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Assisted Living Goes Under the Microscope

The tremendous growth of the assisted living industry in the 1990s has been well-documented in popular media coverage and industry trade press. Although there are still tremendous opportunities to educate the marketplace, it is clear that in a relatively short period of time, assisted living has become recognized as a key component of the U.S. long-term care continuum by policy-makers, lenders and investors, developers and operators, and the public.

During this decade, the vast majority of what has been written (and broadcast) about the assisted living industry has been positive. While industry trade coverage has often focused on the abundance of capital for financing new development, popular media coverage has typically centered on the economic efficiency of assisted living, its residential, home-like characteristics, and its growing popularity among today's older adults and their families. The fact is, while there has been occasional negative press coverage, public scrutiny of assisted living to date has been minimal.

Although there is no reason to believe that the immense popularity of assisted living will falter any time in the foreseeable future, don't be surprised to see assisted living as the focus of several public examinations in the next few years, some of which will almost certainly give the industry a good case of indigestion. As you examine the studies summarized below, keep in mind that a number of these inquiries will highlight the strengths and weaknesses of a very diverse sector that encompasses both professional owners and managersof purpose-built assisted living residences and a substantial pool of less sophisticated firms that often own and operate non-purpose-built settings.

NATIONAL STUDY OF ASSISTED LIVING FOR THE FRAIL ELDERLY Currently being conducted for the U.S. Department of Health and Human Services (HHS), Assistant Secretary for Planning and Evaluation (ASPE) by the Research Triangle Institute, this study is the largest of the studies currently being conducted. Initiated in 1994 and originally slated to take only two years to complete, the study's supporting materials indicate it will examine the following five points: 1) trends in demand for, and supply of, assisted living facilities; 2) barriers to development of assisted living; 3) the extent to which the current supply matches the central philosophical tenets embodied in the concept of assisted living; 4) the effect of key features that embody the philosophical tenets on selected outcomes; and 5) the types of regulation, quality assurance and accountability mechanisms that exist for the assisted living market to determine which aspects are most likely to maximize key outcomes, and which are most likely to inhibit the development of assisted living.

The ASPE assisted living study is likely to be the most expansive (and certainly most expensive) examination of the assisted living industry since its inception in the early 1980s. In addition to its lack of focus, the study's conclusions will be drawn from a probability sample consisting of settings with 11 or more residents that offer a minimum of two meals per day and help with at least one activity of daily living. With this very broad sample, the ASPE study is likely to include settings that few industry professionals would categorize as "assisted living." By including traditional board and care homes in an assisted living study, HHS may publish questionable findings that may, at least temporarily, taint professional owners and managers of purpose-built assisted living.

A good example of how the reputation of the assisted living industry can be negatively affected by board and care homes is illustrated by a tragic fire that took place on April 20, 1998. Arlington Manor, a boarding home 40 miles north of Seattle, caught fire resulting in eight resident fatalities. Press coverage of the fire repeatedly referred to the setting as an assisted living facility when it clearly was not licensed as such, lacking the appropriate sprinkler systems and other safety features required of assisted living facilities in the state.

INSTITUTE OF MEDICINE, QUALITY IN LONG-TERM CARE COMMITTEE As part of its Special Initiative on Health Care Quality, the Institute of Medicine (IOM) is studying quality of care in all long term-care settings, including assisted living. The goals of the IOM study are to evaluate quality assessment and improvement tools and their use to inform consumers, policymakers, providers and others of key opportunities and obstacles to achieving better health outcomes for individuals and populations.

IOM held public hearings in early March with over 50 groups, including the American Seniors Housing Association, submitting written and/or oral testimony relating to the above mentioned goals of the project (see box this page). The hearings gave consumer and provider groups an opportunity to comment early in the process.

Although the IOM study is not expected to be completed until sometime next year, it is important to note that it was the IOM whose examination of long-term care quality in the mid-1980s ultimately led to passage of the Nursing Home Protection Act and OBRA '87, a federal regulatory scheme that has plagued the nursing home industry ever since. Although the current IOM study of long term care quality is not congressionally-funded (as was the case in the mid-1980s), the IOM has credibility in Washington and its findings will likely be scrutinized by policy-makers.

GAO, HEALTH, EDUCATION AND HUMAN SVCS. DIVISION At the request of U.S. Senators Charles Grassley (R-IA), John Breaux (D-LA), the Chairman and Ranking Memberof the U.S. Senate Special Committee on Aging, and Ron Wyden (D-OR), the General Accounting Office (GAO) is conducting a study of assisted living in four states (California, Florida, Ohio and Oregon) to examine the following four questions: 1) Do residents of assisted living experience problems related to quality of care and consumer protection? 2) What approaches do states take to protect and ensure quality of care in assisted living? 3) To what extent do assisted living facilities provide consumers with information needed for them to determine whether an assisted living facility is an appropriate setting for their needs? 4) To what extent is written information provided to consumers consistent with facility contracts and state licensing requirements with regard to services provided, aging-in-place and protective oversight?

With this focus on consumer disclosure, resident assessment and service capacity, the GAO study will provide unique insights from over 900 assisted living facilities located in four bellwether states. Results of the GAO assisted living evaluation are expected to be released in October 1998 and, arguably for the first time, will focus the attention of members of Congress on assisted living. Although there is no reason to believe the GAO study will result in Federal oversight of assisted living, it is likely that the study will find enough variation in quality to result in at least one Congressional hearing this year.

ACADEMIC RESEARCH Although the academic community has historically not published much on market-rate seniors housing or assisted living, there is evidence that this will change. Researchers at the Institute for Health Policy at Brandeis University, for example, recently examined resident satisfaction in an as yet unpublished paper titled Resident Experiences in Assisted Living. The study, summarized in the December 1997 issue of ASHA's Seniors Housing Update, found that while residents reported relatively independent and autonomous lives, many experienced unmet health and long-term care needs and limited participation in activities or community life. The authors conclude their paper by speculating that assisted living may actually lead to greater public expenditures for long-term care since seniors who "might have remained in the community before entering a nursing home as private pay residents may instead exhaust their resources in assisted living and still require an extensive nursing home stay at public expense."

Given what we know about the diversity of the assisted living sector and the propensity of board and care settings to be inappropriately included in assisted living studies, it is safe to assume that assisted living will soon begin to face some less than favorable publicity and criticism. Although the diversity of assisted living settings and services is considered by many to be a strength of the industry, it is conceivable that policy-makers will begin to call for increased industry standardization and uniform disclosure policies relative to services, fees, discharge criteria, etc.

It is also possible that the industry's professional owners and managers will be forced to consider strategies for distancing themselves from the board and care sector, which has embraced the assisted living name, in part, in order to obfuscate itself from a history full of well-documented quality problems.

Based in Washington, D.C., ASHA represents the interests of the country's larger and more prominent firms participating in the seniors housing industry.

The monumental demographic shift that will occur in the next few decades makes it imperative that policy-makers seek ways to create a more efficient, competitive, market-driven long-term care delivery system (to) better meet the needs of an aging population. An improved paradigm for long-term care has been created with the proliferation of seniors housing and assisted living. This paradigm is sensitive to consumer needs and preferences, free from the harmful effects of over regulation, and driven by free-market principles that foster highquality efficient service delivery as well as affordable shelter.

ASHA testimony before IOM

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