Media reports commonly refer to the field of assisted living with terms such as “new” and “innovative.” But it is only the rapid expansion of the assisted living market over the last decade that is new. In the United States, the first residential care sites that could properly be called “assisted living facilities” arose more than 20 years ago. Since then, the field has expanded rapidly to encompass a diverse array of residential care settings serving an increasingly diverse senior population with increasingly complex health care needs. Here we’ll look at major trends and developments in the rapidly expanding field of assisted living, including recently compiled federal data on assisted living providers and residents, the prospects for new or expanded Medicare and Medicaid coverage of assisted living services—and persistent medication management challenges that will make assisted living an increasingly important senior care practice setting in the years ahead.
Facility and Resident CharacteristicsIn 1998 the U.S. Department of Health and Human Services (HHS) compiled the first empirical data set describing the assisted living field.The HHS survey data demonstrates that assisted living covers a wide range of facility types, including congregate housing, basic care facilities, and rest homes that look and feel like nursing homes yet fall under different regulatory control.1 The HHS survey found that the average length of operation for assisted living facilities was 15 years, but approximately 58% of facilities had operated for 10 years or less.1 Forty-eight percent of housing units were rooms, as opposed to apartments; of these rooms, 43% were private. Seventy-five percent of all assisted living units, apartments, and rooms were private. Ward-like rooms comprised 3% of all living units.
Assisted living units accounted for approximately 75% of new senior housing in 1998. The National Center for Assisted Living (NCAL) estimates that 25,000 facilities currently house close to 800,000 seniors.2 In 1998, the assisted living market grew an estimated 15%–20%.1 Close to 60% of new residents of assisted living facilities move to the facilities from their private homes.3 Most residents require assistance with one or two activities of daily living (ADLs). However, one-third of residents decline assistance with personal care.2 In contrast, nursing residents on average require assistance with three or more activities of daily living.4 Many assisted living facilities still lack a sound operational policy and procedural framework for optimizing residents’ cognitive and functional abilities, much less quality improvement programs to enhance resident care. In the HHS survey, 21% of facilities reported that they were not providing any care or monitoring by a licensed nurse, but 40% reported in the same survey that they employed a full-time registered nurse.
Medication Management: Still a Major ChallengeWhile nursing services are not provided 24 hours per day, assistance with medication administration is often provided. Assistance may take the form of a reminder, supervision, or administration by a staff member. The staff member administering medications is often a high school graduate, possibly with additional training mandated by the state. Almost one-half of all assisted living residents identified in a recent NCAL survey were receiving some type of assistance with medications. Several years ago, a study of 12 Massachusetts assisted living sites revealed that approximately 47% of those residents were receiving assistance with consuming medications. On average, those residents took 5.48 medications daily.5Some assisted living facilities use a single-source pharmacy and implement pharmacy policy and procedures similar to those typical in skilled nursing facilities, including drug regimen reviews. However, in many assisted living facilities the residents choose their own personal pharmacy and are not offered the benefit of consultant pharmacist services and drug regimen reviews on a facility or resident level. Several facts suggest that drug regimen reviews and medication pass observations performed by consultant pharmacists should be an integral part of residents’ services:
Regulatory DevelopmentsThe regulation of the fast-expanding assisted living field is so nascent that state regulatory agencies still do not agree on basic terminology and definitions. Currently, regulation is found under at least 25 different headings, including “congregate care” and “adult home care.”8 The North Dakota Legislative Council staff for the Budget Committee on Long-term Care has attempted to refine definitions for congregate housing, assisted living, and basic care (Table 1).
In general, states are choosing residential regulatory models over institutional models; thus, the residential setting, not the provided services, drives the regulations created. Predominantly, licensure and certification define the current assisted living regulatory environment. Licensure and certification rules specify requirements for the facility environment, admission and discharge procedures, staffing levels, and staff training.8 In the case of new regulation, a great deal of technical assistance is necessary to retrain assisted living facility administrators who have not kept current on industry changes or don’t have the support personnel available to administrators employed by larger companies. Many “pro-market” assisted living advocates oppose regulatory requirements that closely resemble nursing home regulations, which, despite major revisions implemented in 1999, still focus more on structure and process instead of outcomes reflecting the quality of care. These market leaders believe that regulations should measure regulatory compliance with outcomes such as customer satisfaction, quality of care, and quality-of-life indicators. Further, they say, this approach would encourage creativity among the newer entrants into the market, thus allowing the market to regulate itself by leveraging its own forces to maintain and improve quality of care.2 In October 1999, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) released for comment proposed new assisted living quality-of-care standards in its Comprehensive Accreditation Manual for Assisted Living. It remains to be seen whether the assisted living industry will use and accept the JCAHO standards as the benchmark for quality service.
State Legislative InitiativesIn 1998 Oklahoma became the first state in the country to mandate regular medication reviews by consultant pharmacists in all assisted living facilities, largely as a result of aggressive lobbying efforts by the Oklahoma ASCP Chapter. The Oklahoma regulation stipulates that in all assisted living facilities throughout the state, “medications shall be reviewed monthly by a registered nurse or pharmacist and quarterly by a consultant pharmacist.”North Carolina has also moved to tighten state oversight of assisted living. In 1998, adult home care survey data repeatedly showed medication administration error rates exceeding 20% in assisted living facilities.6 The data prompted a series of newspaper “exposes” published in Raleigh’s News and Observer. As a result, S.B.10, the “Long-term Care Safety Initiative,” was signed into law by the governor on July 21, 1999.9 The bill mandates that the state’s Medical Care Commission adopt rules that “decrease the medication error rate in adult care homes to an acceptable level” by:
The Medical Care Commission wrote a set of temporary rules with a currently proposed effective date of July 1, 2000. An entire section of the rules applies to medications, including facility policy and procedures; medication orders; medication labels; medication administration, storage, and disposition; controlled substances; and pharmaceutical care and pharmacy services. In general, the rules mimic the requirement for nursing facilities in many ways.10 Unlike the majority of states, North Carolina chose a regulatory path that exhibits the kind of rigidity imposed on nursing home pharmacy services. On-site medication reviews are required at least every 90 days. At this time, the rules permit a pharmacist, registered nurse, or physician to complete the medication review. The rules consider the medication review to be a part of the “pharmaceutical care” and “pharmaceutical services” provided to the residents and state, “pharmaceutical care involves the identification, prevention and resolution of medication related problems.”12 In the ideal assisted living residence, where residents retain high levels of independence, autonomy, and dignity, these regulations may appear to be excessive. However, Jan Brickley, pharmacist consultant with the North Carolina Division of Facility Services, believes these regulations are very necessary. First, Brickley notes, residents’ medical problems and medication regimens are often very complex—in many cases, comparable to those encountered in nursing facility populations. Second, the low level of training of many assisted living caregivers and the lack of professional oversight by licensed occupational health care workers further compound the risk of medication-related problems, she notes. Several hearings that took place in January of this year gave assisted living stakeholders an opportunity to discuss these and other concerns. Of paramount concern to consultant pharmacists in North Carolina is the likelihood that nurses will be permitted to perform drug regimen reviews.
Funding InitiativesThe increasing size of the frail elderly population is creating a political environment conducive to initiatives to establish and/or expand Medicare and Medicaid coverage of assisted living services. By 2030, persons 65 and over will represent 20% of the entire U.S. population. Today, there are approximately 34.7 million Americans 65 years and older. In only 10 years, that number will increase by 4.7 million, to 39.4 million.11
With steadily increasing life expectancy, the proportion of seniors with disabilities continues to grow, as does the number of seniors requiring more intensive personal care and nursing services. As has been the case with nursing facility populations, the assisted living resident population will probably be characterized by decreased capability to perform ADLs, as well as increasing complexity of medical problems and medication regimens. According to 1987 statistics, 72% of residents in nursing homes required assistance with three or more ADLs in 1987. The proportion of residents requiring assistance with three or more ADLs increased to 80% in 1996.12,13 Some states attempting to contain the cost and meet the escalating demand for nursing home services have moved to substitute assisted living care for nursing home care. For example, New Jersey assisted living regulations implemented in 1996 require 20% of residents in newly licensed facilities to meet nursing home criteria by the end of the third year of licensure.8 Private funds still pay for an estimated 90% of assisted living services. However, 50% of states now provide some type of reimbursement for assisted living, including Medicaid funding.3 On the whole, state and federal funds are available to pay for a very limited number of assisted living services. But this is likely to change with the escalating cost of nursing home care. Medicaid expenditures on nursing facility services increased from $15 billion in 1992 to $17.4 billion in 1995.12 Medicaid is the largest single source of nursing home reimbursement. Due to the increasing cost of nursing home care, state regulations often permit a higher level of care to be provided in assisted living facilities than most administrators would choose to offer. Many policy makers consider assisted living a less expensive alternative to nursing home care. These same budget-conscious policy makers may not have considered that assisted living may also become a convenient substitute for informal care provided by family and friends. The monthly cost of care varies with the fee structure of the assisted living facility. Some facilities use an all-inclusive rate for room, board, and services. Others use a basic rate, with add-on fees for each additional service chosen. In addition, the resident may have to resort to outside sources to obtain other services such as physical therapy, home medical equipment, and pharmacy services.
A Field Ripe for Greater Pharmacist InvolvementPharmaceutical care involves the identification of potential and actual medication-related problems and subsequent planning and intervention and ongoing evaluation by the health care team to improve a resident’s quality of care and quality of life. Optimizing medication therapy fits nicely into the holistic philosophies of care espoused by assisted living market leaders and industry experts.7
A number of major pharmacy and health care services companies, including Cleveland-based NCS Healthcare and Tampa, Florida–based PharMerica Inc., have already leveraged their expertise in drug therapy to develop attractive wellness programs for assisted living facilities.14 NCS offers a pharmacy-based wellness program called “LiveWell.” The PharMerica program is “Leisure Care.” It is not only their experience in managing drug therapy and dispensing in long-term care that puts consultant pharmacists in an ideal position to be key players in the growing field of assisted living. Their experience achieving full compliance with complex long-term care regulations makes the pharmacist a valuable asset to administrators, nursing directors, and executives. Pharmacists possess three core competencies in long-term care settings: medication regimen consulting, medication dispensing and administration expertise, and management of regulatory compliance. Now it is incumbent upon consultant pharmacists and dispensing pharmacists to step up their efforts to “sell” these skills in the assisted living environment with the goal of improving and maintaining quality of care and quality of life for assisted living residents.
References
American Society of Consultant Pharmacists. | |||||||||||||||||||||||||
