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.

Medicare/Medicaid

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 […]

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 […]

Potential Actions to Advance Well-being in Assisted Living

Apr 23, 2024
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

Potential Actions to Advance Well-being in Assisted Living

by Lea Efird-Green

CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

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 […]

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 […]

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

Dec 1, 2023
Background: Assisted living (AL) is an increasingly common, place of care for dying persons. However, it remains unclear to what extent residents are able to age in place or if AL represents an additional transition before death. Objectives: Examine the sociodemographic characteristics, comorbidities, health care utilization, and end-of-life care pathways of AL residents before death. […]

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

by Lea Efird-Green

Background: Assisted living (AL) is an increasingly common, place of care for dying persons. However, it remains unclear to what extent residents are able to age in place or if AL represents an additional transition before death. Objectives: Examine the sociodemographic characteristics, comorbidities, health care utilization, and end-of-life care pathways of AL residents before death. […]

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

Dec 1, 2023
Background Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed […]

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

by Lea Efird-Green

Background Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed […]

Assisted Living or Nursing Home: Who is Moving In?

Jul 1, 2023
Background Despite the rapid growth of assisted living (AL) communities and the increasing similarity between AL and nursing home (NH) populations, little is known about the characteristics of older adults at the time of AL admission and how these characteristics compare to individuals newly admitted to NH from the community. This study examined the individual, […]

Assisted Living or Nursing Home: Who is Moving In?

by Lea Efird-Green

Background Despite the rapid growth of assisted living (AL) communities and the increasing similarity between AL and nursing home (NH) populations, little is known about the characteristics of older adults at the time of AL admission and how these characteristics compare to individuals newly admitted to NH from the community. This study examined the individual, […]

Likelihood of Assisted Living Residents Aging in Place as a Factor of Dual Medicare-Medicaid Eligibility at the End of Life

May 1, 2023
WHAT THIS MEANS FOR YOU: This study used Medicare enrollment and claims records to examine more than 142,000 AL residents’ ability to stay in their community in the last 30 days of life. Residents who were eligible for both Medicaid and Medicare (dual eligibles) were much less likely than those not eligible for Medicaid to remain in AL in their last 30 days of life or die there. However, this difference varies by state.

Likelihood of Assisted Living Residents Aging in Place as a Factor of Dual Medicare-Medicaid Eligibility at the End of Life

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used Medicare enrollment and claims records to examine more than 142,000 AL residents’ ability to stay in their community in the last 30 days of life. Residents who were eligible for both Medicaid and Medicare (dual eligibles) were much less likely than those not eligible for Medicaid to remain in AL in their last 30 days of life or die there. However, this difference varies by state.

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.

Association of Medicaid Financing and Concentration of Assisted Living Residents Dually Eligible for Medicare and Medicaid

Feb 1, 2023
WHAT THIS MEANS FOR YOU: About 25% of Medicare beneficiaries in AL are also eligible for Medicaid, 78% of whom lived in 20% of AL communities nationally. This study analyzed 47 state policies, 5 of which had no Medicaid coverage for AL services (put abbreviations of the five states here). However, those states had the highest concentration of Medicaid-eligible people residing in AL, meaning that Medicaid coverage in those 5 states could benefit many residents.

Association of Medicaid Financing and Concentration of Assisted Living Residents Dually Eligible for Medicare and Medicaid

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: About 25% of Medicare beneficiaries in AL are also eligible for Medicaid, 78% of whom lived in 20% of AL communities nationally. This study analyzed 47 state policies, 5 of which had no Medicaid coverage for AL services (put abbreviations of the five states here). However, those states had the highest concentration of Medicaid-eligible people residing in AL, meaning that Medicaid coverage in those 5 states could benefit many residents.

CMS HCBS State Transition Plans

Jan 11, 2023
This interactive map provides a high-level summary of Statewide Transition Plans (STP) with Final Approval from the Centers for Medicare & Medicaid Services (CMS). The map is updated as CMS updates the states’ approval status. 

CMS HCBS State Transition Plans

by Lea Efird-Green

This interactive map provides a high-level summary of Statewide Transition Plans (STP) with Final Approval from the Centers for Medicare & Medicaid Services (CMS). The map is updated as CMS updates the states’ approval status. 

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

Oct 1, 2022
Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and […]

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

Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and […]

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).

State Medicaid Financing and Access to Large Assisted Living Settings for Medicare–Medicaid Dual-Eligibles

Feb 1, 2022
WHAT THIS MEANS FOR YOU: This study examined two groups of Medicare beneficiaries residing in large (25+ beds) AL communities in 2014: dual Medicare and Medicaid beneficiaries, and Medicare-only beneficiaries. Among 506,193 beneficiaries, 18% were dually eligible; they tended to be younger, minority, and have more chronic health conditions. The share of dual-eligibles by state varied widely; states with Medicaid financing for AL had more dual-eligibles, but variation in state room and board regulations did not have a significant relationship to dual-eligible rates.

State Medicaid Financing and Access to Large Assisted Living Settings for Medicare–Medicaid Dual-Eligibles

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined two groups of Medicare beneficiaries residing in large (25+ beds) AL communities in 2014: dual Medicare and Medicaid beneficiaries, and Medicare-only beneficiaries. Among 506,193 beneficiaries, 18% were dually eligible; they tended to be younger, minority, and have more chronic health conditions. The share of dual-eligibles by state varied widely; states with Medicaid financing for AL had more dual-eligibles, but variation in state room and board regulations did not have a significant relationship to dual-eligible rates.

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.

Post-Acute Care Transitions and Outcomes among Medicare Beneficiaries in Assisted Living Communities

Jan 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data were used to analyze post-acute care referrals for over 104,000 assisted living residents. The most common referral after hospitalizations was to skilled nursing. Referrals to skilled nursing were associated with a lower likelihood of emergency department visits and hospital readmissions; however, there was higher likelihood of long-term skilled nursing placement and death.

Post-Acute Care Transitions and Outcomes among Medicare Beneficiaries in Assisted Living Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data were used to analyze post-acute care referrals for over 104,000 assisted living residents. The most common referral after hospitalizations was to skilled nursing. Referrals to skilled nursing were associated with a lower likelihood of emergency department visits and hospital readmissions; however, there was higher likelihood of long-term skilled nursing placement and death.