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Housing Options

Nursing Homes vs Assisted Living

Background

Physicians are often called upon to advise families about housing options for older patients who can no longer live at home. Up until the 1990s, long-term care choices for the vulnerable patient were limited; essentially, a person either lived at home with supplemental services or moved to a nursing home (NH). Concerns about NH cost and quality of care, growth in the aging population, and a desire to live in non-institutional environments gave rise to an alternative: assisted living (AL) residences. This new model combined apartment-style housing, personal care, and some health care services. Due to its consumer-centered philosophy encouraging choice, dignity and independence, AL residences rapidly emerged as a popular alternative to NHs for individuals not requiring skilled nursing care (e.g., stage III or IV pressure sores, feeding tubes, 24 hour nursing supervision). Until recently, many adults living in an AL residence would have been cared for in a NH: one in four AL residents requires a NH level of care, though this does not mean they are receiving the highest level of NH care available.1 Now that there are choices in long-term care, do physicians have adequate knowledge of the differences to make appropriate referrals and ensure that a patient's health-related needs are met?

Nursing Homes Versus Assisted Living

Due to its longevity, physicians may be more familiar with NH's patient admission requirements, services offered (e.g., personal care, 24-hour skilled nursing care, medical care, rehabilitation services) and funding mechanisms than with those of AL residences. Moreover, the AL industry can be difficult to fathom for various reasons. Unlike regulated nursing homes, AL residences are state-regulated and licensed by the Department of Health or a similar agency, and services vary significantly by state. There is no nationally agreed upon definition of an AL residence, though most provide housing, meals, help with select activities of daily living (ADL) and medication management. Most states use the term AL in their licensing, though some refer to AL as "personal care homes" (Georgia), "residential care residences" (Indiana), or "homes for the aged" (Washington). Moreover, some housing models may look like AL residences, but they are not licensed and only provide minimal services, such as room and board and recreational activities.

Nursing Services in Assisted Living

Physicians need to be aware that the availability of health-related services in AL residences vary considerably by state, and even by residence within the same state. Some states view AL as a stop along the continuum of care between independent living and NH care, and only allow for limited nursing services. Other states, including Oregon and New Jersey, view AL as a viable option to NHs, allowing, but not mandating, AL residences to provide more extensive nursing services to allow residents to age-in-place.

Understanding the Differences

Several studies have shown that an AL residence's marketing materials may contain inaccuracies or lack information crucial to an informed choice (e.g., staffing, rate increases, discharge policies.)2 It is no wonder that it can be a daunting choice for both physicians and families to ascertain the appropriate long term care placement, especially during a crisis, when decisions typically occur. Families, however, rely on physicians for advice on long term care options. Without adequate understanding of the complex issues involved in selecting a long term care facility, a knowledge deficit may lead to either (1) premature placement in a NH or (2) an inappropriate placement in an AL, which necessitates a second placement in a NH. As our population ages, more older adults will seek long term care housing; currently there are 1.6 million NH residents and approximately 600,000 to 1 million AL residents.3 As it is estimated that AL demand will outgrow NH demand in the next decade, it is critical that physicians understand the similarities and differences between these two long term care housing models.4

Summary

Assisted living is state regulated and the services vary considerably from state to state and even by residence within the same state. Some states view AL as a stop along the continuum of care between independent living and NH care, and only allow for limited nursing services. Other states view AL as a viable option to NHs, allowing, but not mandating, AL residences to provide more extensive nursing services to allow residents to age-in-place. Physicians should acquaint themselves with the  AL regulations in the state where they practice and with the various types of long term care options in their own communities. If patients are struggling to maintain a healthy lifestyle at home, even with supplemental services, physicians should advise patients and their families to explore long term care housing options. Patients interested in AL residences should be advised to obtain information in writing on staffing, level of services for current and possible future needs, pricing, and discharge policies. The resources in this section contain several guidebooks to help consumers make an educated long term care housing choice.

  1. Mollica R. Testimony Before Senate Special Committee on Aging, 2003. Available at http://www.nashp.org. Accessed Aug, 2005.
  2. Assisted living: quality of care and consumer protection issues in four states. Washington, DC: U.S. General Accounting Office; 1999.
  3. Administration on Aging, Assisted Living. Available at http://www.aoa.gov/prof/notes/Docs/Assisted_Living.pdf. Accessed Augt, 2005.
  4. Meyer, H., (1998);.The bottom line on assisted living. Hospitals and Health Networks, July 20, 1998.
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