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.

Quality Improvement

Fall Prevention Care Management: Implementation and Outcomes of a Project to Reduce Fall Risks of Older Adults in Assisted Living Facilities

May 1, 2023
Background Accidental falls are common among older adults and may lead to devastating consequences. One promising approach to reduce falls is to engage older adults in fall risk reduction through care management. Purpose This article describes the implementation by undergraduate nursing students of a 6 week interdisciplinary Fall Prevention Care Management (FPCM) intervention to improve […]

Fall Prevention Care Management: Implementation and Outcomes of a Project to Reduce Fall Risks of Older Adults in Assisted Living Facilities

by Lea Efird-Green

Background Accidental falls are common among older adults and may lead to devastating consequences. One promising approach to reduce falls is to engage older adults in fall risk reduction through care management. Purpose This article describes the implementation by undergraduate nursing students of a 6 week interdisciplinary Fall Prevention Care Management (FPCM) intervention to improve […]

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

May 1, 2023
Objective Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States. Design Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services. Setting and Participants A […]

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

by Lea Efird-Green

Objective Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States. Design Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services. Setting and Participants A […]

Interprofessional care in a retirement and assisted living community: the complexity of teamwork

Apr 1, 2023
Teamwork is an aspiration in the delivery of interprofessional care to older adults, but how does it play out in residential settings that combine independent living, assisted living, and skilled nursing care? This study investigated teamwork as an organic part of a retirement and assisted living community immersed in mission-driven care. Drawing on 44 in-depth […]

Interprofessional care in a retirement and assisted living community: the complexity of teamwork

by Lea Efird-Green

Teamwork is an aspiration in the delivery of interprofessional care to older adults, but how does it play out in residential settings that combine independent living, assisted living, and skilled nursing care? This study investigated teamwork as an organic part of a retirement and assisted living community immersed in mission-driven care. Drawing on 44 in-depth […]

Robots in Assisted Living Facilities: Scoping Review

Mar 1, 2023
Background Various technological interventions have been proposed and studied to address the growing demand for care of residents in assisted living facilities, in which a preexisting shortage of professional caregivers has been exacerbated by the COVID-19 pandemic. Care robots are one such intervention with the potential to improve both the care of older adults and […]

Robots in Assisted Living Facilities: Scoping Review

by Lea Efird-Green

Background Various technological interventions have been proposed and studied to address the growing demand for care of residents in assisted living facilities, in which a preexisting shortage of professional caregivers has been exacerbated by the COVID-19 pandemic. Care robots are one such intervention with the potential to improve both the care of older adults and […]

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

Mar 1, 2023
Objectives Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year 2018. Design We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data Set […]

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

by Lea Efird-Green

Objectives Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year 2018. Design We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data Set […]

Digital Immunization Tracking in Long-Term Care and Assisted Living Facilities

Feb 1, 2023
A disproportionate share of the health impacts of COVID-19 has been borne by older adults, particularly those in long-term care facilities (LTCs). Vaccination has been critical to efforts to combat this issue, but as we begin to emerge from this pandemic, questions remain about how to protect the health of residents of LTC and assisted […]

Digital Immunization Tracking in Long-Term Care and Assisted Living Facilities

by Lea Efird-Green

A disproportionate share of the health impacts of COVID-19 has been borne by older adults, particularly those in long-term care facilities (LTCs). Vaccination has been critical to efforts to combat this issue, but as we begin to emerge from this pandemic, questions remain about how to protect the health of residents of LTC and assisted […]

Well-being of professional older adults’ caregivers in Alberta’s assisted living and long-term care facilities: a cross-sectional study

Feb 1, 2023
Background For the care need of older adults, long-term care (LTC) and assisted living (AL) facilities are expanding in Alberta, but little is known about the caregivers’ well-being. The purpose of the study was to investigate the physical health conditions, mental and emotional health (MEH), health behaviour, stress levels, quality of life (QOL), and turnover […]

Well-being of professional older adults’ caregivers in Alberta’s assisted living and long-term care facilities: a cross-sectional study

by Lea Efird-Green

Background For the care need of older adults, long-term care (LTC) and assisted living (AL) facilities are expanding in Alberta, but little is known about the caregivers’ well-being. The purpose of the study was to investigate the physical health conditions, mental and emotional health (MEH), health behaviour, stress levels, quality of life (QOL), and turnover […]

Now You’re Tax‐Exempt, Now You’re Not: Property Taxation of Assisted Living Facilities

Jan 1, 2023
This research is motivated by a change in Florida that affected assisted living facilities (ALFs) by removing the property tax exemptions for those operated by nonprofit organizations. As such, this paper addresses two research questions: (1) Are there systematic differences between Florida’s for‐profit and nonprofit‐designated ALFs in terms of operations and service provision? (2) What […]

Now You’re Tax‐Exempt, Now You’re Not: Property Taxation of Assisted Living Facilities

by Lea Efird-Green

This research is motivated by a change in Florida that affected assisted living facilities (ALFs) by removing the property tax exemptions for those operated by nonprofit organizations. As such, this paper addresses two research questions: (1) Are there systematic differences between Florida’s for‐profit and nonprofit‐designated ALFs in terms of operations and service provision? (2) What […]

Feasibility study of student-led fall prevention care management: Reducing fall risks in assisted living facilities

Jan 1, 2023
Falls are common in Assisted Living Facilities (ALFs). We evaluated the feasibility, acceptability, and preliminary impact of student-led Fall Prevention Care Management (FPCM) on reducing fall risks in ALFs. Residents who were age ≥65, had a fall in the previous year or considered high fall risk at the facility, and who had a MoCA cognition […]

Feasibility study of student-led fall prevention care management: Reducing fall risks in assisted living facilities

by Lea Efird-Green

Falls are common in Assisted Living Facilities (ALFs). We evaluated the feasibility, acceptability, and preliminary impact of student-led Fall Prevention Care Management (FPCM) on reducing fall risks in ALFs. Residents who were age ≥65, had a fall in the previous year or considered high fall risk at the facility, and who had a MoCA cognition […]

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

Dec 1, 2022
ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

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

by Lea Efird-Green

ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

Are Online Reviews of Assisted Living Communities Associated with Patient-Centered Outcomes?

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Findings from this study suggest that AL's online reviews may signal quality of care issues, offering consumers information to make more informed decisions in their AL selection, and that reviews may offer insight into residents' perspectives. However, ratings should not replace, but rather complement, other traditional ways of assessing resident experiences because of rating system limitations. Additionally, ratings may assist providers in making improvements to their ALs based on resident feedback, and function as a data source for policymakers about AL quality of care.

Are Online Reviews of Assisted Living Communities Associated with Patient-Centered Outcomes?

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Findings from this study suggest that AL’s online reviews may signal quality of care issues, offering consumers information to make more informed decisions in their AL selection, and that reviews may offer insight into residents’ perspectives. However, ratings should not replace, but rather complement, other traditional ways of assessing resident experiences because of rating system limitations. Additionally, ratings may assist providers in making improvements to their ALs based on resident feedback, and function as a data source for policymakers about AL quality of care.

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

Oct 1, 2022
Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of […]

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

by Lea Efird-Green

Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of […]

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

Oct 1, 2022
Background and Objectives License inspection data have commonly been used as a quality measure for nursing homes but have not yet been used to assess the quality of assisted living/residential care (AL/RC) communities. Drawing on resource dependency theory, we test the hypothesis that structural and environmental characteristics influence AL/RC quality as measured by deficiency citations […]

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

by Lea Efird-Green

Background and Objectives License inspection data have commonly been used as a quality measure for nursing homes but have not yet been used to assess the quality of assisted living/residential care (AL/RC) communities. Drawing on resource dependency theory, we test the hypothesis that structural and environmental characteristics influence AL/RC quality as measured by deficiency citations […]

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 […]

Pilot Testing of the Promoting Positive Care Interactions Intervention in Assisted Living

Aug 1, 2022
The current study aimed to test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI) intervention designed to establish positive care interactions between staff and residents in assisted living (AL) using an online approach. PPCI was implemented in one AL community using a single group pre-/posttest design; 17 care staff were recruited […]

Pilot Testing of the Promoting Positive Care Interactions Intervention in Assisted Living

by Lea Efird-Green

The current study aimed to test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI) intervention designed to establish positive care interactions between staff and residents in assisted living (AL) using an online approach. PPCI was implemented in one AL community using a single group pre-/posttest design; 17 care staff were recruited […]

The Impact of FFC-AL-EIT-D in Assisted Living during the COVID-19 Pandemic

Jun 1, 2022
The purpose of this study was to test the preliminary effectiveness and feasibility of implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle in Assisted Living Communities with Residents with Dementia (FFC-AL-EIT-D) during the pandemic. This was a single group pre-post study design including 51 communities in a single state. The […]

The Impact of FFC-AL-EIT-D in Assisted Living during the COVID-19 Pandemic

by Lea Efird-Green

The purpose of this study was to test the preliminary effectiveness and feasibility of implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle in Assisted Living Communities with Residents with Dementia (FFC-AL-EIT-D) during the pandemic. This was a single group pre-post study design including 51 communities in a single state. The […]

Developing a Toolkit to Improve Resident and Family Engagement in the Safety of Assisted Living: Engage – A Stakeholder-Engaged Research Protocol

May 1, 2022
Assisted living (AL) communities are experiencing rising levels of resident acuity, challenging efforts to balance person-centered care—which prioritizes personhood, autonomy, and relationship-based care practices—with efforts to keep residents safe. Safety is a broad-scale problem in AL that encompasses care concerns (e.g., abuse/neglect, medication errors, inadequate staffing, and infection management) as well as resident issues (e.g., […]

Developing a Toolkit to Improve Resident and Family Engagement in the Safety of Assisted Living: Engage – A Stakeholder-Engaged Research Protocol

by Lea Efird-Green

Assisted living (AL) communities are experiencing rising levels of resident acuity, challenging efforts to balance person-centered care—which prioritizes personhood, autonomy, and relationship-based care practices—with efforts to keep residents safe. Safety is a broad-scale problem in AL that encompasses care concerns (e.g., abuse/neglect, medication errors, inadequate staffing, and infection management) as well as resident issues (e.g., […]

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living

Apr 1, 2022
Assisted living (AL) communities are long-term care settings where people live, work, and visit, and where social relationships and care, including end-of-life care, are negotiated. Assisted living is fraught with uncertainty and conflict about values, especially given residents’ cognitive and physical frailty. These value-laden issues have implications for both resident and care partners’ experiences. Yet, […]

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living

by Lea Efird-Green

Assisted living (AL) communities are long-term care settings where people live, work, and visit, and where social relationships and care, including end-of-life care, are negotiated. Assisted living is fraught with uncertainty and conflict about values, especially given residents’ cognitive and physical frailty. These value-laden issues have implications for both resident and care partners’ experiences. Yet, […]

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

Feb 1, 2022
Objectives Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living. Design We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs). Setting and Participants The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 […]

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

by Lea Efird-Green

Objectives Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living. Design We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs). Setting and Participants The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 […]

Rapid Adoption of Electronic Health Record and Health Information Exchange among Assisted Living Communities, 2010–2018 

Feb 1, 2022
Adoption of electronic health records (EHRs) and health information exchange (HIE) is a key tool to improving the quality of care in assisted living communities (ALC). We examined whether EHRs were being used in ALC to support HIE in 2010 and 2018. We found that adoption of EHR and HIE functions increased substantially over the […]

Rapid Adoption of Electronic Health Record and Health Information Exchange among Assisted Living Communities, 2010–2018 

by Lea Efird-Green

Adoption of electronic health records (EHRs) and health information exchange (HIE) is a key tool to improving the quality of care in assisted living communities (ALC). We examined whether EHRs were being used in ALC to support HIE in 2010 and 2018. We found that adoption of EHR and HIE functions increased substantially over the […]