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Through the evolution of the assisted living model, the needs of residents have become more challenging, staffing shortages have worsened, regulations have become more complex, financing and accessibility have become insufficient, and the need for consumer support, education and advocacy has grown, according to industry experts.

Together, those factors have limited the ability of the industry, the largest residential provider of long-term care in the nation, to adequately provide assistance and promote living, which has had negative consequences for aging in place and well-being, according to a Health Affairs commentary.

In the commentary, Sheryl Zimmerman, MSW, PhD, executive director of the Center for Excellence in Assisted Living at the University of North Carolina at Chapel Hill (CEAL@UNC); Robyn Stone, DrPH, LeadingAge senior vice president of research and co-director of the LeadingAge LTSS Center @UMass Boston; Paula Carder, PhD, director of the Institute on Aging at Portland State University, Oregon; and Kali Thomas, PhD, associate director of health services research in the Center for Equity in Aging at Johns Hopkins School of Nursing, presented recommendations in four areas — workforce, regulations and government, consumer needs and roles, and financing and accessibility — to help assisted living “meet its promise.”

“Today’s assisted living does provide assistance and enable aging in place with a good quality of life — but not for everyone,” the authors concluded. “It is time to devote attention to ways that would enable assisted living owners and operators to provide care and service in a way that consumers desire — assistance in meeting needs combined with the highest achievable quality of living through autonomy, flexibility, dignity and choice”

The authors called for policies to increase staffing, boost wages and training, establish staffing standards, enable greater use of third-party services, encourage uniform data reporting, and provide incentives for owners and operators to facilitate access to lower-income individuals.

As of 2018, almost 1.7 million older adults required residential long-term care, with more than half (918,700) residing in assisted living communities, according to the authors. In 2022, 24 national experts said the industry was at a crossroads and called for reimagining assisted living due to financial, regulation and workforce challenges, along with rising needs of residents.

Although the assisted living model’s capacity to address complex care needs is limited, the needs of residents are substantial. According to the commentary, up to 70% of assisted living residents have cognitive impairment — one-third to half of assisted living residents have a diagnosis of Alzheimer’s disease and related dementias — 25% have depression, more than one-fourth have six or more chronic conditions, and 11% have serious mental illness.

“In many ways, assisted living has been a natural experiment, exposing people to different types of settings over time,” the authors wrote. “The evolution from early models to current options has not been planful or coordinated, and numerous types of assisted living now exist.”

According to the authors, states use 182 license classifications that could be combined in 350 different ways to oversee assisted living, creating “widespread confusion.”

The philosophy of assisted living aims to adapt services in response to resident needs and preferences. “In reality, however, as the field has evolved and resident acuity [health needs] has increased, assisted living has become both short on assistance and short on living,” the authors wrote, noting that necessary support is not always available and aging in place is not always feasible.