What Is Assisted Living?
Assisted living is a term that is often used as though everyone understands it in the same way. But that’s not the case. Assisted living is just a generic term like hotel or automobile that covers a lot of options. Before getting into the specifics, here’s a simple definition: Assisted living is a residence where groups of people share meals and other activities and where individuals can receive personal assistance to maintain their independence. People who choose assisted living typically would have difficulty living completely on their own but do not require constant medical attention.
You can also think about assisted living as an intermediate step in long-term care. It’s in the middle of the spectrum of long-term care, which often goes from independent living to assisted living to nursing-home care. Independent living can be in your own home or the entry level of assisted living or in special housing for older people. About 70 percent of residents in assisted living come to the facility from their own house or apartment.
In this section I cover a more formal definition of assisted living, what services are included, which healthcare options may be provided, and tips for finding a facility to provide a broader understanding of all that assisted living covers.
Interpreting industry and government language
Most definitions of assisted living come from industry or government sources and emphasize different aspects of this setting. It’s important to keep the source in mind when you gather information. For example, Argentum (formerly the Assisted Living Federation of America), a trade organization, says, “Assisted living is a housing and healthcare option that combines independence and personal care in a residential setting.” This is a good definition as far as it goes, but it doesn’t tell you what personal care means and what healthcare services are likely to be offered.
The Eldercare Locator, a free service connected with the federal Administration for Community Living (ACL), has an even more specific definition: “Assisted-living facilities offer a housing alternative for older adults who may need help with dressing, bathing, eating, and toileting but do not require the intensive medical and nursing care provided in nursing homes.” This definition, while accurate, doesn’t include younger adults who may want or need the kinds of services available in assisted living. It also underestimates the importance of the social aspects of assisted living.
Living with a congenial group of people with whom to share meals, activities, and conversation is a potential benefit, since social connections have been shown to improve health and well-being as well as to reduce medical costs. Keep in mind, though, that it is sometimes hard to make new friends in assisted living because residences experience a lot of turnover. Most people stay in assisted living for only 22 months, according to the 2010 National Survey of Residential Care Facilities. Nearly 60 percent move on to a nursing facility, a third die, and the rest move home or to another location. Note: The 2010 survey has not been updated and has been replaced by a survey with a different name — the National Survey of Long-Term Care Providers. The Centers for Disease Control and Prevention (CDC) website has several recent reports on aspects of assisted living.
State governments, which license group residences, call assisted-living facilities by different names. Some examples of state licensing categories are residential care facilities for the elderly (California), residential facilities for groups (Nevada), and personal care homes and assisted-living facilities (Pennsylvania).
You may also come across the acronym ALF in your search. It is shorthand for assisted-living facility, not the character in the TV series popular in the 1980s. Similarly, ALP is an abbreviation for assisted-living program, not a mountain.
Owners of assisted-living facilities tend to shy away from that term in the name, preferring more appealing names like village, community, manor, or any phrase that evokes a secure and invigorating lifestyle.
Your state’s name for assisted living is not as important as its licensing requirements and its monitoring activities. Some states have detailed standards about what counts as assisted living and what must be provided, as well as building and safety regulations. States may require training for staff, background criminal checks, and other safeguards. Regulations in other states are less definitive. The National Center for Assisted Living, a provider organization, has information about state offices and a state regulatory review. Another important publication is the National Center for Assisted Living’s “Guiding Principles for Assisted Living.” This guide offers a good check on the kinds of information that providers should be giving you as a prospective resident, including contracts, finances, and resident transfers.
When you check out your state’s regulations, find out whether it has a bill of rights for assisted-living residents. Most states have such a document and generally require facilities to post it and give copies to residents. These documents may be lengthy. Some of the items include the right to privacy, to confidentiality of personal and medical information, to have private communications with a physician or attorney, to practice the religion of one’s choice, and to be given notice about transfers or fee increases. Some are negative rights, such as the right not to be coerced or required to perform work. However, not all the documents tell residents how to complain if they feel their rights have been violated. One way is to contact the state’s long-term care ombudsman, who is responsible for investigating complaints in nursing homes and assisted-care facilities. You can find the ombudsman in your area. Or you can contact the National Consumer Voice for Quality Long-Term Care.
What assisted living offers
All assisted-living facilities, however defined, offer three main components:
- Shelter: Residents are given a place to live, usually a private unit or apartment.
- Meals: Food is provided, although not necessarily three meals a day.
- Staff: The facility staff provide the assistance that comes with the name. In addition to managers and activity directors, most facilities have aides or attendants to help with bathing, dressing, getting around with a cane or walker, and other daily tasks.
When it comes to services provided by staff, you may frequently hear the term ADLs. It stands for activities of daily living, which are the actions people take for granted until they can’t do them by themselves anymore — dressing, bathing, going to the bathroom, and feeding themselves. ADLs have a companion term — IADLs, or instrumental activities of daily living — that includes tasks like making phone calls, managing money, managing medications, shopping, and cooking. People in assisted living may also need help with these responsibilities.
Assisted-living facilities may be located in cities and look like ordinary apartment buildings. Some are in suburban locations with lots of open space. There are fewer assisted-living sites in rural areas.
Some assisted-living facilities are luxurious and provide a wide range of services and amenities. At the other end of the spectrum, some facilities have small staffs and offer limited assistance.
When you’re considering an assisted-living facility, be sure to ask about staffing: how many, training, special skills, and background checks. If the management seems evasive, probe further. The response will give you an idea of whether this is a place you want to consider further or avoid.
Assisted-living facilities may be large or small. About a third of all facilities are considered large (25 or more beds), but they have more than 80 percent of all assisted-living residents. About 82 percent of all facilities are run by for-profit organizations, some of which are national or regional chains. The rest are run by charitable or religious organizations or by state, city, or local governments.
In general, larger facilities have more staff and can offer more activities. This benefit may be offset by frequent staff changes and a more impersonal management style. Your preferences about small-group living versus a large residence should be part of your decision. If you or your parent have always lived in a private house with few close neighbors, it may be difficult to adjust to large-group living, even if you have your own apartment. Or a new environment may be just what you are looking for.
A CDC analysis comparing smaller and larger assisted-living facilities found that in 2016, in larger facilities, more residents were age 85 and older, and a higher percentage of people needed personal care assistance. Residents in smaller facilities were also more likely to be receiving Medicaid. The percentage of residents who had fallen in the previous 90 days increased with the bed size of the facilities.
Check out healthcare services
The healthcare services offered in assisted living vary considerably. Most common is assistance with administering medications. Some states require staff with specialized training to help with this task. Some assisted-living facilities have medical staff, usually a nurse, available 24/7 on-site; others have a part-time nurse or someone on call.
Compared to practice 20 years ago, assisted-living facilities are now accepting people with more serious chronic conditions. The National Center for Health Statistics, a government agency, reported in 2010 that 82 percent of assisted-living facility residents had Alzheimer’s disease or dementia, high blood pressure, heart disease, or a combination of those conditions. Some assisted-living facilities have adapted to the greater healthcare and assistance needs of these residents, while others have not. The 2016 CDC survey described in the previous section found that among residents of smaller facilities (4–25 beds), the prevalence of Alzheimer’s disease and depression was higher, but the prevalence of cardiovascular disease was lower.
If you have a chronic condition that requires frequent monitoring and checkups, be sure to ask whether you can continue to see your own doctor or what alternatives will be available, especially if you’re moving to a new area.
Alzheimer’s disease and other types of dementia are conditions that require specific care and are a huge factor when making a long-term plan. A 2012 MetLife Mature Market Institute survey of long-term care costs found that about half of assisted-living facilities provided Alzheimer’s and dementia care, but 61 percent of them charged an additional fee. Sometimes the special units or programs within a facility are called memory care, perhaps to avoid the stigma of dementia. If memory care is important in your plan, be sure to ask about the staff qualifications and training, types of programs available, and opportunities for interaction with other residents. Also ask whether behavioral interventions are used instead of psychoactive drugs, which should generally be avoided. And care for people with dementia should be more than keeping them from wandering; it should include activities designed to stimulate their minds and keep them active.
More information on assisted-living facilities
Your goal is finding the right assisted-living situation, one that offers the right balance of independence and privacy with the kinds of assistance you need now and may need later. After you know more about assisted living, you can begin your fact-finding process.
You can get information about specific assisted-living facilities from many sources. A lot of marketing information stresses the living aspect of assisted living and glosses over the assisted part. It’s hard to find out how friendly the staff is, whether management is responsive to concerns, and all the other quality-of-life questions that matter so much. You have to ask about and observe these aspects for yourself. But you can learn a lot from some basic resources, including the following:
- Eldercare Locator: This federal resource is a good place to start. It directs you to your nearest Agency on Aging for assistance. There is also a basic introduction to assisted living.
- State websites: State websites are important because you can generally find which assisted-living facilities have a lot of health and safety violations or don’t offer what you’re looking for. You can then eliminate these from consideration. Some states also have good consumer information, specific to that state, on their Office of Aging or Health and Human Services websites. Note, though, that these agencies have different names in different states.
- Your state’s long-term care ombudsman: This individual investigates complaints about assisted-living facilities and nursing homes. Check with that office, usually located in the State’s Office on Aging, to find any complaints about a specific facility and how they’ve been addressed.
- The Commission on Accreditation of Rehabilitation Facilities: This nonprofit organization lists continuing-care retirement communities that meet its survey standards about business practices, philosophy and physical environment, and some aspects of assisted living.
- Argentum (formerly the Assisted Living Federation of America): A membership organization of assisted-living providers, this group has a website where you can search for its state partners.
- Internet sites: When you search on the Internet for “assisted living,” you can find ads for specific facilities as well as companies that offer to help you find a facility in your area. Sometimes these companies are endorsed by celebrities, which isn’t a guarantee of quality. Personal assistance from “care” or “family” advisers may be available. Facilities on these lists typically pay to be included, so not all options may be offered to you.
- Friends or relatives: People you know who are currently in or have lived in assisted-living facilities are a good resource for information on local facilities. Keep in mind, though, that one person’s good or bad experience may not convey the whole picture.
- Doctors and other healthcare professionals: Talk to doctors and nurses with experience in providing care to assisted-living facility residents.
Use more than one resource, because no single one is likely to have all the options. Be aware of the criteria for including the assisted-living facilities and the sponsorship of the list. And none of these resources can tell you what it’s really like to live there. You should address questions about quality of life in your visits to various facilities. I suggest some specific questions in the later section “Beyond the Brochure: What to Look For When You Visit.”