An elderly couple embracing, enjoying an outdoor meal with the family in a courtyard.
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The assisted living industry is fighting back against growing scrutiny over staffing challenges and what consumer groups and the lay media say is a cost structure that prices many older adults out of services by citing high resident and family satisfaction rates and an overall value to the healthcare continuum.

In response to Thursday’s US Senate Special Committee on Aging hearing focusing on safety, staffing and pricing in the assisted living sector, associations representing operators submitted comments highlighting the industry’s role in caring for a growing aging population.

“Selecting an assisted living community is a very personal decision, and most often older adults or their loved ones are looking for care in their hometown. Additionally, the reason residents and families love assisted living is because each community is unique, adapting to the needs and wants of their local communities,” National Center for Assisted Living Executive Director LaShuan Bethea told McKnight’s Senior Living. “Today’s hearing demonstrated the very important need to continue to educate policymakers, families and the public about the diversity within the assisted living profession, as well as the benefits to state-based regulation in promoting person-centered care and innovation.”

LeadingAge President and CEO Katie Smith Sloan said in a statement that the hearing and recent national news coverage that preceded it “underscore the urgent need for our policymakers to address the shortcomings of our country’s current approach to financing long-term care.”

All of the national industry associations agreed that keeping assisted living regulation at the state level would be more effective than federal oversight.

“This regulatory framework encourages states to innovate and explore ways to provide cost-effective long-term care at a much more local level than could ever be replicated by one-size-fits-all federal regulations,” Argentum President and CEO James Balda wrote in his comments to the committee. 

The industry is working to develop recommendations for providers that would standardize approaches to some challenges, he said. Last year, Argentum, the American Seniors Housing Association, LeadingAge and NCAL joined with the National Association for Regulatory Administration to form the Quality in Assisted Living Collaborative to identify, define and develop model guidance for assisted living. 

“The industry-wide initiative is expected to result in greater consistency across states, and the collaboratives resources will be available to aid and educate providers, regulators, policymakers and other stakeholders,” Balda wrote.

ASHA President and CEO David Schless added that the collaborative also is seeking input from a designated workgroup of industry stakeholders, regulators and consumers.

“These approaches to creating industry guidance or models are an appropriate and productive way to improve outcomes in assisted living, identify new challenges and inform future policy recommendations for assisted living,” Schless wrote. “These initiatives should be encouraged.”

And although the federal government does not regulate assisted living as it does nursing homes, Schless said in submitted comments that the industry is “highly and appropriately regulated at the state level, where rigorous oversight is provided and laws are updated as needed or desired.”

According to NCAL’s 2023 Assisted Living State Regulatory Review, two-thirds of states reported changes to requirements for assisted living licensure or certification from 2020 to 2022, and another 31% did so between 2022 and 2023. 

Schless said that state licensing and practice requirements generally address the core elements of operation and practice, including residency agreements, disclosure of service costs, resident need assessment and care planning, resident rights, community policies, staffing and training requirements, medication assistance services, food and dietary provisions, third-party provider offerings, resident safety, service limitations, community survey requirements, physical plant and life safety mandates. 

“State regulation of assisted living and memory care allows for a more responsive process when policymakers, industry, consumers and other stakeholders call for a change in rules,” Schless wrote, adding that ASHA and LeadingAge jointly publish a Senior Housing Regulatory Handbook, which annually compiles the latest state regulatory agency requirements for all 50 states and Washington, DC. 

Pointing to the recent articles in The Washington Post that examined the “tragic but isolated” incidents of resident elopements, all of the associations noted that the reporting failed to note how rare such incidents occur in assisted living. And the industry advocates all agreed that wrongdoing must be investigated and punished, including community closures, if warranted.

Residents, families ‘highly satisfied’

Before the committee hearing, NCAL, along with sister organization the American Health Care Association, which advocates for the skilled nursing industry, released a “fact check” of the assisted living industry, which also pointed to studies showing that residents and families consistently are happy with the care they receive. 

NCAL also highlighted a report from NORC at the University of Chicago that found that assisted living communities help reduce residents’ frailty after move-in. In addition, the association said, a recent Brown University analysis of its National Quality Award Program found that Silver and Gold-level recipients had better outcomes compared with non-recipients, leading to lower hospitalizations, emergency department visits and transitions to nursing homes.

NCAL also pointed out that it published a white paper last year advocating for a public-private partnership to identify opportunities that expand affordable assisted living options for low- to moderate-income older adults.

Balda said that senior living communities also enjoy consistently high customer satisfaction ratings. According to the JD Power 2023 US Senior Living Satisfaction Survey, he said, assisted living/memory care and independent living providers scored higher than the travel and hospitality industries. Industry surveys also reflect a 90% satisfaction rating among residents, who also give the setting an 85% for having high value, 70% for providing an improved health outlook, and almost 75% for providing an improved quality of life. 

Value of assisted living

Pointing to a 2022 study from NORC at the University of Chicago, Argentum noted that the average assisted living resident manages 14 chronic conditions, with the most common being Alzheimer’s disease and related dementias (42%), heart disease (34%), depression (28%), diabetes (17%) and chronic obstructive pulmonary disease (15%). 

“By coordinating care and managing these chronic conditions, assisted living communities improve the health and well-being of their residents while decreasing the financial strain on the healthcare system,” Balda said. “Compared to other long-term care providers, assisted living offers lower costs, improved quality of life, better health outcomes, and reduced healthcare costs.”

Argentum quantified the value of assisted living in a white paper released last spring. Assisted living, according to the report, costs an average of $54,000 and includes housing, meals, transportation and socialization. That compares with $108,405 for a private room in a nursing home as well as the average cost of a home health aide, which can be $61,776 for 40 hours a week or as much as $235,000 for around-the-clock coverage.

Assisted living also preserves Medicare and Medicaid safety net programs, according to Balda, who said that as many as 61% of older adult residents would have to move into more expensive skilled nursing facilities at a cost of $43.4 billion annually if assisted living was not an option. 

“The assisted living care model focuses on the social determinants of health, chronic disease management, social interaction and often facilitates care coordination with other healthcare providers,” Balda wrote. “Though no assisted living facility receives Medicare dollars, this coordinated care, including social and preventative care, keeps seniors healthier and saves Medicare an estimated $15.4 billion through reduced hospitalizations and readmissions, less social isolation, and delay in far costlier skilled nursing care.”

Schless said that the industry recognizes the challenges of meeting the growing demand for its services, specifically by those in the middle-income market. But he noted that only a small percentage of providers engage in Medicaid waiver programs in states that allow assisted living participation as a home- and community based service, because dollars are limited and availability varies.

Schless called on policymakers and stakeholders to collaborate to address ways to incentivize retirement savings, to pursue policy options to reignite the long-term care insurance market, and to consider new government assistance programs to subsidize the cost of care.

Addressing workforce issues

The senior living industry lost hundreds of thousands of jobs during the COVID-19 pandemic (Argentum estimates that 100,000 jobs were lost during the first 20 months alone) and will have 3 million job openings by 2040, according to Argentum.

Modifying priorities in federal workforce programs, Balda said, could dramatically increase the pipeline of new caregivers for assisted living and other long-term care providers.

Schless said that it is time to look beyond the nation’s borders for a solution and give immigration reform serious thought.

“We understand the need to couple border security with legal immigration reform. We support efforts to address both challenges,” Schless said. “However, there are thousands of people here in the US awaiting work authorization. Therefore, we urge action to expedite work authorization documents for those who are currently eligible.”

Sheryl Zimmerman, MSW, PhD, executive director of the newly established CEAL@UNC, said in comments submitted to the committee that the quality of assisted living care depends on the quality and quantity of staff members, noting that providing care is labor-intensive. She said that staffing is the primary challenge for assisted living, where wages are relatively low and staff recruitment and retention are major concerns. 

Most residents’ care and service needs are personal and supportive, with staff members providing help with activities of daily living as well as medical monitoring and medication management, Zimmerman said, adding that in addition to time, training is needed to help staff members capably attend to residents’ psychosocial care needs, especially for residents with dementia.

“All too often, these residents are treated with antipsychotic medications when staff do not have the time or are unaware of how to prevent or lessen their distress,” she said. “Sufficient number of well-trained staff are critically needed to strengthen assisted living care.”

Feasible solutions already on the table

Zimmerman said that numerous feasible solutions have been proposed to improve care and outcomes in assisted living, including promoting consumer education using common definitions and standardized reporting and decoupling services from housing to promote choice.

Access and equity, she said, could be addressed by expanding Medicaid coverage, diversifying housing options, modifying services and offering tax incentives and public subsidies to operators who open their door to middle-income individuals.

The quality of care and outcomes, Zimmerman said, could be improved through regulations that encourage quality improvement, by promoting quality initiatives, and by adhering to consensus recommendations for medical and mental healthcare. 

Staffing, she added, might become more efficient if guidance or standards for staff training, supervision and compensation were devised, as well as supportive immigration policies, needs-based staffing and funding to support family involvement in care. 

LeadingAge, in written testimony submitted to the Aging Committee, offered several recommendations at the national level, including establishing a clearinghouse and technical assistance center to promote education on the wide variety of state approaches to assisted living, to evaluate their effect on quality and to support adoption of the most effective state models.

LeadingAge also recommended establishing a national resource center for assisted living and dementia care training, establishing a national system to finance long-term care services and supports, and studying policy barriers to states offering Medicaid-funded assisted living.

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