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

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

Jun 1, 2024
Objectives To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). Design Retrospective cohort study. Setting and Participants We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 […]

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

Objectives To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). Design Retrospective cohort study. Setting and Participants We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 […]

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

Jun 1, 2024
Objective Investigate how assisted living and residential care (AL/RC) and memory care (MC) contexts are associated with the 90-day prevalence of antipsychotic medication use (APU), considered a quality measure in long-term care. Design All licensed AL/RC settings in Oregon received an annual mailed questionnaire to provide aggregate resident demographics, health acuity, health service use, payment […]

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

by Lea Efird-Green

Objective Investigate how assisted living and residential care (AL/RC) and memory care (MC) contexts are associated with the 90-day prevalence of antipsychotic medication use (APU), considered a quality measure in long-term care. Design All licensed AL/RC settings in Oregon received an annual mailed questionnaire to provide aggregate resident demographics, health acuity, health service use, payment […]

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

May 1, 2024
Objectives Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study […]

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

by Lea Efird-Green

Objectives Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study […]

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

May 1, 2024
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 […]

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

by Lea Efird-Green

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 […]

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

Oct 1, 2023
Objectives To examine the associations between COVID-19 pandemic waves (1–4) and prevalent antipsychotic, antidepressant, benzodiazepine, anticonvulsant, and opioid use among assisted living (AL) residents, by setting (dementia care vs other). Design Population-based, repeated cross-sectional study. Setting and Participants Linked clinical and health administrative databases for residents of all publicly subsidized AL homes (N = 256) […]

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

by Lea Efird-Green

Objectives To examine the associations between COVID-19 pandemic waves (1–4) and prevalent antipsychotic, antidepressant, benzodiazepine, anticonvulsant, and opioid use among assisted living (AL) residents, by setting (dementia care vs other). Design Population-based, repeated cross-sectional study. Setting and Participants Linked clinical and health administrative databases for residents of all publicly subsidized AL homes (N = 256) […]

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

Jul 1, 2023
Objective We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. Design Repeated cross-sectional study. Setting and Participants Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. Methods Counts and […]

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

by Lea Efird-Green

Objective We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. Design Repeated cross-sectional study. Setting and Participants Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. Methods Counts and […]

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.

“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.

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.

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.

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.

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.

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.

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.

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 […]

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 […]

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 […]

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 […]

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 […]

Melatonin Prescribing in Assisted Living

Jun 1, 2022
WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.

Melatonin Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.