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Living History – The Evolution of Assisted Living Facilities

Below is a detailed overview of how assisted living facilities have evolved over the years, as well as some thoughts about the future of assisted living. This site is designed to be a helpful resource for any looking to learn more about what assisted living is, exactly, and the origins of this particular segment of elderly care.

What is Assisted Living? Assisted Living is a type of elderly care that offers a level of attention and independence between those offered by nursing homes (which land on the higher end of the spectrum) and independent living (which would fall on the lower end).

Inception of the Modern Assisted Living Facility: By the late 1970s it was becoming apparent that the institutionalized setting of nursing homes was no longer acceptable for most aging seniors and their families. As advances in medicine allowed seniors to age in place, many were balking at the idea of nursing home placement. With rumors of mistreatment and neglect surrounding long-term care gaining more and more publicity, the need for change was evident.

Health, Housing and Hospitality: In the mid-70s, Dr. Keren Brown Wilson’s mother motivated her to take a stance for the frail and aging.  It is reported that as a 60-year-old resident of a nursing home, Jessie F. Richardson, asked her daughter to do something to help people like herself.  It was those words that helped motivate Brown Wilson to focus her life’s work on assisting frail and low-income elders.

With custodial care being a predominant function of nursing homes, Brown Wilson examined the aspects which were most “institutional” such as shared bathrooms, communal showers and doors that don’t lock; all of which take away a very basic right to privacy.  She wanted to devise a way to keep providing medical and daily care for older adults while also providing them with the dignity and respect they so deserved.  She told the Oregonian in 2010, “We basically combined what I call the three Hs: health, housing and hospitality.”

Known by many as the “architect” of the assisted living model, Brown Wilson jumped through financial hoops in order to secure funding for what would become the nation’s first recognized assisted living facility in Portland Oregon. In 1981 Park Place opened its doors and was a hit from the beginning. “It did things that weren’t prohibited, but that weren’t popular (at the time), like let people have a lock on their door,” Brown Wilson said. By 1986, the model of ALs included 24-hour staffing to provide residents with personal and health-related services, but also offered expansive community area and activities designed to facilitate social-interaction.  The services provided by the facilities were individualized and could provide care ranging from medication administration and dementia care to incontinence maintenance.

Between the mid-90s and 2000, the number of assisted livings grew exponentially.  From mom and pop private establishments to large corporate (for-profit and not-for-profit) establishments, assisted living quickly became a mainstream option for aging adults.   Companies like Presbyterian Homes, Genesis HealthCare and Heartland have paved the way for advances in assisted living.

Best of Both Worlds: So, what exactly is an assisted living facility? Perhaps the best definition for assisted living can be found within Oregon’s care philosophy. It states: Assisted living… is a program that promotes resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and homelike surroundings. Often seen as the best of both worlds, assisted livings provide their residents with the privacy and comforts of home, but also provides the necessary means to assist in activities of daily living (ADL).  Most residents of ALs need more supervision and assistance than can be received at home without outside support, but do not require the intensive medical or custodial care that is provided in a skilled nursing facility.

Today, many ALs are not only able to provide assistance with basic ADLs but also provide medical care for those who are not sick enough to be hospitalized and don’t require the care of a skilled nursing facility. There is also a trend for ALs to offer physical, occupational and speech therapy to residents in order to allow them to maintain their highest level of function. This is particularly important for seniors whose goal is to age in place.

In addition to the “traditional” assisted living facility, personal care and board homes, group homes and residential care homes fall under the AL umbrella.   These small-scale facilities are usually located in residential settings and are privately owned.  In many states, these smaller facilities do not require the same staffing levels as required by the ALFs.

The regulations for any assisted living facility are state regulated.  Each state has set forth standards which the facilities must adhere to.  The Assisted Living Federation of America lists the specific regulations for each state.

Evolution of Financial Responsibility: In the beginning, assisted livings were geared towards those who could afford to pay for their care.  It quickly became evident that the masses were not in a position to be able to pay privately for the long durations.  Brown Wilson was not only instrumental in developing the first ALF, but also for developing the first assisted living program reimbursed by Medicaid.

In most states, low-income seniors can apply for Medicaid waiver programs which will help pay for home and health services in assisted living facilities.  Unfortunately, medical assistance does not usually cover room and board for assisted living. Often, residents are forced to give portions of their social security to the facilities as compensation.

Even though many senior citizens are living on a fixed income a vast majority still pay out of pocket for assisted living costs.  Most funds are drawn from savings, trust funds or investment accounts.  Others find their relatives willing to help pay for their long-term care. In addition to private pay options, long-term care insurance, veteran’s benefits and in some cases medical assistance can help cover the costs of assisted living.

Growth of AL: Since 1981, it is estimated that over 40,000 more assisted living facilities have been developed nationwide. The 1990s were a period of mass expansion as  In a Harvard faculty study published in the journal “Health Affairs” it was found that there is, on average, 23 assisted-living beds per every 1,000 people aged 65 and older across the United States.  This varies state to state and does not include facilities with less than 25 beds. The top three states for assisted living are Minnesota, Virginia and Orgeon with a combined total of 193 beds per 1,000 persons 65 and over,  whereas West Virginia, Connecticut and Hawaii round out the bottom three with only 13 beds per 1,000. The study also showed that the vast majority of assisted livings are located in wealthier and better educated areas and are less likely to be located in rural areas or those with minority populations.  The author of the study, David Stevenson, believes this is simply due to the fact that most ALs are paid by private resources.

SNF vs. ALF vs. IL vs. CCRC: The aging community today has more options than ever before when it comes to long-term care.  For many their ultimate goal is to preserve their health in order to stay in their private home as long as possible.

Independent Living (IL) communities provide housing for seniors who for all intents and purposes live, as the name implies, independently.  Many of these communities consist of private homes or apartments and offer only minimal assistance with home maintenance.  The underlying goal of many of these communities is to eliminate the social isolation that plagues many seniors as they become older.

Skilled Nursing Facilities (SNF) provide the most comprehensive care of all the senior house options.  Also known as nursing homes, SNFs are often a last resort for many seniors.  SNFs can can provide the 24/7  support that is needed for those in declining health who need more intensive medical interventions.  Skilled nursing facilities can also be a good referral source for assisted livings.  Many nursing homes now offer post-acute rehabilitation and some residents are able to regain enough functional mobility after and injury or illness that assisted living may be a viable option for housing.

The Continuing Care Retirement Communities (CCRCs) may offer aging seniors the most options.  The goal of these communities is to provide all levels of living and care to help ease the transition when failing health dictates a move to a higher level of care. Many CCRCs are private pay communities and after an initial lump-sum deposit, the cost for all levels of  care remain the same.  The goal of these settings is to provide a sense of community while helping aging seniors to keep living independently as long as possible.

AL Advocacy: Over the course of the years, several agencies have been developed to further the interests and protect aging Americans.  Without the support of these groups assisted living would not be what it is today and what it has the potential to be in the years to come.

CCAL-Advancing Person-Centered Living: Founded in 1995, CCAL is the only national assisted living consumer organization.  Its goal is to promote and foster person-center living practices by advancing policies and research.  Ultimately, helping to create a “a life centered on personal preference and values that stress dignity, choice, self-determination and individuality regardless of where they live and what services and supports they may need.”  Some of CCALs accomplishments since 1995 include:

  • Operated the only national telephone Helpline to assist consumers and healthcare professionals with questions, problems and advocacy needs related to assisted living. An internet component to the Helpline was added in 2000.

  • Published a consumer booklet, Choosing Assisted Living: Considerations for Making the Right Decision.

  • Served as the co-facilitator for the U.S. Senate Special Committee on Aging on an eighteen-month national initiative to develop assisted living recommendations

  • Pilot tested an innovative “Community Partnership” (CP) project, to build and strengthen collaborative relationships among residents, staff, and family members in assisted living communities.

Assisted Living Federation of America (ALFA): ALFA describes itself as the “is the shared voice of resident-centered, consumer-driven senior living and the seniors and families served. Through outreach, advocacy and media, ALFA informs the public and policymakers about the critical role senior living communities play to champion quality of life for seniors.”  It’s interesting to note that ALFA does not condone the use of the term Assisted Living Facility In fact, they believe that several commonly used terms are taboo in the industry. For example, they believe the terms house, residence or community should replace the phrase assisted living facility.  In addition words like unit or bed should be replaced by room or suite; or admissions and discharges should be replaced with move-in or move-out.

American Assisted Living Nurses Association (AALNA): AALNA’s goal is to promote effective nursing practice in assisted living such that nurses as well as residents benefit. It is the only association dedicated exclusively for assisted living nurses.  The organization is run by volunteer nurses whose goals include sharing best-practices, promoting the professional growth of AL nurses through education, research and public policy, and developing a network of AL nurse.

National Center for Assisted Living (NCAL): The NCAL is the assisted living branch of the American Health Care Association. Its goal is to serve the needs of the assisted living community through advocacy, education, research, professional networking and quality initiatives.   In addition to national advocacy, NCAL also fights for state-specific efforts

The Future: As the baby boomer generation ages, the need for sustained long-term care is going to be vital. Individual states which regulate ALFs may need to Assisted livings facilities will continue to be an integral part of the continuum of care. Each state will need to continue to enforce and establish new regulations to ensure the safety and well-being of society’s most vulnerable.  Perhaps one of most critical issues facing the future of assisted livings is funding.  With economic hardships hitting most or all Americans, states will need to continue conversations surrounding financial aid for the elderly.

As seniors continue to age in place, assisted living facilities will need to continue building strong relationships with outside agencies such as hospice and home health agencies.  Each of these levels of care may be vital for helping a resident remain in the assisted living even when their health is declining.  Without such agencies, the transition to skilled nursing centers is a realistic possibility for many.

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