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

From Nursing Homes to Home Care: Examining the Impact of the COVID-19 Pandemic on Direct Care Worker Transitions

Jun 1, 2025
Objectives: Due to poor working conditions and low wages, workforce turnover in the long-term care industry has been a longstanding issue. Increased risks to workers caused by the COVID-19 pandemic exacerbated these issues. Thus, many states offered wage supports (eg, hazard pay) to try to stabilize the workforce. Our objective was to examine how exits […]

From Nursing Homes to Home Care: Examining the Impact of the COVID-19 Pandemic on Direct Care Worker Transitions

by Lea Efird-Green

Objectives: Due to poor working conditions and low wages, workforce turnover in the long-term care industry has been a longstanding issue. Increased risks to workers caused by the COVID-19 pandemic exacerbated these issues. Thus, many states offered wage supports (eg, hazard pay) to try to stabilize the workforce. Our objective was to examine how exits […]

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

Apr 1, 2025
Objective: To examine trends in home health care (HHC) use in congregate living and compare characteristics of HHC use between Medicare patients in congregate living and those in other home settings. Design: Retrospective cohort study describing HHC use, in and outside of congregate living, using national Medicare claims, assessment, and administrative data (2014-2019). We compared […]

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

by Lea Efird-Green

Objective: To examine trends in home health care (HHC) use in congregate living and compare characteristics of HHC use between Medicare patients in congregate living and those in other home settings. Design: Retrospective cohort study describing HHC use, in and outside of congregate living, using national Medicare claims, assessment, and administrative data (2014-2019). We compared […]

Urinary Incontinence Is an Independent Risk Factor for Nursing Home Placement among Assisted Living Residents

Apr 1, 2025
Objectives: Prior studies suggested that urinary incontinence (UI) may be a risk factor for nursing home (NH) placement among older community-dwelling individuals. Our objectives were to evaluate if UI is an independent risk factor in NH placement among assisted living (AL) residents and assess the impact of UI on NH placement by race/ethnicity. Design: This […]

Urinary Incontinence Is an Independent Risk Factor for Nursing Home Placement among Assisted Living Residents

by Lea Efird-Green

Objectives: Prior studies suggested that urinary incontinence (UI) may be a risk factor for nursing home (NH) placement among older community-dwelling individuals. Our objectives were to evaluate if UI is an independent risk factor in NH placement among assisted living (AL) residents and assess the impact of UI on NH placement by race/ethnicity. Design: This […]

The Impact of Enhanced Group Activity Kits (EGAKs) on Well-being of Persons with Dementia

Jan 1, 2025
Objectives: People living with dementia (PLwD) often feel lonely and bored. This study examined the impact of group activities on the well-being of this population when these activities were facilitated by enhanced group activity kits (EGAKs) and compared the impact of this intervention with (1) group activities not facilitated by EGAKs and (2) the absence […]

The Impact of Enhanced Group Activity Kits (EGAKs) on Well-being of Persons with Dementia

by Lea Efird-Green

Objectives: People living with dementia (PLwD) often feel lonely and bored. This study examined the impact of group activities on the well-being of this population when these activities were facilitated by enhanced group activity kits (EGAKs) and compared the impact of this intervention with (1) group activities not facilitated by EGAKs and (2) the absence […]

Assisted Living, Residential Care, and Memory Care Staffing Level Dynamics: Oregon, 2017-2023

Jan 1, 2025
Objectives: To examine changes in staffing levels over time in Oregon assisted living and residential care (AL/RC) communities between 2017 and 2023. Design: Longitudinal study of licensed AL/RC communities. Setting and Participants: A total of 1720 setting-year observations from 535 individual AL/RC communities in Oregon between 2017 and 2023. Methods: Primary data were collected through […]

Assisted Living, Residential Care, and Memory Care Staffing Level Dynamics: Oregon, 2017-2023

by Lea Efird-Green

Objectives: To examine changes in staffing levels over time in Oregon assisted living and residential care (AL/RC) communities between 2017 and 2023. Design: Longitudinal study of licensed AL/RC communities. Setting and Participants: A total of 1720 setting-year observations from 535 individual AL/RC communities in Oregon between 2017 and 2023. Methods: Primary data were collected through […]

The Meaningful Engagement Assessment for Residents with Dementia in Assisted Living Settings

Jan 1, 2025
Providing meaningful activity is a critical dimension of person-centered care for residents with dementia in all settings, including assisted living. Defined broadly as participation in physical, social, and leisure activities that provide meaning and value to the person and are tailored to individualized interests and preferences, meaningful activity has implications for well-being, mental health, cognition, […]

The Meaningful Engagement Assessment for Residents with Dementia in Assisted Living Settings

by Lea Efird-Green

Providing meaningful activity is a critical dimension of person-centered care for residents with dementia in all settings, including assisted living. Defined broadly as participation in physical, social, and leisure activities that provide meaning and value to the person and are tailored to individualized interests and preferences, meaningful activity has implications for well-being, mental health, cognition, […]

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

Jan 1, 2025
Objectives: To identify different approaches (unique domains) and indicators to evaluate quality in assisted living communities in the United States. Design: Scoping review supplemented with key informant and technical panel guidance. Setting and Participants: Assisted living settings and residents. Methods: We obtained feedback on our review protocol and search strategy from key informants with expertise […]

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

by Lea Efird-Green

Objectives: To identify different approaches (unique domains) and indicators to evaluate quality in assisted living communities in the United States. Design: Scoping review supplemented with key informant and technical panel guidance. Setting and Participants: Assisted living settings and residents. Methods: We obtained feedback on our review protocol and search strategy from key informants with expertise […]

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

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This retrospective cohort study used Medicare data from 2008-2018 from 12,451 AL communities to examine the risk of hospitalization for Medicare-Medicaid dual eligibles. Out of 620,542 Medicare beneficiaries, the 1-year risk of hospitalization was higher for dually enrolled individuals. The risk was higher in high-dual AL communities than in low-dual AL communities for both dually enrolled (7.4%) and Medicare only (9.4%) individuals.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This retrospective cohort study used Medicare data from 2008-2018 from 12,451 AL communities to examine the risk of hospitalization for Medicare-Medicaid dual eligibles. Out of 620,542 Medicare beneficiaries, the 1-year risk of hospitalization was higher for dually enrolled individuals. The risk was higher in high-dual AL communities than in low-dual AL communities for both dually enrolled (7.4%) and Medicare only (9.4%) individuals.

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

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This cross-sectional Canadian study examined 88 AL communities' survey responses to assess medical care provider involvement. A total of 54 AL communities had an established medical care provider, and doctors cared for more than 50 patients in 36% of homes and 46% visited homes weekly. Almost two-thirds of communities had nurses accompany physicians on rounds, and two-thirds provided residents with palliative care. Residents in homes with medical care providers were 76% less likely to seek care from a physician in the community.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional Canadian study examined 88 AL communities’ survey responses to assess medical care provider involvement. A total of 54 AL communities had an established medical care provider, and doctors cared for more than 50 patients in 36% of homes and 46% visited homes weekly. Almost two-thirds of communities had nurses accompany physicians on rounds, and two-thirds provided residents with palliative care. Residents in homes with medical care providers were 76% less likely to seek care from a physician in the community.

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

Dec 1, 2024
This Canadian cohort study included 10,012 AL residents and 131,679 home care recipients who applied for beds in nursing homes to examine the transition differences between the 2 groups. There were 6,049 transitions from AL residents and 85,190 from home care to nursing homes. Living in an AL, rather than in the community, led to a roughly 13% decrease in the 5-year risk of transition to nursing homes despite similar relative clinical complexity and healthcare needs, meaning that assisted living is an important part of the long-term care continuum.

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

by Lea Efird-Green

This Canadian cohort study included 10,012 AL residents and 131,679 home care recipients who applied for beds in nursing homes to examine the transition differences between the 2 groups. There were 6,049 transitions from AL residents and 85,190 from home care to nursing homes. Living in an AL, rather than in the community, led to a roughly 13% decrease in the 5-year risk of transition to nursing homes despite similar relative clinical complexity and healthcare needs, meaning that assisted living is an important part of the long-term care continuum.

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

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This study used observational data from 678 nursing staff at NHs and 432 nursing staff at AL communities in Ohio to assess their direct care nursing staffing patterns. Both NHs and AL communities had better daytime staffing ratios than overnights, although NH staffing ratios were superior to those in AL communities. In AL and NH memory care units, staffing patterns were similar. As acuity increases in AL communities, more nursing staff will likely be required, especially on overnight shifts.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used observational data from 678 nursing staff at NHs and 432 nursing staff at AL communities in Ohio to assess their direct care nursing staffing patterns. Both NHs and AL communities had better daytime staffing ratios than overnights, although NH staffing ratios were superior to those in AL communities. In AL and NH memory care units, staffing patterns were similar. As acuity increases in AL communities, more nursing staff will likely be required, especially on overnight shifts.

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

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This nested case-control study in Ontario examined differences between community-dwelling and new AL residents to understand transitions to AL communitiess. New residents had higher rates of diagnosed dementia, mood disorders, cardiac arrhythmias, mild cognitive impairment, and falls than community-dwelling peers. New AL residents also had lower odds of having a spousal caregiver than a child caregiver. However, these residents also had higher rates of participation in activities of interest in the last seven days.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This nested case-control study in Ontario examined differences between community-dwelling and new AL residents to understand transitions to AL communitiess. New residents had higher rates of diagnosed dementia, mood disorders, cardiac arrhythmias, mild cognitive impairment, and falls than community-dwelling peers. New AL residents also had lower odds of having a spousal caregiver than a child caregiver. However, these residents also had higher rates of participation in activities of interest in the last seven days.

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

Oct 1, 2024
WHAT THIS MEANS FOR YOU: This crossover trial examined 38 residents in 5 AL communities to test a new lighting system to reduce nighttime falls. Using cameras to capture falls, falls density was found to be 34% lower in the intervention condition than the control condition, although this reduction was not statistically significant. The results were promising enough to continue testing in a larger trial, which is ongoing.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This crossover trial examined 38 residents in 5 AL communities to test a new lighting system to reduce nighttime falls. Using cameras to capture falls, falls density was found to be 34% lower in the intervention condition than the control condition, although this reduction was not statistically significant. The results were promising enough to continue testing in a larger trial, which is ongoing.

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

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This study used cross-sectional data from 2017-2022 from Adult Foster Homes (AFHs) in Oregon to examine trends in family involvement and home and resident characteristics. Data showed declines in familial social visits and help with appointments in 2021/22 following COVID-19, but by 2023 social visits were back to pre-pandemic levels. However, there was less familial support in going on outings and getting to medical appointments, and there were disparities in that rural and Medicaid AFHs had less family support for residents in all areas. The continued decline in medical appointment and outings support presents concerns for resident socio-emotional well-being.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used cross-sectional data from 2017-2022 from Adult Foster Homes (AFHs) in Oregon to examine trends in family involvement and home and resident characteristics. Data showed declines in familial social visits and help with appointments in 2021/22 following COVID-19, but by 2023 social visits were back to pre-pandemic levels. However, there was less familial support in going on outings and getting to medical appointments, and there were disparities in that rural and Medicaid AFHs had less family support for residents in all areas. The continued decline in medical appointment and outings support presents concerns for resident socio-emotional well-being.

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This cross-sectional study examined the relationship between self-compassion, anxiety and depressive symptoms, and job satisfaction from 391 caregivers across 13 nursing homes and assisted living communities in 3 states. Older caregivers, those with higher education, and those who were born outside the US reported highest self-compassion, while white caregivers reported the lowest. Self-compassion was negatively associated with mental health symptoms and positively associated with job satisfaction, meaning that its use could be beneficial as one method to address workforce issues in long-term care.

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional study examined the relationship between self-compassion, anxiety and depressive symptoms, and job satisfaction from 391 caregivers across 13 nursing homes and assisted living communities in 3 states. Older caregivers, those with higher education, and those who were born outside the US reported highest self-compassion, while white caregivers reported the lowest. Self-compassion was negatively associated with mental health symptoms and positively associated with job satisfaction, meaning that its use could be beneficial as one method to address workforce issues in long-term care.

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.

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.

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.

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.

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.

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.

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.