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

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.

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.

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.

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

Dec 1, 2022
WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

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

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Data from over 560,000 Medicare recipients revealed that residents with dementia experienced 33.4 more excess deaths per 100,000 compared to those without dementia during the COVID-19 pandemic. Residents in memory care communities did not have significantly different mortality rates compared to those in general assisted living settings.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from over 560,000 Medicare recipients revealed that residents with dementia experienced 33.4 more excess deaths per 100,000 compared to those without dementia during the COVID-19 pandemic. Residents in memory care communities did not have significantly different mortality rates compared to those in general assisted living settings.

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

Jun 1, 2022
WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.

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

Jun 1, 2022
WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

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.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Monitoring Laboratory Parameters for Drug Toxicity in Assisted Living Facilities

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This quality improvement project focused on performing recommended laboratory tests per FDA medication labeling in a 58-bed assisted living community. Before the project, almost 60% of resident records had gaps in lab monitoring of medications, which was worsened because of COVID-19 restrictions. The project focused on close provider collaboration to ensure labs were conducted; after the project, almost 90% of residents received necessary lab tests for their medications.

Monitoring Laboratory Parameters for Drug Toxicity in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This quality improvement project focused on performing recommended laboratory tests per FDA medication labeling in a 58-bed assisted living community. Before the project, almost 60% of resident records had gaps in lab monitoring of medications, which was worsened because of COVID-19 restrictions. The project focused on close provider collaboration to ensure labs were conducted; after the project, almost 90% of residents received necessary lab tests for their medications.

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

Feb 16, 2022
WHAT THIS MEANS FOR YOU: This literature review explores how COVID-19 created challenges for both residents and staff in assisted living by providing an overview of its impact and suggesting actions to improve outcomes. Studies showed that residents experienced a decline in their health and happiness because of infection control measures, which made them feel lonely and isolated. Staff faced problems such as staff shortages, feeling overwhelmed and stressed, and dealing with emotional struggles. The article suggests solutions such as improving infection control, giving better training to staff, introducing Essential Caregiver programs, and encouraging residents to socialize more.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This literature review explores how COVID-19 created challenges for both residents and staff in assisted living by providing an overview of its impact and suggesting actions to improve outcomes. Studies showed that residents experienced a decline in their health and happiness because of infection control measures, which made them feel lonely and isolated. Staff faced problems such as staff shortages, feeling overwhelmed and stressed, and dealing with emotional struggles. The article suggests solutions such as improving infection control, giving better training to staff, introducing Essential Caregiver programs, and encouraging residents to socialize more.

Reimagining Medical Care in Assisted Living

Feb 1, 2022
WHAT THIS MEANS FOR YOU: Three industry-wide proposals were recommended to enhance medical care quality for AL residents: regular on-site medical visits; employing experienced professionals in long-term and end-of-life care; and the introduction of an AL medical director role to establish rules, staff qualifications, and collaboration. The researchers acknowledge that adaptations may be necessary to adhere to these recommendations due to community size and availability of resources.

Reimagining Medical Care in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Three industry-wide proposals were recommended to enhance medical care quality for AL residents: regular on-site medical visits; employing experienced professionals in long-term and end-of-life care; and the introduction of an AL medical director role to establish rules, staff qualifications, and collaboration. The researchers acknowledge that adaptations may be necessary to adhere to these recommendations due to community size and availability of resources.

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

Feb 1, 2022
WHAT THIS MEANS FOR YOU: A quality improvement initiative implemented by 810 Wisconsin assisted living communities serving over 20,000 residents found that most communities (88%) were able to comply with membership requirements and 71% remained enrolled for more than 2 years. This model could be reproduced in other states to improve quality.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A quality improvement initiative implemented by 810 Wisconsin assisted living communities serving over 20,000 residents found that most communities (88%) were able to comply with membership requirements and 71% remained enrolled for more than 2 years. This model could be reproduced in other states to improve quality.