RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING

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1 RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING By Liz Jensen, RN MSN, RN-BC Clinical Director, Direct Supply, Inc. RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING

2 Introduction Now is an exciting time to be an Assisted Living provider. People are living longer and the total number of older adults continues to grow, creating unprecedented conditions in Senior Living. Advances in medicine will continue to extend the lives of adults, and those born in the 1920s and 1930s will experience longevity not achieved by their parents. With the baby boomer generation reaching older adulthood over the next 30 years, providers are preparing for a fundamental shift in how they think about senior housing, care and services. We hear a lot these days about rising acuity in Assisted Living, but what is driving this change? It s a combination of several leading factors, including consumer demand, expanded provider capabilities and changes as a result of healthcare reform. RESIDENTIAL CARE COMMUNITIES 89 % provide physical, occupational or speech therapy 89 % provide hospice care 76 % provide Skilled Nursing services 68 % provide disease-specific programs for residents with dementia According to the National Survey of Residential Care Facilities, older adults are increasingly delaying the age they move into Senior Living. Many who live in Senior Living desire to stay in their current apartment and community and, with advancing age, are asking their providers to help them meet their needs. Providers are responding to their residents requests for more services and are adding additional onsite services, including physical therapy (PT), occupational therapy (OT), fitness programs and nutrition counseling. Some are also adding nursing and other professional staff and utilizing newer technology, including telemedicine, community connection, and call and monitoring services. Many states are adding or changing regulations to allow for expanded levels of service, while other states regulations are more restrictive, which may limit the type and amount of services an Assisted Living community can provide. The changes within the healthcare system as a result of the Affordable Care Act (ACA) will impact Assisted Living providers as they contribute to reducing rehospitalizations and improving health outcomes for Medicare and Medicaid beneficiaries.

3 According to the 2012 CDC National Survey of Residential Care Facilities (which includes Assisted Living, personal care homes, adult care homes, board care homes and adult foster care), communities are providing increasingly complex services that are provided by employees, other providers through arrangement, or both. Some of the findings illustrated here include: 89% of communities provide therapeutic services, including physical, occupational or speech therapy 89% provide hospice care 76% provide Skilled Nursing services 68% provide disease-specific programs for residents with Alzheimer s disease and other related dementia Assisted Living providers are realizing the benefits and challenges of meeting the rising acuity needs of their residents. Assisted Living has historically focused on providing individualized services, such as assistance with medication, meals and bathing, with an emphasis on choice, independence and dignity. As residents choose to age in place in their Assisted Living communities, providers are increasingly challenged with retaining this focus while balancing the needs and issues that accompany caring for a population with increasingly complex clinical and functional needs. Some of the common challenges include staffing, resident engagement, expectations for care and clinical capacity, including staff competency and community capabilities. As the resident ages in place or develops an illness or care need, residents and their families may expect to be able to receive a different level of care and services than the community is able to offer. Recruiting and retaining qualified staff and managing scheduling can be challenging as well. Deciding how to best improve clinical capacity and deliver nursing, nursing assistant and therapy services, or adding additional services such as those of a nurse practitioner, dietitian or exercise physiologist, is challenging due to the varied needs of residents, availability of qualified staff and costs associated with these services. Many providers are realizing the benefits of expanding their services to meet these changing needs. The greatest benefit may be in allowing residents the choice to age in place if not for the rest of their lives, at least for a longer period of their older adult life. Offering expanded care and services means the Assisted Living provider plays a larger role in overall quality outcomes for the resident. By focusing on the resident, providers may also realize a positive impact on their businesses. Marketing the results of resident-focused programs that may reduce complications associated with chronic conditions, reduce trips to the hospital and increase customer satisfaction are all great ways to promote a community. This also supports occupancy rates by having fewer residents move out and help build a positive reputation in the community at large, thereby attracting more residents who may want to move in. Assisted Living providers are playing an even more important role in the healthcare continuum for older adults and are ramping up their capabilities by providing more holistic care and services for residents of advancing age to help them improve health, address physical limitations and manage multiple chronic conditions. This paper will provide clinicians and operators of Assisted Living communities with information and insights into: Changes that are occurring in the older adult population in the United States, and the impact these changes may have on residents functional abilities and health RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 3

4 38.6 MILLION by MILLION by MILLION by MILLION in MILLION IN MILLION IN 2015 Ages Ages Ages 85+ Common chronic conditions in aging adults that increase the risk for hospitalization or the need to move out to a different level of care Considerations when developing a plan to address rising acuity, including ideas for program development, strategies to improve clinical capacity, and ideas on how to promote independence and involve residents in their own care Trends in services that Assisted Living providers are adding to accommodate the changing needs of their residents, now and in the future The Current Landscape Demographics of the Older Adult Population Change is upon us in the United States with unprecedented growth in the population of older adults. Senior Living experts caution providers against jumping too quickly into planning for the baby boomer generation. While it is important to plan ahead, the average age of residents in Assisted Living today is 87. This means for the next 15 years, providers will primarily continue to serve the silent generation, those born between 1925 and Data from the Pew Research Center indicates this generation is the most educated, healthiest and wealthiest group of elders ever seen in the United States. According to research compiled by the Joint Center for Housing Studies at Harvard University: By 2030, the population aged 50 or over will increase to 132 million.... The baby boom is projected to nearly double the number of adults aged from 21.7 million in 2010 to 38.6 million in The population aged will also continue to grow. After increasing from 10.1 million in 1990 to 13.1 million in 2010, the number of people aged is projected to reach 30.1 million in 2040.

5 According to the Centers for Disease Control and Prevention, the oldest old, those 85 years and older, are expected to triple from 6.3 million in 2015 to 17.9 million in Healthcare Reform & Assisted Living We are entering an era in healthcare that has been building for many years. Healthcare reform is changing how Medicare providers will be paid, setting timelines for achieving goals and moving from volume to value. These unprecedented changes are challenging hospitals and all providers in the post-acute care continuum to work together, linking payment to quality and outcomes. Assisted Living providers have an important role in the changing healthcare landscape, as Assisted Living facilities are often an attractive option for seniors discharged from hospitals, and in some instances, communities can even provide a lower-cost option for care. In some states, however, stricter regulations may hinder the services Assisted Living communities can provide. If those regulations were addressed, Assisted Living communities could become more desirable. The Department of Health & Human Services (HHS) has helped guide healthcare toward quality over quantity, and it announced in January 2015 that its goal for 2016 is for 30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide. By 2018, HHS expects to see 50% of Medicare provider payments in alternative payment models and almost all Medicare fee-for-service payments to be tied to quality and value; at least 85% in 2016 and 90% in The Centers for Medicare and Medicaid Services (CMS) has been conducting demonstration projects to test and determine effective programs for linking payment to quality. Hospitals have voluntarily been participating in bundled payments and other value-based purchasing programs for the last few years. The Hospital Readmission Reduction Program (HRRP), a provision of the Affordable Care Act, impacts hospital revenue by cutting Medicare rates for hospitals with high readmission rates. The care and services that a person receives after being discharged from the hospital, especially within the first 30 days after discharge, is becoming increasingly important to hospitals, discharge planners and physicians to prevent rehospitalizations. According to the Centers for Medicare and Medicaid Services (CMS) Readmissions Reduction Program, CMS plans to eventually make all hospital discharges apply to this program. Currently, the HRRP is focused on 30-day readmission rates for Medicare beneficiaries with a diagnosis of: Congestive heart failure Pneumonia Myocardial infarction Orthopedic surgery Chronic Obstructive Pulmonary Disease (COPD) Hospitals and ACOs want to partner with post-acute care providers who are demonstrating the ability to keep residents from returning to the hospital. The IMPACT Act was signed into law in This new law requires post-acute care providers across the continuum of care to incorporate standardized clinical assessments in order to be able to publicly report on common quality measures, provide this information to consumers when transitioning into a post-acute care setting and to support interoperability of information at transfer. This new requirement is expected to RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 5

6 be implemented by October Under the IMPACT Act, standardized clinical assessments will be required for Long Term Care Hospitals (LTCH), In-Patient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), Home Health (HH) and acute care hospitals. The number of older adults living in Skilled Nursing facilities has declined by 20% between 2000 and Meanwhile, the number of older adults living in Assisted Living is increasing: 1992 = 266, = 416, = 735, U.S. Census Bureau 2 U.S. Department of Health & Human Services 3 National Center for Assisted Living As part of the IMPACT Act, public reporting of quality measures across care settings will be required to help beneficiaries with their post-acute care decision making. Failure to collect and report data will result in payment penalties. According to CMS, measures include: Skin integrity and changes in skin integrity; Functional status, cognitive function, and changes in function and cognitive function; Medication reconciliation; Incidence of major falls; Transfer of health information and care preferences when an individual transitions; Resource use measures, including total estimated Medicare spending per beneficiary; Discharge to community; and All-condition risk-adjusted potentially preventable hospital readmissions rates In 2015, CMS announced a new program to test bundled payment and quality measurement called the Comprehensive Care for Joint Replacement Model (CJR). This is the first mandatory model of bundling care and will be tested in 800 hospitals in 67 geographic regions starting in April This model will focus on care associated with hip and knee replacements to encourage collaboration between hospitals, physicians and post-acute care providers (Centers for Medicare & Medicaid Services, 2015). Hospitals will be responsible for tracking outcomes from admission through 90 days post discharge. Although the hospital will hold the sole financial risk in this bundle, the regulation

7 allows hospitals to share incentive payments and risk with other providers to improve outcomes. Industry expert Avalere analyzed costs associated with caring for people with hip and knee replacements and found they are significantly less when seniors are discharged to home care or home health. This data indicates Assisted Living providers may find they are considerably more attractive partners for hospitals to discharge to rather than Skilled Nursing facilities or In-Patient Rehabilitation facilities. Assisted Living providers can also play an important role in healthcare reform by helping older adults manage their chronic conditions and maintain their health so they can avoid hospitalization in the first place. If a resident is discharged from the hospital and returns to his or her Assisted Living home, the provider plays an important role in helping the resident coordinate needed care and services to recover and avoid rehospitalization. This is critical to reducing overall healthcare costs, especially costs to the Medicare program. Collecting data on resident outcomes that are aligned with other providers and sharing this information with hospitals, ACOs and others is an important step in demonstrating the key role of Assisted Living in the post-acute care continuum, which can impact community reputation, census and long-term growth. Outcome Measures Reported by Assisted Living Providers Although Assisted Living providers are not required to standardize clinical assessments, many Assisted Living providers recognize in order to effectively communicate outcome measures with hospitals, ACOs and other care settings, standardizing data collection and reporting will be necessary. Consideration should be given to aligning data collection and outcome measures with current national initiatives, such as the IMPACT Act, CMS QMs, ACO/MCOs, Five Star and Med Pac. Older Adult Lifestyles, Care Needs & Assisted Living As people age, their health and wellness needs change as well. Historically, when an older adult required care and services that could not be met at home, he or she looked to Skilled Nursing facilities to help meet that need. Despite the growth of the older population, the U.S. Census Bureau reports the number of people living in Skilled Nursing centers has declined by 20% between 2000 and Many older adults are living in their homes longer, with assistance from family or home health services. Others have found community living opportunities that are providing alternatives not available before, like Assisted Living. The Joint Center for Housing Studies anticipates the number of older adults receiving long-term care at home, or in Assisted Living communities and Skilled Nursing facilities, will increase from 15 million in 2000 to 27 million in Assisted Living communities are uniquely positioned to provide older adults with the option to live in their home and maintain individual choice when determining the type of care and services they need. Since the late 1970s, when the concept of Assisted Living first started, and the early 1980s, when the first Assisted Living community opened, aging adults and their families have found Assisted Living to increasingly give them opportunities to regain or maintain their health, independence and quality of life. RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 7

8 ASSISTED LIVING RESIDENTS ARE CHANGING The average Assisted Living resident needs help with 2 to 3 ADLS Bathing Dressing Toileting Transferring Eating Meal preparation Managing medication 72 % 52 % 36 % 25 % 22 % 87 % 81 % Female 74 % Male 26 % Age 87 Use a Walker 45 % Use a Wheelchair 23 % Source: National Survey of Residential Care Facilities (2010) The average Assisted Living resident has 2 to 3 of the TOP 10 CHRONIC CONDITIONS 10 YEARS OF RISING ACUITY IN ASSISTED LIVING Average Age in Average Age in Average Length of Stay 2001 Average Length of Stay Months 22 Months % 28 % 13 % 15 % 45 % 34 % 17 % 23 % Using a Walker With Heart Disease With Diabetes Hypertension 57 % Alzheimer s/dementia 42 % Heart Disease 34 % Depression 28 % Arthritis 27 % Osteoporosis 21 % Diabetes 7 % Using a Wheelchair COPD 15 % Cancer 11 % Stroke 11 % Source: National Survey of Residential Care Facilities (2010) 1 Facts & Trends NCAL Assisted Living Sourcebook 2 National Survey of Residential Care Facilities

9 According to the National Center for Assisted Living (NCAL), there are approximately 735,000 people living in Assisted Living communities in the United States today. The NCAL s Resident Profile reports 70% of people who move to an Assisted Living community are moving from their private home. 9% move in after being in a Skilled Nursing facility, and the rest come from independent living, a family member s home or another Assisted Living or group community. According to the U.S. Department of Health & Human Services and the National Center for Assisted Living, the number of older adults living in Assisted Living is increasing: , , ,000 According to the Genworth 2013 Cost of Care Survey, there are generally four ways to pay for Long Term Care: Medicare, Medicaid, out of pocket or private Long Term Care insurance. The costs associated with Assisted Living vary by state. The Genworth 2013 Cost of Care Survey found the national median cost for Assisted Living was $3,450 per month, representing a 4.55% increase from In the 2009 Overview of Assisted Living Report, it notes 50% of Assisted Living providers participate in Medicaid. In those communities, one in four residents will pay for some or all of their services with Medicaid. This same report notes 25% of Assisted Living communities offered an all-inclusive rate where care fees are included in the monthly rate, whereas 45% of Assisted Living communities offered a tieredrate model with bundled services. By providing tiered levels of service, many providers allow residents the option of paying for additional care and services, such as assistance with ADLs, on an as-needed basis. Assisted Living Today Services Offered by Assisted Living Communities are Expanding Assisted Living communities are evolving offerings by expanding services to meet the rising acuity of their residents, all while continuing to promote a greater quality of life, dignity and choice. According to the 2010 National Survey of Residential Care Facilities, the most common services provided across all Assisted Living communities include: 96% provide basic health monitoring 93% offer incontinence care 99% deliver social and recreational activities 93% serve special diets Larger providers with 26 to 100+ beds are more likely to provide more of the following services for residents: 56% to 63% provide physical and occupational therapy services 46% to 48% provide social services counseling 66% provide case management services This survey also demonstrates that providers are increasing nursing care or arranging for nursing services to meet the needs of their residents. 79% of all providers offer some level of nursing service, either on-staff or arranged through partnerships as indicated here: 52% providers offer availability of services by an RN or LPN 25% arrange for nursing services 2% arrange and provide nursing services 21% do not offer nursing services RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 9

10 Finding and keeping qualified staff is a concern for many Assisted Living providers. The National Center for Assisted Living reported in a 2015 Vacancy, Retention and Turnover Survey that out of 580 Assisted Living communities, the turnover rate was 25% in nursing, with 13.6% among CNAs and 36.4% among resident caregivers. Although the median turnover rate for staff is 24%, down 6% from 2012, many providers may be concerned about having the right staff to meet the rising acuity needs of their resident population. Length of Stay & Departures from Assisted Living, Plus Hospitalization & Rehospitalization Considerations According to the CDC, the average length of time a resident lives in an Assisted Living community is 22 months, which is 14 months less than the average length of stay 10 years ago. According to the 2010 National Survey of Residential Care Facilities: 59% move to a nursing facility 33% pass away 8% move into their previous home or to a family member s or other s home To determine what could be causing the decreased amount of time residents are spending in Assisted Living, it s important to understand the factors that impact why residents leave a community today. As the average age of residents entering into Assisted Living rises, frailty also increases. In a 2015 study published in the Journal of Gerontology: Medical Sciences, researchers from Johns Hopkins Bloomberg School of Public Health found that residents living in Assisted Living communities were more than twice as likely to be frail than those in private homes. Frailty characterized by symptoms of weakness, exhaustion and limited mobility may create an increased risk for falls, chronic disease and disability. In this same study of nearly 7,500 adults age 65 and older, 15% of residents were identified as being frail and an additional 45% were identified as pre-frail. Among the frail, 42% were hospitalized in the previous year compared to 22%

11 of the pre-frail. Over half of the frail residents also had a fall in the previous year. Given the growing number of adults 85 and older in Assisted Living, providers should consider the impact frailty may have on the resident s ability to continue living in an Assisted Living community. Providers should also consider their own ability to address frailty in their resident population so they may improve quality of life and delay the need for a move. In a study completed by the CDC and NCHS in 2012, it was identified that 1 in 10 residents in a residential care or Assisted Living community had an emergency department visit within the previous 90 days or was discharged from an overnight hospital stay in the previous 90 days. 12% of residents visited the ER in the last 90 days Of the 10% of residents who had a discharge from an overnight stay in the last 90 days, 18% were readmitted to the hospital within 30 days of discharge The reasons why a resident may need to move out of an Assisted Living community include, but may not be limited to: 1. A change in healthcare needs that can t be met in the Assisted Living community. Reasons why the community may not be able to meet care needs include, but are not limited to: State regulations in certain states that limit the type of care they are able to receive in Assisted Living Service levels that are not able to accommodate resident needs Staffing levels Staff competency and capabilities 2. An illness or injury that requires hospitalization and a discharge to a Skilled Nursing facility for rehabilitation that, when combined with changes in other chronic conditions, may result in an ongoing increase in care needs that can t be met in the Assisted Living community. According to the Healthcare Cost & Utilization Project (HCUP), the most common causes for older adults to be hospitalized from a community setting include: Cardiac conditions, arrhythmia, heart failure, atherosclerosis COPD Complications related to diabetes Infections Injuries as a result of a fall Furthermore, the subsequent consequences of a hospitalization in an older adult are significant. Research by Lum, Studenski, Degenholtz and Hardy (2012) states that hospitalized Medicare beneficiaries who are discharged and readmitted to the hospital within 30 days are nearly three times more likely to die within one year. CMS has reported the most frequent reasons for rehospitalization include: 24.5% are readmitted for congestive heart failure 17.9% are readmitted for pneumonia 19.8% are readmitted with acute myocardial infarction Considerations when identifying residents at higher risk for readmission may include, but are not limited to, residents: With a prior hospitalization in the past 12 months Who experienced an ICU stay while in the hospital Who had a long stay (greater than 10 days) in the hospital RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 11

12 CHRONIC CONDITION MANAGEMENT CONSIDERATIONS: Disease awareness and education Medication management Nutrition counseling and meal preparation Fluid management Routine assessments Sleep quality and quantity Exercise Psychosocial relationships Management of co-morbidities and risk factors Environmental adaptations With a prior fall With a current infection Who take multiple medications and have had recent medication changes Who are noncompliant with physician treatment recommendations, including dietary recommendations to manage fluid volume, medication adherence and exercise With a cognitive impairment Helping older adults stay healthy and out of the hospital is a key to maintaining quality of life and reducing healthcare costs. The Future for Assisted Living Focusing on Health, Wellness & Managing Chronic Conditions Assisted Living has served an important function for older adults over the years. Providers have shared they take great pride in helping residents in a variety of ways, including staying connected and engaged to the things that matter most or managing physical and cognitive changes that otherwise would lead to a decline in quality of life. For example, providers may coordinate nursing care and therapy services for residents after joint replacement surgery to provide the opportunity to return home during recovery. In this rapidly changing environment, Assisted Living providers are in a unique position to provide holistic support, care and services to older adults that help them manage their chronic conditions and reduce the risk for hospitalization. Working with the resident to develop a service plan that supports resident independence and choice, while integrating principles of chronic disease management, supports this goal. The U.S. Department of Health and Human Services has identified a framework for chronic disease self-care management. The framework outlines evidence supporting the importance of applying these programs in multiple settings, including home, work, Assisted Living communities and other environments. The following information is summarized from chronic disease management recommendations from:

13 The American Heart Association The American Association of Cardiovascular and Pulmonary Rehabilitation The American Diabetes Association The American Geriatrics Society Key considerations for Assisted Living providers to think about when developing service plans to help residents manage chronic conditions include: Population or community health approaches. Assess the most common chronic conditions in a community and develop interventions, including screening programs, risk-reduction interventions, environmental modifications, health education and physical activity promotion. Encourage physical therapists and physicians to collaborate on assessments of residents to detect limitations keeping them from exercising and moving normally Exercise, including attitudes about exercise, physician recommendations for exercise, and access and instruction on strength and conditioning exercises; exercise plans should be considered and recommended, as indicated, for all residents. Cadore, Rodríguez-Mañas, Sinclair and Izquierdo (2013) identified a multi-component exercise intervention program that consists of strength, endurance and balance training appears to be the best strategy for improving gait, balance and strength as well as reducing the rate of falls in elderly individuals and consequently maintaining their functional capacity during aging. Awareness and education for residents about their diseases, including self-care, the importance of ongoing monitoring for changes in condition, available treatments and self-management, including medication management, nutrition, exercise and reducing risk factors Medication management, including medication reconciliation, dosing, assistance with taking the right medications at the right time and monitoring for side effects Nutrition counseling, meal preparation and help with eating, when needed Fluid management, especially for residents with congestive heart failure and renal conditions Routine assessments to monitor for changes, including weight, blood pressure, heart rate, respiratory rate, temperature, edema, oxygen saturation, blood glucose or A1c, PT/INR and other labs, as well as changes in cardiac rhythms, changes in balance, vision and hearing Sleep, including quality and quantity of sleep, assistance with managing medications taken for sleep and routinely assessing for changes in sleep patterns Psychosocial relationships that support a healthy lifestyle, including support with making changes to lifestyle choices, nutrition and exercise Management of co-morbidities and risk factors including, but not limited to: Alzheimer s/dementia Glucose management High cholesterol Obesity Inactivity Excessive use of alcohol Smoking Stress Loss RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 13

14 SERVICE EXPANSION CONSIDERATIONS Add a community gym with fitness and nutrition counseling Host healthy living seminars Offer women s health and aging educational programs Partner with senior citizen community centers to offer exercise classes, art classes and intergenerational activities Create programs to engage psychosocial support for wellness goals such as smoking cessation, weight management, support for depression and grief counseling Increase access to snacks and beverages outside of normal dining hours Provide counseling on sleep disorders and strategies to improve sleep Diversify staff to include more nurses, therapists, social services, and exercise and fitness professionals on site Offer on-site fitness counseling to assist in developing exercise plans and teaching proper exercise techniques Management plans to help residents with physical limitations that may impact their ability to care for themselves. For example, assistance with opening medication if arthritis makes it difficult to manage Environmental adaptations to improve quality of life, promote engagement in the community, encourage activities and exercise, and reduce the risk for falls and injuries. Adaptations may include lighting, furniture selection or repositioning, noise reduction, use of hip protection and nurse call systems Changing Care Models & Expanding Services While focusing on providing residents with dignity and choice, many Assisted Living providers are increasingly partnering with care providers and working to balance the needs and requests of residents with chronic conditions with state regulations, licensing requirements and payer sources, such as Medicaid. Changing care models, expanding partnerships with other clinicians and care providers, establishing preferred provider relationships and adding additional services are some of the unique ways Assisted Living providers are adapting their business in response to rising acuities. Assisted Living providers have shared with us that they are: Hiring more RNs & LPNs to provide nursing management and services during more hours of the day and night Hiring more nonlicensed care providers to provide assistance with ADLs, exercise and medication assistance. Based on the state and regulatory requirements, these may include CNAs, med-techs, universal workers, etc. Hiring more nurses and nursing assistants to provide care and services 24/7 in a dedicated Memory Care community Hiring on-site personal trainers to provide exercise and fitness counseling and supervision in a wellness clinic

15 Hiring social workers to provide counseling, support and guidance to residents in accessing community resources and developing advanced directives Partnering with contracted rehabilitation services to proactively initiate assessments for residents experiencing a decline, as well as providing outpatient rehabilitation, strength and balance assessment, and training to reduce fall risk during post-hospital care and recovery, especially for residents with cardiac conditions and post-op surgical procedures, such as joint replacements Partnering with home health agencies to provide routine assessments and chronic disease management Developing a preferred provider network with home health agencies and hospice that can offer residents a choice when needing additional levels of nursing care and services Partnering with a physician and/or nurse practitioner to provide clinic hours at the community, allowing residents to access a healthcare provider for minor illness or injury Partnering with a physician and/or nurse practitioner as a medical resource for nursing and care providers in the community, providing convenient access for questions regarding a resident health concern or change in condition Adding dedicated spaces and dedicated staff to provide Memory Care Many providers are expanding services to meet the changing needs of residents and their families: Offer move-in assessments by physical therapists to identify opportunities to improve function and ability to participate in activities and exercise Add a wellness gym, and invite residents from the community to join the gym and access fitness and nutrition counseling there for a modest fee Host healthy living seminars for community members Offer educational programs specifically geared toward women s health and aging Partner with senior citizen community centers to offer exercise classes, art classes and intergenerational activities Create programs to engage psychosocial support for wellness goals, such as smoking cessation, weight management, support for depression and grief counseling Increase access to snacks and beverages outside of normal dining hours Provide counseling on sleep disorders and strategies to improve sleep Assisted Living providers are expanding clinical capacity and improving clinical competency and capabilities. Many are adding more nursing and rehabilitation services on site to assess and help residents with managing their chronic conditions, such as: Add clinically focused programs that drive outcomes to help reduce rehospitalization and hospitalization rates, improve functional outcomes, reduce the use of off-label antipsychotics and reduce unintended health outcomes Implement clinical decision-support tools, like INTERACT, to assist with clinical actions and decision making that helps hospitalization rates; INTERACT tools specifically developed for Assisted Living providers also offer guidance for the types of clinical capabilities that Assisted Living communities should be considering to meet the needs of their residents Diversify staff to include more nurses, therapists, social services, and exercise and fitness professionals on site RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 15

16 POST-ACUTE CONTINUUM OUTCOME MEASURES: Rehospitalization rates Falls Infections Pressure ulcers Discharge to community setting Functional and cognitive status Adverse medication errors Off-label use of anti-psychotics Customer satisfaction 1 1 National Study of Long Term Care Providers Prepare to provide and/or coordinate nursing care and therapy services for residents with hip and knee replacements who will be discharged directly from the hospital Offer on-site nurse practitioners or physicians to address non-urgent concerns and prevent hospitalization Provide on-site therapy services including physical, occupational and speech Offer on-site fitness counseling to assist in developing exercise plans and teaching proper exercise techniques Provide on-site nutrition counseling to support healthy eating Make accommodations for resident needs through on-site staff support or working with outside agencies to offer additional levels of care and services (e.g., private aides, home health, hospice, etc.) Select products that help staff improve their clinical capabilities, such as vital signs equipment, pulse oximetry, balance assessment tools, glucometers, etc. Add tele-monitoring technologies that transmit health-related data, improve communication between residents and care providers, and offer new, innovative insights to help with early identification of changes in condition and other health-related information Some providers are focusing on evolving strategies to help decrease the risks of adverse events for residents and staff: Evaluating for symptoms of frailty upon move-in and periodically thereafter. A multi-disciplinary approach to evaluate for frailty includes the resident s physician, therapist and nursing staff Implement QAPI process and strategies to drive quality outcomes Offer resident education programs on chronic disease management including self-monitoring, medication management, the benefits of exercise and early recognition of changes

17 Provide in-room communication technology that allows residents to keep track of appointments, better manage medications and communicate with family members and other care providers Improve medication reconciliation policies and practices Optimize medication storage and assist devices to support safer medication delivery Reduce fall risk through a comprehensive approach including improved assessments for balance and strength, plus environmental adaptations including bathroom grab bars, adjustable-height beds, furniture design, lighting and flooring solutions, noise reduction and more Reduce injury risk from falls through improved technology and adherence to using hip protection Reduce the risk of resident and staff injury through the installation and use of lifts, both for helping with transfer needs and in the case of emergency if a fall occurs Install advanced monitoring systems to allow residents at risk for wandering to have increased freedom within the community Evaluate mattresses, wheelchair cushions and frequently used chairs to reduce the risk of pressure ulcer development Add AEDs along with specific policies and procedures, and educate staff on use communities with 4 to 10 beds (11%). Assisted Living providers are using technology to: Implement EHRs to aid in capturing clinical care needs, changes in condition, and services that assist in improving record keeping and streamlining the process for collecting and analyzing outcome data Collect and share outcome data with residents, families, hospital discharge planners, physicians and other groups, plus payer sources that have an interest in understanding the outcomes the community is achieving. Data collection tends to focus on key functional outcomes that impact hospitalization rates, such as post-op recovery, infections and exacerbation of a cardiac condition. Additional outcomes of interest include, but are not limited to, how managing a chronic condition promotes healthy aging and decreases risks including falls, loss of independence and loss of dignity Focus on outcome measures that are aligned with currently recognized measures in the post-acute continuum. These include, but are not limited to: hospitalization and rehospitalization rates and the reasons why, falls with and without injuries, infections, pressure ulcers, functional and cognitive status, adverse medication errors, off-label use of anti-psychotics, staff turnover, customer satisfaction and discharge to the community Collecting Data & Reporting Outcomes According to the National Study of Long Term Care Providers, in 2012, 20% of residential care communities used electronic health records (EHRs). Communities with more than 100 beds (36%) were more than three times as likely to have implemented EHRs as RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 17

18 Summary It s an exciting time to be an Assisted Living provider. Continued advances in medicine will extend the lives of older adults, and those born in the 1920s and 1930s will experience longevity not achieved by their parents. With the independentminded baby boomer generation reaching older adulthood over the next 30 years, our thoughts about life and aging will fundamentally change. It s an exciting time to be an Assisted Living provider. Over the next 10 to 15 years, continued advances in medicine will extend the lives of older adults, and the independent-minded baby boomer generation will fundamentally change how we think about life and aging. Research on the aging population in the United States indicates the need and desire for Assisted Living will continue to grow. Assisted Living plays a unique role in helping older adults age in their homes and maintain their health and quality of life for a longer period of time. Applying a holistic approach and framework for chronic disease management can be beneficial for clinicians developing a service plan for a resident. The average person living in Assisted Living has two to three chronic conditions, such as hypertension, heart disease, Alzheimer s/dementia, depression, arthritis, diabetes and more. And older adults are at increased risk for adverse events related to medication errors, unrecognized changes in condition and frailty, just to name a few. Nurses and therapists working with residents in Assisted Living can help develop and contribute to service plans that include routine assessments, education on chronic disease management, exercise, medication management and psychosocial support. These are key elements of a chronic disease management approach to support health management and aging in place for older adults. Assisted Living providers must work within the scope of state regulations and licensure requirements when implementing new services and programs. Preparing to deliver an additional level of care and services may require additional staffing, enhanced staff education and additional equipment and supplies. Assisted Living providers are not just managing rising acuity, though. They are also actively accommodating the requests of residents and the community by broadening their services.

19 These expanded services often include: providing enhanced nursing and rehabilitation services on site; diversifying staff to incorporate more care providers, including nurses, therapists, advanced practice nurses, physicians, dietitians, and exercise and fitness professionals; using technology and environmental changes designed specifically to decrease risks for adverse events and injuries for both residents and staff; and adding unique services such as community gyms, nutrition counseling and classes on topics including preparing healthy meals, meditation and exercise. Many providers are recognizing the important role they play in the post-acute care continuum. Taking an active role in helping older adults manage their chronic conditions and stay healthy not only benefits the resident, but offers tangible benefits to the healthcare system and provider by reducing costs and improving census and reputation in the community. Collecting data on key outcome measures and sharing this information with other key stakeholders, such as hospitals and ACOs, is crucial to being successful in managing rising acuity. Is your community ramped up and ready for rising acuity and the future of Assisted Living? Bibliography The Current Landscape Demographics of the Older Adult Population Housing America s Older Adults: Meeting the Needs of an Aging Population. Joint Center for Housing Studies of Harvard University. Web. 6 June < harvard.edu/sites/jchs.harvard.edu/files/jchs_housing_ americas_older_adults_2014_key_facts.pdf>. Decennial census, Population Estimates and Projections. U.S. Census Bureau, June Long-Term Care Services in the United States: 2013 Overview. National Center for Health Statistics Reports, Number 1. Centers for Disease Control. Web. < services_2013.pdf>. Pew Research Center. (2015, March 19). Comparing millennials to other generations. Retrieved from Healthcare Reform & Assisted Living IMPACT Act of 2014 & Cross Setting Measures. Centers for Medicare and Medicaid Services. Web. < Patient-Assessment-Instruments/Post-Acute-Care- Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting- Measures.html>. The Future of Assisted Living in the Era of Healthcare Reform. Center for Excellence in Assisted Living. Web. < White-Paper-Formatted-FINAL v3.pdf>. RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 19

20 CMS Readmissions Reduction Program. Web. 21 July < Centers for Medicare & Medicaid Services. (2015). Comprehensive care for joint replacement model. Retrieved from Fuller, B. (2015). Bundled payments: What s new and next? [PowerPoint slides]. Retrieved from com/eof/pdf/bundled_payments-where_are_we_and_ What s_next.pdf Outcome Measures Reported by Assisted Living Providers AHCA/NCAL Quality Initiative. AHCA/NCAL. Web. < Pages/NCALRecognitionProgram.aspx>. CMS Readmissions Reduction Program. Web. < IMPACT Act of 2014 & Cross Setting Measures. Centers for Medicare and Medicaid Services. Web. < Patient-Assessment-Instruments/Post-Acute-Care- Quality-Initiatives/IMPACT-Act-of-2014-and-Cross- Setting-Measures.html>. Older Adult Lifestyles, Care Needs & Assisted Living Caffrey, Ph.D., Christine; Harris-Kojetin, Ph.D., Lauren; Rome, M.P.H., Vincent; Sengupta, Ph.D., Manisha. Characteristics of Residential Care Communities by Community Bed Size: United States, Centers for Disease Control and Prevention National Center for Health Statistics. Web. <

21 2013 Cost of Care Survey Home Care Providers, Adult Day Health Care Facilities, Assisted Living Facilities and Nursing Homes. Tenth Addition. Genworth. Web. 1 July < genworth.com/dam/americas/us/pdfs/consumer/ corporate/130568_032213_cost%20of%20care_ Final_nonsecure.pdf> Overview of Assisted Living Report. AHCA/NCAL. Web. 1 July < Documents/09%202009%20Overview%20 of%20assisted%20living%20final.pdf>. National Association of Assisted Living. (n.d.). Resident profile. Retrieved from org/ncal/resources/pages/residentprofile.aspx Spillman, B., Liu, K., & McGilliard, C. (2002, November 22). Trends in residential long-term care: Use of nursing homes and assisted living and characteristics of facilities and residents. Retrieved from aspe.hhs.gov/basic-report/trends-residential-longterm-care-use-nursing-homes-and-assisted-living-andcharacteristics-facilities-and-residents West, L., Cole, S., Goodkind, D., & He, W. (2014). 65 in the United States: 2010 (Rep.). Retrieved publications/2014/demo/p pdf Assisted Living Today Services Offered By Assisted Living Communities Are Expanding Findings from the NCAL 2013 Assisted Living Staff Vacancy, Retention, and Turnover Survey. NCAL, February Web. < operations/documents/vrt%20report%202013% 20FINAL.pdf>. National Survey of Residential Care Facilities (2010). Centers for Disease Control and Prevention. Web. < Assisted Living Residents Are Changing ALFA, accessed at alfa/ Assisted Living Resident Demographics. Assisted Living Federation of America. Web. 22 May < Demographics.asp>. Key Demographic Info. AHCA/NCAL. Web. 1 June < Pages/ResidentProfile.aspx>. National Survey of Residential Care Facilities Centers for Disease Control and Prevention, Web. < Facts and Trends: The Assisted Living Sourcebook. AHCA/NCAL, Web. 2 July < Documents/Assisted_Living_Sourcebook_2001.pdf>. Lum, H., Studenski, S., Degenholtz, H., & Hardy, S. (2012). Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries. Journal of General Internal Medicine, 27(11), doi: /s Length of Stay & Departures from Assisted Living, Plus Hospitalization & Rehospitalization Considerations National Study of Long-Term Care Providers, CDC/NCHS. Web. 16 July < data/nsltcp/long_term_care_services_2013.pdf>. Foltz-Gray, Dorothy. Most Common Causes of Hospital Admissions for Older Adults. AARP. RAMPING UP FOR RISING ACUITY IN ASSISTED LIVING 21