National Assisted Living Quality of Life Study – Phase I: a
“Who’s Living Where…And Why It Matters”
Andrew Carle, MHSA Executive-in-Residence/Director George Mason University – Program in Senior Housing Administration
#ALFA2014
Overview: Part I: George Mason University – Department of Health Administration & Policy – Program in Senior Housing Administration
Part II: AL “Quality of Life” Study Part III: Strategic Need Part IV: Study Design/Key Findings Part V: Implications/Next Steps
I. GMU/Dept. Health Admin & Policy George Mason University: • Largest university in VA • 33,000+ Students • Nationally Ranked
• USN&WR: “#1 School to Watch” (2010 & 12) • Princeton Review: #1 Diversity • $130M Research
Department of Health Administration & Policy: • College of Health and Human Services (3,100 students) •“Top 20” Graduate Programs in Health Administration (2014)
• Nationally Recognized Faculty • Health Policy/Medicare/ACA
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Program in Senior Housing Administration: First academic program dedicated exclusively to Senior Housing Administration (2001): Undergraduate: • Bachelor of Science Health Administration - Concentration in Senior Housing Admin (BS-SHA) Graduate: • MHA/Graduate Certificate SHA • “Executive Seminars” http://seniorhousing.gmu.edu 4
Part II: National Assisted Living “Quality of Life” Study Objectives: Phase I: • Identify and measure key “Quality of Life” (QOL) indicators for a “typical” AL resident Phase II: • Compare to “Peer Acuity Seniors” living at home
Hypothesis: AL residents will have better QOL indicators than “peer acuity seniors” living at home, with either no or limited assistance: • Hospitalizations • • • • •
• Re-hospitalizations
Falls/Injuries Medication Errors ADL/IADL Compliance Cognition/Depression Nutrition 5
Part III: Strategic Needs (4) 1. Consumers (Media) & Regulators:
2. Accountable Care Organizations (ACO’s):
• Industry has relied on
• Ability to document cost savings in health care system
anecdotal evidence of “quality” to defend itself • Need to move from 31,000 individual communities to “Senior Housing Industry” providing proactive, tangible, measurable benefits to aging populations
• Today: • Re-hospitalizations
• Tomorrow: • Hospitalizations
From “Youth” to “Adult” stage in Product Life Cycle 6
Strategic Needs… 3. Medicaid:
4. LTC Insurance:
• Home and Community Based Services (HCBS) initiatives only compare “living at home” services vs. skilled nursing care
• Growing industry requiring documented contribution of covered products and services: – Future version of CLASS Act may offer additional opportunities
• Potential to document value
of AL services as a primary component of HCBS, vs. “living at home”
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Part IV: Study Design/Findings Data Resource: National Survey of Residential Care Facilities (NSRCF): • 8,094 Residents; 2,302 Communities •
Included group homes and communities of 4+ beds, but excluded those serving only adults with severe mental illness or developmental disabilities
• Facilities Data Brief • •
December 2011 Size, Ownership, Multi-facility
• Residents Data Brief • •
March 2012 Demographics, Health Status, Physical Functioning
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Study Phases: Phase I: Secondary Data Analysis Key Objectives: 1. Examine characteristics of
residents in NSRCF dataset
Q: What represents a “typical” assisted living resident? 2. Identify statistically significant
differences among AL residents and/or AL communities I.e. “Peer” group by resident and community type
Phase II: Survey Design, Data
Analysis, Synthesis
Key Objectives: 1. Identify and recruit sample population of at-home “Peer Acuity Seniors” 2. Conduct data collection, analysis; synthesize, disseminate findings Estimated Timeline: • June 2014 to May 2016
Timeline: • Oct. 2012 to Jan. 2014 9
Key Issue – Phase I: What represents a “typical” AL resident? 1. Are NSRCF residents statistically similar for ALL characteristics across ALL types of communities? i.e. “Homogenous” • Residents in all communities are essentially the “same”
2. Are NSRCF residents statistically DIFFERENT in characteristics (resident mix), but equally distributed across ALL types of communities? • Ex: The mix of Non-MC vs. MC residents is essentially the same in all communities 3. Are NSCRF residents significantly different in BOTH resident mix and type of communities? • If so, what represents the “majority”? 10
Principle NSRCF Data Categories Researched: • Resident Demographics • Resident Health Status/Acuity • Resident “Risk” Factors
NSRCF Community Characteristics: • Small
Communities 4-10 Beds (50% communities/10% residents) • Medium 11-25 Beds (16% communities/9% residents) • Large/X-Large 26–100+ Beds
Sunrise Senior Living - Fair Oaks, VA
(35% communities, 81% residents)
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Overall Findings: Demographics The majority of AL residents are 85+ years old, female, Caucasian, widowed, and have lived in the community for 1-3 years. They moved into the community from a private “home�, and are nonMedicaid/private pay. Characteristic Age 85+ Female Caucasian Widowed Previous Residence: Private Home Non-Medicaid/Private Pay
Percent 54% 70% 91% 62% 74% 80% 12
Overall Findings: Health/Acuity The majority of AL residents have multiple chronic conditions, with hypertension, Alzheimer’s/dementia, and CHF as the top 3 conditions. They require an equal amount of assistance with either 1-2 or 3-5 ADLs. A minority of residents have a development disability or severe mental illness (SMI). Characteristic Multiple Chronic Conditions (2-10)
Percent 76%
- Hypertension
57%
- Alzheimer’s/Dementia
42%
- Congestive Heart Failure (CHF)
34%
1-2/3-5 ADL Limitations
37%/37%
Developmental Disability
3%
Severe Mental Illness (e.g. Schizophrenia)
8%
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Overall Findings: Risk A minority of AL residents are reported to have fallen (with injury), visited an emergency room, or been hospitalized overnight, during the past year. Characteristic
Percent
Falls with Injury
15%
ER Visit
35%
Overnight Hospitalization
24%
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Findings of Interest (1): Residents of large communities were more likely to be age 85+. Residents of small communities were nearly three times more likely to be age 65 or younger and nonCaucasian, and two times more likely to utilize Medicaid. Small (4-10)
Medium (11-25)
Large (26+)
Less than 65
23%
21%
8%
85+
43%
45%
56%
Non-Caucasian
21%
12%
7%
Medicaid
32%
31%
16%
Characteristic
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Findings of Interest (2): Larger communities had significantly more residents with 2-3 chronic conditions, including CHF, Hypertension, and Osteoporosis. They were more likely to have a reported incident of either a fall with injury or ER visit during the past year. Characteristic
Small (4-10)
Medium (11-25)
Large (26+)
44%
46%
52%
- CHF
25%
30%
36%
- Hypertension
50%
54%
58%
- Osteoporosis
15%
18%
21%
Fall with Injury
9%
14%
16%
ER Visit
28%
33%
36%
2-3 Chronic Conditions
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Findings of Interest (3): Small/medium communities had more residents with 3-5 ADL limitations, developmental disabilities, SMI, Alzheimer’s, or depression. On a percentage basis, small communities had five times more residents with a developmental disability than large communities, and 1.3 times as many with Alzheimer’s Disease. Characteristic
Small (4-10)
Medium (11-25)
Large (26+)
3-5 ADL’s
62%
37%
34%
Dev. Disabled
10%
7%
2%
Severe Mental Ill
13%
15%
6%
AD/dementia
53%
40%
41%
Depression
36%
31%
26% 18
Findings of Interest (4): Smaller communities were more likely to have residents who “often/sometimes� exhibited difficult behaviors, including creating disturbances, being verbally threatening, physically aggressive, or removing their clothes. They were more likely to require medications to control behavior. Characteristic
Small (4-10)
Medium (11-25)
Large (26+)
Create Disturbance
26%
19%
14%
Verbally Threatening
14%
12%
10%
Physically Aggressive
13%
10%
7%
7%
4%
3%
35%
26%
19%
Removed Clothing Requires Medication(s) to Control Behavior
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Part V: Phase I Implications/Next Steps •
Communities of different sizes are serving different populations, yet are often viewed in the aggregate as “assisted living” by consumers, media, and policy makers • Should there be multiple and clearly defined licensing categories? “Specialty” vs. “Senior”?
•
Is the “split” small community mix of younger residents with DD/SMI, in combination with older residents with Alzheimer’s/dementia, appropriate? • Are these “Memory Care only” communities? • “Co-housed” residents? 20
Next Steps - Phase II: How do we identify “peer acuity” seniors living at home, in order to compare to the “typical” assisted living resident? -
Via public solicitation? Via government agency (Ex: Area Agency on Aging)? Via “lost leads” (clinically/financially appropriate but did not move-in)?
To which measures do we compare? - One year forward? - One year back? 21
Is assisted living improving “quality of life”? Better than alternatives? THE TIME TO ANSWER THESE QUESTIONS HAS ARRIVED.
Publication: “Resident Characteristics and Chronic Health Conditions”. 2014 Seniors Housing & Care Journal (October) Thank You!========= Andrew Carle, Executive-in-Residence George Mason University Program in Senior Housing Administration (E) acarle@gmu.edu (P) 703-993-9131 (W) http://seniorhousing.gmu.edu
#ALFA2014