Nursing Homes vs Assisted Living FAQ

A: The most common activities that AL residents need help with are bathing, dressing, and taking medications. While all NHs must provide assistance with these activities, not all AL residences are required to do so, though most do. It is critical that patients get in writing the personal care services that an AL residence under consideration provides, and if they are included in, or are in addition to the monthly fee. Some residences charge a flat monthly rate which covers housing and a minimum of personal care related services (e.g., daily dressing and weekly bath assistance) and charge extra fees, by the hour or by a flat fee, for assistance above and beyond the base level of care provided. Medication management may also be charged as an additional fee. The average monthly base price for an AL residence in 2003 was $2,379; monthly average base fees varied by state from $1,020 in Jackson, Mississippi to $4,429 in Washington, DC.⁵

Patients should be advised to inquire about the level of personal care assistance offered. For example, does the AL residence define "assistance with bathing" as having an aide present to supervise or does it mean hands-on help with washing? Again, the patient should request that the AL residence include the level of care provided in the contract, sometimes referred to as the "resident agreement".

A: Although AL is predominantly private pay, currently 50,000 adults who require a NH level of care are reimbursed through Medicaid waivers for AL health-related expenses.⁶ This is in stark contrast to Medicaid's reimbursement of 1 million adults in NHs.⁷ The majority of states (n=42) offer Medicaid waivers for AL health-related services but the reimbursement is very limited; states limit the number who may qualify at any one time.⁸ If research can demonstrate that AL is a cost efficient alternative to NH care for lower acuity patients, an increase in government reimbursement may follow.

Not all AL residences that accept Medicaid, however, will offer the services that can accommodate a patient's scheduled and unscheduled needs. For example, for a patient with Type II diabetes, would appropriate staff be available to give a diabetic patient an insulin injection at 2:00 am if required? Some state regulations do not allow staff to give injections or allow only specific types of injections (insulin as opposed to intramuscular). Can they offer a special diabetic menu or does the AL residence only provide a standard diet? Can the residence or an outside agency offer wound care if needed? Some states (e.g., Florida) allow an AL residence to manage routine dressings that do not require packing or irrigation.

A: Yes, but the services provided under "self-administering" can vary, depending on state regulation. For example, in New York State, self-administering includes prompting, identifying the medication for the resident, bringing the medication to the resident, opening containers, positioning the resident, disposing of used supplies, and storing the medication. In Florida, the regulations also allow for guiding the hand to the patient's mouth. Some states have strict guidelines that require that only a licensed nurse administer medications (e.g., Delaware); but most states, including New York, allow unlicensed staff if they have received formal training and are under the supervision of a RN. These aides are commonly referred to as medication technicians ("med techs"). To reduce medication errors, some states (e.g., Connecticut), require a review every 90 days by the prescriber, pharmacist, or registered nurse.

Be sure that your patient discusses what medication services (e.g., ordering, administering, monitoring) are provided by the residence, whether they have a quality assurance program, and whether additional fees are involved. If referring a patient who may need emergency medications, the family should inquire whether the residence can handle this request. Patients should be advised to inquire if an AL residence has staff to provide full 24-hour service to address care needs, including medication assistance (as opposed to having only a concierge-type person on duty.)

A: Experts state that individuals with dementia function better in familiar, home-like settings, with individualized care plans (e.g., choice in AM wakeup time or food selection). AL can offer individuals in moderate stages of dementia needed ADL assistance, supervision, and medication management. It is only in the late, more advanced stages of dementia that skilled nursing care is usually required. Several issues, however, must be addressed, including behavioral management, the need for assistance with evacuation during an emergency, and wandering and elopement. Approximately 25% of all AL residences have separate units, referred to as special care units, dedicated to serving adults with Alzheimer's and related dementias. At least 30 states have regulations⁹ pertaining to these units, including criteria on

• admission and retention
• assessments
• individual care plans
• physical design
• egress control
• staff ratios
• staff training
• therapeutic activities

Arkansas and Maine have some of the most comprehensive guidelines for special care units, addressing the environment, programming, staffing levels and dementia-specific education. The vast majority of residences, however, charge a higher fee per month for special care units than for tenancy in a regular AL. Physicians can advise patients to contact their local
 Alzheimer's Association for help with choosing an appropriate long term care facility in their community.

A: It depends on both the state regulations and on the AL residence's individual policy. For example, in New York, an "enhanced" level of AL allows for residences to admit and care for more impaired residents, including those that "are chronically chairfast and unable to transfer, or chronically require the physical assistance of another person to transfer." Other states (e.g., North Dakota) specify that AL residences are not allowed to admit or retain residents who need either a one or two person transfer. Some AL residences have been documented, either through Department of Health inspections or through exposes in the press, to retain residents whose acuity levels surpass the state regulations. At times, this occurs when the residence does not have sufficiently trained staff to provide adequate care. For example, many AL residences (even if the state law does not allow) will assist with a one person transfer; the two person assist requires more staffing, and many states do not allow the use of lifting equipment (e.g., Hoyer lift). Consequently, a resident requiring a two person assist in an AL may not be transferred to and from a wheelchair, toilet or bed as often as needed, putting the resident at risk for negative outcomes (e.g., pressure sores).

In comparison, NHs accept and retain residents who are wheelchair users and need transfer assistance. In general, NHs provide care for a more impaired resident population; the average resident is dependent in 4 ADLs.¹⁰

A: There is a heated debate in the long term care industry regarding the appropriate type and length of time (e.g., 14 days) for nursing services in AL. State regulations run the gamut, from limited (e.g., medication administration, urine tests, routine dressings that do not require packing or irrigation), to intermittent (e.g., change of colostomy bag , catheter care, administration of oxygen, routine care of an amputation or fracture, prophylactic, and palliative skin care), but most states do not allow for on-going 24-hour skilled nursing care (e.g., stage III or IV pressure sores, ostomy care, ventilator care). Some states specify conditions or services that are not allowed in AL residences, including serving residents who are bedridden for 14 consecutive days or more, have stage III or IV ulcers, are ventilator dependent, or need feeding tubes. Other states specify that 24-hour care can be provided if the residence meets certain criteria. For example, an "enhanced" AL residence in New York may serve a patient in need of 24-hour skilled nursing care or medical care if:

• The resident hires appropriate nursing, medical, or hospice staff to meet his or her needs.
• The resident's physician and home care services agency determine and document that the resident can be safely cared for in the residence.
• The AL provider agrees to retain the resident and coordinate the care of all providers.

To view the AL regulations in the state where you practice  click here.

A: No. Unlike nursing homes, the majority of states do not require AL residences to have any nurse (RN or LPN) on duty, day or night. Seventeen states specify some type of nursing involvement, especially states that allow for higher acuity levels.¹¹ For example, Montana has three levels of care; the highest level must employ or contract with a RN to provide or supervise nursing services. Of the 17 states with nursing staff regulations, the majority only require nurse availability "as needed", including on call availability for provision of certain nursing duties (e.g., care plans, medication supervision, nursing services). A residence, however, may decide to employ a nurse even though it is not a state requirement. According to a national study of AL residences (1998), 71% of AL residences had a full- or part-time RN or LPN on staff. Slightly more than half (54%), however, reported that they would only provide some nursing services (e.g., taking blood pressure, urine tests) with outside agencies performing additional needed services.¹²

Because the acuity needs of AL residents have increased over the past decade, organizations such as the Consumer Consortium of Assisted Living recommend that residences have a nurse on staff. State policy trends in assisted living appear to be moving toward the delivery of more health care services, which will necessitate more nursing staff involvement. Some physicians advocate for using Medicare Part B.

Additionally, as with nursing services, AL residences are not required to provide or arrange for medical services (e.g., physical therapy, podiatry, physician visits, or dental hygiene), but some do. The American Medical Directors Association calls for more physician oversight, stating that "many individuals moving into AL residences are cognitively impaired and/or have multiple illnesses that require some type of physician oversight and care-the type of care that is not currently required by most states."¹³

Patients and their families should clarify if AL staff (e.g., nurse or social worker) will be providing case management services, including calling for appointments, coordinating the medical visits, and informing the physician of changes in the resident's medical status. AL residences may not be sufficiently staffed to provide case management and the responsibilities may fall on the patients and their families.

A: No. Many states require that aides have some training, but do not mandate that the training take place before providing resident care. According to a national study on AL, only 11% of the aides completed required training prior to the start of work.¹⁴ In comparison, aides in NHs are required to have a minimum of 75 hours of training (10 days) and to pass an exam before they can provide direct resident care. Most AL aides receive either on-the-job training, pre-service training or a combination of the two. The most common amount of required training is between one and 16 hours of training.¹⁶ Some states mandate specific course content (e.g., first aid, resident rights, infection control, emergency evacuation, ADL care); however, no exam is required for unlicensed aides. Additionally, many states do not mandate specific staff-to-resident ratios, but only staffing "sufficient to provide the care needed by residents."

A: The most common reason for discharge is to move the resident to a NH for a higher level of care. This brings up a critical issue: under what circumstances will a patient be discharged? Many AL residence's marketing materials state that residents will be able to "age-in-place" and never have to move, but in reality, that is not the case. State policy generally specifies the range of allowable services, but AL residences are not required to provide all the services allowed by law. Patients and their families should inquire (and have written documentation if they sign a contract) about an AL's discharge policy. For example, is the residence licensed to, and do they have sufficiently trained staff to be able to safely retain a patient who, during their tenancy;

• needs assistance with walking
• uses a wheelchair
• needs help with transferring (one or two person assist)
• has urinary or bowel incontinence
• needs nursing care for more than 14 days
• has moderate to severe cognitive impairments

A: Yes. Even though there is considerable overlap among patients in AL residences and those in NHs, most AL residences do not have professional staff that can take care of patients with unstable medical conditions that require frequent observation, assessment, and intervention by a licensed professional nurse, including unscheduled nursing services.