A National Survey of Assisted Living Facilities

The Gerontologist Vol. 43, No. 6, 875 882 Copyright 2003 by The Gerontological Society of America A National Survey of Assisted Living Facilities Catherine Hawes, PhD, 1 Charles D. Phillips, PhD, MPH, 1 Miriam Rose, MEd, 2 Scott Holan, MS, 3 and Michael Sherman, PhD 3 Purpose: Throughout the 1990s, assisted living was the most rapidly growing form of senior housing. The purpose of this paper is to describe the existing supply of assisted living facilities (ALFs) and examine the extent to which they matched the philosophy of assisted living. Design and Methods: The study involved a multistage sample design to produce nationally representative estimates for the ALF industry. Administrators of nearly 1,500 eligible ALFs were interviewed by telephone. Results: As of 1998, there were an estimated 11,459 ALFs nationwide, with 611,300 beds and 521,500 residents. Nearly 60% offered a combination of low services and low or minimal privacy, whereas only 11% offered relatively high services and high privacy. Seventythree percent of the resident rooms or apartments were private. Aging-in-place was limited by discharge policies in most ALFs for residents who needed help with transfers, had moderate to severe cognitive impairment, had any behavioral symptoms, or needed nursing care. The industry is largely private pay and unaffordable for low- or moderate-income persons aged 75 unless they use assets as well as income to pay. Implications: ALFs differed widely in ownership, size, policies, and the degree to which they manifested the philosophy of assisted living. This diversity represents a challenge for consumers in terms of selecting an appropriate facility and for policy This research was prepared under contracts HHS-100-94-0024 and HHS-100-98-0013 from the Office of Disability, Aging, and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services. The Public Policy Institute, the Research Group of AARP, the Alzheimer s Association, and the National Institute on Aging also provided support for this project. Grant RO1-HS-10606 from the Agency for Health Care Research and Quality supported additional analyses of these data. We acknowledge the assistance of Vince Iannacchione, Linda Lux, Margaret Byron, and Lisa Wrage of the Research Triangle Institute and Dr. Pam Doty of the ASPE. The views expressed in this paper do not necessarily reflect the views of any of the sponsoring organizations or our home institutions. Address correspondence to Catherine Hawes, PhD, School of Rural Public Health, 3000 Briarcrest, Suite 416, Bryan, TX 77802. E-mail: hawes@srph.tamushsc.edu 1 Department of Health Policy and Management, Texas A&M University System Health Science Center, College Station, TX. 2 Myers Research Institute, Menorah Park Center for Senior Living, Beachwood, OH. 3 Department of Statistics, Texas A&M University, College Station, TX. makers in terms of deciding what role they want assisted living to play in long-term care. Key Words: Assisted living, Residential care facilities, Long-term care. Assisted living has been the most rapidly growing segment of senior housing over the past several years. Despite this, there is substantial variation across states and individual observers about what assisted living is. However, among key consumer and provider groups, there is general agreement on the key aspects of what constitutes assisted living. The Assisted Living Quality Coalition was a group representing consumer groups (the Alzheimer s Association and AARP) and provider associations (the American Association of Homes and Services for the Aging, the Assisted Living Federation of America, the American Seniors Housing Association, and the American Health Care Association s National Center for Assisted Living). According to the Coalition (1998), an assisted living setting is as follows: A congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health related services; designed to minimize the need to move; designed to accommodate individual residents changing needs and preferences; designed to maximize residents dignity, autonomy, privacy, independence, and safety; and designed to encourage family and community involvement. (p. 4) As suggested by this definition, the key philosophical elements of assisted living include the following: (a) services and oversight available 24 hr a day; (b) services to meet scheduled and unscheduled needs and facilitate aging in place; (c) care and services provided or arranged so as to promote independence; (d) an emphasis on consumer dignity, autonomy, and choice; and (e) an emphasis on privacy and a homelike environment. Although there has been general agreement, at least at the national level and among provider Vol. 43, No. 6, 2003 875

groups, on the key principles or elements of assisted living, there has been less agreement on the degree to which the current industry embodies these principles. This article is an attempt to address that issue and presents data from a telephone survey of the administrators of assisted living facilities (ALFs) across the country (Hawes, Rose, & Phillips, 2000). These facilities were selected from a national probability sample of all facilities that met the criteria for inclusion in the study. Thus, the findings are representative of the industry as a whole. As such, they represent the first empirical data on the characteristics of the assisted living industry nationwide, based on a representative national sample of facilities. The specific objectives of this telephone survey were to determine the size and nature of the supply of ALFs and to describe the basic characteristics of the assisted living industry, particularly in terms of the services, accommodations, and basic price. Methods In order to conduct the survey and obtain generalizable results, project staff implemented a complex, multistage sampling design. This process is described in detail elsewhere (see Iannacchionne, Byron, Lux, Hawes, & Wrage, 2000). At the first stage, project staff selected a random sample of 60 geographic areas, known as first stage sampling units (FSUs). These 60 FSUs were composed of 1,086 counties in 34 states. In these geographic areas, project staff created a comprehensive listing of places thought to be ALFs. Staff used a combination of sources to create this list, including state licensure agencies, industry trade associations, local and national retirement facility directories, telephone book yellow page advertisements, and Internet listings. From this list of potential candidate facilities, project staff selected a stratified, random sample of 2,945 places. The administrators of these places were then surveyed by telephone to determine the facility s eligibility for the study and, if eligible, to secure information about the facility s size, services, price, and accommodations. The study s basic eligibility criteria were that a facility had to serve a primarily elderly population and have more than 10 beds. A previous study funded by the Department of Health and Human Services and Office of the Assistant Secretary for Planning and Evaluation (DHHS ASPE) focused on licensed and unlicensed board and care homes. Two thirds of those facilities had 10 or fewer beds, and the study found that none of the small homes called themselves assisted living. Few provided assistance with more than two activities of daily living (ADLs; Hawes et al., 1995). Thus, we concluded that the vast majority of these small facilities would not provide the services generally considered a fundamental part of assisted living. Further, the small homes tended to serve a younger population of residents and a population that was more likely to have mental retardation, developmental disabilities, or persistent mental illness. In addition, no states that licensed a specific category known as assisted living reported any facilities with fewer than 11 beds. For these reasons, ASPE and the project staff decided to exclude small homes from this study of assisted living for frail elderly persons. In addition, the facility either had to represent itself as an assisted living facility or offer at least a basic level of services, which included 24-hr staff oversight, housekeeping, at least two meals a day, and personal assistance, defined as help with at least two of the following: medications, bathing, or dressing. The administrators of a sample of 2,945 candidate facilities were then surveyed by telephone during 1998. If the candidate facility met the study eligibility criteria specified in a set of screening questions, then the administrator was asked to respond to questions about the facility, its size, occupancy, accommodations, services, price, and policies on admission and discharge. A total of 1,547 of these facilities were eligible for inclusion in the study. Among those eligible for the survey, administrators in a total of 1,251 facilities were interviewed. This provided an overall response rate of 81%. An adjustment for nonresponse was included in the facility weights (Iannacchione et al., 2000). Because of the complex nature of the sample, analyses were performed by using SUDAAN in order to provide appropriate variance estimates (Shah, Barnwell, & Bieler, 1996). Results Using the definition presented herein, there were an estimated 11,459 ALFs nationwide, with approximately 611,300 beds and 521,500 residents, as of the beginning of 1998 (see Table 1). The average bed size was 53 beds; 67% of the ALFs had 11 50 beds; 21% had 51 100 beds; and 12% had more than 100 beds. Facility occupancy averaged 84%. The most common monthly charge was $1,582 for a potential annual cost of almost $19,000. A room was the dominant type of residential unit (57%) in ALFs; 43% of the units were apartments. These results are based on the most detailed information administrators provided about the accommodations (i.e., when they provided an exact count of the number of apartments and rooms). In another item on the survey, they were asked to estimate the distribution between rooms and apartments. The responses to this other item indicated that administrators estimated that 48% of the units were apartments and 52% were rooms. The most common type of room was a private 876 The Gerontologist

Table 1. General Characteristics of Facilities Facility Characteristic Response SE General characteristics Total est. no. of eligible facilities 11,459 636 Total est. no. of beds 611,328 30,059 Total est. no. of residents 521,550 26,258 Total est. occupancy rate nationwide (%) 84.0 1.0 % eligible facilities on multilevel campuses 45.5 2.6 % that are self-described assisted living facility 71.5 1.7 % of facilities in metropolitan counties 76.7 3.7 % of facilities in rural counties 23.3 3.7 Avg. bed size (no.) 53.4 2.3 Avg. number of residents (no.) 45.5 2.1 Rates For facilities with single rate, average monthly rate ($) 1710 82 Highest reported monthly rate in the facility sample 6440 NA For facilities with multiple rates ($) Avg. lowest monthly rate 1338 33 Avg. highest monthly rate 2137 47 Avg. most common monthly rate 1583 34 Highest reported rate in the facility sample 7130 NA Accommodation type Proportion of units that are apartments (%) 47.6 NA Proportion of units that are bedrooms (%) 52.4 NA Notes: Weighted data are given that yield national estimates. It is important to remember that our population includes only those places that (a) serve mainly older persons; (b) have 11 or more beds; (c) were in operation as of late 1996 to early 1997 (and thus were on the sampling frame); and (d) are either a self-described assisted living facility or a facility that offers at least two meals a day, housekeeping, 24-hr staff, and assistance with one or more activity of daily living and medications or help with two or more activities of daily living. We use the term facility to refer to single-level or free-standing facilities and facilities that are part of multilevel campuses, as well as assisted living units that may be a section of another facility, such as a nursing home. NA ¼ not applicable. room with a full bathroom (42% of all single rooms). The most common type of apartment was a onebedroom, single occupancy apartment (41%). Most ALFs offered consumers a range of options in terms of private or shared accommodations. Only 27% of the facilities had all-private accommodations. A plurality of ALFs (45%) had a mix of private and shared units. However, slightly more than one fourth of the ALF administrators (28%) reported that the facility had at least one bedroom shared by three or more unrelated residents. Although ALFs offered residents a range of options, 73% of all resident units were private, and 25% of the units were semiprivate, that is, shared by two unrelated persons. Two percent of resident units were in ward-type rooms that housed three or more unrelated persons. Table 2. Facility Characteristics Privacy and Services Facility Characteristic Response SE Level of privacy % of facilities that are high privacy (80% of accommodations are private) 31.3 2.0 % of facilities that are low privacy (21% of accommodations are semiprivate) 40.3 1.8 % of facilities with minimal privacy (1 bedroom shared by 3 or more persons) 28.4 1.8 % of facilities with 100% private accommodations 26.7 1.8 % of facilities with 50% private accommodations 51.8 2.3 Level of services % of facilities that provide high services (RN on staff at least 40 hr per week and provides nursing care with own staff) 30.6 1.9 % of facilities with low services 65.0 2.0 % of facilities with minimal services (does not offer assistance with 2 ADLs or 1ADL and medications) 4.3 0.6 % of facilities that have full-time RN on staff, provide or arrange nursing care, and will retain resident who needs nursing care 16.9 1.3 % of facilities that provide or arrange nursing care and will retain resident who needs nursing care 30.0 1.9 Facility type % of facilities with high services and high privacy 10.9 1.1 % of facilities with high services and low privacy 11.6 1.0 % of facilities with low services and high privacy 18.4 1.5 % of facilities with low services and low privacy 26.9 1.8 % of facilities with minimal services (does not offer help with medications and 1 ADL or help with ADLs) or minimal privacy ( 1 bedroom shared by 3 or more residents) 32.2 1.8 Note: RN¼ registered nurse; ADL ¼ activity of daily living. Although nearly three quarters (73%) of the rooms or apartments were private, slightly less than two thirds (62%) of the units offered a private full bathroom (i.e., toilet, sink, and shower or tub). An additional 6% of the units had a private half bath (i.e., toilet and sink). However, more than one third (38%) of all ALF units required the resident to share a bathroom. Facilities were classified into five groups based on their levels of services or privacy. These classification categories are described in Table 2. Other dimensions or cut-points might have been used, but these classes were considered the most appropriate for our analytic purposes. However, for other purposes Vol. 43, No. 6, 2003 877

Table 3. Facility Retention and Admission Policies Facility Characteristic % SE Percent of facilities that will retain residents... With behavior symptoms (e.g., wanders; socially inappropriate behavior) 24.0 1.2 With urinary incontinence 63.2 2.5 Who needs nursing care 32.3 1.9 Who uses wheelchair 69.2 1.9 Who receives help with locomotion 61.8 2.1 Who receives help with transferring 45.7 2.0 Who has moderate to severe cognitive impairment 45.0 1.9 Who requires temporary nursing care 81.9 1.3 Who needs nursing care for.14 days 28.0 1.4 Discharges: % of facilities that have discharged 1 residents in past 6 months because resident needed nursing care 71.7 1.7 Percent of facilities that will admit residents... With behavioral symptoms (e.g., wandering; socially inappropriate behavior) 28.0 1.6 With urinary incontinence 61.4 2.5 Who needs nursing care 31.5 1.8 Who uses wheelchair 70.7 1.9 Who receives help with locomotion 61.9 2.2 Who receives help with transferring 43.9 2.2 Who has moderate to severe cognitive impairment 47.0 2.0 Table 4. Services Offered and Resident Characteristics Facility Characteristic % SE Percent of facilities with services provided or arranged Housekeeping 99.1 0.3 2 meals a day 99.3 0.3 3 meals a day 98.3 0.4 24-hr staff 98.8 0.3 Medication reminders 91.7 0.9 Central med. storage or assistance w/meds 87.6 1.1 Assistance w/bathing 97.3 0.5 Assistance w/dressing 94.3 0.8 Any care or monitoring by RN or LVN 79.5 1.5 Any therapy services 73.8 1.5 Nurse staffing (%) Any licensed nurse on staff (RN or LPN) full or part time 71.2 2.2 Any RN on staff full or part time 54.8 2.5 RN on staff 40 hr/week 39.8 1.8 RN on staff,40 hr/week 25.1 3.0 LPN on staff full or part time 52.9 2.0 General resident characteristics % of heavy care residents (receive assistance w/3 ADLs) 23.6 1.3 % of residents with moderate to severe cognitive impairment 34.1 1.2 Note: RN, LVN, LPN ¼ registered, licensed vocational, or licensed practical nurse; ADL ¼ activity of daily living. or in other samples, other schemes may be equally useful. As Table 2 indicates, almost one third of the sample offered either minimal services or minimal privacy, whereas another 27% offered low services and low privacy. The greatest variation among facilities came in the degree of privacy, rather than service. Although the bulk of the ALFs did not offer high services involving a full-time registered nurse on staff and provision of nursing care with their own staff (69%), very few (4.3%) offered minimal services, that is neither nursing care or oversight nor assistance with ADLs. The ADLs we asked about included bathing, dressing, locomotion, toilet use, transfers, and eating. Most ALFs (65%) reported that they offered residents assistance with at least two ADLs or one ADL and medications. These results indicate that only approximately 11% of facilities offered both high privacy and high service. Most ALFs (see Table 3) reported a willingness to admit residents with moderate physical limitations, such as using a wheelchair (71%) or needing help with locomotion (62%), that is, walking or using a wheelchair or cart. However, fewer than half the ALFs (44%) were willing to admit residents who needed assistance with transfers (i.e., in or out of bed, a chair, or wheelchair). Administrators also reported that fewer than half the ALFs would admit a resident with moderate to severe cognitive impairment (47%). We do not know with any certainty how the administrators may have defined moderate to severe cognitive impairment. However, we suggested a definition in an earlier question. In it, we suggested that moderate to severe cognitive impairment meant that a resident had a problem with short-term memory or poor ability to make decisions about his or her daily life. Many facilities had idiosyncratic policies about admission and retention. That is, the administrators responded it depends when asked about whether the facility would admit or retain residents with a specified condition. For example, one quarter (26%) of the administrators responded it depends when asked whether they would admit a resident with moderate to severe cognitive impairment. One third (33%) reported that it depends when asked whether they would retain a resident with moderate to severe cognitive impairment. When the it depends response was given, it was counted as a no because residents and families could not rely on either admission or retention in such instances. Facilities also had criteria about the retention of residents with certain types of conditions or problems, although, as with admission policies, many facilities had idiosyncratic policies. Nearly one third of the administrators (31%) reported that the ALF would not retain a resident who used a wheelchair (or that it depends ), and 38% would discharge a resident who needed assistance with locomotion. Fewer than half (45%) of the ALFs would definitely retain a resident with moderate to severe cognitive impairment, and 76% would not retain residents 878 The Gerontologist

Table 5. Comparison Between Single-Level and Multilevel Facilities General Characteristics Facility Characteristic Free Standing (SE) Multilevel (SE) General characteristics Total est. no. of facilities 6,241 (468.8) 5,217 (407.1) % of ALFs by campus type 54.5 (2.6) 45.5 (2.6) Total est. no of beds 270,449 (18,311.6) 340,879 (25,068.7)** Total est. no. of residents 224,414 (15,427.4) 297,136 (2,248.5)** Total est. occupancy rate (%) 83.0 (1.0) 86.0 (1.0)* % that are self-described ALFs 67.7 (2.4) 76.1 (2.3) % of ALFs in metropolitan counties 70.0 (4.5) 84.7 (3.7)** % of ALFs in rural counties 30.0 (4.5) 15.3 (3.7)** Average bed size (no.) 43.3 (2.6) 65.3 (3.3)** Average number of residents (no.) 36 (2.3) 57 (3.0)** Rates For facilities with single rate, average monthly rate ($) 1,501 (84.1) 1,975 (118.3)** For facilities with multiple rates ($): Average lowest monthly rate 1,222 (40.9) 1,477 (38.7)** Average highest monthly rate 1,957 (54.8) 2,348 (54.2)** Average most common monthly rate 1,451 (43.3) 1,742 (44.5)** Note: ALF ¼ assisted living facility. *Significant at p,.01; **significant at p,.001. with behavioral symptoms (e.g., wandering). Seventytwo percent of the ALFs would not retain a resident who needed nursing care for more than 14 days. Nearly three quarters of the ALFs (72%) reported that one of more of their residents had been discharged within the past 6 months because the resident needed nursing care. ALF administrators estimated that approximately 24% of their residents received help with three or more ADLs, such as bathing, dressing, and locomotion. They estimated that approximately one third of the residents (34%) had moderate to severe cognitive impairment, that is, problems with short-term memory or with making decisions about daily life tasks and activities. As Table 4 indicates, nearly all facilities provided or arranged 24-hr staff, three meals a day, and housekeeping. More than 90% of the ALF administrators also reported that the facility provided medication reminders and assistance with bathing and dressing; 88% of the ALFs provided or arranged central storage of drugs or assistance with administration of medications. Almost three quarters of the ALFS (71%) had a licensed nurse, either a registered nurse (RN) or licensed vocational nurse (LVN), working on staff full or part time. Slightly more than half of the ALFs (55%) reported having an RN on staff either full or part time. Forty percent of the ALFs reported having a full-time RN on staff. Administrators were also asked whether the facility provided services with their own staff or arranged with an outside agency for the provision of the service. With the exception of therapies, if an ALF offered a service, particularly personal assistance, such as help with bathing, dressing, or managing medications, nearly all (i.e.,. 88%) provided it with their own staff. Approximately half (52%) of the facilities provided some care or monitoring by a licensed nurse (RN or LPN) with their own staff, and one quarter (25%) arranged for nursing care with an agency. However, one in five ALF administrators (21%) reported that the facility did not arrange or provide any care or monitoring by a licensed nurse. One of the major distinctions in the assisted living sector is between those ALFs that are operated as free-standing or single-level facilities and those operated as part of a multilevel campus that includes other levels of service, most often a nursing home. In 1998, multilevel facilities comprised 46% of the industry and housed an estimated 56% of ALF residents. Tables 5 through 8 illustrate the substantial differences between these two types of facilities. ALFs on multilevel campuses, in comparison to free-standing ALFs, were significantly larger, more expensive, more likely to offer private accommodations, more likely to offer higher levels of service, more likely to admit and retain individuals who were in wheelchairs or needed nursing services, and more likely to offer therapies or monitoring or care by licensed nursing staff. Discussion Any attempt to understand assisted living and its role in providing long-term care to the frail elderly population is hindered by the lack of a common definition of assisted living. Places known as ALFs differed widely in ownership, auspice, size, and philosophy. Indeed, the results of this national survey identified four different types of ALFs within the industry that had very different patterns with respect to accommodations, services, staffing, poli- Vol. 43, No. 6, 2003 879

Table 6. Comparison Between Single-Level and Multilevel Facilities Privacy and Services Facility Characteristic Free Standing (SE) Multilevel (SE) Level of privacy % of facilities that are high privacy (80% of accommodations are private) 22.8 (2.7) 41.5 (2.6)** % of facilities that are low privacy (21% of accommodations are semiprivate) 41.4 (2.1) 39.1 (2.6) % of facilities with minimal privacy (1 bedroom shared by 3 persons) 35.8 (3.0) 19.5 (2.1)** % of facilities with 100% private accommodations 19.8 (2.7) 35.0 (2.2)** % of facilities with 50% private accommodations 63.2 (3.0) 38.2 (2.6)** Level of services % of facilities that provide high services (RN on staff 40 hr/week and provides nursing care with own staff) 19.9 (1.6) 43.5 (2.5)** % of facilities with low services 76.4 (1.8) 51.4 (2.5)** % of facilities with minimal services (does not offer assistance with 2 ADLs or 1 ADL and medications) 3.7 (0.8) 5.2 (0.83) Facility type % with high services and high privacy 5.2 (0.9) 17.7 (1.6)** % with high services and low privacy 16.3 (2.2) 21.0 (1.8)** % with low services and high privacy 7.1 (1.1) 16.9 (1.7)** % with low services and low privacy 32.2 (2.1) 20.5 (2.3)** % with minimal service or minimal privacy 39.1 (2.8) 23.8 (2.2)** Note: ADL ¼ activity of daily living; RN ¼ registered nurse. **Significant at p,.001. cies on admission and retention of residents, and price. Some of these types, such as those offering high privacy and high services, appeared to be consistent with the philosophy of assisted living. Other types, such as those providing low or minimal privacy and low services, seemed much closer to the traditional concept of domiciliary care or board and care, with few services and relatively little privacy. Given this, we attempted to address four basic questions about assisted living and its ability to meet the needs of the frail elderly population. Do ALF Environments Match the Philosophy of Assisted Living? The answer to this question is mixed. On the one hand, residents of ALFs had considerably more privacy and choice in accommodations than did residents of most nursing homes and the majority of board and care homes. On the other hand, there was significant variability within the assisted living industry, and a substantial segment of the industry provided accommodations that did not appear consistent with the environmental aspects of the assisted living philosophy, particularly the segment of the industry that offered only shared accommodations. Do ALFs Meet Health-Related Unscheduled Needs of Residents? This issue is still an open question. Variations in staffing patterns and admission and retention policies suggest that not all ALFs are prepared to meet the scheduled and unscheduled needs of residents. For example, 29% of the ALFs had no licensed nurse on staff, raising questions about their ability to recognize changes in a resident s health or functional status that signal a need for evaluation or treatment. Further, a significant proportion of facilities were unwilling to admit or retain residents with significant health-related needs, such as help with locomotion, assistance with transfers, or care or monitoring from a nurse. What is less clear is the source of these variations. Certainly, in some states, licensing regulations limit the services, such as nursing care, that ALFs may provide; however, most states are changing their regulations to allow assisted living and other residential care facilities to provide more extensive health care services to a fairly impaired resident population (Mollica, 1998). Most facilities appear to have considerable flexibility in determining what services to provide and what policies to implement regarding admission and discharge. Can ALF Residents Age in Place? The answer depends on one s concept of aging in place. For example, facility retention policies suggest that, in most ALFs, a resident could move from relative independence (e.g., needing or wanting only meal preparation, housekeeping, and staff that can respond to emergencies) to a stage at which the resident needed help with bathing, dressing, and managing medications and used a wheelchair to get around. If this span or change in needs were the definition of aging in place, then ALF admission and retention policies indicate that they were willing to allow residents to age in place. In contrast, if 880 The Gerontologist

Table 7. Comparison Between Single-Level and Multilevel Facilities Retention and Admission Policies Facility Characteristic Free Standing (SE) Multilevel (SE) Percent of facilities that will retain residents... With behavior symptoms (e.g., wanders; socially inappropriate behavior) 22.9 (2.0) 25.4 (1.9) With urinary incontinence 64.1 (3.3) 62.0 (2.8) Who needs nursing care 26.1 (2.3) 39.7 (2.4)** Who uses wheelchair 62.7 (2.7) 77.0 (1.6)** Who receives help with locomotion 57.8 (2.7) 66.5 (2.5)* Who receives help with transferring 43.8 (2.9) 48.0 (2.2) Who has moderate to severe cognitive impairment 47.6 (2.6) 41.8 (2.2) Who requires temporary nursing care 80.5 (1.8) 83.7 (1.9) Who needs nursing care for.14 days 27.7 (2.1) 28.4 (2.0) Discharges: % of facilities that have discharged 1 residents in past 6 months because of need for nursing care 65.7 (2.4) 78.8 (2.4)** Percent of facilities that will admit residents... With behavior symptoms (e.g., wanders; socially inappropriate behavior) 27.6 (2.6) 28.5 (2.6) With urinary incontinence 61.2 (3.4) 61.5 (2.5) Who needs nursing care 25.7 (2.2) 38.6 (2.2)** Who uses wheelchair 63.9 (2.7) 78.8 (1.6)** Who receives help with locomotion 58.6 (2.9) 65.7 (2.3) Who receives help with transferring 42.3 (3.0) 45.8 (2.4) Who has moderate to severe cognitive impairment 49.5 (2.9) 49.3 (2.3) *Significant at p,.01; **significant at p,.001. aging in place meant that the average consumer could select an ALF and reasonably expect to live there to the end of his or her life, regardless of changes in health or limitations in physical and cognitive functioning, then the answer must be no. In most ALFs, a resident would be discharged once he or she needed help with transfers, had cognitive functioning that had progressed from a mild loss to a moderate or severe limitation, or exhibited behavioral symptoms, such as wandering or resisting ADL assistance. The same was true for a resident who needed nursing care or monitoring for more than 2 weeks. Thus, there were facility policies and practices that limited the ability of ALF residents to age in place. The degree to which these were a reflection of facility choices versus a reaction to state licensing regulations is not known. However, as already noted, states are increasingly offering greater Table 8. Comparison Between Single-Level and Multilevel Facilities Services Offered and Resident Characteristics Facility Characteristic Free Standing (SE) Multilevel (SE) Percent of facilities with services provided or arranged Housekeeping 98.8 (0.5) 99.5 (0.2) 2 meals a day 99.3 (0.3) 99.3 (0.3) 3 meals a day 99.1 (0.4) 97.4 (0.6)* 24-hr staff 98.7 (0.5) 98.8 (0.3) Medication reminders 91.5 (1.3) 91.9 (1.0) Central medn. storage or assistance w/meds 88.5 (1.4) 86.5 (1.3) Assistance w/bathing 98.1 (0.6) 96.5 (0.7) Assistance w/dressing 95.4 (1.1) 93.0 (1.2) Any care or monitoring by RN or LVN 72.9 (1.9) 87.5 (1.7)** Any therapy services 66.2 (2.3) 82.9 (1.7)** Nurse staffing (%) Any licensed nurse on staff (RN or LPN) full or part time 59.7 (2.6) 84.9 (1.8)** Any RN on staff full or part time 44.7 (2.8) 66.8 (2.8)** RN on staff 40 hr/week 28.7 (1.9) 53.2 (2.3)** RN on staff, 40 hr/week 22.5 (3.4) 29.7 (3.4) LPN on staff full or part time 40.3 (2.0) 68.0 (2.3)** General resident characteristics Avg. % of heavy care residents (receive assistance w/3 ADLs) 21.5 (1.6) 26.2 (1.8) Avg. % of residents with moderate to severe cognitive impairment 36.1 (1.9) 31.7 (1.3) Note: RN, LVN, LPN ¼ registered, licensed vocational, or licensed practical nurse; ADL ¼ activity of daily living. *Significant at p,.01; **significant at p,.001. Vol. 43, No. 6, 2003 881

flexibility to assisted living and residential care facilities in terms of the services they may provide and the types of residents they may admit and retain. Thus, the ability of residents to age in place seems more likely to be a product of facility choices about the resident mix they wish to serve and the market niche they wish to occupy. Additional evidence supporting this contention was found in analysis of facility factors associated with discharge of residents, including interviews with a probability sample of discharged residents or their next of kin (Phillips, Hawes, Spry, & Rose, 2000). Is Assisted Living Affordable? Assisted living was largely not affordable for moderate- and low-income persons aged 75 or older, unless they disposed of their assets and spent them down to supplement their income. Few elderly persons had incomes sufficient to cover even the basic monthly charge in the average ALF. According to data from the U.S. Bureau of the Census (1998, Table 8, Income Distribution of Older Persons ), 84% of persons aged 75 and older had incomes of less than $25,000 per year in 1997. With annual charges for basic services of more than $20,000, the average high-service ALF and the average highprivacy ALF would be unaffordable for the vast majority of older persons, particularly because they must also pay for other basic needs (e.g., supplemental insurance, out-of pocket spending on health care and medications, clothing, and so on) as well as any charges by the ALF for supplemental services such as additional ADL assistance or transportation. Further, to the degree that some ALFs were affordable for low- and moderate-income older persons, additional analysis indicates they were more likely to be ALFs categorized as offering low or minimal services and low or minimal privacy. There are four basic limitations to our study findings. First, although we provide generalizable findings, the study is limited to the study s definition of assisted living and exclusion of small facilities from the study sample. It is worth noting that none of the states that specifically licensed ALFs in 1996 and 1997 reported having any ALFs with fewer than 11 beds. Second, the data reported here represent responses from administrators. Some of these data were necessarily estimates made by the administrators, such as the proportion of residents with moderate to severe cognitive impairment. Such estimates should be regarded as such, rather than the more precise data that would result from cognitive testing. Third, the study reports data on facility policies and practices but is unable to attribute these definitively to either state regulations governing the facilities or to individual choices by the facilities. Finally, these findings represent a snapshot of a dynamic and largely young industry at a particular point in time. At the same time, responses from this national probability sample of ALFs provide the most comprehensive picture of the assisted living industry to date. References Assisted Living Quality Coalition. (1998). Assisted living quality initiative: Building a structure that promotes quality. Washington, DC: Author. Hawes, C., Rose, M., & Phillips, C. D. (2000). A national study of assisted living for the frail elderly: Results of a national survey of assisted living facilities. Beachwood, OH: Myers Research Institute, Menorah Park Center for Senior Living. Hawes, C., Wildfire, J., Mor, V., Wilcox, V., Spore, D., Iannacchione, V., et al. (1995). A description of board and care facilities, operators and residents: Analysis of the effect of regulation on the quality of care in board and care. Research Triangle Park, NC: Research Triangle Institute. Iannacchionne, V., Byron, M., Lux, L., Hawes, C., & Wrage, L. (2000). National survey of assisted living for the frail elderly: Final sampling and weighting report. Beachwood, OH: Myers Research Institute, Menorah Park Center for Senior Living. Mollica, R. (1998). State assisted living policy 1998. Portland, ME: National Academy for State Health Policy. Phillips, C. D., Hawes, C., Spry, K., & Rose, M. (2000). A national study of assisted living for the frail elderly: Residents leaving assisted living Descriptive and analytic results from a national sample. Beachwood, OH: Myers Research Institute, Menorah Park Center for Senior Living. Shah, B. V., Barnwell, B. G., & Bieler, G. S. (1996). SUDAAN user s manual: Release 6.4 (2nd ed.) [Computer software and manual]. Research Triangle Park, NC: Research Triangle Institute. U.S. Bureau of the Census. (1998). Money income in the United States, 1997. In 1998 current population survey (Series P60-200). Washington, DC: U.S. Government Printing Office. Received June 5, 2002 Accepted October 8, 2002 Decision Editor: Laurence G. Branch, PhD 882 The Gerontologist