While the definition of assisted living varies widely across states, there are several core terms that appear in state definitions. Assisted living is generally viewed as home-like and offers residential units and the availability of supportive and health-related services available to meet scheduled and unscheduled needs, twenty-four hours a day. Assisted living is viewed as the consumer's home, and as such includes the amenities that people generally expect in a residence, including a door that locks, a private bathroom, temperature control, a food preparation area, and the freedom to make choices about the types of services that are available. In addition, twenty-eight states have included a philosophy of assisted living (up from twenty-two states in 1998 and fifteen in 1996). These statements describe assisted living as a model that promotes the independence, dignity, privacy, decision-making, and autonomy of residents, and supports aging in place.
Regulations specifically governing assisted living have grown rapidly. By 2000, twenty-nine states and the District of Columbia had a licensing category or statute using the term assisted living, and four other states were in the process of developing such regulations. By contrast, only twenty-two states had such regulations in 1998. However, assisted-living facilities are regulated in the other states under rules that may use other terms, such as residential care facilities or personal care homes.
In 2000, states reported a total of 32,886 licensed facilities with 795,391 units or beds, a 30 percent increase over 1998. However, information was not reported by all states. Assisted living has developed primarily as a private pay market. However, by mid-2000, thirty-eight states covered services in residential settings—under either assisted-living or board-and-care licensing categories—through Medicaid, and coverage was being planned in three other states plus the District of Columbia. While the number of states covering services in residential settings has grown, the number of beneficiaries served remains limited with about 60,000 people served, a 50 percent increase in two years. Over 36 percent of the units (or beds) are located in three states: California (136,719), Florida (77,292), and Pennsylvania (73,075). Since 1998, the number of licensed facilities has soared in Delaware (by 214 percent), Iowa (144 percent), New Jersey (139 percent), and Wisconsin (119 percent). Ten states reported growth in licensed facilities of between 40 percent and 100 percent in the past two years: Alaska, Arizona, Kansas, Indiana, Massachusetts, Minnesota, Nebraska, New York, South Dakota, and Texas.
Within the industry and among state officials, there is often a debate about where assisted living lies on a social-medical continuum. Hawes et al. found that some operators view assisted living as a nonmedical model (without RN staffing) that provides high privacy and low service. Others view it as a high-privacy/high-service model that offers a wide range of services, aging in place, and private units. Over half of all the facilities were considered low-privacy/low-service models that offered shared units and limited health services. The study also pointed out that many in the industry question whether privacy and service level were accurate variables to use in describing assisted living. The report concludes that there is no agreement at the operational level on what constitutes assisted living.
The Hawes report also examined whether facilities support aging in place, the ability to receive additional services as needs change. Fifty-four percent would not retain residents needing transfer assistance, 68 percent would not serve residents needing nursing care, and 55 percent would not retain people with severe cognitive impairment. Twenty-four percent of assisted-living residents received help with three or more activities of daily living (ADLs), compared to 84 percent of nursing-home residents. The authors note that these findings suggest that assisted living may not serve as a substitute for nursing-home care. However, in the absence of assisted living, it is likely that many residents with fewer ADL impairments would seek nursing home placement. The differences in impairment levels between residents of assisted-living facilities and nursing homes may in fact be due to the availability of assisted-living facilities to serve residents with relatively low needs.
Findings from Hawes et al. contrast with those from Mollica which indicate that 87 percent of state licensing agencies feel that assistedliving facilities are providing as high a level of care as allowed by regulation. Anecdotally, licensing-agency staff indicate that some facilities may be serving people longer than they should (based on their staff capacity and training), even though the level of need is consistent with what is allowed by regulation.
The 1999 U.S. General Accounting Office (GAO) study of assisted living in four states (California, Florida, Ohio, and Oregon) concluded that these facilities support aging in place. Seventy-five percent of facilities included in the report said that they admitted residents who have mild to moderate memory or judgment problems, are incontinent but can manage on their own or with some help, have a short-term need for nursing care, or need oxygen supplementation. However, this level of care may be limited since it implies that people with severe memory loss who need more than occasional assistance with incontinence or who need nursing services for longer periods would not be served.