A National Typology of Health Service Regulation in Assisted Living

BACKGROUND AND OBJECTIVES

State-regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents' outcomes across similarly regulated communities.

RESEARCH DESIGN AND METHODS

We used qualitative and quantitative methods to empirically develop and describe a typology of state AL regulations that captures inter- and intrastate variation. Based on the rules governing health services, we created regulatory specificity scores for 5 thematic dimensions: medication administration, third-party care, skilled nursing, medication review, and licensed nurse staffing. With these scores, we conducted a K-means cluster analysis to identify groups of AL license types. To differentiate the regulatory types, we calculated standardized mean differences across structure, process, outcome, and resident characteristics of the AL communities licensed under each type.

RESULTS

We identified 6 types of AL differentiated by the regulatory provisions governing health services: Housing, Holistic, Hybrid, Hospitality, Healthcare, and Health Support. The types align with previous work and reflect tangible differences in resident characteristics, health service structures, processes, and outcomes.

DISCUSSION AND IMPLICATIONS

This typology effectively captures differences across regulated dimensions and can inform and support quality of care. Researchers, policy-makers, and consumers may benefit from using this typology and acknowledging these differences in AL licensure when designing research studies, developing policies, and selecting an AL community.

Does Assisted Living Provide Assistance And Promote Living?

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have worsened; regulations have become complex; the need for consumer support, education, and advocacy has grown; and financing and accessibility have become insufficient. Together, these factors have limited the extent to which today's assisted living adequately provides assistance and promotes living, with negative consequences for aging in place and well-being. This Commentary provides recommendations in four areas to help assisted living meet its promise: workforce; regulations and government; consumer needs and roles; and financing and accessibility. Policies that may be helpful include those that would increase staffing and boost wages and training; establish staffing standards with appropriate skill mix; promulgate state regulations that enable greater use of third-party services; encourage uniform data reporting; provide funds supporting family involvement; make community disclosure statements more accessible; and offer owners and operators incentives to facilitate access for consumers with fewer resources. Attention to these and other recommendations may help assisted living live up to its name.

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.

Will medical cause of death certifications data quality improve in the UK with the new medical examiner system?

OBJECTIVES

There are deficits in the completeness, accuracy and timeliness of death certification internationally. In April 2023, England implemented a statutory Medical Examiners system primarily aiming to improve the quality of certification of death data. We sought to assess the current quality of death certification among general practitioners and medical examiners.

METHODS

An online survey was conducted with general practitioners and medical examiners in the Yorkshire region to determine how Medical Certifications of Cause of Death (MCCD) are completed and commonly experienced sources of errors (e.g., a lack of a reported time frame, absent or inadequate reporting of comorbidities, incorrect underlying cause-of-death, and an inaccurate sequence of events).

RESULTS

The survey was completed by general practitioners (n = 95) and medical examiners (n = 9). Participant responses, including to a hypothetical case, confirmed the quality of the certification was less variable among MEs compared to GPs, but still below international standards.

CONCLUSIONS

Efforts to enhance the quality of death certification require further consideration. Mandating a medical examiner system may not lead to intended improvements in the quality and cause of death data that form a critical component of mortality statistics that underpin health planning and monitoring.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

OBJECTIVES

Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities.

DESIGN

We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations.

SETTING AND PARTICIPANTS

AL regulations and licensed AL communities across all 50 states in 2018.

METHODS

We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health-related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those that impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission.

RESULTS

The largest group of ALs (29% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than 8 of every 10 licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment.

CONCLUSIONS AND IMPLICATIONS

The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (eg, health, mental health, cognitive). Although future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policy makers to better understand the options in their state and how various AL licensure classifications compare to one another.

State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life

Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.

REGULATORY COMPLIANCE AND RESIDENT OUTCOMES IN OREGON ASSISTED LIVING COMMUNITIES

The outsized negative impact of the COVID-19 pandemic among residents of assisted living (AL) communities has drawn attention to the existing challenges that licensing agencies face in providing oversight in this setting. While regulatory compliance inspections in AL may be a critical tool for promoting high-quality care, no published research has examined the association between deficiencies and resident outcomes in AL. Using novel data collected from 331 AL communities in Oregon (response rate=62%) merged with deficiency data from inspections, we examined whether the number of deficiencies is associated with the following resident outcomes as measured at the community level: share of residents who fell at least one time (fall rate), who were hospitalized overnight (hospitalization rate), and who were treated in the hospital emergency room (ER rate) in the last 90 days. Negative binomial regression models that controlled for a robust set of community (e.g., size, rurality, profit status, “memory care” units) and resident (e.g., age, Medicaid use, ADL needs) characteristics showed a weak, but statistically significant, association between deficiencies and hospitalization rate (IRR=1.05). However, there was no statistically significant association between deficiencies and falls or ER visits among residents. The time lag between inspections and the resident outcome data did not moderate these observed associations. With more states moving to make available such deficiency data on public-facing websites, these results have policy implications for the role and content of regulatory compliance inspections for ensuring quality in AL communities and informing the public.

EXPERT CONSENSUS PANEL RECOMMENDATIONS FOR MEDICAL AND MENTAL HEALTH CARE IN ASSISTED LIVING

Assisted living (AL) is now the largest residential provider of long-term care in the U.S., and the acuity of AL residents has been rising. However, AL is not a health care setting, and concern has grown about the medical and mental health care needs of AL residents. Because there is no guidance to inform this care, a Delphi consensus panel of 19 experts was convened, and their recommendations were compared to actual practice. Panelists rated 200 discrete items, 43 of which met standard recommendation cut points (rated as important by at least 75% of panelists) and reflected four critical components of AL: the tenets of AL, the role AL plays in providing long-term care for persons with dementia, the need for pragmatism in response to the diversity of AL, and workforce needs. Next steps regarding implementation of the recommendations will be discussed.

TRENDS IN MENTAL ILLNESS ACROSS ASSISTED LIVING SETTINGS: RESIDENT AND COMMUNITY FACTORS

Although rates of serious mental illness (SMI), depression, and anxiety are becoming more common among assisted living (AL) and residential care (RC) residents, few studies have investigated resident and community-level factors to ensure that the settings and resources are adequate to meet residents’ mental health needs. Using a representative sample of Oregon AL/RC residents (n = 1,013), this study uses descriptive cross-sectional analysis to examine intrastate variation in the prevalence of SMI, depression, and anxiety related to: (1) resident-level characteristics (e.g., mental illness comorbidity, psychotropic medication use, and Medicaid status); (2) community-level characteristics (e.g., facility type and urban/rural geographic designation); and (3) health services utilization (e.g., emergency room visits and hospital admission). Results indicate that 12% of AL/RC residents had an SMI diagnosis, nearly half of whom also had depression and anxiety, and 80% were Medicaid eligible. One in six residents with SMI received at least three psychotropic medications in the last week. Residents with SMI were also more likely to live in RC facilities than AL facilities, in facilities with Medicaid contracts, and in urban rather than rural settings. Compared to residents without SMI, a larger share of residents with SMI utilized hospital emergency rooms (32% vs. 18%) and were admitted to the hospital overnight (15% vs. 9%). Findings underscore characteristics associated with potentially higher needs among AL/RC residents with SMI compared to their counterparts, with implications for the high quality provision of mental health services and quality of life and care in these settings.

ANTIPSYCHOTIC MEDICATION USE IN ASSISTED LIVING/RESIDENTIAL CARE: DO ORGANIZATIONAL CHARACTERISTICS MATTER?

This study investigates how assisted living/residential care (AL/RC) and memory care (MC) contexts are associated with the prevalence of antipsychotic medication use (APU). Primary data were collected from a statewide representative sample of AL/RC settings through the Oregon Community-Based Care study from 2017-2019 and combined with publicly available administrative data. Framed by Donabedian’s model of care quality, we examine associations among 90-day prevalence of APU, organizational, care process, and AL/RC resident population characteristics using random intercepts regression models. Every licensed AL/RC setting in Oregon receives an annual mailed survey to provide aggregate resident demographics, health acuity, health service use, payment type and organizational policies. Organizational measures (e.g., profit status, license type, geographic designation) were collected from state websites. The average 90-day prevalence of APU among all Oregon AL/RC settings is 30.7%, though rates differ by MC endorsement (23.9% in AL/RC and 42.7% in MC). Compared to care processes and resident population characteristics, organizational characteristics were associated with larger magnitudes of difference in rates of APU. Nonprofit settings were associated with lower rates of APU in both AL/RC (β= -4.4 percentage points, [95% CI: -8.4, -0.4]) and MC (β= -12.4, [95% CI: -21.2, -3.6]. Compared to low-Medicaid settings, settings with very high proportions of Medicaid residents were associated with higher prevalence of APU, +8.9 in AL/RC (95% CI: 1.7, 16.1) and +11.0 in MC (95% CI: 2.3, 19.8). Policymakers might consider how organizational resource capacity influences APU in AL/RC settings, especially if APU prevalence is treated as a quality indicator.

A VISION FOR THE FUTURE OF ASSISTED LIVING RESEARCH: LEVERAGING ADMINISTRATIVE DATA TO STUDY QUALITY

Because the assisted living industry is neither federally regulated nor federally licensed, methodologies to study the quality of long-term care used in other settings (e.g., annual inspection reports, resident assessment data) do not exist for the large and growing number of assisted living communities and their residents. The objective of this presentation is to present a vision for the future of assisted living research to inform quality using large, national datasets. To do this, the presenter will discuss existing approaches to identify and characterize assisted living communities and their residents using administrative data. A specific focus will be to highlight the opportunities and challenges associated with each approach. The presenter will offer suggestions for possible enhancements in existing approaches and next steps in the study of assisted living aimed at understanding and improving the quality of care delivered in these settings.

REIMAGINING POLICY-INFORMED RESEARCH FOR THE FUTURE OF ASSISTED LIVING

Researchers have long known that states are responsible for licensing assisted living (AL). Recent analyses indicate that the regulatory landscape is more complex, as states have numerous license classifications that can be combined in multiple ways through various subtypes and designations applied to settings under the AL umbrella. Other sources of complexity include within-state policy variation in terms of affordability and access, person-directed care, emergency preparedness, workforce, and diversity and inclusion. This presentation describes a vision and framework for future research informed by this complex policy landscape. We describe how researchers can better conceptualize types of ALs, and provide guidance for how and why AL researchers might shift from the current practice of analyzing AL settings by the “state” versus by license type, among other categorizations.

Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place

Importance

Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place.

Objective

To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place.

Design, Setting, and Participants

This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022.

Exposures

Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US.

Main Outcomes and Measures

Presence in assisted living residences on the date of death.

Results

The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71).

Conclusions and Relevance

The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of AL was dispersed across three or more agencies, and administrative support varied in terms of staffing and budget allocations. Operations also varied. While most agents could deploy a range of monitoring and enforcement tools, less than half compiled data concerning inspections, violations, and penalties. Less than 10 states shared such information in a manner that was easily accessible to the public. Future research should determine how these varied administrative structures and processes deter or contribute to AL communities' efforts to implement regulations designed to promote quality of life and provide for the safety of residents.

Memory care reduces nursing home admissions among assisted-living residents with dementia

INTRODUCTION

We compare nursing-home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living.

METHODS

Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis.

RESULTS

Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = -1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87-1.00]), a lower risk of nursing-home admission (risk difference = -2.2 percentage points [P < .001], hazard ratio = 0.87 [-.79-0.95]), and a lower risk of a long-term nursing home admission (risk difference = -1.1 percentage points [P < .001], hazard ratio = 0.71 [0.57-0.88]).

DISCUSSION

Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living.

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel: A Consensus Statement

IMPORTANCE

Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents' medical and mental health needs. No guidance exists to inform this care.

OBJECTIVE

To identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic.

EVIDENCE REVIEW

A Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility.

FINDINGS

Consensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs.

CONCLUSIONS AND RELEVANCE

In this consensus statement, 43 recommendations important to medical and mental health care in AL were delineated that are highly pragmatic as a guide for practice and policy.

Beyond the Medication Pass: Attitudes, Ethics, Agency, and Antipsychotic Medications in Assisted Living/Residential Care

Background and Objectives

As-needed (PRN) antipsychotic medication use (APU) among assisted living/residential care (AL/RC) residents is a controversial health policy issue. AL/RC care staff, families, clinicians, researchers, and policymakers disagree about PRN APU to manage behavioral expressions associated with residents’ dementia or cognitive impairment.

Research Design and Methods

Semi-structured interviews among eleven direct care staff (n=3), licensed nurses (n=2), administrators/executive directors (n=4), and consultant pharmacists (n=2) currently working in Oregon AL/RC. Using situational analysis, we identify, describe, and visualize positions and ideologies by job role to theorize PRN APU decision-making.

Results

Three broad processes underlie APU to manage residents’ behavioral expressions: justifying PRN APU, moralizing APU, and balancing local practices (e.g., managing behavioral expressions, respecting individuals) with nonlocal practices (e.g., professional authority). People involved in the situation of APU in AL/RC describe positive and negative justifications, and personal moral positions that frame PRN antipsychotics or nonpharmaceutical interventions as “right” or “wrong,” driving various approaches to behavior management. Participants described a converse orientation between perceived level of agency within and proximity to the situation of APU. Those most closely involved, or local, to the situation of passing medications (e.g., direct care staff and nurses) expressed less agency compared to nonlocal physicians and policymakers, who are not involved in the day-to-day practices within AL/RC.

Discussion and Implications

This study raises practice and policy implications regarding APU in AL/RC settings. Care staff roles, ethical considerations, and perceived agency inform decision-making on whether to use antipsychotic medications. Participants described costs and benefits associated with both PRN APU and nonpharmaceutical interventions when responding to AL/RC residents’ behavioral expressions. Participants’ experiences emphasize the interactions across multiple levels of care. Balancing regulatory goals with resident-centered practices underscores the need for a systems-level perspective, extending beyond direct care staff passing antipsychotic medications to residents.

Dementia and COVID-19 Infection Control in Assisted Living in Seven States

Background

Assisted living (AL) is the largest residential long‐term care provider in the United States, including for persons with Alzheimer's disease and related dementias. Despite recognizing the challenge of infection control for persons with dementia, this study of 119 AL communities is the first to describe dementia‐relevant COVID‐19 infection control across different types of AL communities, and to discuss implications for the future.

Methods

From a parent study sampling frame of 244 AL communities across seven states, 119 administrators provided data about COVID‐19 infection control practices and resident behaviors. Data were collected from July 2020 through September 2021. Communities were differentiated based on the presence of beds/units dedicated for persons living with dementia, as being either dementia‐specific, mixed, or integrated. Data obtained from administrators related to feasibility of implementing seven infection control practices, and the extent to which residents themselves practiced infection prevention. Analyses compared practices across the three community types.

Results

Less than half of administrators found it feasible to close indoor common areas, all community types reported a challenge organizing group activities for safe distancing, and more than half of residents with dementia did not wear a face covering or maintain physical distance from other residents when indicated. Dementia‐specific AL communities were generally the most challenged with infection control during COVID‐19.

Conclusion

All AL community types experienced infection control challenges, more so in dementia‐specific communities (which generally provide care to persons with more advanced dementia and have fewer private beds). Results indicate a need to bolster infection prevention capacity when caring for this especially vulnerable population, and have implications for care in nursing homes as well.

The Imperative to Reimagine Assisted Living

Assisted living (AL) has existed in the United States for decades, evolving in response to older adults' need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home. The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce. These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.

COVID-19 Perspectives of Assisted Living and Health Care Providers in Seven States

Thirty percent of COVID-19 deaths in long-term care were in assisted living (AL), indicating challenges providing care. This project recruited AL administrators and medical and mental health care providers in a seven-state stratified random sample of 250 communities; it asked what was most challenging responding to COVID-19, what was successful, how to have better dealt with COVID-19, and how others could have helped. The most common challenge was addressing residents’ psychosocial needs, explained as “No contact - no hugging. The seniors require touch. It's something we've always done, and we can't do; we're required not to do it.” Successes included infection prevention, and in hindsight, administrators discussed staffing. Related to external entities, one commented, “Come in the building and see what we're doing. Don't sit behind a freaking screen and act like you know what we're doing.” Providers stressed patient access to care and social isolation. Implications will be discussed.

Experiences of Rural and Urban Assisted Living Communities in Oregon During COVID-19 Pandemic

This study presents findings on the impact of the COVID-19 pandemic as reported by a representative sample of Oregon assisted living communities (AL) between December 2020 and March 2021. Of the 559 AL eligible to participate, 346 completed eleven questions related to their experiences since March 2020. These questions covered topics such as access to personal protective equipment (PPE) and accurate information, communication with and support from government agencies, ability to find staff and new residents, ability to address pandemic-related concerns of residents’ families and staff, use of virtual visits and telehealth for residents, and visitor restrictions. Response categories ranged from 0 (strongly disagree) to 4 (strongly agree) and we coded “agree” and “strongly agree” responses as having experienced that issue. Among responding AL, 42% were located in rural or frontier areas. We present three findings. First, most AL experienced adverse impact due to COVID-19, especially regarding issues likely to be outside of their control compared to those within their control. Second, while almost all urban-based AL reported that their residents used virtual communication technologies and tools for telemedicine/telehealth (96%) or virtual social visits (96%), rural AL were less likely to report so (90% and 92%, respectively). Finally, rural AL experienced significantly greater staffing difficulties (75%) compared to their urban counterparts (82%). In sum, while all AL would benefit from better regulatory guidance on policies and access to PPE, rural AL might especially benefit from additional, context-specific resources.

Excess Mortality Attributable to COVID-19 Among Assisted Living Residents

This study examines the excess mortality attributable to COVID-19 among a national cohort of assisted living (AL) residents. To do this, we compare the weekly rate of all-cause mortality during 1/1/20-8/11/20 with the same weeks in 2019 and calculated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). All-cause mortality rates, nationally, were 14% higher in 2020 compared with 2019 (mean, 2.309 vs. 2.020, respectively, per 1000 residents per week; adjusted IRR, 1.169; 95% CI 1.165-1.173). Among the 10 states with the highest community spread, the excess mortality attributable to COVID-19 was 24% higher, with 2.388 deaths per 1000 residents per week in 2020 during January-August vs 1.928 in 2019 (adjusted IRR, 1.241; 95% CI 1.233-1.250). These results suggest that AL residents suffered excess mortality due to COVID-19.

Assisted Living Administrators’ Mental and Emotional Health During the COVID-19 Pandemic

Little is known about assisted living (AL) administrators’ mental and emotional health, particularly during a global pandemic in which most of their residents are highly vulnerable to infection, hospitalization, and death. Considering that administrator turnover and burnout have been associated with negative outcomes such as decreased quality of resident care, low staff morale, and reduced financial solvency, this study examined how AL administrators described their mental and emotional state throughout the first year of the COVID-19 pandemic. Using thematic analysis, our team coded 18 qualitative interviews conducted from May-August 2021. The themes included declining physical health due to stress, feelings of inadequacy and self-doubt, and increased burnout. Many administrators described increased staffing challenges as directly impacting their daily stress levels. Some administrators described feeling guilty and doubting their interpretation or implementation of regulations, particularly in incidents that further distanced residents from peers and loved ones. A few administrators described their disposition or personality changing due to what they experienced during the pandemic. One administrator stated, “I'm not an anxiety person, but I feel anxiety about a lot of things. In fact, my doctor has talked to me about starting some medications to help with that.” Multiple administrators made comments such as, “I don't know that there could be a more stressful position than executive director of assisted living…the COVID pandemic reinforced that. This is rough.” Understanding AL administrators’ mental and emotional health during a public health crisis allows for understanding, supporting, and retaining critical leaders in long-term care communities.

Structural Racism is Associated with Assisted Living Location

Our objective was to measure the association between structural racism, a previously unmeasured but theoretically causal factor, and assisted living communities (ALCs) location as fewer ALCs are located in counties with a greater percentage of the population reported as Black (PPB). We used a recently developed measure of structural racism—the racial opportunity gap (ROG), which compares the economic mobility of Black and White people who grew up in the same area with parents who had similar incomes. We estimated a multilevel mixed-effects bivariate regression model to examine the factors contributing to the presence of ALC. We relied on state and county random effects. The likelihood of an assisted living being located in a census tract in 2019 was significantly positively associated with the percent of the population over the age of 65 (OR=150.1573, p=<0.001), the PPB (OR=2.9916, p=0.004), and higher median incomes (OR=1.0, p=<0.001). In contrast, rurality (OR=0.5656, p=<0.001), unemployment rates (OR=0.0288, p=<0.001), and census tracts that have a high PPB in addition to a high county ROG (OR=.0058, p=0.0137) are all associated with a lesser likelihood of an ALC. The interaction coefficient between the ROG and PPB reverses the previously documented negative association between the PPB and ALC presence. This result empirically supports the premise that structural racism, not population race alone, is a negative determinant of where an ALC is located within a county.

State Regulatory Response to COVID-19 Limited Assisted Living Resident Caregiver Networks

This paper describes a qualitative content analysis of assisted living emergency rules, revised regulations, and executive orders responding to the COVID-19 pandemic. Using key search terms, we identified 36 states that enacted policies between February and October 2020. The following themes occurred most frequently: testing, infection control, access restrictions, suspension of requirements, and reporting. The convoys of care model recognizes internal, external, formal, and informal caregivers as essential members of an AL resident’s care network. We found that non-staff care providers, including external formal caregivers (e.g. home health and hospice) and informal caregivers (e.g. family), were most often addressed in policies limiting access. Informal caregivers were the least often specifically addressed in these policies. Given the importance of these network members in the AL context, these policies have implications for the wellbeing of the resident and care network.

A Typology of Health Services Regulated in U.S. Assisted Living Communities

State agencies regulate assisted living (AL) with varying approaches across and within states. The implications of this variation for resident case mix, health service use, and policy, are not well described. We collected health services-relevant AL regulatory requirements for all 50 states and DC and used a mixed-methods approach (thematic analysis; k-means cluster analysis) to identify six types: Housing, Affordable, Hybrid, Hospitality, Healthcare, and Hybrid-Healthcare. We stratified Medicare claims data by regulatory type, identifying variation in resident case mix and health service use. Housing and Affordable clusters have larger proportions of dual-eligible beneficiaries, Black residents, and residents of Affordable had more long-term nursing home use compared to other clusters. Dual-eligible beneficiaries account for 26.6% of Housing cluster residents compared to 8.1% of Hybrid Healthcare cluster residents. We provide other examples and explain the implications in terms of sampling AL for single and multi-state studies, racial disparities, and health-related policies.

Seven-State Study of Assisted Living and Healthcare Providers’ Responses to COVID-19

COVID-19 has inordinately affected assisted living (AL), such that the proportion of fatalities to cases has been 21% in AL versus 2.5% for the general population. Understanding how AL administrators and medical and mental health providers have responded to COVID-19 can inform health care going forward. Using a seven-state stratified random sample of 250 communities, administrators were interviewed and providers completed questionnaires regarding COVID-19 practices. Preliminary data indicate that 79%, 44%, and 62% of administrators reported serving meals in rooms to segregate residents, using telemedicine, and providing extra pay for staff, respectively. Perceived use/effectiveness of practices differed based on dementia case-mix (e.g., face coverings, social distancing). Providers reported less access to patients (82%), more telehealth (63%), and less ability to provide care (43%). However, they uniformly reported high confidence in AL staff ability to prevent (94%) and respond to outbreaks (96%). Discussion will summarize points important for future care.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

OBJECTIVES

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

All AL residents and select staff in 250 AL communities in 7 states.

METHODS

Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7 days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics.

RESULTS

Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7 days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n = 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n = 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds.

CONCLUSIONS AND IMPLICATIONS

The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

BACKGROUND AND OBJECTIVES

License inspection data have commonly been used as a quality measure for nursing homes but has not yet been used to assess the quality of assisted living/residential care (AL/RC) communities. Drawing on resource dependency theory, we test the hypothesis that structural and environmental characteristics influence AL/RC quality as measured by deficiency citations ("deficiencies") issued during license inspections.

RESEARCH DESIGN AND METHODS

Using data from 526 licensed AL/RC communities in Oregon that received a license inspection visit between 2008 and 2016, we examined the prevalence of deficiencies by type and year. We estimated regression models to identify structural and environmental characteristics associated with the number of deficiencies.

RESULTS

Most (79%) inspections resulted in at least one deficiency. The most common deficiencies concerned medications and treatments (57%), change of condition and monitoring (48%), and resident health services (45%). Structural characteristics associated with higher odds of receiving one or more deficiencies included: larger size, memory care designation, shorter administrative tenure, and for-profit status. Environmental characteristics associated with higher odds of receiving one or more deficiencies included: rural location, lower unemployment, and market concentration. The number and likelihood of a given community receiving a deficiency decreased over time.

DISCUSSION AND IMPLICATIONS

Resource dependency theory constitutes a useful framework to consider the role of structural and environmental factors that affect AL/RC quality, including resident needs, institutional knowledge, resource availability, and market pressure. License inspection data are a viable option for assessing the quality of AL/RC communities.

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.

"What Keeps Me Awake at Night": Assisted Living Administrator Responses to COVID-19

Background and Objectives

Assisted living (AL) constitutes an important sector of residential long-term care, yet there has been limited research about the impact of the coronavirus disease 2019 (COVID-19) pandemic in this setting. This qualitative study sought to understand the impact of the early stages of the pandemic (February-August 2020) from AL administrators’ perspectives.

Research Design and Methods

Semi-structured phone interviews were conducted with 40 AL administrators in Oregon. A stratified sampling method emphasizing rurality, profit status, Medicaid acceptance, and memory care (MC) designation was used to maximize variation in perspectives. We asked eight questions aimed at understanding the impact of the COVID-19 pandemic on their roles and AL residents and their families, as well as AL operations, such as staffing and resource procurement. Audio-recorded interviews were transcribed and analyzed using an iterative thematic analysis.

Results

We identified three themes that characterize AL administrators’ response to COVID-19: emotion and burn-out management, information management, and crisis management. Based on their experiences, administrators made suggestions for managing future crises.

Discussion and Implications

Our findings demonstrate the slow-burning but devastating impact of the COVID-19 pandemic in AL communities similar to recent findings in nursing homes. Coupled with the limited resources, perceived external pressures, and the ongoing pandemic, many administrators were managing but not thriving in these domains. AL as a care setting, and the role of administrators, requires more scholarly and policy attention, especially regarding emergency preparedness and response.

Estimation of Excess Mortality Rates Among US Assisted Living Residents During the COVID-19 Pandemic

This cohort study examines rates of mortality among US assisted living residents during the COVID-19 pandemic in comparison with the same period in 2019.

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.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities

BACKGROUND AND OBJECTIVES

Assisted living (AL) residents with dementia commonly exhibit behavioral expressions (BEs), yet no study has examined how AL staff perceive of and respond to BEs in terms of the "ABC" model of antecedents, behaviors and consequences, or how perceptions relate to organizational characteristics. Understanding staff perceptions may inform interventions.

RESEARCH DESIGN AND METHODS

A convergent, mixed-methods design was used in a study of health care supervisors from 250 AL communities in seven states who reported 366 cases of resident BEs (one successful and one unsuccessful case). Qualitative analysis identified antecedents, BEs, staff responses, resident outcomes, and disposition (aging in place or discharge). Content analysis identified themes and compared case types. Descriptive statistics examined organizational characteristics associated with identifying antecedents.

RESULTS

One-quarter of cases recognized antecedents; slightly more were identified in successful (28%) compared to unsuccessful cases (20%); staff in dementia-only and smaller communities identified antecedents more often. Combativeness and anxiety were the most frequently reported BEs. The majority of both types of cases reported staff responses. Medication management was enacted as a response in 40% of cases compared to psychiatric assessment in 33% of cases.

DISCUSSION AND IMPLICATIONS

Staff training is indicated to increase AL staff recognition of antecedents; doing so might reduce use of antipsychotic medications. Psychiatric assessment plays an important role in dementia care in AL and warrants further examination. Results could be helpful for applied behavioral researchers interested in developing ways to improve identification of antecedents of BEs of persons with dementia.

Cognition-Enhancing, Antipsychotic, and Opioid Medication Use Among Assisted Living and Residential Care Residents in Oregon

OBJECTIVES

Explore community- and resident-level characteristics associated with polypharmacy and use of cognition-enhancing, antipsychotic, and opioid medications among a statewide representative sample of assisted living and residential care (AL/RC) residents.

DESIGN

Cross-sectional, descriptive.

SETTING AND PARTICIPANTS

A total of 1135 AL/RC residents living in 387 licensed communities in Oregon were recruited. One-third of residents lived in communities certified to provide memory care to residents with dementia.

METHODS

All licensed AL/RC communities received a mail survey with questions about 3 randomly selected residents' demographic, health service use, health conditions, medication use, and payment information. We estimated bivariate and multiple logistic regression models, resulting in unadjusted and adjusted odds ratios of resident- and community-level characteristics associated with each medication use indicator.

RESULTS

One in 5 residents took a cognition-enhancing medication (20%) in the prior 7 days. Just more than one-fifth (22%) and one-quarter (25%) of residents took opioid or antipsychotic medications, on a scheduled or as-needed basis in the prior 7 days, respectively. Residents with Alzheimer's disease or related dementia (ADRD) living in rural communities were half as likely to take cognitive-enhancing medications compared with their urban counterparts. When controlling for all resident and community covariates, residents with ADRD were almost 3 times as likely to receive an antipsychotic and half as likely to receive an opioid compared to residents without an ADRD diagnosis.

CONCLUSIONS AND IMPLICATIONS

Understanding variation in the use of medications associated with behavioral expressions of ADRD in AL/RC residents is a crucial clinical and policy area.

Connecting policy to licensed assisted living communities, introducing health services regulatory analysis

OBJECTIVE

To document dementia-relevant state assisted living regulations and their changes over time as they pertain to licensed care settings.

DATA SOURCES

For all states, current directories of licensed assisted living communities and state regulations for each year, 2007-2018, were obtained from state agency websites and Nexis Uni, respectively.

STUDY DESIGN

We identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally.

DATA COLLECTION/EXTRACTION METHODS

We used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question-based coding to record the presence or absence of specific policies for each classification and study year.

PRINCIPAL FINDINGS

Our team empirically documented provisions requiring dementia-specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two.

CONCLUSIONS

We identified significant, previously undocumented, within-state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia-designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings.

To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living?

OBJECTIVE

In nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs.

DESIGN

Observational, cross-sectional AL data linked to publicly reported NH measures.

SETTING AND PARTICIPANTS

Random sample of 250 AL communities and the full sample of 3371 NHs in 7 states.

METHODS

We calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects.

RESULTS

The prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = -0.03; 95% confidence interval (CI) -0.50 to -0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs' prescribing rates (b = 0.43; 95% CI 0.16-0.70; P = .002).

CONCLUSIONS AND IMPLICATIONS

This study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.

Assisted Living: Optimal Person-Environment Fit

Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. This article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person-environment fit provides an organizing framework for our commentary. The environment of AL emphasizes choice, independence, and privacy. The acuity of health care needs in AL residents has evolved since its inception. Unlike earlier residents, many today live with multiple chronic conditions and need for functional supports. Regulated by states, there is high variability in oversight, staffing, and resources available in AL. Families play an important role in supporting residents, yet expectations for their engagement may not be clear. Descriptive research abounds but there is a need for more sophisticated approaches to understanding how the AL environment can provide optimal supports for older adults, across all states and across income and racial/ethnic groups. There are several methodological challenges to AL research, including the high variability among AL settings and across states, the lack of common data elements, and difficulty accessing representative samples. With the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability. [Research in Gerontological Nursing, 14(1), 5-12.].

The Impact of Changes in Direct Care Staffing Policies and Outcomes for Assisted Living Residents With Dementia

We identified a cohort of 410,413 Medicare beneficiaries residing in 10,623 large (25+bed) assisted living (AL) communities between 2007 and 2017. We conducted linear probability models with a difference-in-difference framework to examine the association between hospitalization and changes in regulations pertaining to staff training (model 1) and staffing levels (model 2), adjusting for time trends, resident characteristics, and state-license fixed effects. During this 11-year period, six states changed their staff training requirements and two states introduced/increased direct care staffing levels. A change in regulations related to staffing levels was associated with a reduction in the probability of hospitalization during the month of -0.0056 percentage points (95%CI=-0.008,-0.003). A change in regulations related to staff training was associated with a reduction in the probability of hospitalization during the month of -0.0035 percentage points (95%CI=-0.006,-0.002). The policy effects represent clinically important differences of approximately 21% in the mean monthly hospitalization rate. Part of a symposium sponsored by Assisted Living Interest Group.

Local Nursing Home Prescribing Patterns and Psychoactive Prescribing in Assisted Living

Because prescribing practices in long-term care settings may reflect regional influences, we examined how potentially inappropriate antipsychotic and antianxiety medication prescribing in assisted living (AL) compared to prescribing in nursing homes (NHs) based on their proximity, using generalized linear models adjusting for facility characteristics and state fixed effects. Data were derived from a seven state sample of AL communities and data for the same seven states drawn from publicly available data reported on the Nursing Home Compare website. In adjusted analyses, AL rates of antipsychotic use were not associated with the rates in the nearest or farthest NHs. However, AL communities that were affiliated with a NH had lower rates of potentially inappropriate antipsychotic use (b=−0.27[95%CI=−0.50,−0.04]). In a separate model, antianxiety medication prescribing rates in AL were significantly associated with neighboring NHs’ rates of prescribing (b=2.65[95%CI=1.00,4.29]). Findings suggest efforts to change prescribing in NHs may influence prescribing in AL.

“Doing the Impossible with the Inadequate”: COVID-19 Response in U.S. Assisted Living Settings

The COVID-19 pandemic has disproportionately affected long-term care operators, staff, residents and their families; although much attention has been given to nursing homes, largely lost in the discourse are assisted living, residential care, and dementia care (AL) communities. As part of a broader, ongoing study assessing states’ AL regulations regarding medical and mental health care for residents with Alzheimer’s and related dementias (ADRD), stakeholders across the United States were recruited in July and August 2020 for semi-structured interviews to provide their perspectives on AL policies and practices specific to COVID-19 response. Stakeholders (n=32) consisted of state healthcare and trade association representatives, clinical practitioners, operators, researchers, and dementia care experts experienced in AL-related operational, healthcare, and regulatory affairs. Using thematic analysis, we describe several emerging topics regarding the opportunities, challenges, and innovations of responding to COVID-19 within the unique context of AL. States’ public health responses to COVID-19 lacked an understanding of the broader long-term care system, especially AL’s scope and purpose, workforce, capacity to implement infection control practices and policies, and unintended consequences of social isolation for older adults, specifically residents living in dementia care units. Despite these challenges, stakeholders described opportunities to expand telehealth infrastructure, communication and collaboration across states and among operators, and several innovations to mitigate the effects of social isolation. It is imperative for policymakers to understand the nuances of the AL context and design regulations and public health responses grounded in a whole-person perspective and in partnership with operators during, and beyond, pandemic circumstances.

Implementing Oregon’s New Quality Measurement Program for Assisted Living Communities

Oregon legislation requires assisted living (AL) communities to report selected quality measures to the state licensing agency. The Quality Measurement Program (QMP) includes five metrics that assess different areas of resident safety and wellbeing: falls, antipsychotic medication use, staff training, staff retention, and resident satisfaction. This paper describes findings based on our 2019 survey of AL communities and offers suggestions for stakeholders interested in public reporting and quality metrics. Assisted living providers reported 28% of AL residents and 38% of memory care (MC) residents fell at least once in the prior 90 days, with 39% and 45% reporting an injury, respectively. Antipsychotic medication use was 20% among AL and 44% among MC residents. These findings and the survey methods used to collect them, combined with stakeholder and state agency staff participation, informed the current QMP approach. We describe how to collect meaningful quality metrics within the AL context.

Variation in Assisted Living Regulations Within and Across States

Assisted living (AL) regulations have been long recognized as being highly variable across states. A new approach developed by our team, Health Services Regulatory Analysis, allows for a more granular identification of within-state variation in AL regulation. We identified 172 licensing classifications from the 50 states and DC representing 58 primary license types, 48 sub-types, and 66 designations that can modify a primary or sub-license. Over two-thirds (72%) of dementia-specific classifications require that all staff receive initial dementia training, compared to only one-third (33%) of general AL classifications. This trend is similarly reflected in cognitive-screening requirements, present in 67% of dementia-specific classifications and 42% of general AL classifications. Regulatory theory describes how licensing agencies respond to various forces and values. Within-state AL regulatory variation reflects a combination of oversight mandates, population-specific needs (e.g., people with dementia), historic policies, and provider influence, with implications for consumers, policy-makers and researchers. Part of a symposium sponsored by Assisted Living Interest Group.

Pro Re Nata Use of Psychotropic Medications in Assisted Living

This study examined the use of pro re nata (PRN, or as needed) psychotropic medications among assisted living (AL) residents. We examined prescriptions and administrations, and compared use based on dementia diagnosis. Data sources included interviews with administrators of 250 AL communities in 7 states and medication administration record review for the prior 7 days; analyses were weighted to the entire state. The percent of all residents prescribed a PRN psychotropic medication was 10.3%. However, residents with a dementia diagnosis were twice as likely to have a PRN psychotropic prescription (15.2% versus 7.2%; p<.001). The majority of psychotropic medications prescribed and administered were for anxiolytics/hypnotics rather than antipsychotics. Additional resident-level factors significantly associated with higher PRN prescribing included psychiatric diagnosis, incontinence, hospice use, confusion/disorientation, and agitation. We summarize these and other findings in the context of state regulatory requirements for staffing, chemical restraints, and dementia care.

How Assisted Living Staff Conceive of Dementia Care

For those who provide care to the more than 40% of persons with dementia in assisted living (AL) communities, behavioral expressions (BEs) can be challenging. The objective of this mixed-methods study was to understand how AL staff conceive of BEs and what strategies they use to address them. Staff from 250 AL communities in seven states were asked to describe one successful and unsuccessful case of care. A conceptual model related to antecedents, behaviors, and consequences was developed and expanded to include staff strategies and outcomes of care; organizational characteristics associated with care practices were examined. Anxiety/restlessness, combativeness and resistance to care were the most prevalent BEs. Medical interventions (e.g., inpatient psychiatric assessment, medication management) were used in two-thirds of cases. Person-centered care was used more often in successful cases. Respondents in dementia-only communities identified antecedents to BEs more often than those in other communities.