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

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Promoting Positive Care Interactions, a staff training program to establish positive care interactions with residents, was tested with 17 care staff in the memory care unit of one assisted living community. Although there were no significant changes in staff outcomes, participants’ perception of the community’s environment and policies improved, and staff showed good engagement throughout the study.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Promoting Positive Care Interactions, a staff training program to establish positive care interactions with residents, was tested with 17 care staff in the memory care unit of one assisted living community. Although there were no significant changes in staff outcomes, participants’ perception of the community’s environment and policies improved, and staff showed good engagement throughout the study.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Using Medicare data from 2018, data from over 255,000 people across 24,000 assisted living communities found differences in health outcomes based on race/ethnicity and dual eligibility, including hospital admissions, emergency room (ER) visits, and nursing home placements. For instance, Black and Hispanic residents had lower proportions of ER visits than their white counterparts, but Hispanic residents had higher 30-day readmission rates. Dual eligibility negatively impacted these outcomes more than race/ethnicity alone.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using Medicare data from 2018, data from over 255,000 people across 24,000 assisted living communities found differences in health outcomes based on race/ethnicity and dual eligibility, including hospital admissions, emergency room (ER) visits, and nursing home placements. For instance, Black and Hispanic residents had lower proportions of ER visits than their white counterparts, but Hispanic residents had higher 30-day readmission rates. Dual eligibility negatively impacted these outcomes more than race/ethnicity alone.

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
WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.

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

WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.

Class and Culture in the Making of an Assisted Living Market

Jul 1, 2022
WHAT THIS MEANS FOR YOU: A qualitative study of high-end assisted living communities in Chile based on 40 staff, resident, and family interviews found that managers explain these communities’ purpose as meeting the need for household help, making it a class privilege for wealthy residents. Residents view their communities as a luxury and emphasize their choice to live there, indicating control and independence. This research highlights how social class influences perceptions and acceptance of different forms of care.

Class and Culture in the Making of an Assisted Living Market

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A qualitative study of high-end assisted living communities in Chile based on 40 staff, resident, and family interviews found that managers explain these communities’ purpose as meeting the need for household help, making it a class privilege for wealthy residents. Residents view their communities as a luxury and emphasize their choice to live there, indicating control and independence. This research highlights how social class influences perceptions and acceptance of different forms of care.

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

Jun 1, 2022
WHAT THIS MEANS FOR YOU: Function Focused Care was tested in 51 assisted living communities in one state during the COVID-19 pandemic. Although there was no change in resident falls, emergency room visits, hospitalizations, or transfers to nursing homes, organizational policies and environments supporting physical activity for residents improved.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Function Focused Care was tested in 51 assisted living communities in one state during the COVID-19 pandemic. Although there was no change in resident falls, emergency room visits, hospitalizations, or transfers to nursing homes, organizational policies and environments supporting physical activity for residents improved.

Governance of Assisted Living in Singapore: Lessons for Aging Countries

Jun 1, 2022
WHAT THIS MEANS FOR YOU: In Singapore, assisted living regulations relate to required physical infrastructure, admission assessments, and staffing requirements. They are primarily practice guidelines, with a plan to make them legislatively explicit and permanent by 2023. Other regulations remain missing, such as staff training requirements and a monitoring structure, and must be addressed if assisted living is to be a safe and viable option for quality care.

Governance of Assisted Living in Singapore: Lessons for Aging Countries

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In Singapore, assisted living regulations relate to required physical infrastructure, admission assessments, and staffing requirements. They are primarily practice guidelines, with a plan to make them legislatively explicit and permanent by 2023. Other regulations remain missing, such as staff training requirements and a monitoring structure, and must be addressed if assisted living is to be a safe and viable option for quality care.

Yoga Practice as a Coping Strategy for Older Adults in Assisted Living Facilities: A Qualitative Content Analysis

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study explored how 15 residents of 4 assisted living communities used yoga as a coping strategy during and after an 8-week yoga intervention. Qualitative interviews indicated that residents found yoga helpful for relaxing, felt more energized, and that it helped connect them with others.

Yoga Practice as a Coping Strategy for Older Adults in Assisted Living Facilities: A Qualitative Content Analysis

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study explored how 15 residents of 4 assisted living communities used yoga as a coping strategy during and after an 8-week yoga intervention. Qualitative interviews indicated that residents found yoga helpful for relaxing, felt more energized, and that it helped connect them with others.

Impact of Dentures on Oral Health-Related Quality of Life in Assisted Living Facility Elders, Guntur District, Andhra Pradesh

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study investigated how wearing dentures affects the oral health-related quality of life and wellbeing of older adults residing in assisted living in India. Among 587 residents, those using removable partial dentures were more satisfied with their appearance and dental function than those with complete dentures. However, oral health impact (e.g., functional limitations, physical pain, social disability) was higher for complete denture users.

Impact of Dentures on Oral Health-Related Quality of Life in Assisted Living Facility Elders, Guntur District, Andhra Pradesh

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated how wearing dentures affects the oral health-related quality of life and wellbeing of older adults residing in assisted living in India. Among 587 residents, those using removable partial dentures were more satisfied with their appearance and dental function than those with complete dentures. However, oral health impact (e.g., functional limitations, physical pain, social disability) was higher for complete denture users.

Factors Associated with the Quality of Staff-Resident Interactions in Assisted Living

Jun 1, 2022
WHAT THIS MEANS FOR YOU: Using data from 379 residents from 59 assisted living communities, residents who were more frequently agitated tended to have worse care interactions with staff, while being in a for-profit community was associated with more positive interactions. Staff training in how to minimize resident agitation may improve the positivity of care interactions.

Factors Associated with the Quality of Staff-Resident Interactions in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using data from 379 residents from 59 assisted living communities, residents who were more frequently agitated tended to have worse care interactions with staff, while being in a for-profit community was associated with more positive interactions. Staff training in how to minimize resident agitation may improve the positivity of care interactions.

Dementia and COVID-19 Infection Control in Assisted Living in Seven States

Jun 1, 2022
WHAT THIS MEANS FOR YOU: The study examined how 119 assisted living administrators in 7 states implemented COVID-19 infection control practices from July 2020 to September 2021, including the feasibility of select infection control practices. Results indicated that although there were infection control challenges across all community types, dementia-specific communities faced the most difficulties. Less than half of administrators found it feasible to close indoor common areas, and residents, especially in dementia-specific communities, were less likely to wear masks and -wearing and physical distancing.

Dementia and COVID-19 Infection Control in Assisted Living in Seven States

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study examined how 119 assisted living administrators in 7 states implemented COVID-19 infection control practices from July 2020 to September 2021, including the feasibility of select infection control practices. Results indicated that although there were infection control challenges across all community types, dementia-specific communities faced the most difficulties. Less than half of administrators found it feasible to close indoor common areas, and residents, especially in dementia-specific communities, were less likely to wear masks and -wearing and physical distancing.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Melatonin Prescribing in Assisted Living

Jun 1, 2022
WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.

Melatonin Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

Jun 1, 2022
WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

Jun 1, 2022
WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.

Engagement with life among the oldest-old in assisted living facilities: enriching activities and developmental adaptation to physical loss

May 1, 2022
WHAT THIS MEANS FOR YOU: This study examined the activities, motivations, and barriers to activity engagement of 20 residents ages 80-94 residing in two AL communities. Resulting themes included a common longing for enriching activities among all residents; those with functional limitations found it harder to engage in such activities; and participants perceived the activities provided in their communities as being geared toward those with cognitive impairment. Thus, participants who were cognitively fit but had significant mobility impairments were in most need of engaging community activities.

Engagement with life among the oldest-old in assisted living facilities: enriching activities and developmental adaptation to physical loss

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined the activities, motivations, and barriers to activity engagement of 20 residents ages 80-94 residing in two AL communities. Resulting themes included a common longing for enriching activities among all residents; those with functional limitations found it harder to engage in such activities; and participants perceived the activities provided in their communities as being geared toward those with cognitive impairment. Thus, participants who were cognitively fit but had significant mobility impairments were in most need of engaging community activities.

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).

“We Weathered the Storm”: A Qualitative Phenomenological Study of the Lived Experience of Assisted Living Administrators during the COVID-19 Pandemic

May 1, 2022
WHAT THIS MEANS FOR YOU: A qualitative study interviewing five assisted living administrators about their experiences during the COVID-19 pandemic found frequent changes in the administrators' experiences during the pandemic, including having limited resources and responding to rapid policy shifts.

“We Weathered the Storm”: A Qualitative Phenomenological Study of the Lived Experience of Assisted Living Administrators during the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A qualitative study interviewing five assisted living administrators about their experiences during the COVID-19 pandemic found frequent changes in the administrators’ experiences during the pandemic, including having limited resources and responding to rapid policy shifts.

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

May 1, 2022
WHAT THIS MEANS FOR YOU: This study protocol describes the methods to be used in developing a toolkit for increased resident and family engagement in assisted living community safety planning; it includes a scoping review, qualitative interviews, and stakeholder meetings. The study’s goals include identifying, prioritizing, and evaluating existing engagement methods around safety concerns in assisted living and developing a toolkit that helps residents and families engage more frequently.

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

WHAT THIS MEANS FOR YOU: This study protocol describes the methods to be used in developing a toolkit for increased resident and family engagement in assisted living community safety planning; it includes a scoping review, qualitative interviews, and stakeholder meetings. The study’s goals include identifying, prioritizing, and evaluating existing engagement methods around safety concerns in assisted living and developing a toolkit that helps residents and families engage more frequently.

Effects of the Mobility-Fit Physical Activity Program on Strength and Mobility in Older Adults in Assisted Living: A Feasibility Study

Apr 1, 2022
WHAT THIS MEANS FOR YOU: In a 12-week study of 30 assisted living residents, the Mobility-Fit program - which focuses on upper-limb strength to help prevent falls and includes exercises targeting strength, agility, coordination, and balance - participants experienced improvements in knee extension strength, reaction time, and time to stand from a sitting position.

Effects of the Mobility-Fit Physical Activity Program on Strength and Mobility in Older Adults in Assisted Living: A Feasibility Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In a 12-week study of 30 assisted living residents, the Mobility-Fit program – which focuses on upper-limb strength to help prevent falls and includes exercises targeting strength, agility, coordination, and balance – participants experienced improvements in knee extension strength, reaction time, and time to stand from a sitting position.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

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

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Drawing from existing research, theories, and case examples, this article highlighted moral complexities experienced in assisted living (e.g., privacy, sexual intimacy, safety and risk) and proposed a framework to identify and address these issues and promote more ethically sound practices. The proposed model centers on moral decision-making and interpersonal encounters and is intended to guide future research, policy, and practice.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Drawing from existing research, theories, and case examples, this article highlighted moral complexities experienced in assisted living (e.g., privacy, sexual intimacy, safety and risk) and proposed a framework to identify and address these issues and promote more ethically sound practices. The proposed model centers on moral decision-making and interpersonal encounters and is intended to guide future research, policy, and practice.