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

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

Apr 1, 2025
Objective: To examine trends in home health care (HHC) use in congregate living and compare characteristics of HHC use between Medicare patients in congregate living and those in other home settings. Design: Retrospective cohort study describing HHC use, in and outside of congregate living, using national Medicare claims, assessment, and administrative data (2014-2019). We compared […]

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

by Lea Efird-Green

Objective: To examine trends in home health care (HHC) use in congregate living and compare characteristics of HHC use between Medicare patients in congregate living and those in other home settings. Design: Retrospective cohort study describing HHC use, in and outside of congregate living, using national Medicare claims, assessment, and administrative data (2014-2019). We compared […]

Urinary Incontinence Is an Independent Risk Factor for Nursing Home Placement among Assisted Living Residents

Apr 1, 2025
Objectives: Prior studies suggested that urinary incontinence (UI) may be a risk factor for nursing home (NH) placement among older community-dwelling individuals. Our objectives were to evaluate if UI is an independent risk factor in NH placement among assisted living (AL) residents and assess the impact of UI on NH placement by race/ethnicity. Design: This […]

Urinary Incontinence Is an Independent Risk Factor for Nursing Home Placement among Assisted Living Residents

by Lea Efird-Green

Objectives: Prior studies suggested that urinary incontinence (UI) may be a risk factor for nursing home (NH) placement among older community-dwelling individuals. Our objectives were to evaluate if UI is an independent risk factor in NH placement among assisted living (AL) residents and assess the impact of UI on NH placement by race/ethnicity. Design: This […]

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This retrospective cohort study used Medicare data from 2008-2018 from 12,451 AL communities to examine the risk of hospitalization for Medicare-Medicaid dual eligibles. Out of 620,542 Medicare beneficiaries, the 1-year risk of hospitalization was higher for dually enrolled individuals. The risk was higher in high-dual AL communities than in low-dual AL communities for both dually enrolled (7.4%) and Medicare only (9.4%) individuals.

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This retrospective cohort study used Medicare data from 2008-2018 from 12,451 AL communities to examine the risk of hospitalization for Medicare-Medicaid dual eligibles. Out of 620,542 Medicare beneficiaries, the 1-year risk of hospitalization was higher for dually enrolled individuals. The risk was higher in high-dual AL communities than in low-dual AL communities for both dually enrolled (7.4%) and Medicare only (9.4%) individuals.

CMS HCBS State Transition Plans

Sep 23, 2024
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. 

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

Jun 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

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

WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

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

May 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.

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
WHAT THIS MEANS FOR YOU: Using 2017 Medicare data, researchers compared health outcomes from over 25,000 Florida AL residents who resided in an AL on the day of Hurricane Irma’s landfall and either sheltered in place (86% of residents) or evacuated (14% of residents). Evacuation was statistically significantly associated with a 16% higher risk of emergency department visits and with a 51% higher risk of nursing home admissions within 30 days of the hurricane, while hospitalization and mortality rates were similar between the two groups.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using 2017 Medicare data, researchers compared health outcomes from over 25,000 Florida AL residents who resided in an AL on the day of Hurricane Irma’s landfall and either sheltered in place (86% of residents) or evacuated (14% of residents). Evacuation was statistically significantly associated with a 16% higher risk of emergency department visits and with a 51% higher risk of nursing home admissions within 30 days of the hurricane, while hospitalization and mortality rates were similar between the two groups.

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

Mar 1, 2024
WHAT THIS MEANS FOR YOU: Using Medicare Compare and claims data for over 2800 hospice providers, this analysis found that hospices with higher AL patient volume (i.e., a higher share of their annual patient days were from AL residents) had lower quality ratings from family caregivers in key areas such as pain management, breathing help, emotional support, communication, and family training, even when controlling for profit status and daily patient census. This result indicates that hospice providers who more frequently serve AL resident patients are on average of lower quality, and more research to understand this relationship is recommended.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using Medicare Compare and claims data for over 2800 hospice providers, this analysis found that hospices with higher AL patient volume (i.e., a higher share of their annual patient days were from AL residents) had lower quality ratings from family caregivers in key areas such as pain management, breathing help, emotional support, communication, and family training, even when controlling for profit status and daily patient census. This result indicates that hospice providers who more frequently serve AL resident patients are on average of lower quality, and more research to understand this relationship is recommended.

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

Dec 1, 2023
WHAT THIS MEANS FOR YOU: A study of “home time" (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living residents.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of “home time” (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living 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.

Assisted Living or Nursing Home: Who is Moving In?

Jul 1, 2023
WHAT THIS MEANS FOR YOU: Medicare data examined the characteristics of over 770,000 individuals admitted to assisted living and nursing homes directly from the community between 2017 and 2019. Substantial differences were found between these two groups, including that racial/ethnic minorities, those dually eligible for Medicare and Medicaid, and those having two or more skilled nursing facility stays in the last six months were more likely to be admitted to a nursing home. On the other hand, those who were 75 years or older, male, had one skilled nursing facility or hospital stay, or were Medicare fee-for-service beneficiaries were more likely to be admitted to an assisted living community.

Assisted Living or Nursing Home: Who is Moving In?

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data examined the characteristics of over 770,000 individuals admitted to assisted living and nursing homes directly from the community between 2017 and 2019. Substantial differences were found between these two groups, including that racial/ethnic minorities, those dually eligible for Medicare and Medicaid, and those having two or more skilled nursing facility stays in the last six months were more likely to be admitted to a nursing home. On the other hand, those who were 75 years or older, male, had one skilled nursing facility or hospital stay, or were Medicare fee-for-service beneficiaries were more likely to be admitted to an assisted living community.

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.

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.

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.