Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly

The current trend toward admission and retention of severely ill patients in skilled nursing facilities (SNFs) has left a gap in services for those elders who require only limited assistance . Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly is a well-referenced and thorough analysis of the burgeoning development of residential facilities for elders who need some assistance but are not sick enough to require skilled nursing care. Senior residences of all types have mushroomed throughout the United States in response to growing consumer demand. Older residential care (RC) models have evolved into new assisted living (AL) models, which represent a hybrid between a deluxe hotel and a typical SNF. This hybrid, seen as a cure for the gap between home care and institutional care, has been met with largely uncritical enthusiasm. However, this bridging of needs and services is in reality an awkward union. This text provides a thorough look at this new industry, its models and variations, its performance, and its quality of care. The text is structured in three sections: (1) broad issues in RC/AL in today’s long-term care environment, (2) basic components of RC/AL settings, and (3) future directions in RC/AL. An assortment of experts who are largely PhDs in public health administration or gerontology explores each area in depth. The contributing authors are predominantly from the University of North Carolina at Chapel Hill and the University of Maryland. Only three of the 25 authors are from other states. Although this homogeneity of contributors lends a consistent style and unified view to this text, the absence of outside opinion may represent a progressive bias as this field continues to evolve. Much of the information presented in this text is based on a four-state study of AL facilities that grew out of two separate grants funded in 1996 by the National Institute on Aging: Medical and Functional Outcomes of Residential Care (Sheryl Zimmerman, Principal Investigator; J. Kevin Eckert, Co-Principal Investigator) and Alternatives to Nursing Home Care for Alzheimer’s Disease (Philip D. Sloane, Principal Investigator). In consideration of their similar goals and design, the efforts of these two grants were integrated and conducted cooperatively as The Collaborative Studies of Long-Term Care (CS-LTC). The geographic proximity of the sponsoring institutions, the University of North Carolina at Chapel Hill and the University of Maryland, has lent itself to a successful ongoing merger. The CS-LTC is the first study to examine the relationship between the quality (structure and process) of care in this population and final outcomes of care, including adverse medical outcomes, changes in functional status, and health service use. The CS-LTC provides the largest U.S. database on AL models and outcomes. This text represents an overview and initial review of the study’s preliminary data by its primary investigators. The first two chapters describe state policies and regulations and the limitations of current health insurance coverage for long-term care. Detailed information is provided that highlights the extreme heterogeneity of licensing and service requirements across the 50 states and makes it clear that AL is an extremely imprecise phrase that must be qualified in detail as to locale, model, and individual services. The third chapter examines northern European models of AL and outlines their basic description of AL—a smallsize facility with a residential appearance that serves frail persons in a family-oriented, community-based setting and guards elders’ privacy and independence while fostering mental stimulation and health maintenance. An interesting variety of AL models is presented, along with analysis of their potential application in the United States. Subsequent chapters discuss staffing problems and strategies, resident characteristics, and physical environment. An interesting inclusion is the Eden Alternative, an approach that combines a naturalistic physical environment with a team approach to resident care. One of only two chapters primarily authored by a medical doctor, the section on physical environment is written with a focus on the practical. Although much of this information will seem obvious to the experienced geriatric practitioner, enough new facets are explored to make reading it worthwhile. The chapter on the process of care delineates reasonFrom the Department of Medicine, Division of Geriatrics, New York Medical College, Valhalla, New York.