Does Assisted Living Provide Assistance And Promote Living?

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have worsened; regulations have become complex; the need for consumer support, education, and advocacy has grown; and financing and accessibility have become insufficient. Together, these factors have limited the extent to which today's assisted living adequately provides assistance and promotes living, with negative consequences for aging in place and well-being. This Commentary provides recommendations in four areas to help assisted living meet its promise: workforce; regulations and government; consumer needs and roles; and financing and accessibility. Policies that may be helpful include those that would increase staffing and boost wages and training; establish staffing standards with appropriate skill mix; promulgate state regulations that enable greater use of third-party services; encourage uniform data reporting; provide funds supporting family involvement; make community disclosure statements more accessible; and offer owners and operators incentives to facilitate access for consumers with fewer resources. Attention to these and other recommendations may help assisted living live up to its name.

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement.

OBJECTIVES: Assess prevalence of serious mental illness (SMI) alone, and co-occurring with Alzheimer disease and related dementias (ADRD), among Medicare beneficiaries in assisted living (AL). Examine the association between permanent nursing home (NH) placement and SMI, among residents with and without ADRD. DESIGN: 2018-2019 retrospective cohort of Medicare beneficiaries in AL. Residents were followed for up to 2 years to track their NH placement. We used data from the Medicare Enrollment Database, the Medicare Beneficiary Summary File, Minimum Data Set, and a national directory of state-licensed AL communities. AL residents were identified using a validated, previously reported 9-digit zip code methodology. SETTING AND PARTICIPANTS: A cross-sectional study sample included 289,350 Medicare beneficiaries in 17,265 AL communities across 50 states and in the District of Columbia. METHODS: The outcome was permanent NH placement: a continuous stay for more than 90 days. Key independent variable was presence of SMI-schizophrenia, bipolar disorder, and major depression. Other covariates included sociodemographic factors and presence of other chronic conditions, including ADRD. A linear probability model with robust SEs, and AL-level random effects, was used to test the association between SMI diagnoses, ADRD, and their interactions on NH placement. RESULTS: More than half (55.65%) of AL residents had a diagnosis of SMI, among them 93.2% had major depression, 28.5% schizophrenia, and 22.2% bipolar disorder. Individuals with schizophrenia and bipolar disorder had a significantly lower probability of NH placement, a 32% and a 15% decrease relative to the cohort mean, respectively. Placement risk was significantly greater for residents with ADRD compared to those without, increasing for those who also had schizophrenia or bipolar disorder, 12.9% and 1.5% relative to the sample mean, respectively. CONCLUSION AND IMPLICATIONS: Presence of schizophrenia and bipolar disorder, in conjunction with ADRD, significantly increases the risk of long-term NH placement, suggesting that ALs may not be well prepared to care for these residents.

Assisted living residents with dementia: Disparities in mental health services pre and during COVID-19.

BACKGROUND: Little is known about mental health among Medicare beneficiaries with Alzheimer's disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL residents with ADRD, pre and during the COVID pandemic, focusing on race/ethnicity and Medicare/Medicaid dual status. METHODS: A CY2018 cohort of AL residents with ADRD was identified. Outcome was any quarterly in-person or telemedicine mental health visit based on national CY2019-2020 Medicare claims. Key independent variables were individual race/ethnicity and dual status and the AL-level proportion of dual residents. We estimated a linear probability model with random effects and robust standard errors. Quarterly indicators captured service use before and after the onset of the pandemic. RESULTS: The study included 102,758 fee-for-service Medicare beneficiaries with ADRD in 13,400 ALs. One in five residents had any mental health visits prior to the COVID-19 pandemic. Black residents, and those with dual Medicare/Medicaid eligibility, were significantly less likely to use mental health services prior to and during the pandemic. There were no significant differences in visits via telemedicine by race/ethnicity or individual dual status. Residents in AL communities with a higher proportion of duals had a lower likelihood of visits before and during the pandemic. CONCLUSIONS/IMPLICATIONS: Mental health service use among AL residents with ADRD was low and declining prior to the pandemic. Telehealth allowed for mental health visits to continue during the pandemic, albeit at a lower level. Residents in ALs with a higher proportion of duals were less likely to have in-person or telehealth visits. The results suggest that some ALs may find it difficult to assure mental health service provision to this vulnerable population.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma.

Importance: Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown. Objective: To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma. Design, Setting, and Participants: Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024. Exposure: Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall. Main Outcomes and Measures: Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions. Results: The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date. Conclusions and Relevance: In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Measuring older adults' wellbeing when transitioning into assisted living facilities: a confirmatory factor analysis of the Mueller assessment of transition (MAT).

OBJECTIVES: Older adults' wellbeing during the transition into an assisted living facility (ALF) is not well understood and may influence their wellbeing. The Mueller Assessment of Transition (MAT) was created to measure the impact of transition on older adults' wellbeing. Early developmental testing of the MAT revealed a hypothesized model with two constructs (adjustment strategies and constraints to wellbeing). Therefore, the purpose of this study was to confirm the factor structure of the MAT with a representative sample of older adults transitioning into ALFs. METHODS: In a nationwide sample, 108 older adult participants completed the MAT to measure wellbeing when relocating into ALFs. Confirmatory factor analysis (CFA) assessed the structural validity of the MAT. Internal consistency was evaluated, and chi-square tests of association for regional differences in MAT scores were also conducted. RESULTS: The CFA produced strong fit indices to confirm the hypothesized 2-factor (constraints to wellbeing and adjustment strategies) model of the MAT. Cronbach's alpha for the internal consistency was 0.784 and chi-square test indicated no significant regional differences. CONCLUSION: The MAT was established as a valid and reliable standardized assessment. Implications for using the MAT as a tool to measure older adults' wellbeing and future research are discussed.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States.

OBJECTIVES: Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities. DESIGN: We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations. SETTING AND PARTICIPANTS: AL regulations and licensed AL communities across all 50 states in 2018. METHODS: We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health-related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those that impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission. RESULTS: The largest group of ALs (29% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than 8 of every 10 licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment. CONCLUSIONS AND IMPLICATIONS: The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (eg, health, mental health, cognitive). Although future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policy makers to better understand the options in their state and how various AL licensure classifications compare to one another.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations.

OBJECTIVE: We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. DESIGN: Cohort study. SETTING AND PARTICIPANTS: Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662). METHODS: We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics. RESULTS: End-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death. CONCLUSIONS AND IMPLICATIONS: There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.

Barriers and enablers to the implementation of healthy lifestyle interventions for people with disability living in supported accommodation: A systematic review using the consolidated framework for implementation research.

BACKGROUND: People with disability living in supported accommodation often experience significant health disparities, despite the availability of additional support. Healthy lifestyle interventions have been identified as one key health promotion strategy. Implementation science offers an opportunity to explore the factors that influence the efficacy and sustainability of these interventions, yet its application in this context has been underutilized. OBJECTIVE: This systematic review synthesized the barriers and enablers to the implementation of healthy lifestyle interventions delivered to people with disability living in supported accommodation settings. METHODS: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search for relevant literature published between January 2011 and November 2021 was conducted across six databases. The findings of included studies were coded and analyzed according to the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) via deductive content analysis. RESULTS: Five studies were included, and their findings were mapped to 21 out of 38 constructs under the CFIR. Interventions from each study delivered health promotion education and training to staff and/or people with disability. The most prominent determinants that influenced implementation success included an intervention's relevance and its flexibility to adapt to the needs of people with disability, alongside organizational resourcing, and stakeholder endorsement in supporting implementation. CONCLUSIONS: The CFIR provided a systematic approach to explore the implementation of healthy lifestyle interventions. However, further research that is grounded in and guided by implementation science theories is warranted. Despite the scarcity of literature, several compelling, yet preliminary recommendations were drawn from the findings.

Funding systems for care needs of older adults in residential aged care facilities in the Asia-Pacific region: a scoping review protocol.

OBJECTIVE: The objective of this review is to explore the care needs as assessed by the public residential aged care funding systems of Asia-Pacific countries that use both taxation and means-tested user charge. INTRODUCTION: The Asia-Pacific region is at the forefront of population aging. There is increasing reliance on residential aged care facilities to provide formal care, but limited understanding of how care needs are assessed. Most countries have adopted taxation as the primary means to levy capital for funding essential health services; funding may be means-tested for equity. INCLUSION CRITERIA: The population of interest is older adults eligible for care in residential aged care facilities who receive assistance to fund their care. Sources that address the care needs of residents and the assessments relating to care needs, as well as funding systems (taxation, means-testing), will be considered for inclusion. This review will consider any quantitative study, qualitative study, mixed method study, or report from any country in the Asia-Pacific region. METHODS: Databases to be searched include Embase, CINAHL, PubMed, Scopus, and the JBI Database for Evidence-based Practice. Additional records will be identified through the gray literature database Trove, reference lists of included studies, and relevant health organization websites. Sources published in English since 2008 will be eligible for inclusion. Two reviewers will independently screen titles, abstracts, and full-texts for inclusion. Data will be extracted and findings summarized in tabular format and narrative synthesis. Any disagreements between the reviewers will be resolved through discussion or with a third reviewer. SCOPING REVIEW REGISTRATION: Open Science Framework; https://osf.io/h9g7q.

The effect of educational intervention on use of psychotropics in defined daily doses and related costs - a randomized controlled trial.

OBJECTIVE: To investigate the effect of an educational intervention of nursing staff on change in psychotropic use and related costs among older long-term care residents. DESIGN: A secondary analysis of a randomized controlled intervention study with 12 months of follow-up. SETTING: Assisted living facilities in Helsinki, Finland. SUBJECTS: Older (≥65 years) residents (N = 227) living in assisted living facility wards (N = 20) in Helsinki in 2011. INTERVENTION: The wards were randomized into two groups. In one group, the nursing staff received training on appropriate medication therapy and guidance to recognize potentially harmful medications and adverse effects (intervention group); in the other group, the nursing staff did not receive any additional training (control group). MAIN OUTCOME MEASURES: Change of psychotropic use counted as relative proportions of WHO ATC-defined daily doses (rDDDs) among older long-term care residents. In addition, the change in drug costs was considered. Comparable assessments were performed at 0, 6, and 12 months. RESULTS: A significant decrease in both rDDDs and the cost of psychotropics was observed in the intervention group at 6 months follow-up. However, at 12 months, the difference between the intervention and control group had diminished. CONCLUSIONS: Educational training can be effective in reducing the doses and costs of psychotropics. Further studies are warranted to investigate whether long-term effects can also be achieved by various educational interventions. REGISTRATION NUMBER: ACTRN 12611001078943 KEY POINTSWe explored the effect of staff training on psychotropic use and associated costs among older long-term care residents.Educational training of nursing staff was beneficial as regards the actual drug doses of psychotropics, and cost savings in psychotropic medication were achieved.Educational training was efficient in the short-term, but further research is warranted to achieve long-term effects.

Implementation of an Emergency Power Rule: Compliance of Florida Nursing Homes and Assisted Living Facilities.

OBJECTIVE: Thea aim of this study was to explore the relationship between Florida nursing home and assisted living facility characteristics and their ability to comply with a new emergency power rule in the aftermath of Hurricane Irma. METHODS: This study used characteristics data on Florida nursing homes (NHs) (N = 680) and assisted living facilities (ALFs) (N = 2940) in operation between September 2017 and January 2019. Logistic regressions were used to determine whether certain characteristics were associated with compliance with the emergency power rule by January 1, 2019. RESULTS: A total of 219 (32.9%) NHs and 2219 (75.5%) ALFs had an emergency power plan implemented by January 1, 2019. Results suggest having a dementia care unit increased the odds of compliance for NHs, while chain membership, for-profit status, and a higher reliance on Medicaid decreased the odds. Additionally, smaller size, mental health specialty license, and higher reliance on supplemental state funding increased the odds of compliance for ALFs, while nursing care specialty license and for-profit status decreased the odds of compliance. CONCLUSIONS: Policy implications from these results include informing policy-makers on the barriers faced by NHs and ALFs to implement a new regulation that may cause financial difficulties and compromise quality care.

Factors Associated With Assisted Living Facility Closure.

BACKGROUND AND OBJECTIVES: Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home market for the ALF market to examine the organizational, internal, and external factors associated with closure. RESEARCH DESIGN AND METHODS: Data on 1,939 ALFs operating in 2013 from Florida were used to estimate a logistic regression to examine the organizational, internal, and external factors that were associated with closure between 2013 and 2015. RESULTS: During the 2-year study period, 141 ALFs (7.3%) closed. Significant factors associated with increased odds of closure included fewer beds, not accepting Medicaid, and more deficiencies. Two factors (market concentration and population density) were marginally significant. DISCUSSION AND IMPLICATIONS: The results of this study confirm the usefulness of a model that includes organizational, internal, and external factors to predict ALF closure. These outcomes highlight the concerns that closure can affect access to community-based long-term care, especially for rural older adults, and indicate an expansion of Medicaid acceptance in ALFs could be protective against closure.

Staff experiences of diabetes care in residential care facilities for people with severe disabilities in Denmark: a mixed-methods assessment of access to screening for diabetes complications.

OBJECTIVES: To identify the prevalence of diabetes among adults (>18 years) living in residential care facilities in Denmark and to identify the structural, practical, and individual barriers and drivers related to their participation in screening programmes. DESIGN: SETTING: The register-based study included all residents living in residential care facilities in Denmark. The survey and qualitative analysis were carried out exclusively in the Capital Region of Denmark. PARTICIPANTS: For the register-based study, we identified 11 620 residents of care facilities in Denmark (>18 years) and identified the number of residents with diagnosis codes of type 1 or type 2 diabetes or dispensed prescriptions of blood glucose-lowering medication. Staff from 102 psychiatric facilities housing adults with severe psychiatric disabilities were invited to participate in the survey. Of these, 56 facilities participated with one responder each, of which n=16 also participated in follow-up qualitative interviews. RESULTS: Register-based study: of the residents at the facilities, 954 (8%) were diagnosed with diabetes. Descriptive statistics of responses and results from content analysis of interviews were summarised in five themes that illuminated how a screening programme could be tailored to the care facilities: (1) characteristics of residents and care facilities, (2) the care needs of residents, (3) the way care was organised, (4) the specific barriers and drivers for participating in programmes, (5) number of hours and settings for screening programmes. CONCLUSION: To increase the participation of people living in psychiatric care facilities in screening programmes, future programmes should be tailored to the identified needs and barriers experienced by the residential care staff.

Perceptions and experiences of risk management by managers of residential aged care facilities: a qualitative study from Hunan Province, China.

BACKGROUND: With adverse events and injuries recurring in residential aged care facilities (RACFs), older adults' safety in residential age care settings has attracted extensive attention from governments, researchers, and healthcare providers. Risk management is of utmost importance in reducing risks and improving the quality of care for older adults in long-term care. Although previous studies have made great efforts to explore risk management methods and technologies in RACFs, little is known about how managers identify and respond to risks in practice. PURPOSE: This qualitative study aimed to elucidate the perceptions and experiences of managers involved in risk management in RACFs in China. PARTICIPANTS AND METHODS: This study used a phenomenological research design. We conducted semi-structured interviews with 13 managers across 11 RACFs in Changsha City, Hunan Province, China. Data were analysed using Colaizzi's seven steps and NVivo 12 plus software. RESULTS: "Facilitation of an error-free culture" emerged as a central theme of managers' perceptions of risk management. Four sub-themes were revealed, namely "creating an age-friendly physical environment," "paying close attention to frail older adults," "improving the competence of nursing staff," and "building effective management programs." CONCLUSION: Facilitation of an error-free culture was of prime importance in risk management. Managers' experiences can help RACFs to better manage risks, as well as provide new perspectives and approaches for RACFs to improve the quality and outcomes of care. This study developed initiatives for improving resident safety in RACFs and may foster interest in the developing these initiatives.

Medication Management and Deprescribing in Assisted Living Facilities.

Medication management for seniors is a foundation for keeping them healthy and independent. A vital aspect of medication management is the selective discontinuation of medications, or deprescribing. While this is a common practice within nursing homes it seems to be less common among those who live in assisted living facilities. Shockingly little exiting literature was found when conducting a literature review concerning deprescribing in assisted living facilities. Therefore, it was determined to set forth this call to action to focus on deprescribing in assisted living facilities hoping that it would be given more attention to keep our seniors healthy and safe.

Examining Racial and Ethnic Disparities Among Older Adults in Long-Term Care Facilities.

BACKGROUND AND OBJECTIVES: The purpose of this project was to examine individual-level ethnic and racial differences and facility-level differences in types of complaints and rates of complaint resolution in a local long-term care ombudsman program. RESEARCH DESIGN AND METHODS: We employed a mixed-methods sequential explanatory design. First, we analyzed secondary complaint data based on residents' race and ethnicity (n = 464) and facility characteristics (n = 101). We then conducted 2 focus groups with ombudsmen (n = 12) to provide context for our quantitative findings and to explore the ombudsmen's views on disparities in long-term care facilities. RESULTS: Racial and ethnic minority residents were more likely to generate complaints related to residents' rights than nonminority residents. Assisted living facilities were more likely to have complaints related to residents' rights and outside agencies than nursing homes. The rate of complaint resolution increased among facilities with a higher proportion of minority residents, compared to facilities with a lower proportion of minority residents. However, an estimation of cross-level interaction revealed that non-Hispanic White residents in these facilities experienced faster complaint resolution than minority residents. Ombudsmen expressed concerns about communication barriers between minority residents and facility staff and discussed different complaint types and resolution rates according to facility types. DISCUSSION AND IMPLICATIONS: Our findings highlight disparities across long-term care facilities as well as disparities in care minority residents experience. Long-term care ombudsman program complaint data should be disaggregated by race and ethnicity of the residents to advocate for policy change at facility, state, and federal levels.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care.

BACKGROUND/OBJECTIVES: Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services. DESIGN: Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File. SETTING: AL facilities and Medicare HH agencies in the United States. PARTICIPANTS: 741,926 Medicare HH admissions of AL residents in 2017. MEASUREMENTS: Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission. RESULTS: Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)). CONCLUSION: For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department.

BACKGROUND AND OBJECTIVES: Lack of mental health resources, such as inpatient psychiatric beds, has increased frequency and duration of boarding for mental health patients presenting to U.S. emergency departments (EDs). The purpose of this study is to describe characteristics of mental health patients with an ED length of stay of one week or longer and to identify barriers to their disposition. METHODS: This study was conducted in an academic ED in which emergency psychiatric evaluations and care are provided by a Psychiatric Emergency Services (PES) team contained within the Department of Emergency Medicine. Prolonged boarding was defined as an ED length of stay of 7 days or more. Pediatric, adult, and geriatric mental health patients with prolonged ED boarding from January 1 to August 31, 2019 were included. This study includes prospective data collection of the boarding group and retrospective identification and data collection of a comparison group of non-barding patients over the same 8-month period to compare patient characteristics and outcomes for each group. RESULTS: Between January 1 and August 31, 2019, the PES team completed 2,745 new assessments of mental health patients, of whom 39 met criteria for prolonged ED boarding. The following characteristics were associated with boarding: child (8%), male (64%), having Medicaid (49%) or both Medicaid and Medicare (18%), and having either a neurodevelopmental (15%) or neurocognitive disorder (15%) with a median stay of 18 days. Barriers to discharge included being declined from all state inpatient psychiatric hospitals (69%), declined from community living environments (21%), or declined from both (10%). The most common ED non-boarding patients were: Caucasian (64%), have a diagnosis of unspecified mental disorder (including suicidal ideation) or other specified mental disorder (59%) and have private insurance (42%) with a median stay of 1 day. CONCLUSION: In this study of mental health patients with prolonged ED stays, the primary barrier to disposition was the lack of patient acceptance to inpatient psychiatric hospitals, community settings, or other housing. Early identification of potential prolonged boarding, quality treatment and care for those patients, and effective case management, may resolve the ongoing challenges of boarding within the ED.