Connecting policy to licensed assisted living communities, introducing health services regulatory analysis.

OBJECTIVE: To document dementia-relevant state assisted living regulations and their changes over time as they pertain to licensed care settings. DATA SOURCES: For all states, current directories of licensed assisted living communities and state regulations for each year, 2007-2018, were obtained from state agency websites and Nexis Uni, respectively. STUDY DESIGN: We identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally. DATA COLLECTION/EXTRACTION METHODS: We used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question-based coding to record the presence or absence of specific policies for each classification and study year. PRINCIPAL FINDINGS: Our team empirically documented provisions requiring dementia-specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two. CONCLUSIONS: We identified significant, previously undocumented, within-state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia-designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings.

Supports and gaps in federal policy for addressing racial and ethnic disparities among long-term care facility residents.

Older adults from racial and ethnic minority groups are likely to face disparities in their health as well as care experiences in long-term care facilities such as nursing homes and assisted living facilities just as they do in the United States as a whole. Policymakers in the United States face concerns around long-term services and supports to address the growing demands of a rapidly aging population through public and private sector initiatives. It is important to create inclusive and culturally responsive environments to meet the needs of diverse groups of older adults. In spite of federal policy that supports minority health and protects the well-being of long-term care facility residents, racial and ethnic disparities persist in long-term care facilities. This manuscript describes supports and gaps in the current United States' federal policy to reduce racial and ethnic disparities in long-term care facilities. Implications for social workers are discussed and recommendations include efforts to revise portions of the Patient Protection and Affordable Care Act of 2010, amending regulations regarding long-term care facilities' training and oversight, and tailoring the Long-Term Care Ombudsman Program's data collection, analysis, and reporting requirements to include racial and ethnic demographic data.

State Variability in the Prevalence and Healthcare Utilization of Assisted Living Residents with Dementia.

OBJECTIVES: Almost 1 million older and disabled adults who require long-term care reside in assisted living (AL), approximately 40% of whom have a diagnosis of Alzheimer's disease and related dementias (ADRD). States vary in their regulations specific to dementia care that may influence the presence of residents with ADRD in AL and their outcomes. The objectives of this study were to describe the state variability in the prevalence of ADRD among Medicare beneficiaries residing in larger (25+ bed) ALs and their healthcare utilization. DESIGN: Retrospective observational national study. PARTICIPANTS: National cohort of 293,336 Medicare fee-for-service enrollees residing in larger (25+ bed) ALs in 2016 and 2017 including 88,867 (30.3%) residents with ADRD. We compared this cohort's characteristics and healthcare utilization with that of individuals with ADRD who resided in nursing homes (NHs; n = 602,521) and the community (n = 2,074,420). METHODS: Medicare enrollment data, claims, and the NH Minimum Data Set were used to describe differences among ADRD patients in AL, NHs, and the community. We present rates of NH admission and hospitalization, by state, adjusting for age, sex, race, dual eligibility, and chronic conditions. RESULTS: The prevalence of ADRD among AL residents varied by state, ranging from 24% to 47%. In 2017, AL residents with ADRD had higher rates of NH admission than their community-dwelling counterparts (adjusted national average = 24%, ranging from 14% to 35% among states). AL residents with ADRD had higher rates of hospitalization (38%) than populations in either NHs (29%) or the community (34%), and ranged from 29% to 45% of residents among states. CONCLUSION: These findings have implications for states as they regulate AL and for healthcare professionals whose patients reside in AL. Future work is needed to understand specific elements of states' regulatory environments and local markets that may impact access and outcomes for this vulnerable population of residents with ADRD. J Am Geriatr Soc 68:1504-1511, 2020.

State Regulatory Approaches for Dementia Care in Residential Care and Assisted Living.

Purpose: This policy study analyzed states' residential care and assisted living (RC/AL) regulations for dementia care requirements. Estimates suggest that at least half of RC/AL residents have dementia, and 22% of settings provide or specialize in dementia care. Residents with dementia might benefit from regulations that account for specific behaviors and needs associated with dementia, making states' RC/AL regulations address dementia care an important policy topic. Design and Methods: This study examined RC/AL regulations in all 50 states and the District of Columbia for regulatory requirements on five topics important to the quality of life of RC/AL residents with dementia: pre-admission assessment, consumer disclosure, staffing types and levels, administrator training, and physical environment. Results: Sixteen states license or certify dementia care units within RC/AL settings. All states had at least one dementia care requirement, though only four states had requirements for all five of the topics reviewed. Most states addressed administrator training, consumer disclosure, and physical environment, 17 addressed staffing types and levels, and 14 addressed pre-admission assessment for dementia. Thus, most states rely on general RC/AL regulations to cover dementia care policies and practices. Implications: This policy study provides a resource for researchers who do cross-state studies of dementia care in RC/AL settings and state policymakers who are updating RC/AL regulations, including those responding to a 2014 Centers for Medicare and Medicaid Services rule change.

State Long-Term Care Ombudsman programs. Final rule.

The Administration on Aging (AoA) of the Administration for Community Living (ACL) within the Department of Health and Human Services (HHS) is issuing this final rule in order to implement provisions of the Older Americans Act (the Act) regarding States' Long-Term Care Ombudsman programs (Ombudsman programs). Since its creation in the 1970s, the functions of the Nursing Home Ombudsman program (later, changed to Long-Term Care Ombudsman program) have been delineated in the Act; however, regulations have not been promulgated specifically focused on States' implementation of this program. In the absence of regulation, there has been significant variation in the interpretation and implementation of these provisions among States. HHS expects that a number of States may need to update their statutes, regulations, policies, procedures and/or practices in order to operate the Ombudsman program consistent with Federal law and this final rule.

Assisted Living and Nursing.

In summary, some Nebraska ALFs are admitting people on Medicaid waivers and people with relatively advanced dementia. They are retaining people on hospice care. Many employ and even advertize that they have RNs, yet regulations prevent these RNs from using their judgment, from practicing professional nursing. This is a total disregard of what RNs, exercising their full scope of professional practice, can bring to a setting, and of what many of the residents in ALFs need. It is time Nebraska ALFs stepped up to meeting the care needs of the residents they admit and retain by providing RN care and oversight to those who need it. They also should provide more than one level of care so that those who only need help with ADLs do not have to pay for a level of care they do not need. Now that there is a group studying the future of AL in Nebraska, is the time to make the changes in regulations--to no longer interfere with professional nurses' legal scope of practice in a setting where they are employed, and to meet the needs of the residents they are admitting and retaining. Other states should do likewise.

Infection prevention and control standards in assisted living facilities: are residents' needs being met?

BACKGROUND: Assisted living facilities (ALFs) provide housing and care to persons unable to live independently, and who often have increasing medical needs. Disease outbreaks illustrate challenges of maintaining adequate resident protections in these facilities. OBJECTIVES: Describe current state laws on assisted living admissions criteria, medical oversight, medication administration, vaccination requirements, and standards for infection control training. METHODS: We abstracted laws and regulations governing assisted living facilities for the 50 states using a structured abstraction tool. Selected characteristics were compared according to the time period in which the regulation took effect. Selected state health departments were queried regarding outbreaks identified in assisted living facilities. RESULTS: Of the 50 states, 84% specify health-based admissions criteria to assisted living facilities; 60% require licensed health care professionals to oversee medical care; 88% specifically allow subcontracting with outside entities to provide routine medical services onsite; 64% address medication administration by assisted living facility staff; 54% specify requirements for some form of initial infection control training for all staff; 50% require reporting of disease outbreaks to the health department; 18% specify requirements to offer or require vaccines to staff; 30% specify requirements to offer or require vaccines to residents. Twelve states identified approximately 1600 outbreaks from 2010 to 2013, with influenza or norovirus infections predominating. CONCLUSIONS: There is wide variation in how assisted living facilities are regulated in the United States. States may wish to consider regulatory changes that ensure safe health care delivery, and minimize risks of infections, outbreaks of disease, and other forms of harm among assisted living residents.

[Shared-housing arrangements for care-dependent persons. Legal frameworks and numbers in Germany]. / Ambulant betreute Wohngemeinschaften für Menschen mit Pflegebedarf. Versorgungsangebote und gesetzliche Rahmenbedingungen in Deutschland.

BACKGROUND: Since the mid-1990s, supervised shared-housing arrangements (SHA; assisted living facilities) have developed as a specific type of small-scale living facility for elderly care-dependent persons with dementia in Germany, offering services different than those in residential care. Neither a uniform and binding definition of SHA nor reliable estimates concerning numbers currently exist. Since January 2013, SHA have been promoted nationwide in Germany by law. MATERIALS AND METHODS: In a cross-sectional study funded by the National Association of Statutory Health Insurance Funds numbers as well as legal and financial frameworks of SHA in Germany were surveyed. RESULTS: As of February 2013, almost all German "Bundesländer" (federal states) have created special legal regulations for supervised SHA. The results of the present study show at least 1,420 SHA with 10,590 care places for adults in Germany. The regional distribution differs greatly. CONCLUSION: Supervised SHA are increasingly an established care offer among the various long-term care offers in Germany. Different care and support offers help ensure individualized and high quality care for elderly care-dependent persons with dementia.

Cohort differences in dementia recognition and treatment indicators among assisted living residents in Maryland: did a change in the resident assessment tool make a difference?

BACKGROUND: There is a lack of empirical evidence about the impact of regulations on dementia care quality in assisted living (AL). We examined cohort differences in dementia recognition and treatment indicators between two cohorts of AL residents with dementia, evaluated prior to and following a dementia-related policy modification to more adequately assess memory and behavioral problems. METHODS: Cross-sectional comparison of two AL resident cohorts was done (Cohort 1 [evaluated 2001-2003] and Cohort 2 [evaluated 2004-2006]) from the Maryland Assisted Living studies. Initial in-person evaluations of residents with dementia (n = 248) were performed from a random sample of 28 AL facilities in Maryland (physician examination, clinical characteristics, and staff and family recognition of dementia included). Adequacy of dementia workup and treatment was rated by an expert consensus panel. RESULTS: Staff recognition of dementia was better in Cohort 1 than in Cohort 2 (77% vs. 63%, p = 0.011), with no significant differences in family recognition (86% vs. 85%, p = 0.680), or complete treatment ratings (52% vs. 64%, p = 0.060). In adjusted logistic regression, cognitive impairment and neuropsychiatric symptoms correlated with staff recognition; and cognitive impairment correlated with family recognition. Increased age and cognitive impairment reduced odds of having a complete dementia workup. Odds of having complete dementia treatment was reduced by age and having more depressive symptoms. Cohort was not predictive of dementia recognition or treatment indicators in adjusted models. CONCLUSIONS: We noted few cohort differences in dementia care indicators after accounting for covariates, and concluded that rates of dementia recognition and treatment did not appear to change much organically following the policy modifications.

Health care services use in assisted living: a time series analysis.

This article describes British Columbia's regulatory model for assisted living and used time series analysis to examine individuals' use of health care services before and after moving to assisted living. The 4,219 assisted living residents studied were older and predominantly female, with 73 per cent having one or more major chronic conditions. Use of health care services tended to increase before the move to assisted living, drop at the time of the move (most notably for general practitioners, medical specialists, and acute care), and remain low for the 12-month follow-up period. These apparent positive effects are not trivial; the cohort of 1,894 assisted living residents used 18,000 fewer acute care days in the year after, compared to the year before, their move. Future research should address whether and how assisted living affects longer-term pathways of care for older adults and ultimately their function and quality of life.

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

OBJECTIVES: To compare rates of medication errors committed by assisted living staff with different training and to examine characteristics of errors. DESIGN: Observation of medication preparation and passes, chart review, interviews, and questionnaires. SETTING: Stratified random sample of 11 assisted living communities in South Carolina (which permits nonnurses to administer medications) and Tennessee (which does not). PARTICIPANTS: All staff who prepared or passed medications: nurses (one registered nurse and six licensed practical nurses (LPNs)); medication aides (n=10); and others (n=19), including those with more and less training. MEASUREMENTS: Rates of errors related to medication, dose and form, preparation, route, and timing. RESULTS: Medication preparation and administration were observed for 4,957 administrations during 83 passes for 301 residents. The error rate was 42% (20% when omitting timing errors). Of all administrations, 7% were errors with moderate or high potential for harm. The odds of such an error by a medication aide were no more likely than by a LPN, but the odds of one by staff with less training was more than two times as great (odds ratio=2.10, 95% confidence interval=1.27-3.49). A review of state regulations found that 20 states restrict nonnurses to assisting with self-administration of medications. CONCLUSION: Medication aides do not commit more errors than LPNs, but other nonnurses who administered a significant number of medications and assisted with self-administration committed more errors. Consequently, all staff who handle medications should be trained to the level of a medication aide.