By Robyn Stone
Robyn Stone reflects on assisted living—a promising model that didn’t turn out exactly as it was intended.
When assisted living burst onto the scene in the 1980s, many of us in the field of long-term services and supports (LTSS) were immediately taken with the new model, which was designed to provide person-centered care and promote quality of life through supportive and responsive services—all while encouraging independence and helping residents delay or even avoid the need for nursing home care.
Fast forward 40 years and the reviews of assisted living are decidedly mixed. Even though the assisted living field has grown exponentially—it now constitutes half of all long-term care beds in the country—many observers agree that this once-promising model didn’t turn out exactly as it was intended, and that it needs to be reimagined.
That was the consensus among a group of LTSS stakeholders who met for two days last year to think deeply about the future of assisted living. I was a member of that stakeholder group and a co-author of a recent article in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA) in which group members summarized key tensions within the assisted living sector:
- Assisted Living Models: Because there’s never been agreement on what constitutes assisted living, a wide variety of models have evolved over the years, leading to a high level of confusion about assisted living among consumers and raising disturbing questions about whether assisted living is providing the services that residents want and need.
- Assisted Living Regulation: Given the variety of models, it’s not surprising that assisted living regulation has become extremely complicated. The sheer number of state-level assisted living regulations is breathtaking. Some of those regulations create tensions between promoting resident choice and supporting resident safety; others unwittingly prevent states from offering much-needed subsidies to older adults who can’t afford to pay privately for this model.
- Assisted Living Financing: Assisted living is paid for largely by individuals and the price tag—a median cost of $4,300 per month—can be prohibitive for many. All states cover some assisted living costs through Medicaid, but access to those funds is limited. As a result, assisted living serves mainly upper-income older adults even though middle-income older adults are the fastest growing segment of the older population.
- Assisted Living Residents: Assisted living residents are growing older and their needs for medical and social services are increasing. Yet, most assisted living communities don’t have the capacity to meet the service needs of higher-acuity residents.
- Assisted Living Workforce: More than half (59%) of assisted living communities responding to a recent survey reported their workforce situation was worse now than it was in 2020. Eighty-one percent reported having staffing shortages they were unable to fix. As in other LTSS care settings, these workforce challenges are fueled by low wages, insufficient benefits, poor supervision, inadequate training, strenuous workloads, poorly designed job roles, and limited career advancement opportunities.
The JAMDA article, which is available free of charge through 2022, outlines a variety of potential solutions to address these tensions. It calls for decoupling services from housing so residents can better choose the care they receive, developing regulations that promote quality care and consumer preferences, lowering the assisted living price tag to increase access, coordinating and/or integrating community-based care and services into assisted living settings, and taking deliberate steps to strengthen the assisted living workforce. And that’s only a few of the ideas we recommend.
Our paper is not the final word on reimagining assisted living. But it performs a very important service: it establishes clear parameters for a discussion about assisted living that must take place, and soon.
In my view, the required reimagining of assisted living must start with some agreement on the core characteristics that we want all LTSS settings to embody. For me, those characteristics include a homelike environment, person-centered services, a connection with the culture of the local community, a small-scale design, well-trained staff, a deliberate integration of community-based services, including primary care and palliative care, and a financing and regulatory environment that is flexible enough to support these characteristics. All at an affordable cost.
It is significant that our article about “The Imperative to Reimagine Assisted Living” is included in a JAMDA special issue focusing on the need to reimagine all long-term care. It’s clear that our entire LTSS system is ripe for reimagining, especially in light of the COVID-19 pandemic.
If we coordinate those reimagining efforts, perhaps we can create a new model of residential care that fulfills all our aspirations.
It’s certainly worth talking about.
Robyn I. Stone, DrPH, is senior vice president of research at LeadingAge, and co-director of the LeadingAge LTSS Center @UMass Boston. Her widely published work addresses long-term care policy and quality, chronic care for people with disabilities, the aging services workforce, affordable senior housing, and family caregiving.