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.

End of Life

CEAL@UNC Strategic Advisor Presentations

Feb 19, 2025
CEAL@UNC regularly invites organizations and individuals committed to advancing well-being in assisted living through practice, research, and policy to present emerging and relevant topics to its Strategic Advisors. View Presentations

CEAL@UNC Strategic Advisor Presentations

by Lea Efird-Green

CEAL@UNC regularly invites organizations and individuals committed to advancing well-being in assisted living through practice, research, and policy to present emerging and relevant topics to its Strategic Advisors. View Presentations

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 […]

Variation in Hospice Aide Care by Residential Setting

Aug 1, 2024
Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data […]

Variation in Hospice Aide Care by Residential Setting

by Lea Efird-Green

Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data […]

Do End-of-Life Outcomes Differ by Assisted Living Memory-Care Designation?

Apr 1, 2024
Background Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer’s disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate […]

Do End-of-Life Outcomes Differ by Assisted Living Memory-Care Designation?

by Lea Efird-Green

Background Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer’s disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate […]

Hospice Providers Serving Assisted Living Residents: Association of Higher Volume with Lower Quality

Mar 1, 2024
Background Assisted living (AL) community caregivers are known to report lower quality of hospice care. However, little is known about hospice providers serving AL residents and factors that may contribute to, and explain, differences in quality. We examined the association between hospice providers’ AL patient-day volume and their quality ratings based on Hospice Item Set […]

Hospice Providers Serving Assisted Living Residents: Association of Higher Volume with Lower Quality

by Lea Efird-Green

Background Assisted living (AL) community caregivers are known to report lower quality of hospice care. However, little is known about hospice providers serving AL residents and factors that may contribute to, and explain, differences in quality. We examined the association between hospice providers’ AL patient-day volume and their quality ratings based on Hospice Item Set […]

Resident and Caregiver Dyads Talk About Death and Dying in Assisted Living: A Typology of Communication Behaviors

Jan 1, 2024
Background In the U.S., assisted living (AL) is increasingly a site of death, and anxiety about dying has been identified in long-term care residents and their caregivers. Communication about death and dying is associated with better quality of life and care at end of life (EOL). Objective To understand communication behaviors used by AL residents […]

Resident and Caregiver Dyads Talk About Death and Dying in Assisted Living: A Typology of Communication Behaviors

by Lea Efird-Green

Background In the U.S., assisted living (AL) is increasingly a site of death, and anxiety about dying has been identified in long-term care residents and their caregivers. Communication about death and dying is associated with better quality of life and care at end of life (EOL). Objective To understand communication behaviors used by AL residents […]

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents

Dec 1, 2023
WHAT THIS MEANS FOR YOU: Medicare data from 2017 to 2020 for nearly 270,000 individuals from larger AL communities (25+ beds) found that about 35% of residents died during the study period, most often those 85 or older or with dementia. Most residents stayed in assisted living until their last year of life, but almost 20% left before their last month of life. Among those who lived in the community 30 days before death, nearly half died at the community without any healthcare transition, while over 13% had 3 or more healthcare transfers before death. Due to the prevalence of residents dying while in residence in assisted living, end-of-life practices and policies should be evaluated.

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from 2017 to 2020 for nearly 270,000 individuals from larger AL communities (25+ beds) found that about 35% of residents died during the study period, most often those 85 or older or with dementia. Most residents stayed in assisted living until their last year of life, but almost 20% left before their last month of life. Among those who lived in the community 30 days before death, nearly half died at the community without any healthcare transition, while over 13% had 3 or more healthcare transfers before death. Due to the prevalence of residents dying while in residence in assisted living, end-of-life practices and policies should be evaluated.

Turning It Over to God: African American Assisted Living Residents’ End-of-Life Preferences and Advance Care Planning

Jul 1, 2023
WHAT THIS MEANS FOR YOU: A qualitative study in a 100-bed assisted living community catering to African American residents found that a shared belief that God was ultimately in control related to end-of-life and advance care planning preferences, although this relationship was influenced by other individual-level factors like age, pain, function, health literacy, and past experiences with healthcare.

Turning It Over to God: African American Assisted Living Residents’ End-of-Life Preferences and Advance Care Planning

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A qualitative study in a 100-bed assisted living community catering to African American residents found that a shared belief that God was ultimately in control related to end-of-life and advance care planning preferences, although this relationship was influenced by other individual-level factors like age, pain, function, health literacy, and past experiences with healthcare.

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.

State Regulations and Assisted Living Residents’ Potentially Burdensome Transitions at the End of Life

Jun 1, 2023
WHAT THIS MEANS FOR YOU: The study examined potentially burdensome end-of-life transitions (e.g., repeated hospitalizations) in relation to state regulations, using Medicare claims data for over 129,000 assisted living residents in communities with 25 or more beds between 2017-2019. There were no associations between transitions and regulations about third-party services or staffing, and small associations between transitions and medication management regulations. These inconclusive results indicate that more research is needed to understand the wide variety of end-of-life outcomes experienced by assisted living residents.

State Regulations and Assisted Living Residents’ Potentially Burdensome Transitions at the End of Life

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study examined potentially burdensome end-of-life transitions (e.g., repeated hospitalizations) in relation to state regulations, using Medicare claims data for over 129,000 assisted living residents in communities with 25 or more beds between 2017-2019. There were no associations between transitions and regulations about third-party services or staffing, and small associations between transitions and medication management regulations. These inconclusive results indicate that more research is needed to understand the wide variety of end-of-life outcomes experienced by assisted living residents.

“You Gotta Have Your Cry”: Administrator and Direct Care Worker Experiences of Death in Assisted Living

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Qualitative data from 27 administrators and 38 direct care workers in 7 assisted living communities found that when residents died, staff members balanced their personal feelings about death and their work role in a process called “managing the normalization of death” with varying levels of perceived success. Additional resources and training about managing resident death, including improved collaboration with hospice services and clearer end-of-life care policies, might be helpful for staff.

“You Gotta Have Your Cry”: Administrator and Direct Care Worker Experiences of Death in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Qualitative data from 27 administrators and 38 direct care workers in 7 assisted living communities found that when residents died, staff members balanced their personal feelings about death and their work role in a process called “managing the normalization of death” with varying levels of perceived success. Additional resources and training about managing resident death, including improved collaboration with hospice services and clearer end-of-life care policies, might be helpful for staff.

Association between State Regulations Supportive of Third-Party Services and Likelihood of Assisted Living Residents in the US Dying in Place

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from nearly 170,000 residents from over 8,000 assisted communities with more than 25 beds who died between 2017 and 2019 indicated that in states with regulations supportive of third-party hospice services, residents were significantly more likely to die in assisted living than in a hospital or nursing home.

Association between State Regulations Supportive of Third-Party Services and Likelihood of Assisted Living Residents in the US Dying in Place

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from nearly 170,000 residents from over 8,000 assisted communities with more than 25 beds who died between 2017 and 2019 indicated that in states with regulations supportive of third-party hospice services, residents were significantly more likely to die in assisted living than in a hospital or nursing home.

Successful Aging in Assisted Living: The Importance of Near Visual Acuity

Sep 1, 2022
Successful aging among independent community-dwelling older adults and those in residential settings is paramount to aging in place. The purpose of the current study was to explore how sensory, cognitive, and functional impairments affect successful aging in assisted living (AL) settings. Vision compromise was noted for near visual acuity (NVA) (14.3%) and distance visual acuity […]

Successful Aging in Assisted Living: The Importance of Near Visual Acuity

by Lea Efird-Green

Successful aging among independent community-dwelling older adults and those in residential settings is paramount to aging in place. The purpose of the current study was to explore how sensory, cognitive, and functional impairments affect successful aging in assisted living (AL) settings. Vision compromise was noted for near visual acuity (NVA) (14.3%) and distance visual acuity […]

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.

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

May 1, 2022
WHAT THIS MEANS FOR YOU: This study examined end-of-life care in assisted living – specifically whether residents died in the community or elsewhere and received hospice care -- and whether these were associated with select factors. Among 100,783 Medicare beneficiaries who died in 16,560 communities during 2018–2019, nearly 60% died in their community, with 84% receiving hospice care. Communities with more Medicare-Medicaid enrollment had more residents dying in the community, and white residents were more likely than Black ones to use hospice care. In states with less strict assisted living regulations (e.g., for dementia care, admission/retention, and staffing/training), residents were more likely to die outside of the community (e.g., in a hospital or nursing home).

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined end-of-life care in assisted living – specifically whether residents died in the community or elsewhere and received hospice care — and whether these were associated with select factors. Among 100,783 Medicare beneficiaries who died in 16,560 communities during 2018–2019, nearly 60% died in their community, with 84% receiving hospice care. Communities with more Medicare-Medicaid enrollment had more residents dying in the community, and white residents were more likely than Black ones to use hospice care. In states with less strict assisted living regulations (e.g., for dementia care, admission/retention, and staffing/training), residents were more likely to die outside of the community (e.g., in a hospital or nursing home).

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

“You Lose Some Good Friends”: Death and Grief in Assisted Living

Mar 1, 2022
WHAT THIS MEANS FOR YOU: In a qualitative study including interviews with 18 residents in 21 assisted living communities, as well as reviews of community documents and observational field notes, residents reported that staff communication and community-level memorials following residents’ death were not consistent with a “family-like” atmosphere, and residents’ grief took many forms.

“You Lose Some Good Friends”: Death and Grief in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In a qualitative study including interviews with 18 residents in 21 assisted living communities, as well as reviews of community documents and observational field notes, residents reported that staff communication and community-level memorials following residents’ death were not consistent with a “family-like” atmosphere, and residents’ grief took many forms.

Assisted Living Administrators’ Approaches to Advance Care Planning

Feb 1, 2022
WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.

Assisted Living Administrators’ Approaches to Advance Care Planning

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.

State Variation in Potentially Burdensome Transitions among Assisted Living Residents at the End of Life

Feb 1, 2022
WHAT THIS MEANS FOR YOU: There are significant differences in the quality of end-of-life care in AL. Research on 37,668 deceased Medicare beneficiaries who lived in AL found that 1 in 5 experienced challenging transitions including frequent hospitalizations before their death. Burdensome transitions, especially in the last three days of life, varied widely among states, which may be associated with state-level regulations.

State Variation in Potentially Burdensome Transitions among Assisted Living Residents at the End of Life

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: There are significant differences in the quality of end-of-life care in AL. Research on 37,668 deceased Medicare beneficiaries who lived in AL found that 1 in 5 experienced challenging transitions including frequent hospitalizations before their death. Burdensome transitions, especially in the last three days of life, varied widely among states, which may be associated with state-level regulations.