Assisted living facilities (ALFs) may be going the way of cable TV. Still around, but with a limited future.
Their residents are changing. Even as their needs become more complicated, they are demanding less institutional-like care. At the same time, assisted living will have to find its place in a world where medical and social care are becoming better coordinated and providers will be expected to organize themselves in very different ways than today.
Assisted living was once a creative alternative to nursing homes. Soon, something new will replace ALFs. The details remain uncertain, but we can begin to see what this new model of residential care will look like.
Today, assisted living is a hybrid. It provides more care than independent living but less than a nursing home. Yet, residents often think of ALFs as institutions rather than homes. Assisted living is not a Medicare benefit and facilities are paid by Medicaid in only very limited circumstances. They are not regulated by the federal government, but are subject to state rules, which vary widely.
At their best, they are less costly and more homelike than nursing facilities, and a way for seniors (and some younger people with disabilities) to live in a cost-effective and safe environment. At their worst, they fail to provide needed services to residents who require much more than a room, meals, and Bingo.
ALF residents are quite sick, often with multiple chronic illnesses. Four in ten have dementia (a higher percentage than nursing home residents), one quarter suffer from depression, one-third have diabetes, and more than half have high blood pressure.
And they have significant care needs. Sixty percent need help bathing, more than half need assistance walking. More than one in three can’t get to the bathroom on their own, and one in five needs help eating, according to the National Study of Long-Term Care Providers (NSLTCP). ALFs are, in many ways, the new nursing homes.
How do they meet the needs of their residents? By some measures, not very well. One in five residents will visit an emergency department in a 12 month period and nearly 24 percent will be hospitalized, the NSLCP reports. Vicki Freedman of the University of Michigan and my Urban Institute colleague Brenda Spillman find (firewall) that 42 percent of ALF residents will experience an negative event as a result of having care needs unmet. For instance, they commonly wet their clothes because they can’t get to the bathroom without help.
As nursing homes abandon the long-stay business for more lucrative post-acute and rehabilitation patients, Baby Boomers will need an alternative. But not today’s ALFs. What will assisted living look like in 2020?
Fewer operators: As payments are squeezed, small and medium-sized providers will close or be acquired by larger operators. Many small not-for-profits will disappear.
Better integration with medical providers. The business model of ALFs has been based on social supports rather than health care. But health systems are looking for partners who can provide social and quasi-medical services (such as medication management) and even rehab in lower cost settings. In that environment, ALFs might participate in Accountable Care Organizations or bundled payment arrangements where they share revenue—and risk—with traditional health systems, insurance companies, or large physician practices.
The idea of such integrated medical care is not new—the Erickson continuing care communities have had their own Medicare Advantage plan for years—but it has generated limited interest—so far.
Person-centered care: No, that doesn’t mean Wi-fi or updating the elevator music from Glenn Miller to the Beatles. It does mean customizing care for residents.
Fewer heads in beds: The old business model was based on filling rooms. The new one may focus on virtual assisted living that delivers services to people living in the community rather than in its buildings. For instance, it could mean contracting with apartment complexes to provide services such as medication and case management, as well as home health. Or building relationships with local faith-based organizations or senior villages to provide community-based care. Call it home care-plus.
Harvard Medical School professor David Grabowksi and colleagues have interviewed industry executives to learn their view of the future. The results of their study are preliminary, but they’ve found the business may split into two models: One focused on housing and hospitality; the other on integrated delivery of medical and social care.
Industry leaders told David and his colleagues that risk-sharing with health systems is “inevitable” though there have been no deals with medical providers yet. While firms are exploring health information systems, none had yet acquired the IT necessary to share data with health systems or even track utilization in their communities.
For these changes to take hold, states will have to rethink their regulatory structures. Assisted living operators are unlikely to better integrate with health systems if it requires a skilled nursing license. Balancing consumer protection and innovation will be a big challenge.
As with health care, senior services face an environment of enormous disruption. Some providers will embrace it. Others will be destroyed. For consumers, it might mean more choices and a better quality of life.
Howard in your article you brought up ALF working with ACOs and offering medication management and increasing medical care for their residents. Today, less than 17% senior care facilities have some kind of EMR. Ones with EMR are usually connected with more advance care organizations. We do not have to wait into the future. Our platform – ZibdyHealth offers a complete medication management and many more patient care services for completely free. It is free for the patient, provider or payer. Any caregiving organization can adopt our platform and offer those services to their members in less than 10 minutes. A caregiver at ALF can manage senior’s health and link them back to their family via ZibdyHealth so that family can monitor health of their loved one remotely. http://www.zibdy.com/Blog.aspx?PostID=er6y3sh678a64 and http://www.zibdy.com/Blog.aspx?PostID=er4t3er56ry64.
Some very good points made!. Over 90% of people wish to remain in their homes (at least until it become impractical). No one really wants to go to a SNF. That leaves a lot of blurred lines between those choices as shown by ALFs extending their care options further (and naturally charging for them). Who is to say what other choices may appear as options? Just look at the explosion of home service providers to address the market need for service help to keep people at home. On the product side there is also a need for innovative products for that same population (hence my “Friendly Beds” to help with bed mobility). Your point is well-made- who knows what the future holds for the typical ALF world of today? It will have changed or evolved into different factions unlike today’s facilities.
It is really interesting to think how assisted living will work in the future. I think that focusing on care that is delivered to your home, over the facility itself, is a good idea. As long as the elderly get the care they need, that is what is important.
It’s interesting how there are assisted living business models that are changing. Contracting with an apartment complex to provide services like medication, case management, and home health seems like a great assisted living option. That would be a good option for my mom since she still wants to live independently. I should consider that to make sure that she gets the care that she needs.
Un des joueurs avec un contrat expirant (voir liste ci-dessous) est meneur Jeremy Lin.