Kaiser Health News has reported that an expert panel studying America’s assisted living facilities (ALFs) finds that such facilities these days are often coming up short on meeting the shifting needs of residents who are tending to be older and in more compromised health.
“It’s a clarion call for change,” said Kaiser, signaling a need to give more attention to residents’ medical and mental health needs than what has typically been the case. Kaiser cited National Center for Health Statistics that say 55% of ALF residents are 85 and older, 77% require help with bathing, 69% with walking, and 49% with toileting. Plus, more than half have high blood pressure, a third or more have heart disease, and nearly a third suffer from diagnosable depression. Upwards of 40% have dementia or moderate to severe cognitive impairment. This last statistic is confirmed in research also done by the Alzheimer’s Association.
A spokesperson for the expert panel studying the issue said, “The nature of the clientele in assisted living has changed dramatically,” but there are no widely accepted standards for addressing these evolving physical and mental health needs. The panel report made more than 40 recommendations to address the gaps in care, based on input from patient advocates, assisted living providers, and specialists in medical, psychiatric and dementia care.
Recommendations for improving care at Assisting Living Communities
More and better trained staffing was a key recommendation. However, ALFs have, like nursing homes, found it difficult to recruit and retain staff, especially in the aftermath of the COVID-19 pandemic and with changes in job preferences among the labor force. Reports were not uncommon of having only one professional staff on hand at night in an ALF for 30 to 40 residents. Also recommended was better training of staff in managing dementia, other mental illness, and end-of-life care in general. Regarding the mental health issues, the expert panel also recommended that incoming ALF residents receive formal cognitive assessments. The panel further advocated that facilities have policies in place for managing disruptive/aggressive behaviors of residents, with an emphasis on protocols that do not automatically turn to medication as a first resort.
Kaiser observed that assisted living has long been envisioned as a “social” model with a home-like setting, complemented by help with comparatively simple daily tasks such as bathing and dressing, plus opportunities for interaction with other residents. One expert panel member suggested this model may be “outmoded” now, or at least not as uniformly fit for all residents. Nonetheless, the panelists agreed they do not want assisted living to become a “medical” model—meaning more like nursing homes—even as ALFs take steps to better manage the medical/mental needs of residents.
The assisted living picture in Colorado
According to the Denver Regional Council of Governments (DRCOG), there are more than 600 assisted living facilities in Colorado, with approximately 350 ALFs in the Denver metro area alone. These facilities range in size from a handful of residents to sometimes close to 300. (DRCOG is an Area Agency on Aging and an AgeWise Colorado Provider.)
An estimated 15% of Coloradans—or roughly 900,000 residents—are age 65 and over, and this population cohort is the fastest growing in the state. Those numbers are projected to double by 2050. According to caring.com, approximately 76,000 Colorado seniors have Alzheimer’s disease or another form of dementia. That figure is expected to rise by 20% in the next five years. There were close to 2,000 deaths from Alzheimer’s in 2019, making it the 6th leading cause of death in the state.
Action by the Colorado legislature
In an effort to ensure that assisted living residents are receiving the highest quality of care, Colorado lawmakers in 2022 passed legislation mandating dementia-specific training for professional caregivers in assisted living communities and some other long-term care settings. The bill, SB22-079, requires the State Board of Health in the Department of Public Health and Environment (DPHE) to adopt rules requiring nursing care facilities and assisted living residences to provide dementia training for staff who deliver direct-care services to clients and residents of such facilities. (A similar training requirement applies to staff in adult day care facilities.)
The legislation cited statistics indicating that in Colorado 48% of nursing facility residents and 42% of clients in residential care facilities, including assisted living residences, have dementia. These numbers were given as one reason why better training in care for these populations is important. The legislation’s text observes that “training has the dual benefit of supporting direct-care staff and increasing the quality of care provided to residents or program participants to whom they provide care.” It also notes that staff turnover in care facilities is an ongoing challenge, and “dementia training can more adequately prepare direct-care staff for the responsibilities of these jobs, potentially reducing stress, staff burnout, and turnover.” Plus, it is the direct-care staff who make up “the single most important determinant of quality dementia care across all care settings.”
Specific dementia-care training required in Colorado
The legislation directs the State Board of Health to lay out specifics for covered facilities such as what the length and frequency of dementia training will be, who among the staff should be trained and in what timelines this training will be done, and requirements for continuing education in dementia training. The training itself must include the following topics: a) dementia diseases and related disabilities; b) person-centered care; c) care planning; d) activities of daily living; and e) dementia-related behaviors and communication. Continuing education must include information on best practices in the treatment and care of persons with dementia disease and related disabilities.
Colorado Gov. Jared Polis signed the bill into law in May of 2022. The rules take effect on January 1, 2024. Deborah Lively, director of public policy and public affairs at LeadingAge Colorado, was quoted as saying some covered facilities are already voluntarily conducting more dementia-specific training than this law will require, whereas others, including assisted living communities that operate secure memory care units, already are required under federal and/or state regulation to do some of what this new law requires in terms of training.
The main purpose of the law, Lively said, is to set a dementia training “floor” for staff members in the specified care settings. This will fill in the parts of the dementia training requirement that each setting is not already required to do. The law also will help ensure that when residents move from one care setting to another, they and their families will know that staff members have at least that minimum level of training. Lively also noted that while LeadingAge Colorado helped with drafting the bill, there is a concern that the legislation does not yet provide additional funding for the training it requires. Without that funding, the associated training costs could burden the care facilities.
Other measures guiding assisted living in Colorado
DRCOG has published information about other steps Colorado takes to monitor and/or improve quality of care in ALFs. The Ombudsman Program, for example, is a resource people can consult when choosing an ALF or seeking help with its quality of care. DRCOG says this is a free advocacy program for residents of ALFs “who might feel powerless and vulnerable.” Learn more and locate your regional ombudsman at https://www.coombudsman.org/.
Every long-term care facility in Colorado has an ombudsman assigned to visit and investigate complaints from family and residents. Ombudsmen are required to visit assisted living residences at least once every three months. DRCOG states that “long-term care ombudsmen are responsible for educating residents, family members, and care providers about the rights that residents have been granted under federal and Colorado law.” These advocates are trained to identify issues affecting resident rights and are ideally suited to provide information to consumers when selecting long-term care facilities.
DRCOG says that in addition to providing room and board, a Colorado ALF must also provide at least the following services: personal care services, protective oversight, social care, and regular supervision available on a 24-hour basis. Personal care services include a physically safe environment, supervision, and assistance with activities of daily living (referred to as ADLs) such as medication administration, bathing, dressing, and toileting.
“Protective oversight” includes “monitoring the needs of residents to ensure that they receive the services and care necessary to protect their health, safety, and well-being.” Some ALFs, known as secured facilities, also have locked doors to prevent residents with dementia from leaving the building, and some specialize in providing care to such residents.
ALFs with more than three residents who are not related to the owner of the facility are required to be licensed by the Colorado DPHE. Facilities that accept Medicaid payments must also be certified by the Colorado Department of Health Care Policy and Financing. Also in Colorado, assisted living residences are surveyed by DPHE at least annually, and results of the survey are available to the public and accessible on the DPHE website (https://cdphe.colorado.gov/assisted-living-residences).
Staffing in Colorado’s assisted living facilities
Again according to DRCOG, staffing in Colorado’s ALFs may differ based on the needs of the residents. ALFs often try to provide a home-like environment while providing 24-hour non-medical supervision. In smaller homes, it is common for the owner to be directly involved with resident care. Larger communities, by contrast, have an administrator who is responsible for the overall management and daily operations of the facility, and various staff members provide direct resident care.
ALFs are required to have at least one staff member onsite whenever residents are present, 24 hours a day. However, there are no state-mandated staff-to-resident ratios. Rather, “an assisted living residence must employ the type and number of care providers necessary to operate the home in compliance with Colorado Department of Public Health and Environment regulations.” If the facility accepts Medicaid, the federal government requires a staffing ratio of 1 staff member to every 10 residents during the day, and 1 staff member to every 15 residents at night. The staffing ratio for a secured environment is 1 staff member to every 6 residents.
Staffing at ALFs generally includes Qualified Medication Administration Persons (QMAPs), whose responsibility it is to distribute medication to residents. There has been an increase in assisted living residences having either a Licensed Practical Nurse (LPN) or Registered Nurse (RN) on staff. They typically are given the title “wellness coordinator.” They oversee the medication program and the QMAPs. As of November 1, 2008, all assisted living communities are required to have on site at all times at least one staff member who has been trained in cardiopulmonary resuscitation (CPR) and first aid. They are also required to have training in lift assistance.
Steps to selecting an assisted living facility in Colorado
What is the best approach to selecting an ALF in Colorado? DRCOG offers a number of suggestions. Here are some of the key ones:
Think about what location will be best for the resident and what size facility. Confirm an ALF’s age requirements, if any. Ensure that the level of care needed will be provided, including special needs the resident will have. This can encompass things like therapeutic diets, assistance with mobility, medication administration, continence issues, and managing specific disorders like dementia and Alzheimer’s.
What to look for when you visit a prospective facility. Visit facilities at least twice. The first visit should be scheduled with the admissions office. The second visit should be unannounced, perhaps in the evening. Among things you should look for: Is the facility clean? Do you smell any odors? Get permission to view a resident’s room, bathroom, and shower. Are they clean and equipped with grab bars? Is there a home-like atmosphere to the resident space? Is there adequate privacy? Visit during a meal and see if the posted menu reflects what the residents are eating. Are the residents served their meals promptly? Is the dining area clean and pleasant?
Observe and talk with residents and staff members. Ask the residents about the care they receive. Do residents respond well to the staff members? Do staff members seem to respect and enjoy the residents? Are staff members wearing their identification badges? Do they respond promptly to requests for assistance? Are call lights within the resident’s reach?
Are the residents clean and well groomed, up and active during the day, engaged in activities and interacting with one another? Ask to see the activities scheduled for the month. What does the facility do to promote resident-directed care? Are residents involved in their own care planning? How much autonomy do they exercise in their daily routines? How is transportation provided and how comprehensive is it?
Ask how much training each staff member receives and who provides it. Does it include training for specific needs of residents? Also ask about the staff turnover rate. A “consistent staffing method” is a scheduling practice where the same care providers work with the same residents so that the staff can anticipate the residents’ needs. Note that if you are visiting without a tour guide, someone should tactfully inquire about your presence at the facility. This is an informal security measure.
Learn about the facility’s management and administration. Is it appropriately licensed? Is the facility locally owned or part of a large national organization? Ownership of a facility could reflect how responsive the facility will be to your concerns or complaints. How long has the administrator been at the facility? Beware of frequent changes in key administrative positions or ownership. Read the most recent state survey. Facilities are required to make the survey available to residents and visitors. As mentioned earlier, survey results are also available on the Colorado DPHE website (https://cdphe.colorado.gov/assisted-living-residences).
Understand the facility payment system and determine how you or your loved one will pay for the housing and care needs. ALFs accept a variety of payment sources, including Medicaid, Medicare, long-term care insurance, and private pay. It is important to note that Medicare pays for long-term care only under specific circumstances. Understand the daily rate. Some ALFs offer a “menu” of services that detail costs associated with each service provided. Other assisted living residences will assess residents and assign them a “rating” and base the cost of services on where they fall in a spectrum. Some facilities will ask relatives of potential residents to assume responsibility for expenses that are not paid in full by the resident. Before agreeing to be held financially liable, you should consult an elder law attorney.
Before finalizing your decision . . .
Read the contract or admission agreement completely and thoroughly. It is a binding legal document. Arbitration clauses are becoming more common in admission agreements. By signing an arbitration agreement, you are waiving your right to sue the facility if you are not satisfied with the care your loved one receives. Consult with an attorney if you have questions.
Review the facility admission policy. This policy should include what resident care a facility can and cannot accommodate. Prior to admission, the facility should conduct an admission assessment to identify the care needs of the future resident. Equally important, understand the facility discharge policy. Discharge practices are governed by state and federal regulations. This policy should explain how and why discharge notices are issued and clearly state that the notice must be in writing. Ask under what circumstances your loved one could be asked to leave.
Read and understand all facility policies and procedures. These may include a bed-hold policy, termination clause, the type of transportation that will be provided and at what rate, therapeutic diets that are offered and at what rate, emergency protocols, and evacuation plans.
And remember you can always contact your local ombudsman, who will be able to assist you in finding a facility that best fits your or your loved one’s needs. See https://www.coombudsman.org/. The service is free to residents and their families. Ombudsmen help ensure the health, safety, welfare, and rights of residents living in long-term care facilities. If a problem does develop after admission, you can contact your local ombudsman for assistance and information.