Assisted Living

The size, layout, and shared nature of living units is an issue that often creates conflict in policy development. Older board-and-care rules allow shared rooms, toilets, and bathing facilities. Existing facilities that want to be licensed for assisted living often oppose rules requiring apartment-style units and single occupancy. Some states have grandfathered existing buildings or maintain separate board-and-care categories that allow shared rooms.

Single occupancy apartments or rooms dominate the private market. A 1996 survey of non-profit facilities conducted by the Association of Homes and Services for the Aging found that 76 percent of the units in free-standing facilities and 89 percent of units in multilevel facilities were private (studio, one-, or two-bedroom units). A similar survey by the Assisted Living Federation of America in 2000 found that 87.4 percent of units in ALFA member facilities were studio, one-, or two-bedroom units and 12.6 percent were semiprivate. Hawes et al. found that 73 percent of the units were private and meet the privacy aspect of the philosophy of assisted living, but only 27 percent of the facilities had all private units.

A 1998 survey of assisted-living facilities by the National Investment Conference (NIC) found that cooking appliances were more likely to be available in geographic areas where there was greater competition among facilities. The inclusion of stoves in living units is declining, however, and facilities are more likely to include microwave or toaster ovens in units. The survey also found that 17 percent of residents shared a unit. Fifty-two percent said that they shared their unit for economic reasons, 30.4 percent for companionship, and 14.9 percent because a private unit was not available. Just under 65 percent of those who shared a unit were satisfied with the arrangement, while 35.7 percent would prefer a single unit.

Nationally, consumer demand and competition are more likely than regulatory policy to determine whether studio or apartment-style living units are available. Licensing rules in eleven states and Medicaid-contracting specifications in four states require apartment-style units.

States seeking to facilitate aging in place and to offer consumers more long-term care options allow more extensive services. These states view assisted-living facilities as a person's home. In a single-family home or apartment in an elderly housing complex, older people can receive a high level of care from home health agencies and in-home service programs. Several states extend that level of care to assisted-living facilities.

The extent and intensity of services generally follow state criteria. Services can be provided or arranged that allow residents to remain in a setting. Mutually exclusive resident policies, which prohibit anyone needing a nursing-home level of services from being served in board-and-care facilities, have been replaced by aging-in-place provisions. However, drawing the line has been controversial in many states. In many states, some nursing home operators see assisted living as competition for their patients and oppose rules which allow skilled nursing services to be delivered outside the home or nursing-home setting.

Most states require an assessment and the development of a plan of care that determines what services will be provided, by whom, and when. Residents often have a prominent role in determining what services they will receive and what tasks they will do for themselves. A key factor in assisted-living policies is the extent of skilled nursing services that are allowed.

Hawes et al. found that nearly all facilities (94 percent) provided or arranged for assistance with self-medication; 97 percent assisted with bathing; and 94 percent offered help with dressing. Although nearly all states allow central storage of medications, 88 percent of the facilities provided or arranged this service. Arizona, for example, has three service levels that allow supervisory care services, personal-care services, and directed-care services. Residents in facilities with a supervisory care license may receive health services from home-health agencies. Facilities with a personal-care services license can provide intermittent nursing services and can administer medications. Other health services may be provided by outside agencies. Directed-care service facilities provide supervision to ensure personal safety, cognitive stimulation, and other services for residents who are unable to direct their own care.