Background
Assisted living care is a form of long-term care. Although assisted living facilities (ALFs) cater to populations other than senior citizens (for example, individuals with disabilities), most facilities provide services for retired senior citizens. Those individuals who require assistance with general activities of daily living such as housekeeping and cooking but do not need significant medical care can often avoid an unnecessarily early entry into a nursing home by first living in an assisted living facility. Therefore, these facilities provide varying degrees of daily assistance for otherwise healthy and independent seniors.
Although assisted living as a practice is regulated throughout the United States, not all states use the same terminology, making comparisons difficult. States use various terminology—senior housing, board and care, adult foster care—that may or may not espouse the principles of ALFs; accordingly, state regulation of a particular facility may be minimal to nonexistent. For example, some states regulate the type of services while others regulate the building itself. Many of the states with a high percentage of seniors, such as Florida, have adopted an inclusive umbrella model that regulates the entire ALF. However, this lack of consistent federal oversight throughout all states proves confusing for many individuals—especially those searching for long-term care. However, “assisted living facility” is the most common term for long-term care that provides some, but not all, assistance in activities of daily living for its residents.
The ongoing cost of long-term care often consumes the retirement savings of many seniors. The combined expenses of medications, doctor visits, and personal assistance often outweigh simple housing costs, and elderly individuals are often at risk for injury when performing household chores at home. However, seniors now have the option of an ALF, which often provides individual treatment plans that maintain privacy and dignity by permitting broad independence at a fraction of what nursing homes charge. To contain costs, assisted living facilities have replaced comprehensive in-house medical services, such as those available at traditional nursing homes, with individual treatment plans that provide their residents with the optimal amount of help for their particular situations.
Assisted living facilities are fundamentally different from other senior-oriented care options. Similar to child-care facilities, adult day-care facilities provide daytime care for seniors who live with their children. Often, adult day-care facilities cater to individuals who have cognitive dysfunction (for example, memory loss or Alzheimer’s disease). Adult day-care facilities typically operate during the weekday work hours, providing caregivers respite either during the day or during their work commitments. In contrast to ALFs, residents leave the facility at the end of the day.
Another senior-oriented care option is a nursing home. Nursing homes are similar to ALFs in that the resident lives full time at the facility; however, nursing homes manage medical routines, provide intensive medical care, and provide 100 percent of daily care—often including dressing, bathing, and additional self-care activities.
Types of Assisted Living Facilities
Although differences abound in ALFs, there are basic similarities. Assisted living facilities typically require residents to be generally in control of the majority of their activities of daily living. Residents are expected to perform their own bathing, dressing, and personal care, including medication routines. Although some residents might have minor memory impairments, most are generally in good physical and psychological health, and ALFs strive to create an environment to foster the continued good health of their residents. Strong social connections can often form between residents at cohesive ALFs, an important element of the aging process. Research suggests maintaining strong social interactions is key to maintaining health and well-being as one ages.
There are as many living arrangements as there are ALFs. Some ALFs resemble hostels with eight or more beds in one room, several rooms to a floor, and a separate communal bathroom. Because of the high volume of residents, these ALFs often do not offer individualized treatment plans and, in a situation reminiscent of nursing homes, independence and autonomy are often replaced by resident infantilization. Although these ALFs lack privacy and the staff-to-resident ratio, by necessity, is high, these are generally the least expensive among all the ALFs. General health and well-being often decline rapidly after admittance, forcing relocation to a more care-intensive facility. Accordingly, these ALFs have the quickest resident turnover of all the long-term care facilities.
On the opposite end of the ALF spectrum is the assisted living retirement community. These facilities mimic in-home care as precisely as possible. Whereas retirement communities are generally populated by completely healthy and independent older adults, assisted living retirement communities offer all the amenities and privacy of retirement communities as well as daily in-home care. Often these communities have extensive amenities, including recreation facilities, swimming pools, and other outside sport facilities. In addition, they frequently have numerous staff members dedicated to organizing and maintaining these amenities. Accordingly, these facilities are generally the most expensive but offer the greatest privacy and most closely resemble the aging-at-home experience.
Between crowded communal living and luxurious retirement-style living is the most common form of ALFs, the apartment-style assisted living facility. Constructed as typical apartments, these facilities provide each resident with a complete and separate living facility. Each unit generally has a complete bathroom, bedroom, and living room—full kitchens are often not included. Each resident lives independently but eats in a communal dining room with other residents. Communal social rooms and twenty-four-hour security and staff presence are standard amenities. High-end facilities may provide shuttle services, hairdressers, comprehensive exercise facilities—often with a full-time activity director—and monthly visits from nurse practitioners or medical doctors. Regardless of their size, most ALFs often look and feel like home for the residents and their visitors.
Safety Concerns
The expansion of assisted living facilities benefits the long-term care industry writ large. Prior to the large numbers of ALFs, nursing homes bore the brunt of aging seniors. Seniors experiencing even the smallest impediment in independence were forced into nursing homes. Because nursing homes are designed to cater to the most dependent seniors, even the most functional seniors often experience precipitous drops in functioning from early entry. The same health impediments that nursing homes cater to are, conversely, also a struggle for ALFs.
The line between whether someone should remain in his or her home versus residing in an ALF can be difficult to determine for a spouse and other family members. Often safety concerns become the final determinant. An inability to cook for themselves or minor memory concerns (for example, forgetfulness with the stove) are often used to rationalize a difficult decision. This decision may be easier in the future, however, as research suggests that ALFs prolong independence compared to remaining in one’s residential setting. Often removing one’s responsibility for a few activities of daily living relieves stress and mental reserves, allowing the senior to focus on other personal care routines. The independent orientation of ALFs stands in contrast to nursing homes, which often contribute to dependency rather than facilitate independence.
Just as safety concerns may lead to the move to an ALF, the decision to discharge a resident from an ALF is also often driven by safety concerns. Because ALFs do not provide twenty-four-hour intensive service, residents are free to come and go from the facility and use the bathroom or other accident-prone areas. Residents who are either cognitively impaired or whose health has declined dramatically are often asked to leave the ALF, and for many seniors the next move is into a nursing home.
Regardless of the size, philosophical orientation, or services provided, ALFs provide a much-needed option in long-term care. Seniors with minor impairments can extend their functional independence for many years, and seniors in ALFs actually experience prolonged independence over remaining in home. In tandem with the rapidly aging population, ALFs are evolving even as they struggle with their own identity nationally and within each state.
Perspective and Prospects
Assisted living facilities burgeoned as the aging baby boomers began to approach retirement. Baby boomers, the generation born between 1946 and 1964, are healthier and more independent than retirees of the past, and the long-term care industry responded to this demographic shift with the expansion of ALFs. Prior to the broad expansion of ALFs, seniors in need of even the smallest amount of assistance were forced into nursing homes unless they could afford costly in-home care.
Developments in long-term care have involved graduated levels of care in one facility to accommodate residents’ needs as they age. In contrast to assisted living–only facilities, where residents must move out after they become unable to bathe, dress, or manage their general health successfully, facilities that offer an increased level of care as needed permit residents to move through their retirement years in a single location. Providing flexible services is especially important to a senior’s quality of life, as familiarity and daily routines often can mask advancing stages of mental confusion.
These facilities, sometimes referred to as continuing-care retirement communities, have residence fees that are typically higher—depending on the size of the apartment and the geographic location the prices vary and can be upwards of $100,000—thus limiting this option to the most wealthy of seniors. Nevertheless, these facilities are an important part of the ongoing redefinition of independent living. Where pure ALFs provide a designated set of services, continuing care communities can adapt to the particular needs of each resident throughout the aging process.
This revolution in long-term care has also carried over to nursing homes and has led to the creation of green nursing homes. These nursing homes house approximately ten residents in a large houselike structure and provide a full range of personal care and medical services. As in ALFs, the focus in these green homes is on independent thriving. Whereas nursing homes were historically viewed as the last option for seniors, these green nursing homes are often abundant with plants, domestic animals, homelike furnishings, and daily visitors and volunteers who try to keep the residents and staff cheerful and healthy.
Irrespective of any particular facility or philosophy of care, assisted living facilities are the favored choice of aging seniors. No spouse or family member wants to watch a loved one lose control of daily functioning. Overworked and economically strapped children of aging parents often find themselves faced with a difficult decision. By focusing on dignity, independence, and freedom, assisted living facilities make these choices easier for many.
Bibliography
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Mollica, Robert, et al. Residential Care and Assisted Living Compendium: 2007. Washington, D.C.: Department of Health and Human Services, 2007.
NIH Senior Health. "Long-Term Care." National Institutes of Health, 2012.
Polzer, Karl. Assisted Living State Regulatory Review. Washington, D.C.: National Center for Assisted Living, 2009.
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