Assisted living communities are now the fastest-growing component of post-acute and long-term care, or PALTC, in the United States. As residents have gotten older and their health conditions more medically complex, these communities are looking more like nursing homes did 30 years ago, while for their part nursing homes are looking more and more like small hospitals.
Responding to these trends over the past few years, AMDA –The Society for Post-Acute and Long-Term Care Medicine, brought together a diverse group of stakeholders to work toward consensus on how best to address the growing and increasingly complex health care needs of assisted living residents in a consistent, optimal way. This will require a cultural shift from owners and operators, who will need to embrace the fact (with some reluctance) that assisted living communities no longer are simply a social / hospitality model; they have become an important healthcare setting within PALTC.
Assisted living owners and operators have resisted this shift for a variety of understandable reasons. Wherever healthcare is being provided, state and federal regulations usually come into play. Public funding such as Medicare and Medicaid, as well, generally invites more state or federal oversight.
To be clear, AMDA has never advocated for federal regulation of assisted living. Making sure there’s consistent delivery of appropriate medical care in these communities, however, has been a priority for us for some time now — and will continue to be an important focus of our work on behalf of patients, residents and families.
As part of those efforts, our members have asked us to define a role for the oversight of healthcare delivery in assisted living communities and to create a model agreement — similar to the model nursing home model medical director agreement we’ve developed (and currently are revising) — and we’re working on that now. The purpose of the assisted living agreement is to ensure that the medical care being provided in assisted living communities meets certain quality criteria or standards that reflect best practices. This includes staff competencies, such as mandatory training in dementia care, and protocols for resident care that feature optimal staffing levels to meet resident needs.
There’s another element to the interest that is growing in providing consistent, standardized care for assisted living residents, and it’s coming from the acute care side. As we all know, hospitals are being penalized for avoidable readmissions, and these penalties apply as much to assisted living transfers as to nursing home transfers. Hospitals will stay away from sending their patients to communities if they are afraid they’ll be readmitted within 30 days of discharge. That’s why it’s incumbent on assisted living owners and operators to look at the provision of healthcare services more strategically and see that it represents an opportunity for them to embrace their role within the spectrum of PALTC settings as much as they have embraced their role as a social or hospitality setting.
To pursue our goal of integrating medical care within assisted living communities, AMDA has now held three National Assisted Living Summits over the past several years. These summits have brought together industry leaders, providers, physicians and thought leaders to identify challenges and obstacles to good care and to determine how best to provide care using an “integrated” model, that is, a model that reflects both the social benefits of assisted living and the need for consistent healthcare services.
The most recent summit, held in partnership with the Center for Excellence in Assisted Living at our 2017 annual conference in Phoenix, included discussions and reports from four workgroups: workforce / staffing considerations; state models and best practices; quality measures, QAPI and technology; and clinical issues in assisted living. You can read more about it here. Like the previous two summits, this discussion demonstrated that there truly is a shared vision and commitment to improving the quality and consistency of care delivered to everyone residing in an assisted living community.
With respect to the role of physicians in assisted living communities, the February 2018 issue of our JAMDA journal featured two editorials on this issue. One argues that physicians should be the leaders in establishing and promoting an integrated model of care that includes both the social / hospitality aspect and the medical aspect. The second concurs with many of these recommendations but prefers more of a team-based approach, in which the physician is an active participant, but not necessarily the leader of the care being provided.
Whichever view you hold, I believe that we’re at an inflection point for the integration of healthcare into assisted living. With the growing role of public funding into assisted living — a setting previously 90% private pay — the industry will either choose to fight a losing battle against increasing regulatory pressure or work to ensure that any new regulations continue to reflect and support the unique characteristics of assisted living.
A couple of approaches are open to us. One is to develop and promote model state regulations that we can all live with. Another is to develop and promote a set of core healthcare criteria that include the areas focused on at the national summits, among others.
In the end, it’s time to stop talking about this and to start thoughtfully and intentionally integrating medical care into assisted living. Residents in assisted living have increasingly acute healthcare needs as well as other challenges, everything from antipsychotic overprescribing to the opioid epidemic — as problematic in assisted living as they are in nursing homes — to mental health / dementia care and substance abuse. And, to meet the expectations and needs of residents and families, we need to make sure this integration is done in a way that acknowledges the specific requirements of each community’s resident population while conforming to well-established healthcare quality criteria.
This is going to take partnership across payers, patient and family advocates, provider groups, and clinicians. AMDA and CEAL have been working on these issues for some time, but we need more participants. The longer we wait, the more likely it is that we won’t be able to have the influence we need to. Instead, we’ll be playing catchup, chasing after regulatory initiatives we don’t much like.
I’d much rather be in front of this change, to make sure we shape these issues in ways that we know are in the best interests of the residents who live in assisted living communities, their families, and the owners, operators and staff who work in them. This changing landscape may seem like a threat, but it also can be an opportunity. Let’s seize this opportunity before it is lost.