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

“You Gotta Have Your Cry”: Administrator and Direct Care Worker Experiences of Death in Assisted Living

Dec 1, 2022
Assisted living (AL) is increasingly a site of end-of-life care and a long-term care location where growing numbers of people are aging in place and dying. Despite these trends, limited research focuses on how death and grief impact the work environment in AL. This grounded theory analysis examined qualitative data collected from 27 administrators and […]

“You Gotta Have Your Cry”: Administrator and Direct Care Worker Experiences of Death in Assisted Living

by Lea Efird-Green

Assisted living (AL) is increasingly a site of end-of-life care and a long-term care location where growing numbers of people are aging in place and dying. Despite these trends, limited research focuses on how death and grief impact the work environment in AL. This grounded theory analysis examined qualitative data collected from 27 administrators and […]

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

Dec 1, 2022
Background Existing literature on online reviews of healthcare providers generally portrays online reviews as a useful way to disseminate information on quality. However, it remains unknown whether online reviews for assisted living (AL) communities reflect AL care quality. This study examined the association between AL online review ratings and residents’ home time, a patient-centered outcome. […]

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

by Lea Efird-Green

Background Existing literature on online reviews of healthcare providers generally portrays online reviews as a useful way to disseminate information on quality. However, it remains unknown whether online reviews for assisted living (AL) communities reflect AL care quality. This study examined the association between AL online review ratings and residents’ home time, a patient-centered outcome. […]

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 […]

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

Dec 1, 2022
Background Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer’s disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with […]

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

by Lea Efird-Green

Background Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer’s disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with […]

Psychotropic Medication Prescribing in Assisted Living and Nursing Home Residents with Dementia after the National Partnership

Dec 1, 2022
BackgroundThe Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay […]

Psychotropic Medication Prescribing in Assisted Living and Nursing Home Residents with Dementia after the National Partnership

by Lea Efird-Green

BackgroundThe Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay […]

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

Dec 1, 2022
Objectives To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19 pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver gender and mental health. Design Cross-sectional and longitudinal survey. Setting and Participants Family/friend caregivers of assisted living residents in Alberta and British Columbia. Methods A […]

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

by Lea Efird-Green

Objectives To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19 pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver gender and mental health. Design Cross-sectional and longitudinal survey. Setting and Participants Family/friend caregivers of assisted living residents in Alberta and British Columbia. Methods A […]

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 […]

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 […]

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

Oct 1, 2022
Objective To evaluate whether assisted living (AL) residents with Alzheimer’s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. Design […]

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

by Lea Efird-Green

Objective To evaluate whether assisted living (AL) residents with Alzheimer’s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. Design […]

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 […]

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 […]

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

Sep 1, 2022
Assisted living (AL) provides the majority of residential long-term care in the United States. Almost 40% of AL residents display behaviors such as aggression and refusing care, 57% of whom receive medications for these behaviors. In nursing homes, concerns about inappropriate antipsychotic prescribing led to initiatives to reduce prescribing, and although there has been concern […]

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

by Lea Efird-Green

Assisted living (AL) provides the majority of residential long-term care in the United States. Almost 40% of AL residents display behaviors such as aggression and refusing care, 57% of whom receive medications for these behaviors. In nursing homes, concerns about inappropriate antipsychotic prescribing led to initiatives to reduce prescribing, and although there has been concern […]

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

Sep 1, 2022
Family or friend caregivers’ concerns about assisted living (AL) residents’ mental health are reflective of poor resident and caregiver mental health. COVID-19-related visiting restrictions increased caregiver concerns, but research on these issues in AL is limited. Using web-based surveys with 673 caregivers of AL residents in Western Canada, we assessed the prevalence and correlates of […]

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

by Lea Efird-Green

Family or friend caregivers’ concerns about assisted living (AL) residents’ mental health are reflective of poor resident and caregiver mental health. COVID-19-related visiting restrictions increased caregiver concerns, but research on these issues in AL is limited. Using web-based surveys with 673 caregivers of AL residents in Western Canada, we assessed the prevalence and correlates of […]

Successful Aging in Assisted Living: The Importance of Near Visual Acuity

Sep 1, 2022
Successful aging among independent community-dwelling older adults and those in residential settings is paramount to aging in place. The purpose of the current study was to explore how sensory, cognitive, and functional impairments affect successful aging in assisted living (AL) settings. Vision compromise was noted for near visual acuity (NVA) (14.3%) and distance visual acuity […]

Successful Aging in Assisted Living: The Importance of Near Visual Acuity

by Lea Efird-Green

Successful aging among independent community-dwelling older adults and those in residential settings is paramount to aging in place. The purpose of the current study was to explore how sensory, cognitive, and functional impairments affect successful aging in assisted living (AL) settings. Vision compromise was noted for near visual acuity (NVA) (14.3%) and distance visual acuity […]

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 […]

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

Aug 1, 2022
Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

by Lea Efird-Green

Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

Aug 1, 2022
Background: Family and friend caregivers play significant roles in advocating for and ensuring quality health and social care of residents in Assisted Living (AL) homes. However, little is known about how the COVID-19 pandemic and related visitor restrictions affected their health and mental well-being. We examined the prevalence and correlates of anxiety and depressive symptoms […]

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

by Lea Efird-Green

Background: Family and friend caregivers play significant roles in advocating for and ensuring quality health and social care of residents in Assisted Living (AL) homes. However, little is known about how the COVID-19 pandemic and related visitor restrictions affected their health and mental well-being. We examined the prevalence and correlates of anxiety and depressive symptoms […]

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

Aug 1, 2022
Depression is common within the first year of relocation to residential care/assisted living (RC/AL). Yet, few studies investigate the relationship between depression and relocation factors that might help identify at-risk residents, such as previous location. This study analyzed cross-sectional resident data (n = 2651) from the National Survey of Residential Care Facilities to test: (1) […]

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

by Lea Efird-Green

Depression is common within the first year of relocation to residential care/assisted living (RC/AL). Yet, few studies investigate the relationship between depression and relocation factors that might help identify at-risk residents, such as previous location. This study analyzed cross-sectional resident data (n = 2651) from the National Survey of Residential Care Facilities to test: (1) […]

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

Aug 1, 2022
Background: Residents of long-term care facilities face significantly greater risk of contracting or dying from coronavirus disease 2019 (COVID-19). However, little is known about COVID-19 in assisted living communities (ALCs) and the potential determinants of its spread. We examined the association between COVID-19 cases in ALCs and the proportion of Medicare-Medicaid (dual) eligible minority residents, […]

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

by Lea Efird-Green

Background: Residents of long-term care facilities face significantly greater risk of contracting or dying from coronavirus disease 2019 (COVID-19). However, little is known about COVID-19 in assisted living communities (ALCs) and the potential determinants of its spread. We examined the association between COVID-19 cases in ALCs and the proportion of Medicare-Medicaid (dual) eligible minority residents, […]

Beyond the Medication Pass: Attitudes, Ethics, Agency, and Antipsychotic Medications in Assisted Living/Residential Care

Aug 1, 2022
Background and Objectives As-needed (PRN) antipsychotic medication use (APU) among assisted living/residential care (AL/RC) residents is a controversial health policy issue. AL/RC care staff, families, clinicians, researchers, and policymakers disagree about PRN APU to manage behavioral expressions associated with residents’ dementia or cognitive impairment. Research Design and Methods Semistructured interviews among eleven direct care staff […]

Beyond the Medication Pass: Attitudes, Ethics, Agency, and Antipsychotic Medications in Assisted Living/Residential Care

by Lea Efird-Green

Background and Objectives As-needed (PRN) antipsychotic medication use (APU) among assisted living/residential care (AL/RC) residents is a controversial health policy issue. AL/RC care staff, families, clinicians, researchers, and policymakers disagree about PRN APU to manage behavioral expressions associated with residents’ dementia or cognitive impairment. Research Design and Methods Semistructured interviews among eleven direct care staff […]

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

Aug 1, 2022
Assisted Living (AL) has become an important residential long-term care option in the United States, yet very little is known about the nature and quality of care received in this setting by racial/ethnic minorities or residents dually eligible for Medicare and Medicaid. Using calendar year 2018 Medicare data, we identified 255,564 fee-for-service Medicare beneficiaries age […]

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

by Lea Efird-Green

Assisted Living (AL) has become an important residential long-term care option in the United States, yet very little is known about the nature and quality of care received in this setting by racial/ethnic minorities or residents dually eligible for Medicare and Medicaid. Using calendar year 2018 Medicare data, we identified 255,564 fee-for-service Medicare beneficiaries age […]

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

Aug 1, 2022
Assisted living facilities are presented as the older person’s home but, at the same time, defined by institutional and communal characteristics. Using Goffman’s (1974/1986) concept of frame, we aim to find out how home, institution and community frames define social roles and shape social relationships and interaction in assisted living facilities. Directed content analysis was […]

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

by Lea Efird-Green

Assisted living facilities are presented as the older person’s home but, at the same time, defined by institutional and communal characteristics. Using Goffman’s (1974/1986) concept of frame, we aim to find out how home, institution and community frames define social roles and shape social relationships and interaction in assisted living facilities. Directed content analysis was […]

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

Jul 1, 2022
Age-related changes shape social connectedness, isolation and loneliness among older adults. Ageing often accompanies decisions about ageing in place or moving (i.e. senior living facility). Scant research compares these two living arrangements and even sparser research focuses on older women. This study, thus, poses the following questions: How do older women (aged 75+ years) experience […]

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

by Lea Efird-Green

Age-related changes shape social connectedness, isolation and loneliness among older adults. Ageing often accompanies decisions about ageing in place or moving (i.e. senior living facility). Scant research compares these two living arrangements and even sparser research focuses on older women. This study, thus, poses the following questions: How do older women (aged 75+ years) experience […]