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

Abstract

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.

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

“…Over half of AL/RC residents (57%) reside in the setting at end-of-life (EoL) ( Thomas, Zhang, et al, 2020 ). EoL care for AL/RC populations is accompanied by unique challenges due to the presence of other residents, who have cognitive impairment as well as staff with varying training and experience with EoL care ( Zimmerman et al, 2015 ).…”

“…AL/RC settings in most states allow residents to receive third-party care including home health or hospice services while residing in the AL/RC setting. In a nationally representative sample, AL/RC residents’ average days spent on hospice in the last month of life ranged from two to fourteen days, depending on the state ( Thomas, Zhang et al, 2020 ). In comparison to older adults living at home, hospice users in AL/RC settings are more likely to have dementia, enroll in hospice services closer to death, and less likely to receive opioids or die in an acute-care setting ( Dougherty et al, 2015 ).…”

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

“…There is a lack of federal regulations on the quality of AL care or on appropriate staffing in AL, and substantial variation exist in state regulatory stringency of AL regarding staffing and training, admission and retention criteria, provision of services such as medication administration, and specialized dementia care units 3,16,32‐34 . It is therefore unclear if the gap in care‐partner support we noted in this study was transient due to worsened health status and post‐acute care transition, or that AL residents, over the years since AL admission, have developed substantial functional impairments whose needs for support may have exceeded the level of support available at AL and may be better cared for with intensive support at a skilled nursing facility.…”

Do Assisted Living Facilities That Offer a Dementia Care Program Differ from Those That Do Not? A Population-Level Cross-Sectional Study in Ontario, Canada

“…Dementia affects more than half of all residents housed in assisted living facilities. [1][2][3] Older adults living with dementia are more likely to experience injuries requiring acute care, be diagnosed with pneumonia, and encounter difficulties with eating. 4,5 Care for dementia is expensive and a widely cited reason for older adults requiring placement in a nursing home.…”

“…[12][13][14] Much of the literature on dementia care in assisted living facilities addresses health service use among residents living with dementia, managing staff, and state-level regulations for dementia care. 1,11,[15][16][17] Studies explicitly investigating the characteristics of retirement homes or assisted living facilities that provide specialized care for dementia (i.e., a dementia care program), and how these characteristics compare to those that do not, are absent. The findings from such studies are important for identifying case mix and examining scope and breadth of care for older adults with complex care needs.…”