Comparing residential long-term care regulations between nursing homes and assisted living facilities

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

OBJECTIVES

To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs).

DESIGN

Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021.

SETTING AND PARTICIPANTS

NHs (n = 678) and ALCs (n = 542) that reported staffing by shift in Ohio.

METHODS

Resident-to-staff ratios in Ohio were calculated from staffing data. The proportion of daily nursing staff assigned to each shift was based on staffing data from the Biennial Survey for NHs and ALCs. Outcomes were calculated for aides and licensed nursing staff.

RESULTS

Ohio's NHs and ALCs had lower resident-to-staff ratios on the day shift. Lower resident-to-staff ratios mean there were more staff per resident (ie, better staffed). For both types of staff and all shifts, overall resident-to-staff ratios were lower in NHs than ALCs. However, resident-to-staff ratios for ALC MCUs were on par with NH MCUs. This was consistent with ALC and NH MCUs staffing in a more similar manner. Across all settings, the day shift had the most staff members present, while a number of ALCs had no licensed nurses on duty during the overnight shift.

CONCLUSIONS AND IMPLICATIONS

NHs and ALCs have different staffing patterns due to differences in resident needs. However, as ALCs provide for more residents that need NH level of care, ALCs may require additional staffing, especially on the overnight shift where some ALCs have no licensed nurses on duty. The evidence here can be used for decision making about future staffing policies, whether facility-wide policies that encompass MCUs or state-wide policies, so that care delivery aligns with care needs.

Population-based estimates of major forms of housing insecurity among community-living older Americans

OBJECTIVES

The number of older adults struggling to maintain adequate housing is growing. Prior studies have used various criteria to measure housing insecurity; however, no standardized definition exists to date. Using a multidimensional approach, our study sought to calculate population-based estimates of various forms of housing insecurity among community-living older Americans and determine how these estimates differ across key characteristics.

METHODS

This study utilized data from the 2011 round of the National Health and Aging Trends Study (NHATS), a prospective longitudinal study of Medicare beneficiaries aged 65 years or older. Three key forms of housing insecurity were operationalized: poor housing affordability (PHA), poor housing quality (PHQ), and poor neighborhood quality (PNQ). Population-based estimates of these forms of housing insecurity were calculated using analytic sampling weights and stratified by age, gender, race and ethnicity, frailty status, and dementia status.

RESULTS

Totally 6466 participants were included in the analysis, representing 29,848,119 community-living older Americans. The mean (standard deviation) age was 77.3 (7.7) years; by weighted percentages, 56.0% identified as female, 81.3% as White, 8.2% Black, and 7.1% Hispanic. At least one form of housing insecurity was identified in 38.5% of older Americans. Individually, the prevalence of PHA was 14.8%, PHQ 24%, and PNQ 12.5%. The prevalence of at least one form of housing insecurity was higher among persons of color (62.9% Black and 66% Hispanic vs White; p < 0.001), those with frailty (40.9% pre-frail and 49.4% frail vs robust; p < 0.001), and those with cognitive impairment (48.1% possible and 51% probable dementia vs no dementia; p < 0.001).

DISCUSSION

Nearly one in three community-living older Americans experience at least one form of housing insecurity. This was most common among vulnerable subgroups. Our multidimensional approach to defining various forms of housing insecurity can be used for future studies focused on improving social determinants of health among high-risk older adults.

Discharge disposition for home health care patients with Alzheimer's disease and related dementia: The role of living arrangements and rural living

PURPOSE

To examine the relationship between living arrangements and discharge disposition, and how this relationship differs by the rural or urban characteristics of the patient's residence among home health care patients with Alzheimer's disease and related dementia (ADRD).

METHODS

This retrospective study used the 2019 Outcome and Assessment Information Set and the Master Beneficiary Summary File. Our study was based on 531,269 Medicare fee-for-service patients with ADRD. We used linear probability regression models to examine the relationship between discharge disposition (to the community vs. an institution) and living arrangements, including an interaction term for rural-urban residence.

FINDINGS

Patients in rural areas (19.8%) were more likely to live alone than those in urban areas (15.2%). Our main results show that patients living at home with others (coefficient: -0.02, p-value < 0.001) or alone (coefficient: -0.03, p-value < 0.001) were less likely to be discharged to the community compared to patients who lived in congregate settings. Also, for patients with ADRD who lived in rural areas, living at home with others (rural*home with others; coefficient: -0.02, p-value < 0.001) or living alone (rural*home alone; coefficient: -0.03, p-value<0.001) were associated with additional lower probabilities of being discharged to their communities.

CONCLUSIONS

A multidimensional approach considering living arrangements to support home health care patients with ADRD could be critical to achieving better health outcomes. Furthermore, implementing area-specific target interventions could be important for improving the care and health of patients with ADRD as well as reducing rural-urban disparities in discharge disposition.

An Examination of Assisted Living Facility Administrator Qualifications Across States

Resident acuity, Medicaid's increased role in funding assisted living, and the COVID-19 pandemic have brought increased attention to the regulatory environment of assisted living facilities (ALFs) and the responsibilities of ALF administrators (ALFAs) are growing increasingly complex. This study explores, describes, and compares the education (degree and assisted living-specific training), experience, exam (competency), and continuing education requirements for ALFAs across all states, and how states' requirements compare to national assisted living associations' suggested standards for entry-level and ongoing practice. Wide variation in ALFA qualifications are identified, with some states found to have extremely low qualification requirements.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are primarily responsible for noncompliance, (2) unclear parameters place direct care workers in a role paradox, and (3) there is a persistent disconnect about when to seek qualified expertise before requesting psychotropic medications. AL/RC-specific mechanisms for medication prescription and administration are necessary to improve the structure and processes of care. Policymakers might consider how regulations unintentionally incentivize task-oriented versus person-centered care practices.

Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study

OBJECTIVE

We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults.

DESIGN

Repeated cross-sectional study.

SETTING AND PARTICIPANTS

Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019.

METHODS

We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios.

RESULTS

There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults.

CONCLUSIONS AND IMPLICATIONS

The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.

Social Connectedness Resource Preferences of Older Adults in Assisted Living: A Scoping Review Based on the WHO-ICF Framework

The current scoping review identified emerging evidence on social connectedness resource preferences of older adults in assisted living facilities (ALFs) and the community. A literature search was performed using several databases. We included review articles published between January 2000 and September 2022 in English and related to social connectedness resources in ALFs and the community. Of 134 titles and abstracts, eight studies were included. Study participants comprised 2,482 older adults from 233 ALFs in the United States. Themes were framed using the World Health Organization's International Classification of Functioning, Disability, and Health. For social activities, older adults preferred facility-based recreation and leisure resources. For community social connectedness, residents preferred participation in civic life activities. Participants of older age preferred facility resources, whereas those of younger age preferred more demanding physical activities. Those from larger enrollment facilities preferred facility-based resources compared to community resources. For moderately and less active residents, participation was limited to less demanding activities. Older adults' preferences varied based on age, physical limitations, and size and location of the facility. Findings suggest opportunities for further research on developing ALF- and community-based resources for older adults' social well-being and quality of life. [Journal of Gerontological Nursing, 49(9), 35-42.].

Growth of Private Pay Senior Housing Communities in Metropolitan Statistical Areas in the United States: 2015-2019

Older adults needing assistance with activities of daily living can receive support in various settings. Senior housing communities, such as independent living, assisted living, and continuing care retirement communities, are an increasingly popular option for adults not requiring nursing home-level care. However, limited research exists due to a dearth of data on these types of communities. We use a proprietary data set to describe the market of private pay senior housing and community-level characteristics in 140 metropolitan statistical areas, from 2015 to 2019. Although the number of senior housing communities increased substantially, the supply of senior housing options supporting the continuum of care has not necessarily kept up with population growth. Describing the supply of senior housing communities across the spectrum of levels of care provides a more complete description of the formal noninstitutional long-term care supply among the 140 most populated metropolitan statistical areas.

An Improved Two-Step Floating Catchment Area (2SFCA) Method for Measuring Spatial Accessibility to Elderly Care Facilities in Xi'an, China

With the continuous aging of society, the demand among elderly citizens for care facilities is increasing. The accessibility of elderly care facilities is a significant indicator for evaluating whether the layout of urban elderly care facilities is reasonable, and research on the spatial accessibility of related facilities has become an important academic issue in recent years. In this paper, based on the lack of accurate measurement in calculating the spatial accessibility of existing elderly care facilities, we improve the mathematical model based on the two-step floating catchment area method (2SFCA) and introduce the probability function of the elderly population's choice, taking into account the influence of institutional capacity and service quality. In terms of the catchment radius, the calculation accuracy is improved by using the shortest distance along the route combined with the real road network instead of choosing the Euclidean distance. In addition, specific travel thresholds are set for the travel characteristics of the elderly. An evaluation model of the accessibility of urban elderly care facilities is constructed with the help of ArcGIS software to evaluate and analyze the accessibility of the current layout of urban elderly care facilities in Xi'an, China. The results show that the improved 2SFCA model is more effective in evaluating the spatial accessibility of elderly care facilities and has higher accuracy than the previous calculation model, which provides a methodological basis and academic reference for the specific planning of urban elderly care facilities.

Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol

Assisted living (AL) communities are experiencing rising levels of resident acuity, challenging efforts to balance person-centered care-which prioritizes personhood, autonomy, and relationship-based care practices-with efforts to keep residents safe. Safety is a broad-scale problem in AL that encompasses care concerns (e.g., abuse/neglect, medication errors, inadequate staffing, and infection management) as well as resident issues (e.g., falls, elopement, and medical emergencies). Person and family engagement (PFE) is one approach to achieving a balance between person-centered care and safety. In other settings, PFE interventions have improved patient care processes, outcomes, and experiences. In this paper, we describe the protocol for a multiple methods AHRQ-funded study (Engage) to develop a toolkit for increasing resident and family engagement in AL safety. The study aims are to engage AL residents and family caregivers, AL staff, and other AL stakeholders to (1) identify common AL safety problems; (2) prioritize safety problems and identify and evaluate existing PFE interventions with the potential to address safety problems in the AL setting; and (3) develop a testable toolkit to improve PFE in AL safety. We discuss our methods, including qualitative interviews, a scoping review of existing PFE interventions, and stakeholder panel meetings that involved a Delphi priority-setting exercise. In addition to describing the protocol, we detail how we modified the protocol to address the unique challenges of the COVID-19 pandemic. Study findings will result in a toolkit to improve resident and family engagement in the safety of AL that will be tested in future research.

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living

OBJECTIVES

Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living.

DESIGN

We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs).

SETTING AND PARTICIPANTS

The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 residents.

METHODS

The model was codesigned iteratively 2009-2012 by a public-private multistakeholder advisory group. Using system usage statistics and project records, we evaluated implementation outcomes: appropriateness, acceptability, adoption, feasibility, fidelity, penetration, and sustainability.

RESULTS

Implementation for ≥1 quarter was feasible for 92% of the 810 ALCs that enrolled. The model has been deemed appropriate and acceptable by public-private stakeholders representing residents, providers, regulators, and payers, and appropriateness for ALCs serving different populations has been iteratively improved through targeted workgroups. The model is currently adopted in Wisconsin by 31% of the 1573 ALCs in provider associations. Among adopters, 88% on average implemented the model with fidelity to key membership rules per quarter. The model achieved demographic and institutional penetration by currently reaching 24% of Wisconsin ALC residents and by leveraging initial grant funding to become integrated in Wisconsin's annual Medicaid budget and being central to Wisconsin's incentive program to managed care organizations. Model implementation for 8 years has been sustained by member enrollment for nearly 4 years on average, with 71% of members enrolled >2 years and sustained early adopters representing 37% that have been enrolled >5 years.

CONCLUSIONS AND IMPLICATIONS

This is the first implementation study of large-scale data-driven quality improvement in assisted living, despite its demonstrated value in other health care sectors. The article proposes a model with core components and implementation strategies drawing on a decade-long public-private collaboration. The implementation study findings establish a promising path and future directions for wider implementation.

State Variation in Long-Term Care Availability, Regulation, and Cost and Suicide Mortality Among Older Adults in the United States: 2010-2015

OBJECTIVES

Residential long-term care (LTC) facilities may be key settings for the prevention of suicide among older adults; however, little is known about the relationship between statewide policies determining characteristics of LTC facilities and suicide mortality. The primary goal of this study was to evaluate the association between state policies regarding availability, regulation, and cost of LTC and suicide mortality among adults aged 55 and older in the United States over a 5-year period.

DESIGN

Longitudinal ecological study.

SETTING AND PARTICIPANTS

LTC residents from 16 states reporting mortality data to the National Violent Death Reporting System (NVDRS) from 2010 to 2015.

METHODS

We linked suicide data from the NVDRS and data sources on LTC services and regulations for 16 states. We applied a natural language-processing algorithm to identify suicide deaths related to LTC. We used fixed effect regression models to assess whether state variation in LTC characteristics is related to variation in the rate of suicide (both overall and related to LTC) among older adults.

RESULTS

There were 25,040 suicides among those aged 55 and older reported to the NVDRS during the study period; 382 suicides were determined to be associated with LTC in some manner. After adjusting for state-level characteristics, greater average nursing home capacity was significantly associated with increase in the cumulative incidence of suicide related to LTC (β = 0.087, SE = 0.026, P < .01), but not overall suicide incidence. Neither cost nor regulation measures were significantly associated with state-level LTC-related suicide incidence.

CONCLUSIONS AND IMPLICATIONS

State-level variations in LTC facility capacity are related to variation in LTC-related suicide incidence among older adults. Given the challenges of preventing suicide among older adults through facility- or individual-level interventions, policies governing the features and provision of LTC services may therefore serve as a means for public health suicide prevention.

Governance of Assisted Living in Long-Term Care: A Systematic Literature Review

Assisted living (AL) is an emerging model of care in countries where long-term care needs are escalating, with emphasis given to promoting independence and autonomy among the residents to achieve active and healthy ageing. Unlike established nursing homes, the governance of AL is nebulous due to its novelty and diverse nature of operations in many jurisdictions. A comprehensive understanding of how AL is governed globally is important to inform regulatory policies as the adoption of AL increases. A systematic literature review was undertaken to understand the different levels of regulations that need to be instituted to govern AL effectively. A total of 65 studies, conducted between 1990 to 2020, identified from three major databases (PubMed, Medline, and Scopus), were included. Using a thematic synthesis analytical approach, we identified macro-level regulations (operational authorisation, care quality assessment and infrastructural requirements), meso-level regulations (operational management, staff management and distribution, service provision and care monitoring, and crisis management), and micro-level regulations (clear criteria for resident admission and staff hiring) that are important in the governance of AL. Large-scale adoption of AL without compromising the quality, equity and affordability would require clear provisions of micro-, meso- and macro-level regulations.

The Relationship Between States' Staffing Regulations And Hospitalizations Of Assisted Living Residents

Assisted living provides housing and long-term care services to more than 811,000 older adults in the United States daily and is regulated by the states. This article describes changes in the specificity of state regulations governing the staffing in assisted living settings (that is, requirements for sufficient staffing or staffing ratios or levels) between 2007 and 2018 and the association between these changes and rates of hospitalization among a national sample of assisted living residents, including a subgroup with dementia. We found that increased regulatory specificity for direct care workers (for example, a change from requiring "sufficient" direct care worker staffing to requiring a specific staffing ratio or level) was associated with a 4 percent reduction in the monthly risk for hospitalization among residents in our sample and a 6 percent reduction among the subgroup with dementia. However, an increase in regulatory specificity for licensed practical nurses was associated with a 2.5 percent increase in the monthly risk for hospitalization and a 5 percent increase among the subgroup with dementia. Given that no federal requirements exist for the number of staff members or composition of staff in assisted living, these findings can inform states' policy decisions about staffing requirements for assisted living settings.

The WeanCare nutritional intervention in institutionalized dysphagic older people and its impact on nursing workload and costs: A quasi-experimental study

AIM

The aim of this study is to explore how a nutritional intervention that improves the biochemical and functional profile of dysphagic older people impacts on nursing workload and costs for nursing homes.

BACKGROUND

Dysphagic institutionalized older people particularly at risk of malnutrition require more intensive support from nursing staff and higher costs for nursing homes.

METHOD

This is an open pre-post longitudinal multicentre quasi-experimental study without a control group.

RESULTS

There is a significant reduction in the number of enemas (from 3.51 to 1.11 enemas), with an average nursing workload reduction from 52 to 16 min per patient every month. Each nurse also spent 20 h less per patient every month spoon-feeding. This resulted in nursing staff cost savings.

CONCLUSIONS

The nutritional intervention led to a significantly better quality of life for the patients manifested through increased independence and social engagement. This reduced workload for nursing staff and costs for nursing home administrators.

IMPLICATIONS FOR NURSING MANAGEMENT

Sensitive, targeted nutritional interventions have the potential to improve nursing home residents' quality of life and enable a more efficient use of resources. This study revealed reduced workload and cost savings due to less time spent administering enemas and spoon-feeding, in addition to reduced malnutritional consequences.

Variability and Potential Determinants of Assisted Living State Regulatory Stringency

OBJECTIVES

We examined state variations in assisted living (AL) regulatory policies for admission/retention, staffing/training, medication management, and dementia care. Factors associated with domain-specific and overall regulatory stringency were identified.

DESIGN

This observational study used the following data sources: 2019 review of state AL regulations; 2019 national inventory of AL communities; 2014 Government Accountability Office survey of Medicaid agencies; 2016 Genworth Cost of Care Survey; and the 2018 Nursing Home Compare.

SETTING AND PARTICIPANTS

Final analyses included 46 states (excluding Alaska, Kentucky, Louisiana, and West Virginia) and the District of Columbia.

METHODS

For each regulatory domain of interest (dependent variables), we generated policy scores by conducting content analysis of state regulatory databases. States were assigned points for presence of each policy (eg, staff training). The number of points assigned to each policy was divided by the total possible number of policy-related points, producing state stringency scores (between 0% and 100%) for each policy domain. Independent variables included market-level characteristics (eg, AL monthly cost), state generosity (eg, proportion of Medicaid aged using AL services), quality of care (eg, percent of nursing homes with few deficiencies), and others. Descriptive analyses and multivariable logistic regression models with stepwise selection were used.

RESULTS

We found significant variations in all policy domains across states. No single policy appeared to clearly dominate a state's rank. AL bed supply, monthly AL cost, proportion of Medicaid beneficiaries receiving AL services, and other variables were significantly associated with regulatory stringency of the domains examined.

CONCLUSIONS AND IMPLICATIONS

There were substantial variations in regulatory stringency across states. Several market and state generosity measures were identified as potential determinants of stringency, but the direction of these associations appeared to depend on what was being regulated. Future studies should examine how regulatory stringency affects access to and care quality in ALs.

Organizational Factors Associated With Retention of Direct Care Workers: A Comparison of Nursing Homes and Assisted Living Facilities

BACKGROUND AND OBJECTIVES

Low retention of direct care workers (DCWs), either certified nursing assistants in nursing homes (NHs) or personal care assistants in assisted living (AL), continues to be an unresolved problem. While numerous studies have examined predictors of DCW retention in NHs, little attention has been paid to differences between settings of long-term care. This study compares the predictors of DCW retention rates across both settings.

RESEARCH DESIGN AND METHODS

The 2017 Ohio Biennial Survey of Long-Term Care Facilities provides facility-level information from NHs and ALs (NHs = 739; ALs = 465). We compare the factors that predict retention rates of DCWs utilizing regression analysis. The factors are structural, financial, resident conditions, staffing, and management characteristics, as well as retention strategies.

RESULTS

Average DCW retention rates were 66% and 61% in ALs and NHs, respectively. Not-for-profit status was significantly associated with higher retention rates across settings. While the percent of residents with dementia and less administrator turnover were associated with significantly higher DCW retention in NHs, these were not significant for ALs. However, in the AL context, a higher county unemployment rate and DCWs' participation in resident care planning meetings were positively related to DCW retention after controlling for all other covariates, while DCW cross-training was negatively associated.

DISCUSSION AND IMPLICATIONS

Retention strategies for DCWs may need to differ by setting, as a result of differing working environments, resources, and regulations.

Coronavirus Disease 2019 Regulatory Response in United States-Assisted Living Communities: Lessons Learned

Coronavirus disease 2019 (COVID-19) has disproportionately affected residents, their families, staff, and operators of congregate care settings. Assisted living (AL) is a type of long-term care setting for older adults who need supportive care but not ongoing nursing care and emphasizes a social model of care provision. Because AL is a type of long-term care, it has at times been referenced along with nursing homes in discussions related to COVID-19 but not recognized for its different care practices that pose unique challenges related to COVID-19; in that manner, it has largely been left out of the COVID-19 discourse, although ~812,000 older adults live in AL. To identify COVID-19 issues specific to AL, stakeholders with expertise in AL operations, policy, practice, and research (n = 42) were recruited to participate in remote interviews between July and September 2020. Using a thematic analysis, we derived the following overarching themes: (1) Policymakers are disconnected from and lack an understanding of the AL context; (2) AL administrators were left to coordinate, communicate, and implement constantly changing guidelines with little support; (3) AL organizations faced limited knowledge of and disparate access to funding and resources; (4) state-level regulatory requirements conflicted with COVID-19 guidelines resulting in uncertainty about which rules to follow; and (5) AL operators struggled to balance public health priorities with promoting their residents' quality of life and well-being. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback throughout the policy development process, both state and national.

Characterizing Emergency Department Use in Assisted Living

OBJECTIVES

Little is known about emergency department (ED) utilization among the nearly 1 million older adults residing in assisted living (AL) settings. Unlike federally regulated nursing homes, states create and enforce AL regulations with great variability, which may affect the quality of care provided. The objective of this study was to examine state variability in all-cause and injury-related ED use among residents in AL.

DESIGN

Observational retrospective cohort study.

SETTING AND PARTICIPANTS

We identified a cohort of 293,336 traditional Medicare beneficiaries residing in larger AL communities (25+ beds).

METHODS

With Medicare enrollment and claims data, we identified ED visits and classified those because of injury. We present rates of all-cause and injury-related ED use per 100 person-years in AL, by state, adjusting for age, sex, race, dual-eligibility, and chronic conditions.

RESULTS

Risk-adjusted state rates of all-cause ED visits ranged from 100.9 visits/100 AL person-years [95% confidence interval (CI) 92.8, 109.9] in New Mexico to 162.3 visits/100 AL person-years (95% CI 154.0, 174.7) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 18.7 visits/100 AL person-years (95% CI 17.2, 20.3) in New Mexico to 35.7 visits/100 AL person-years (95% CI 34.7, 36.8) in North Carolina.

CONCLUSIONS AND IMPLICATIONS

We observed significant variability among states in all-cause and injury-related ED use among AL residents. There is an urgent need to better understand why this variability is occurring to prevent avoidable visits to the ED.

COVID-19 Pandemic in Assisted Living Communities: Results from Seven States

OBJECTIVE

To describe variations in COVID‐19 confirmed cases and deaths among assisted living (AL) residents and examine their associations with key AL characteristics.

DESIGN

Observational study employing data on confirmed COVID‐19 cases and deaths in ALs from seven states, through May 29, 2020.

SETTING

Information on COVID‐19 cases/deaths in ALs was obtained from state government websites. A national inventory of ALs was used to identify communities with and without COVID‐19 cases/deaths. Medicare Beneficiary Summary File identifying AL residents was employed to develop AL characteristics. County‐level COVID‐19 laboratory‐confirmed cases/deaths were obtained from publicly available data.

PARTICIPANTS

We found 4,865 ALs (2,647 COVID‐19 cases and 777 deaths) in the seven states. After excluding missing data, the sample consisted of 3,994 ALs (82.1%) with 2,542 cases (96.0%) and 675 deaths (86.9%).

MAIN OUTCOMES AND MEASURES

Outcomes were AL‐level counts of cases and deaths. Covariates were AL characteristics and county‐level confirmed COVID‐19 cases/deaths. Multivariable two‐part models determined the associations of independent variables with the likelihood of at least one case and death in the AL, and with the count of cases (deaths).

RESULTS

State case fatality ranged from 3.32% in North Carolina to 9.26% in Connecticut, but for ALs in these states it was 12.89% and 31.59%, respectively. Among ALs with at least one case, midsize communities had fewer cases (incidence rate ratio (IRR) = 0.829; P = .004) than small ALs. ALs with higher proportions of racial/ethnic minorities had more COVID‐19 cases (IRR = 1.08; P < .001), as did communities with higher proportions of residents with dementia, chronic obstructive pulmonary disease, and obesity.

CONCLUSIONS AND RELEVANCE

ALs with a higher proportion of minorities had more COVID‐19 cases. Many of the previously identified individual risk factors are also present in this vulnerable population. The impact of COVID‐19 on ALs is as critical as that on nursing homes, and is worth equal attention from policy makers.

Two-Step Floating Catchment Area Model-Based Evaluation of Community Care Facilities' Spatial Accessibility in Xi'an, China

Due to the rapid increase in the number of elderly people in Chinese cities, the development and planning of aged care facilities, and particularly community care facilities, which will gradually become the mainstream choice for the elderly in China, is becoming an important topic for urban sustainability. Previous studies have shown that the number and scale of aged care facilities in many cities are far from meeting the needs of the elderly and the overall occupation rate is low. Some of these cities are still expanding and some are undergoing urban renovation. In this process, the scientific planning of community care facilities to promote efficient use of facility resources has become an urgent problem that needs to be solved. In this study, the two-step floating catchment area (2SFCA) method and a potential model based on the Geographic Information System (GIS) were used to carry out a scientific evaluation of the spatial accessibility of community care facilities in the Beilin district of Xi'an. The aims were to explore the best quantitative research methods for assessing the distribution of Xi'an community care facilities' spatial accessibility, provide ideas for similar studies in the future, and further the understanding of spatial allocation of urban community care facilities resources.

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

As the United States population ages, a higher share of adults is likely to use long-term services and supports. This change increases physicians' need for information about assisted living and residential care (AL/RC) settings, which provide supportive care and housing to older adults. Unlike skilled nursing facilities, states regulate AL/RC settings through varying licensure requirements enforced by state agencies, resulting in differences in the availability of medical and nursing services. Where some settings provide limited skilled nursing care, in others, residents rely on resident care coordinators, or their own physicians to oversee chronic conditions, medications, and treatments. The following narrative review describes key processes of care where physicians may interact with AL/RC operators, staff, and residents, including care planning, managing Alzheimer's disease and related conditions, medication management, and end-of-life planning. Communication and collaboration between physicians and AL/RC operators are a crucial component of care management.