Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

Journal of the American Medical Directors Association

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

Jun 1, 2023
Objectives 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 […]

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

by Lea Efird-Green

Objectives 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 […]

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

Jun 1, 2023
Objectives Online reviews provided by users of assisted living communities may offer a unique source of heretofore unexamined data. We explored online reviews as a possible source of information about these communities and examined the association between the reviews and aspects of state regulations, while controlling for assisted living, county, and state market-level factors. Design […]

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

by Lea Efird-Green

Objectives Online reviews provided by users of assisted living communities may offer a unique source of heretofore unexamined data. We explored online reviews as a possible source of information about these communities and examined the association between the reviews and aspects of state regulations, while controlling for assisted living, county, and state market-level factors. Design […]

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

Jun 1, 2023
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 […]

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

by Lea Efird-Green

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 […]

Hospital Proximity and Emergency Department Use among Assisted Living Residents

Jun 1, 2023
Objectives To examine the relationship between AL communities’ distance to the nearest hospital and residents’ rates of emergency department (ED) use. We hypothesize that when access to an ED is more convenient, as measured by a shorter distance, assisted living (AL)-to-ED transfers are more common, particularly for nonemergent conditions. Design Retrospective cohort study, where the […]

Hospital Proximity and Emergency Department Use among Assisted Living Residents

by Lea Efird-Green

Objectives To examine the relationship between AL communities’ distance to the nearest hospital and residents’ rates of emergency department (ED) use. We hypothesize that when access to an ED is more convenient, as measured by a shorter distance, assisted living (AL)-to-ED transfers are more common, particularly for nonemergent conditions. Design Retrospective cohort study, where the […]

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

Jun 1, 2023
Objective To investigate mental health needs and barriers to seeking mental health support in Medicaid funded Assisted Living Facility (M-ALF). Design A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews. Setting and Participants The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or […]

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

by Lea Efird-Green

Objective To investigate mental health needs and barriers to seeking mental health support in Medicaid funded Assisted Living Facility (M-ALF). Design A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews. Setting and Participants The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or […]

Primary Care Telemedicine Use among Assisted Living Residents with Dementia during COVID-19: Race and Dual Enrollment Status

May 1, 2023
In 2023-03-01 12:00:00 2020, restrictions on telemedicine were waived, allowing services to be delivered through video-conferencing or telephone.1,2 Telemedicine offered a way to stay connected with primary care providers during the COVID-19 pandemic,3 which may be particularly suitable for assisted living facility (AL) residents with dementia who have high care needs. Expansion, however, raised concerns […]

Primary Care Telemedicine Use among Assisted Living Residents with Dementia during COVID-19: Race and Dual Enrollment Status

by Lea Efird-Green

In 2023-03-01 12:00:00 2020, restrictions on telemedicine were waived, allowing services to be delivered through video-conferencing or telephone.1,2 Telemedicine offered a way to stay connected with primary care providers during the COVID-19 pandemic,3 which may be particularly suitable for assisted living facility (AL) residents with dementia who have high care needs. Expansion, however, raised concerns […]

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

May 1, 2023
Objective Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States. Design Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services. Setting and Participants A […]

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

by Lea Efird-Green

Objective Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States. Design Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services. Setting and Participants A […]

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

Apr 1, 2023
Objectives More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia. Design This […]

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

by Lea Efird-Green

Objectives More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia. Design This […]

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

Mar 1, 2023
Objectives Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year 2018. Design We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data Set […]

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

by Lea Efird-Green

Objectives Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year 2018. Design We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data Set […]

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

Dec 1, 2022
Objectives To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19 pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver gender and mental health. Design Cross-sectional and longitudinal survey. Setting and Participants Family/friend caregivers of assisted living residents in Alberta and British Columbia. Methods A […]

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

by Lea Efird-Green

Objectives To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19 pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver gender and mental health. Design Cross-sectional and longitudinal survey. Setting and Participants Family/friend caregivers of assisted living residents in Alberta and British Columbia. Methods A […]

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

Dec 1, 2022
ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

by Lea Efird-Green

ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

Oct 1, 2022
Objective To evaluate whether assisted living (AL) residents with Alzheimer’s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. Design […]

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

by Lea Efird-Green

Objective To evaluate whether assisted living (AL) residents with Alzheimer’s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. Design […]

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

Sep 1, 2022
Assisted living (AL) provides the majority of residential long-term care in the United States. Almost 40% of AL residents display behaviors such as aggression and refusing care, 57% of whom receive medications for these behaviors. In nursing homes, concerns about inappropriate antipsychotic prescribing led to initiatives to reduce prescribing, and although there has been concern […]

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

by Lea Efird-Green

Assisted living (AL) provides the majority of residential long-term care in the United States. Almost 40% of AL residents display behaviors such as aggression and refusing care, 57% of whom receive medications for these behaviors. In nursing homes, concerns about inappropriate antipsychotic prescribing led to initiatives to reduce prescribing, and although there has been concern […]

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

Aug 1, 2022
Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

by Lea Efird-Green

Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

Melatonin Prescribing in Assisted Living

Jun 1, 2022
Objectives: Aging is associated with sleep problems, which are common among assisted living (AL) residents. More than 40% of residents have insomnia, and almost 70% have a sleep disturbance of some kind. Melatonin to treat sleep disorders has become common among older adults, but its use in AL is unknown, which is concerning because melatonin […]

Melatonin Prescribing in Assisted Living

by Lea Efird-Green

Objectives: Aging is associated with sleep problems, which are common among assisted living (AL) residents. More than 40% of residents have insomnia, and almost 70% have a sleep disturbance of some kind. Melatonin to treat sleep disorders has become common among older adults, but its use in AL is unknown, which is concerning because melatonin […]

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

Jun 1, 2022
Objectives Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are […]

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

by Lea Efird-Green

Objectives Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are […]

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

Jun 1, 2022
Antibiotic prescribing patterns offer insights into clinical care across different health care settings, especially in nursing homes (NHs). These residents are highly susceptible to infection and are frequently inappropriately treated with antibiotics. Overuse and misuse of antibiotics is a common cause of adverse drug events, colonization, and infections caused by multidrug-resistant bacteria and Clostridioides difficile […]

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

by Lea Efird-Green

Antibiotic prescribing patterns offer insights into clinical care across different health care settings, especially in nursing homes (NHs). These residents are highly susceptible to infection and are frequently inappropriately treated with antibiotics. Overuse and misuse of antibiotics is a common cause of adverse drug events, colonization, and infections caused by multidrug-resistant bacteria and Clostridioides difficile […]

COVID-19 in Assisted Living: Protecting a Critical Long-Term Care Resource

Feb 16, 2022
The COVID-19 pandemic had a big impact on assisted living (AL), a vital setting in long-term care (LTC). Understanding the strengths and opportunities for improvement through practice, policy, and research are essential for AL to be prepared for the next pandemic and other challenges. AL communities experienced the pandemic in unique ways, because of varying […]

COVID-19 in Assisted Living: Protecting a Critical Long-Term Care Resource

by Lea Efird-Green

The COVID-19 pandemic had a big impact on assisted living (AL), a vital setting in long-term care (LTC). Understanding the strengths and opportunities for improvement through practice, policy, and research are essential for AL to be prepared for the next pandemic and other challenges. AL communities experienced the pandemic in unique ways, because of varying […]

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living

Feb 1, 2022
Objectives Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living. Design We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs). Setting and Participants The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 […]

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living

by Lea Efird-Green

Objectives Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living. Design We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs). Setting and Participants The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 […]

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

Feb 1, 2022
Objectives: Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year 2018. Design: We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data […]

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

by Lea Efird-Green

Objectives: Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year 2018. Design: We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data […]