Considerations When Selecting an Assisted Living Residence

The story of Allan and Clare in Allan’s article “Advising Alzheimer’s Caregivers About Assisted Living” is one that can be told by countless families. When the time comes that families no longer have the capacity to provide care for a relative with dementia, the landscape of residential options is a vast unknown. Allan and Clare’s saga details the many differences in assisted living options in New York State, and such variability is not uncommon across the country. More so, this is a field in flux, as in 2012 alone, 18 states made statutory, regulatory, or policy changes that affected assisted living, including major changes related to Alzheimer’s and dementia standards.¹ To complicate the matter, almost one-third of states do not even refer to these settings as assisted living, preferring terms such as residential care or enriched housing program.¹ Consequently, there is no alternative to Allan’s due diligence.

However, there is broad agreement that as a society, we can and should help families as they search for assisted living that best meets their needs and wants. The Agency for Healthcare Research and Quality recently funded a conference on this topic, resulting in recommendations to promote more widespread public reporting about assisted living services to facilitate consumer education, decision-making, and choice to achieve a better fit between the individual and the residence as well as promote quality care and outcomes.² The recommendations promote a three-tiered approach to information-sharing, including providing information from state surveys, standardized information obtained from providers in areas most relevant to consumers, and consumer reviews.² This latter point is especially important, as consumers who scour websites to find an assisted living residence do not always know that the information is often little more than marketing for select settings, or that advertised placement services favor those settings that pay them a fee, which is usually equivalent to one month’s rent.

At least three other issues are presented by Allan and Clare’s story: the potential limitations of aging in place, the evolving nature of nursing home care, and the extent to which choosing a nursing home versus assisted living truly makes a difference. The benefits of not having to transition across settings is well documented, as transitional care is fraught with errors and poor outcomes.³ However, when a setting can no longer meet the needs of an individual, aging in place should not be the Holy Grail. Instead, if additional services cannot be secured, a careful plan of transitional care is indicated. Historically, transitioning to a nursing home has been considered abhorrent by some, but the “culture change” movement has made other options of nursing home care available that are far afield from the institutional models of care most people envision. An especially current model of new care is typified by the Green House^® Project nursing homes that are now being evaluated by the Robert Wood Johnson Foundation.⁴

Finally, one might ask the extent to which the selection of a residence actually matters at all. Preferences aside, a recent systematic review found that outcomes do not differ between nursing homes and residential care or assisted living settings for people with dementia except when medical care is indicated.⁵ While the quality of care across settings is of obvious importance, it may matter less what type of setting is chosen, compared with the quality of the setting and the families’ proximity so as to stay involved in the life of their relative. 

Dr. Zimmerman reports no relevant financial relationships.

References

1.     Polzer K. Assisted Living State Regulatory Review. Washington, DC: National Center for Assisted Living; 2013. www.ahcancal.org. Accessed December 6, 2013.

2.     Zimmerman S, Cohen LW, Horsford C. Public reporting recommendations issued for assisted living. Provider Long Term & Post-Acute Care. www.providermagazine.com/archives/2013_Archives/Pages/1213/Group-Proposes-Public-Reporting-For-Assisted-Living.aspx. Accessed December 19, 2013.

3.     Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533-536.

4.     The Green House Project. Robert Wood Johnson University Website. www.rwjf.org/en/grants/grantees/the-green-house-project.html. Accessed December 6, 2013.

5.     Zimmerman S, Anderson WL, Brode S, et al. Systematic review: effective characteristics of nursing home and other residential long-term care settings for people with dementia. J Am Geriatr Soc. 2013;61(8):1399-1409.