered care, where the unique personal differences that infiltrate every aspect of residents’ lives are not only to be considered but, to the extent possible, accommodated
      The intersection where all necessities converge, however, is health care. The need for assistance with managing health care is a unifying factor that coerces residents to this setting and distinguishes it from other residential settings. Health care is the core or essence of assisted living, and to prevent this model from mutating into a disguised form of a nursing home, and to maintain its identity as a social model of care, there are challenges that must be successfully overcome.
      Below are seven challenges that assisted living must solve to remain a viable alternative to nursing homes. These are not the only challenges, but confronting them head-on should be the highest priority.

      1. Integrated Care

      Declining health is the leading reason residents come to assisted living. It is also a leading challenge in managing assisted living residents and the leading reason residents leave assisted living.
      An integrated care model of assisted living recognizes that health care must be the core “feature of excellence” that is blended with real estate and hospitality to deliver maximal benefit to its residents.

      2. Transitions

      Many people fail to recognize that health care is managed in acute care settings (like hospitals) differently than in chronic care settings (like assisted living). The goal of hospitals is short term, standardized treatment of a resident’s illness or episode of care. In the hospital setting, the forming of nurturing and healing relationships often falls victim to fast-paced efficiency in an effort to reduce the length of stay and cost of care.
      In assisted living, however, the opposite prevails. The emphasis has evolved from treatment of an illness to recovery from the illness. Because residents are now in their home, relationships and person-centered care are paramount.
      These opposite approaches to health care management, although necessary in our current health care system, are most successfully reconciled by a health care (or transitional care) coordinator. This role is key to ensuring that residents are connected with the necessary components of health care to complete their recovery.

      3. Acuity

      Most experienced workers would agree that the acuity levels in assisted living are already high and are often similar to those of nursing home patients. But there is no standard definition of acuity or how it might be used in everyday operations. New and practical definitions, albeit imperfect, should be considered (“Coming to Grips With ‘Acuity Creep’ in Assisted Living,” Mar. 21, 2016;
      Accepting the limits on resident acuity that can be competently managed in an individual assisted living community can be a thorny issue. But defining an acuity limit and sticking to it is imperative. The consequences of accepting a resident whose health care acuity exceeds the ability of workers to competently manage it endangers the existing residents by diverting staff and other resources toward the highest acuity residents, leaving the lower acuity residents with unmet health care needs.
      An additional concern with accepting high-acuity residents is that it invites oversight and regulation from outside agencies. Thus, it is in the interest of assisted living communities to employ the use of a practical measure of acuity at the time a resident applies to move in.

      4. Chronic Disease Management

      Assisted living residents have multiple chronic diseases and take a plethora of medications to treat these diseases. The challenge in managing these elderly residents is to maintain all the diseases and medications in equilibrium, in balance with each other. Any disruption in this delicate equilibrium caused by one disease acting up can affect all the other diseases. A resident’s health house of cards may come tumbling down, resulting in an emergency department visit, hospitalization, or readmission.
      The biggest roadblock to managing assisted living resident health care is the physical and communication gap between the residents and their physician. The traditional doctor–patient relationship becomes disrupted by this gap, and it is replaced by awkward, inefficient communication that delays the assessment and treatment of changes in condition.
      The secret to managing chronic diseases is to close the gap, and the best remedies are the following two.
      First, we need to deliver onsite primary care directly to the residents (i.e., the traditional house call), either within the assisted living community or even in a resident’s own room. As intuitive and inherently valuable as this might seem, many assisted living communities resist attempts to partner with medical professionals who are willing, often at their own financial risk, to perform this function.
      Second, we need to employ health care coordinators to facilitate communication. These invaluable team members unite two different health care settings by ensuring communication of intended treatment plans from one setting to the next, thus allowing the new health care team to make informed choices when modifying the plan of care for the new setting. Coordinators also can alleviate a significant burden of care from the cadre of other assisted living workers who are involved in scheduling necessary tests and appointments for residents, arranging transportation, renewing prescriptions, communicating with families, and so on. The entire assisted living community benefits from workers who are less distracted and more productive with attending to other resident care concerns. If assisted living communities devote a full-time equivalent position to a health care coordinator who serves all their residents, they may find the improved worker productivity worth the investment.

      5. Data and Analytics

      Health care in assisted living often seems like a black box. The dearth of actionable and easily understood data means that very few people can clearly and accurately articulate the details of their residents’ and community’s health care profiles. Fewer still have any perception of how these characteristics compare with the other communities within their own city or assisted living corporation.
      Only 3% of inpatient long-term care providers (mostly nursing homes) have reported they have the capability of data-driven analytics needed to lower the cost of care, reduce unnecessary hospital readmissions, and ensure facilities receive proper reimbursement for the care provided to patients.
      Even fewer assisted living communities have this capability. So there is a monumental need for assisted living communities to develop internal strategies to employ data and analytics to provide optimal care for their residents and to be competitive referral sources for fragile elderly residents.

      6. Quality Measures

      Assisted living communities must be able, upon request, to objectively validate the quality of the health care they are providing to their residents. Health care data must be collected, tracked, analyzed, and communicated to employees and families to drive performance improvement.
      Examples of important quality measures include emergency department transfers, hospitalizations, readmissions, falls, pressure ulcers, behavioral disturbances, pain control, ambulance calls and transfers, and resident and employee satisfaction surveys. Top performance with these important quality measures is a key reflection of healthy and successful assisted living management. They also are an important determinant of 5-star ratings in the post-acute setting.
      Critically, the absence of federal oversight in assisted living should not be a reason to delay quality measure initiatives. The assisted living industry would benefit from more active participation with the Center for Excellence in Assisted Living (CEAL) by supporting a standardized set of quality measures tailored to its unique social model.

      7. Falls

      Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a broken hip or head injury. The average hospital cost for a fall-related injury is nearly $40,000. Additionally, falls are a leading contributor to liability costs, which are then passed down in the rent paid by all residents.
      In nursing homes, 70% of falls occur when patients are alone in their rooms. The data are insufficient to conclude whether this is mirrored in assisted living communities, but a robust, targeted falls-reduction program should be in place for every assisted living community.
      Dr. Fuller is a physician entrepreneur and executive vice president of clinical affairs for Doctors Making Housecalls, the largest geriatric medical practice in the southeast United States and the one specializing in onsite primary health care delivery in over 400 assisted living communities.