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.

Academic Publication

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

Jun 1, 2024
Objective Investigate how assisted living and residential care (AL/RC) and memory care (MC) contexts are associated with the 90-day prevalence of antipsychotic medication use (APU), considered a quality measure in long-term care. Design All licensed AL/RC settings in Oregon received an annual mailed questionnaire to provide aggregate resident demographics, health acuity, health service use, payment […]

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

by Lea Efird-Green

Objective Investigate how assisted living and residential care (AL/RC) and memory care (MC) contexts are associated with the 90-day prevalence of antipsychotic medication use (APU), considered a quality measure in long-term care. Design All licensed AL/RC settings in Oregon received an annual mailed questionnaire to provide aggregate resident demographics, health acuity, health service use, payment […]

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 […]

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 […]

Does Assisted Living Provide Assistance And Promote Living?

May 1, 2024
Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have […]

Does Assisted Living Provide Assistance And Promote Living?

by Lea Efird-Green

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have […]

Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living

May 1, 2024
Importance Resident-to-resident aggression in assisted living facilities can result in physical and psychological harm, but its prevalence is unknown. Objective To estimate the prevalence of resident-to-resident aggression, including physical, verbal, and sexual, among residents in assisted living facilities. Design, Setting, and Participants This study used cross-sectional, observational data from a clinical trial, in which residents […]

Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living

by Lea Efird-Green

Importance Resident-to-resident aggression in assisted living facilities can result in physical and psychological harm, but its prevalence is unknown. Objective To estimate the prevalence of resident-to-resident aggression, including physical, verbal, and sexual, among residents in assisted living facilities. Design, Setting, and Participants This study used cross-sectional, observational data from a clinical trial, in which residents […]

Bioethics in Gerontology: Developing a Typology of Ethical Issues in Assisted Living

May 1, 2024
Assisted living (AL) simultaneously is home to older adults who cannot live independently and a place where people work and visit and, therefore, where value conflicts are apt to arise. In this report we present the “Typology of Ethical Issues in Assisted Living” with emphasis on its development. The typology derives from a synthesis of […]

Bioethics in Gerontology: Developing a Typology of Ethical Issues in Assisted Living

by Lea Efird-Green

Assisted living (AL) simultaneously is home to older adults who cannot live independently and a place where people work and visit and, therefore, where value conflicts are apt to arise. In this report we present the “Typology of Ethical Issues in Assisted Living” with emphasis on its development. The typology derives from a synthesis of […]

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 […]

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

May 1, 2024
Objectives Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study […]

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

by Lea Efird-Green

Objectives Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study […]

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

May 1, 2024
Context: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. Objective: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December […]

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

by Lea Efird-Green

Context: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. Objective: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December […]

Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19

Apr 1, 2024
Background Little is known about mental health among Medicare beneficiaries with Alzheimer’s disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL […]

Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19

by Lea Efird-Green

Background Little is known about mental health among Medicare beneficiaries with Alzheimer’s disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL […]

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 […]

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 […]

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 […]

Perceptions of the Use of Terms of Endearment among Older Adults in an Assisted Living Facility

Apr 1, 2024
Background ‘Elderspeak’ has been defined as a form of communication overaccommodation used with older adults that typically involves inappropriate simplified speech. One aspect of elderspeak is the use of terms of endearment such as ‘honey’, sweetie’ and ‘dear’. There is disagreement regarding the use of terms of endearment with older adults, with differing views on […]

Perceptions of the Use of Terms of Endearment among Older Adults in an Assisted Living Facility

by Lea Efird-Green

Background ‘Elderspeak’ has been defined as a form of communication overaccommodation used with older adults that typically involves inappropriate simplified speech. One aspect of elderspeak is the use of terms of endearment such as ‘honey’, sweetie’ and ‘dear’. There is disagreement regarding the use of terms of endearment with older adults, with differing views on […]

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

Apr 1, 2024
Older adults in assisted living facilities (ALF) are at risk for low physical activity (PA) and high sedentary behavior (SB), both of which place them at risk for negative health outcomes. The purpose of this scoping review was to synthesize evidence describing the volume of device-measured PA/SB, factors associated with PA/SB, and interventions designed to […]

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

by Lea Efird-Green

Older adults in assisted living facilities (ALF) are at risk for low physical activity (PA) and high sedentary behavior (SB), both of which place them at risk for negative health outcomes. The purpose of this scoping review was to synthesize evidence describing the volume of device-measured PA/SB, factors associated with PA/SB, and interventions designed to […]

Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living

Apr 1, 2024
Objectives The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents’ age, gender, comorbidities, and […]

Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living

by Lea Efird-Green

Objectives The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents’ age, gender, comorbidities, and […]

The Impact of Assisted Living Organizational Structure and Process Characteristics on Staff Absence During COVID-19

Apr 1, 2024
Quality of care in assisted living communities (ALCs) is important to consumers. The coronavirus disease of 2019 (COVID-19) pandemic and associated emergency policies have posed major challenges on staff recruitment and retention. This study aimed to examine the relationship between organizational characteristics of ALCs in Florida and challenges with staff absence during COVID-19 (N = 129 ALCs). […]

The Impact of Assisted Living Organizational Structure and Process Characteristics on Staff Absence During COVID-19

by Lea Efird-Green

Quality of care in assisted living communities (ALCs) is important to consumers. The coronavirus disease of 2019 (COVID-19) pandemic and associated emergency policies have posed major challenges on staff recruitment and retention. This study aimed to examine the relationship between organizational characteristics of ALCs in Florida and challenges with staff absence during COVID-19 (N = 129 ALCs). […]

Experiences of COVID-19 Restrictions on Physical Activity in Assisted Living

Apr 1, 2024
Physical activity is an important health behavior for older adults in assisted living, however the COVID-19 pandemic may have disrupted this behavior. This study examined the effects of the pandemic on physical activity experiences in this population. Semi-structured interviews were conducted and analyzed using thematic analysis. Participants described barriers to physical activity, transitions in their […]

Experiences of COVID-19 Restrictions on Physical Activity in Assisted Living

by Lea Efird-Green

Physical activity is an important health behavior for older adults in assisted living, however the COVID-19 pandemic may have disrupted this behavior. This study examined the effects of the pandemic on physical activity experiences in this population. Semi-structured interviews were conducted and analyzed using thematic analysis. Participants described barriers to physical activity, transitions in their […]

A Step Toward Better Care: Understanding What Caregivers and Residents in Assisted Living Facilities Value in Health Monitoring Systems

Apr 1, 2024
The past several decades have seen significant advances in monitoring older adults’ health and well-being. However, creating viable, practical monitoring systems for informing caregivers requires understanding which behaviors and signs to track and what approaches best present that information. To investigate how technology can be leveraged to better augment caregivers’ workflows, we take a multi-stage, […]

A Step Toward Better Care: Understanding What Caregivers and Residents in Assisted Living Facilities Value in Health Monitoring Systems

by Lea Efird-Green

The past several decades have seen significant advances in monitoring older adults’ health and well-being. However, creating viable, practical monitoring systems for informing caregivers requires understanding which behaviors and signs to track and what approaches best present that information. To investigate how technology can be leveraged to better augment caregivers’ workflows, we take a multi-stage, […]

Quality of Life in Assisted Living Facilities for Seniors: A Descriptive Exploratory Study

Mar 1, 2024
Introduction Promoting individuals’ health across different life spans has always been key to a holistic nursing practice. Seniors are a diverse population who go through many physical and mental changes as they age. During the last decade, assisted living facilities (ALFs) have dramatically increased in numbers to provide care and living services in a home-like […]

Quality of Life in Assisted Living Facilities for Seniors: A Descriptive Exploratory Study

by Lea Efird-Green

Introduction Promoting individuals’ health across different life spans has always been key to a holistic nursing practice. Seniors are a diverse population who go through many physical and mental changes as they age. During the last decade, assisted living facilities (ALFs) have dramatically increased in numbers to provide care and living services in a home-like […]

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 […]

Using Assisted Living Communities to Enhance Nursing Student Attitudes Toward Older Adults

Feb 1, 2024
Purpose: The older adult population continues to increase, resulting in greater use of health care resources. Nurses will be at the forefront of providing competent care to this population, but many nurses do not wish to work with the aged population after graduation. The current study sought to explore whether the addition of a clinical […]

Using Assisted Living Communities to Enhance Nursing Student Attitudes Toward Older Adults

by Lea Efird-Green

Purpose: The older adult population continues to increase, resulting in greater use of health care resources. Nurses will be at the forefront of providing competent care to this population, but many nurses do not wish to work with the aged population after graduation. The current study sought to explore whether the addition of a clinical […]