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

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

Dec 1, 2024
Objectives To examine how risk of hospitalization among assisted living (AL) residents differs by dual enrollment in Medicare and Medicaid and by the percent of dually enrolled individuals in an AL community. Design Retrospective cohort study. Setting and Participants We used Medicare data from 2008 to 2018 and a national directory of licensed AL communities […]

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

by Lea Efird-Green

Objectives To examine how risk of hospitalization among assisted living (AL) residents differs by dual enrollment in Medicare and Medicaid and by the percent of dually enrolled individuals in an AL community. Design Retrospective cohort study. Setting and Participants We used Medicare data from 2008 to 2018 and a national directory of licensed AL communities […]

Transitions to Nursing Homes Among Residents of Assisted Living and Community-Dwelling Home Care Recipients

Dec 1, 2024
Objectives To examine transitions to a nursing home among residents of assisted living relative to community-dwelling home care recipients. Design Population-based retrospective cohort study emulating a target trial. Setting and Participants Linked, individual-level health system data were obtained from older adults (≥65 years of age) who made an incident application for a bed in a nursing […]

Transitions to Nursing Homes Among Residents of Assisted Living and Community-Dwelling Home Care Recipients

by Lea Efird-Green

Objectives To examine transitions to a nursing home among residents of assisted living relative to community-dwelling home care recipients. Design Population-based retrospective cohort study emulating a target trial. Setting and Participants Linked, individual-level health system data were obtained from older adults (≥65 years of age) who made an incident application for a bed in a nursing […]

Medical Care Provider Involvement in Ontario Assisted Living Homes: A Descriptive Cross-Sectional Survey Analysis

Dec 1, 2024
Objectives: Assisted living is growing in Ontario. Medical services are not regulated in Ontario, resulting in variability of physician involvement. We described medical service provider involvement and practice characteristics in assisted living homes. Design: Descriptive cross-sectional study. Setting and Participants: A total of 88 assisted living homes in Ontario, Canada, which responded to a survey […]

Medical Care Provider Involvement in Ontario Assisted Living Homes: A Descriptive Cross-Sectional Survey Analysis

by Lea Efird-Green

Objectives: Assisted living is growing in Ontario. Medical services are not regulated in Ontario, resulting in variability of physician involvement. We described medical service provider involvement and practice characteristics in assisted living homes. Design: Descriptive cross-sectional study. Setting and Participants: A total of 88 assisted living homes in Ontario, Canada, which responded to a survey […]

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

Nov 1, 2024
Objectives To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). Design Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and Participants NHs (n = 678) and […]

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

by Lea Efird-Green

Objectives To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). Design Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and Participants NHs (n = 678) and […]

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

Nov 1, 2024
Objective To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services. Design Nested case-control study. Setting and Participants Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December […]

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

by Lea Efird-Green

Objective To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services. Design Nested case-control study. Setting and Participants Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December […]

Feasibility of a Novel Lighting System to Reduce Nighttime Falls in Assisted Living Residents With Dementia

Oct 1, 2024
Objectives To determine the feasibility of conducting a trial of a novel nighttime lighting system designed to support postural stability in assisted living (AL) residents, and to estimate intervention effectiveness by comparing the incidence of nighttime falls during the novel lighting condition to that in a control condition featuring a standard nightlight. Design Randomized crossover […]

Feasibility of a Novel Lighting System to Reduce Nighttime Falls in Assisted Living Residents With Dementia

by Lea Efird-Green

Objectives To determine the feasibility of conducting a trial of a novel nighttime lighting system designed to support postural stability in assisted living (AL) residents, and to estimate intervention effectiveness by comparing the incidence of nighttime falls during the novel lighting condition to that in a control condition featuring a standard nightlight. Design Randomized crossover […]

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

Aug 1, 2024
Objective Self-compassion is a healthy way of responding to challenges that may help long-term care professional caregivers (ie, nursing assistants and personal care aides) cope with stress, but its use may vary in important ways. This study explored the relationships between self-compassion and caregiver demographic characteristics, anxiety and depressive symptoms, and job satisfaction in a […]

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

by Lea Efird-Green

Objective Self-compassion is a healthy way of responding to challenges that may help long-term care professional caregivers (ie, nursing assistants and personal care aides) cope with stress, but its use may vary in important ways. This study explored the relationships between self-compassion and caregiver demographic characteristics, anxiety and depressive symptoms, and job satisfaction in a […]

Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

Aug 1, 2024
Objectives: To track the changes that occurred in family involvement among Oregon Adult Foster Home (AFH) residents following the COVID-19 pandemic and to examine the associations between home and resident characteristics and family involvement. Design: Retrospective analysis of repeated cross-sectional data. Setting and Participants: A total of 2027 responses from AFH providers that replied to […]

Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

by Lea Efird-Green

Objectives: To track the changes that occurred in family involvement among Oregon Adult Foster Home (AFH) residents following the COVID-19 pandemic and to examine the associations between home and resident characteristics and family involvement. Design: Retrospective analysis of repeated cross-sectional data. Setting and Participants: A total of 2027 responses from AFH providers that replied to […]

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

Jun 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

Jun 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of data from 463 AL communities in Oregon from 2017-2019 revealed that on average, 30.7% of residents had received antipsychotics in the past 90 days. Nonprofit settings had lower usage compared to for-profit settings, while communities with more residents using Medicaid had higher rates of antipsychotic usage. Residents in memory care were more likely to receive these medications than residents in general AL settings.

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of data from 463 AL communities in Oregon from 2017-2019 revealed that on average, 30.7% of residents had received antipsychotics in the past 90 days. Nonprofit settings had lower usage compared to for-profit settings, while communities with more residents using Medicaid had higher rates of antipsychotic usage. Residents in memory care were more likely to receive these medications than residents in general AL settings.

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

May 1, 2024
WHAT THIS MEANS FOR YOU: This retrospective cohort study used health records from residents in publicly funded AL communities and nursing homes (NHs) in Alberta, Canada from 2017 to 2021 to examine excess deaths during the first two years of the pandemic. Excess deaths were higher in AL communities compared to NHs, especially during weeks identified as pandemic waves (i.e., a surge in COVID-19 infections). The risk of excess death was also greater among residents with dementia or significant cognitive impairment in both AL communities and NHs.

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This retrospective cohort study used health records from residents in publicly funded AL communities and nursing homes (NHs) in Alberta, Canada from 2017 to 2021 to examine excess deaths during the first two years of the pandemic. Excess deaths were higher in AL communities compared to NHs, especially during weeks identified as pandemic waves (i.e., a surge in COVID-19 infections). The risk of excess death was also greater among residents with dementia or significant cognitive impairment in both AL communities and NHs.

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

May 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

Oct 1, 2023
WHAT THIS MEANS FOR YOU: Administrative data from 256 assisted living communities in Alberta during the COVID-19 pandemic found that during waves 2 to 4, antipsychotic use increased, (significantly more for dementia care residents), and that anticonvulsant use increased for assisted living (but not dementia care) residents. Additionally, there was an increase in antidepressant use and a decrease in benzodiazepine use for both assisted living and dementia care residents. The persistence of a pandemic-associated increase in these medications raises concerns about well-established health and wellbeing impacts for residents.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Administrative data from 256 assisted living communities in Alberta during the COVID-19 pandemic found that during waves 2 to 4, antipsychotic use increased, (significantly more for dementia care residents), and that anticonvulsant use increased for assisted living (but not dementia care) residents. Additionally, there was an increase in antidepressant use and a decrease in benzodiazepine use for both assisted living and dementia care residents. The persistence of a pandemic-associated increase in these medications raises concerns about well-established health and wellbeing impacts for residents.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study

Jul 1, 2023
WHAT THIS MEANS FOR YOU: Administrative data from 2013-2019 in Ontario, Canada found a 34% increase in the resident population, and residents experienced increased instances of health conditions including renal disease, mental health issues, cardiac arrhythmias, diabetes, and cancer. Approximately 20% of residents still lived in an assisted living community at the end of the 6-year period, while 10% transitioned to nursing homes. In less than a decade, data revealed increasing medical complexity of assisted living residents, which must be considered for improved policy and practice.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Administrative data from 2013-2019 in Ontario, Canada found a 34% increase in the resident population, and residents experienced increased instances of health conditions including renal disease, mental health issues, cardiac arrhythmias, diabetes, and cancer. Approximately 20% of residents still lived in an assisted living community at the end of the 6-year period, while 10% transitioned to nursing homes. In less than a decade, data revealed increasing medical complexity of assisted living residents, which must be considered for improved policy and practice.

Hospital Proximity and Emergency Department Use among Assisted Living Residents

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study assessed if the distance between AL communities and the nearest hospital was associated with the frequency of emergency department (ED) visits. Almost 541,000 Medicare beneficiaries aged 55 or older residing in over 16,500 AL communities in 2018-2019 were included. The median distance to the nearest hospital was 2.5 miles. Distance was related to ED use, especially for non-critical, visits, such that communities 5 or more miles from a hospital had fewer ED visits than those that were closer to a hospital.

Hospital Proximity and Emergency Department Use among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study assessed if the distance between AL communities and the nearest hospital was associated with the frequency of emergency department (ED) visits. Almost 541,000 Medicare beneficiaries aged 55 or older residing in over 16,500 AL communities in 2018-2019 were included. The median distance to the nearest hospital was 2.5 miles. Distance was related to ED use, especially for non-critical, visits, such that communities 5 or more miles from a hospital had fewer ED visits than those that were closer to a hospital.

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

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

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

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study examined differences in who may be admitted to an assisted living community using regulatory data from 2018. Admission restrictions were categorized into 1) health-related conditions, 2) specified behavior, 3) mental health condition, and 4) cognitive impairment. Almost one-third (29%) of communities are governed by regulations limiting admission of individuals with only a health condition, and slightly fewer (24%) of communities have limitations based on all four categories. Just over 11% of AL communities have no restrictions on who may be admitted.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined differences in who may be admitted to an assisted living community using regulatory data from 2018. Admission restrictions were categorized into 1) health-related conditions, 2) specified behavior, 3) mental health condition, and 4) cognitive impairment. Almost one-third (29%) of communities are governed by regulations limiting admission of individuals with only a health condition, and slightly fewer (24%) of communities have limitations based on all four categories. Just over 11% of AL communities have no restrictions on who may be admitted.

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

Jun 1, 2023
WHAT THIS MEANS FOR YOU: In this study, almost 150,000 on-line consumer reviews from nearly 9,000 assisted living communities were analyzed in the context of community, county, and state variables (e.g., regulatory specificity, rurality). Communities with greater proportions of Medicare/Medicaid residents had lower odds of positive reviews, but communities in states with more direct care worker hours per week per bed had higher odds of positive reviews. Higher staffing may advantage positive consumer perceptions.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In this study, almost 150,000 on-line consumer reviews from nearly 9,000 assisted living communities were analyzed in the context of community, county, and state variables (e.g., regulatory specificity, rurality). Communities with greater proportions of Medicare/Medicaid residents had lower odds of positive reviews, but communities in states with more direct care worker hours per week per bed had higher odds of positive reviews. Higher staffing may advantage positive consumer perceptions.

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

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

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

May 1, 2023
WHAT THIS MEANS FOR YOU: This study used Medicare and CDC datasets to examine telemedicine primary care among 62,000 AL residents with dementia during the first year of the COVID-19 pandemic (2020). During the first three quarters of the pandemic, racially minoritized groups (Black, Hispanic) and Medicare-Medicaid dual eligibles were able to successfully use telemedicine at high rates. Gaps in primary care access between these groups and others (white, non-Medicaid eligible) were reduced due to telemedicine. This could inform CMS decisions about Medicare coverage for telemedicine primary care.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used Medicare and CDC datasets to examine telemedicine primary care among 62,000 AL residents with dementia during the first year of the COVID-19 pandemic (2020). During the first three quarters of the pandemic, racially minoritized groups (Black, Hispanic) and Medicare-Medicaid dual eligibles were able to successfully use telemedicine at high rates. Gaps in primary care access between these groups and others (white, non-Medicaid eligible) were reduced due to telemedicine. This could inform CMS decisions about Medicare coverage for telemedicine primary care.

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

May 1, 2023
WHAT THIS MEANS FOR YOU: A new methodology was developed for identifying Medicare beneficiaries residing in licensed AL communities in the US using zip code data, Medicare enrollment data, and claims data, and exclusion based on AL capacity (licensing information). Results suggested that using licensing information makes identifying AL residents receiving Medicare more accurate, which could inform research and policy by providing new insights into the health of AL residents.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A new methodology was developed for identifying Medicare beneficiaries residing in licensed AL communities in the US using zip code data, Medicare enrollment data, and claims data, and exclusion based on AL capacity (licensing information). Results suggested that using licensing information makes identifying AL residents receiving Medicare more accurate, which could inform research and policy by providing new insights into the health of AL residents.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

Apr 1, 2023
WHAT THIS MEANS FOR YOU: This study of almost 21,000 AL residents in 2017 revealed that those with dementia were prescribed antipsychotics during about 13% of their time residing in AL. This proportion varied by state, with Hawaii having the lowest prescription rate (8%), and Wyoming having the highest (21%). Variations may be due to state regulation of AL communities, but the study was not able to determine if prescription practices were appropriate and tied to health outcomes.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study of almost 21,000 AL residents in 2017 revealed that those with dementia were prescribed antipsychotics during about 13% of their time residing in AL. This proportion varied by state, with Hawaii having the lowest prescription rate (8%), and Wyoming having the highest (21%). Variations may be due to state regulation of AL communities, but the study was not able to determine if prescription practices were appropriate and tied to health outcomes.

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

Mar 1, 2023
WHAT THIS MEANS FOR YOU: Because AL is state-regulated, obtaining information about Medicare beneficiaries in AL can be difficult. This study identified AL Medicare beneficiaries using zip code files, Medicare databases, and other data sets, which can aid researchers and policymakers.

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Because AL is state-regulated, obtaining information about Medicare beneficiaries in AL can be difficult. This study identified AL Medicare beneficiaries using zip code files, Medicare databases, and other data sets, which can aid researchers and policymakers.

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

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.