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.

Medical Care

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 […]

Residency in Long-Term Care Facilities: An Important Risk Factor for Respiratory Syncytial Virus Hospitalization

Nov 1, 2024
Older age and comorbid conditions increase risk for severe for respiratory syncytial virus (RSV). Skilled nursing facilities (SNFs) and assisted living (AL) facilities represent an intersection of risk factors. In a 3-year prospective study in Rochester, New York, we compared the population-based incidence of RSV-associated hospitalization for communitydwelling (CD), SNF, and AL adults aged ≥65 […]

Residency in Long-Term Care Facilities: An Important Risk Factor for Respiratory Syncytial Virus Hospitalization

by Lea Efird-Green

Older age and comorbid conditions increase risk for severe for respiratory syncytial virus (RSV). Skilled nursing facilities (SNFs) and assisted living (AL) facilities represent an intersection of risk factors. In a 3-year prospective study in Rochester, New York, we compared the population-based incidence of RSV-associated hospitalization for communitydwelling (CD), SNF, and AL adults aged ≥65 […]

Paucity of Published Data and Protocols for Hypoglycemia Management in Long-term Care

Oct 1, 2024
Background: Older people with diabetes are at high risk for hypoglycemia. Implementing a hypoglycemia treatment protocol in long-term care (LTC) settings may positively affect patient-related outcomes and health care resource utilization and costs. Anecdotal experience indicates little has been studied and published regarding this clinical practice. Objective: To identify hypoglycemia treatment protocols established for LTC […]

Paucity of Published Data and Protocols for Hypoglycemia Management in Long-term Care

by Lea Efird-Green

Background: Older people with diabetes are at high risk for hypoglycemia. Implementing a hypoglycemia treatment protocol in long-term care (LTC) settings may positively affect patient-related outcomes and health care resource utilization and costs. Anecdotal experience indicates little has been studied and published regarding this clinical practice. Objective: To identify hypoglycemia treatment protocols established for LTC […]

Postimplementation Evaluation in Assisted Living Facilities of an eHealth Medical Device Developed to Predict and Avoid Unplanned Hospitalizations: Pragmatic Trial

Oct 1, 2024
Background: The proportion of very old adults in the population is increasing, representing a significant challenge. Due to their vulnerability, there is a higher frequency of unplanned hospitalizations in this population, leading to adverse events. Digital tools based on artificial intelligence (AI) can help to identify early signs of vulnerability and unfavorable health events and […]

Postimplementation Evaluation in Assisted Living Facilities of an eHealth Medical Device Developed to Predict and Avoid Unplanned Hospitalizations: Pragmatic Trial

by Lea Efird-Green

Background: The proportion of very old adults in the population is increasing, representing a significant challenge. Due to their vulnerability, there is a higher frequency of unplanned hospitalizations in this population, leading to adverse events. Digital tools based on artificial intelligence (AI) can help to identify early signs of vulnerability and unfavorable health events and […]

Examining Care Network Characteristics in Older Adults’ Relocation to Residential Care Settings

Sep 1, 2024
Background and Objectives: When older adults face increasing care needs or limited support, remaining safely and comfortably at home becomes challenging. Extant research has primarily concentrated on characteristics of the older adult or their primary caregiver on nursing home admission. This study examines the risk of older adults transitioning to residential care (e.g., assisted living, […]

Examining Care Network Characteristics in Older Adults’ Relocation to Residential Care Settings

by Lea Efird-Green

Background and Objectives: When older adults face increasing care needs or limited support, remaining safely and comfortably at home becomes challenging. Extant research has primarily concentrated on characteristics of the older adult or their primary caregiver on nursing home admission. This study examines the risk of older adults transitioning to residential care (e.g., assisted living, […]

Prevalence Rates of Diabetic Retinopathy and Undiagnosed Diabetes Among Delaware Nursing Home and Assisted Living Facility Residents

Jul 1, 2024
Objectives: To determine the prevalence of diabetic retinopathy and undiagnosed diabetes among Delaware nursing home and assisted care facility residents. Methods: This cross-sectional study involved the statistical analysis of comprehensive eye examination records of 2,063 nursing home residents residing in 18 facilities and 4 assisted living facilities in Delaware from 2005 to 2009. Descriptive statistical […]

Prevalence Rates of Diabetic Retinopathy and Undiagnosed Diabetes Among Delaware Nursing Home and Assisted Living Facility Residents

by Lea Efird-Green

Objectives: To determine the prevalence of diabetic retinopathy and undiagnosed diabetes among Delaware nursing home and assisted care facility residents. Methods: This cross-sectional study involved the statistical analysis of comprehensive eye examination records of 2,063 nursing home residents residing in 18 facilities and 4 assisted living facilities in Delaware from 2005 to 2009. Descriptive statistical […]

Be Well in AL Recommendations: Resident/Family Checklist

Jun 10, 2024
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living, including through the implementation of consensus medical and mental health care recommendations disseminated through the Be Well in AL Initiative. This checklist, to be used by residents and their families considering or residing in assisted living, is a helpful tool to understand recommended care […]

Be Well in AL Recommendations: Resident/Family Checklist

by Lea Efird-Green

CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living, including through the implementation of consensus medical and mental health care recommendations disseminated through the Be Well in AL Initiative. This checklist, to be used by residents and their families considering or residing in assisted living, is a helpful tool to understand recommended care […]

The Experiences of Routine Powered Mobility Users in an Assisted Living Facility: A Case Study

Jun 1, 2024
Background: The purpose of this study was to explore the contrasting experiences of two routine powered mobility device (PMD) users in an assisted living facility (ALF). Method: A case study approach using three forms of data (semi-structured interview, observation, and media collection of pictures) was used to formulate a comprehensive description of the two PMD […]

The Experiences of Routine Powered Mobility Users in an Assisted Living Facility: A Case Study

by Lea Efird-Green

Background: The purpose of this study was to explore the contrasting experiences of two routine powered mobility device (PMD) users in an assisted living facility (ALF). Method: A case study approach using three forms of data (semi-structured interview, observation, and media collection of pictures) was used to formulate a comprehensive description of the two PMD […]

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 […]

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma

Apr 1, 2024
Importance Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown. Objective To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane […]

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma

by Lea Efird-Green

Importance Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown. Objective To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane […]

Do-Not-Hospitalize Orders in Assisted Living Facilities: Direct Care Workers’ Perspectives

Apr 1, 2024
Purpose: To gather sufficient qualitative data to create an intervention that would prevent direct care workers (DCWs) from sending residents with do-not-hospitalize (DNH) orders to the hospital. Method: This was a qualitative study with eight participants that included a descriptive survey followed by semi-structured interviews. Results: DCWs were unfamiliar with DNH orders and their thinking […]

Do-Not-Hospitalize Orders in Assisted Living Facilities: Direct Care Workers’ Perspectives

by Lea Efird-Green

Purpose: To gather sufficient qualitative data to create an intervention that would prevent direct care workers (DCWs) from sending residents with do-not-hospitalize (DNH) orders to the hospital. Method: This was a qualitative study with eight participants that included a descriptive survey followed by semi-structured interviews. Results: DCWs were unfamiliar with DNH orders and their thinking […]

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

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

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

by Lea Efird-Green

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

Hospital Proximity and Emergency Department Use among Assisted Living Residents

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

Hospital Proximity and Emergency Department Use among Assisted Living Residents

by Lea Efird-Green

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

Injury-Related Emergency Department Use among Assisted Living Residents with Alzheimer’s Disease and Related Dementias

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Using 2018 Medicare data for over 116,000 residents, residents with dementia had a 25% higher risk of going to the emergency room for injuries compared to those without dementia, as well as having a significantly higher chance of being hospitalized for injuries, regardless of whether they lived in general assisted living or memory care.

Injury-Related Emergency Department Use among Assisted Living Residents with Alzheimer’s Disease and Related Dementias

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using 2018 Medicare data for over 116,000 residents, residents with dementia had a 25% higher risk of going to the emergency room for injuries compared to those without dementia, as well as having a significantly higher chance of being hospitalized for injuries, regardless of whether they lived in general assisted living or memory care.

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

Sep 1, 2022
Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

by Lea Efird-Green

Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Using Medicare data from 2018, data from over 255,000 people across 24,000 assisted living communities found differences in health outcomes based on race/ethnicity and dual eligibility, including hospital admissions, emergency room (ER) visits, and nursing home placements. For instance, Black and Hispanic residents had lower proportions of ER visits than their white counterparts, but Hispanic residents had higher 30-day readmission rates. Dual eligibility negatively impacted these outcomes more than race/ethnicity alone.

Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using Medicare data from 2018, data from over 255,000 people across 24,000 assisted living communities found differences in health outcomes based on race/ethnicity and dual eligibility, including hospital admissions, emergency room (ER) visits, and nursing home placements. For instance, Black and Hispanic residents had lower proportions of ER visits than their white counterparts, but Hispanic residents had higher 30-day readmission rates. Dual eligibility negatively impacted these outcomes more than race/ethnicity alone.

Impact of Dentures on Oral Health-Related Quality of Life in Assisted Living Facility Elders, Guntur District, Andhra Pradesh

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study investigated how wearing dentures affects the oral health-related quality of life and wellbeing of older adults residing in assisted living in India. Among 587 residents, those using removable partial dentures were more satisfied with their appearance and dental function than those with complete dentures. However, oral health impact (e.g., functional limitations, physical pain, social disability) was higher for complete denture users.

Impact of Dentures on Oral Health-Related Quality of Life in Assisted Living Facility Elders, Guntur District, Andhra Pradesh

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated how wearing dentures affects the oral health-related quality of life and wellbeing of older adults residing in assisted living in India. Among 587 residents, those using removable partial dentures were more satisfied with their appearance and dental function than those with complete dentures. However, oral health impact (e.g., functional limitations, physical pain, social disability) was higher for complete denture users.

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use among Assisted Living Residents

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study evaluated the impact of function focused care (which trains staff to evaluate residents’ functional capacity and physical activity to optimize their participation in activities) on the use of psychotropic medications and opioids. The study observed 794 residents across 85 communities over 12 months. There was a reduction in opioid use in the treatment group after four months; in the full sample during the overall study period, there was an increase in the use of benzodiazepines and antipsychotics.

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study evaluated the impact of function focused care (which trains staff to evaluate residents’ functional capacity and physical activity to optimize their participation in activities) on the use of psychotropic medications and opioids. The study observed 794 residents across 85 communities over 12 months. There was a reduction in opioid use in the treatment group after four months; in the full sample during the overall study period, there was an increase in the use of benzodiazepines and antipsychotics.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

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.