Assisted living, also referred to as residential care, is an important part of the long-term care continuum. The proliferation of the assisted living movement in the United States began in the mid-1980s as an alternative to nursing home care for individuals who require some ongoing supervision and assistance with care activities, but do not require the medically skilled services provided by nursing facilities. Early assisted living facilities sought to provide homelike private and shared living environments, a variety of care services, recreational opportunities, and supervision and direct assistance as needed (Gerontologist 2007;47[suppl 1]:8–22). Additionally, there was a prominent focus on resident autonomy and choice in these settings. Assisted living communities embraced a social model of care, and they resisted attempts at medicalization and regulation. The assisted living industry has continued to grow and evolve over the past 40 years. Currently, the United States is approaching 30,000 assisted living facilities that provide care and services to over 800,000 residents (AHCA/NCAL, “Assisted Living: Facts & Figures,” 2020; https://bit.ly/3jQhoYs). Although assisted living residents are more independent than nursing home residents, their care needs and medical complexity have increased. Presently, over half of assisted living residents require supervision or assistance with bathing and ambulation, and the majority of residents need help with meal preparation and medication management. The goal for assisted living communities has been “aging in place,” but 60% of residents will eventually require relocation to a nursing home (AHCA/NCAL, “Facts & Figures”). Over the past 16 months during the COVID-19 pandemic, assisted living communities, like other long-term care settings, have faced significant challenges that have placed the physical and emotional health of residents and staff in peril. Although conditions have improved, some assisted living facilities face an uncertain future. However, times of crisis provide opportunities for thoughtful reevaluation of common practices and priorities. I have practiced and conducted research across a variety of long-term care and community settings, but I have really valued my experiences in assisted living communities over the past 25 years. As consumers, staff, owners, operators, medical providers, and policy makers plan for the assisted living communities of the future, I wanted to share my perspective on what I believe works well in assisted living communities as well as some areas for improvement. As Sarah Howd, MD, CMD, chair of the Assisted Living Subcommittee of AMDA – The Society for Post-Acute and Long-Term Care Medicine, reminds us in this issue of Caring, “if you’ve seen one assisted living community, you’ve seen one.” Assisted living communities are licensed and regulated at the state level, which in part explains the wide variety in size, care options, staffing, provision of medical services, and other characteristics. Assisted living communities vary widely: some are free-standing facilities (both large and small), residential group homes, or hybrid models in senior public housing; others are part of continuing care retirement communities. Additionally, some assisted living communities provide specific programs or units to care for specific populations, such as individuals with dementia. When the general public thinks of assisted living, they are likely to picture large, free-standing communities typically located in urban and suburban areas. These larger communities with 26 or more beds make up less than half of assisted living settings. They tend to have private units, common areas for living and dining with a hotel-like appearance, on-site medical services, large group activities, and a variety of other amenities. These larger assisted living settings may be best suited for residents who seek more apartment-style living, can safely navigate a larger physical environment, and value variety in their social interactions and activities. By contrast, 46% of assisted living communities are small, with four to 10 beds. These smaller communities tend to be hiding in plain sight and are often located in neighborhood homes. The smaller facilities tend to have a more homelike appearance, and some staff may live onsite. The bedrooms are often double occupancy, and residents spend the majority of their time in shared common areas. These smaller facilities may rely on family members to take the residents to medical appointments, or they may enlist the support of a medical house-call team and home care services. Based on my own experience during the COVID-19 pandemic, the smaller assisted living communities with staff who live onsite tended to fare a bit better in terms of less exposure to COVID-19 among the residents and staff, and they experienced less social isolation due to fewer required resident room restrictions. These smaller assisted living communities became self-contained; with the exception of visitor restrictions, daily routines remained much the same for their residents. I often counsel friends and family who are exploring assisted living communities for a loved one to visit several and make their decision based on what would be the best fit for the prospective resident. They should avoid making a decision on the physical environment and number of amenities alone. Some older adults may be better suited for a more predictable routine and closer staff supervision, and they wouldn’t want — or know how to use, in some cases — their own refrigerator or microwave oven. Others may be better suited to greater independence, privacy, and choice. Also, not every resident with dementia requires specialized memory care units or facilities. The nice thing about assisted living is that the variety exists. Those of us who work in nursing homes understand that the facility is truly the resident’s home, but unfortunately nursing homes often don’t feel like home. Despite culture change and person-centered care, many nursing facilities still feel like institutions — long hallways, cookie-cutter rooms, institutional furnishings, shared bathrooms for bathing and toileting, and food served on trays. By contrast, no matter the model or size of the facility, assisted living communities are more likely to have a homelike atmosphere. Shared, family-style meals are more common, personal furniture and decorations are welcomed, pets are more common, and daily schedules tend to be a bit less regimented. Although assisted living residents are becoming more medically complex and functionally disabled, and additional regulatory requirements may be advisable to care for the residents with greater needs, we do not want to overshadow the more homelike qualities that initially made the setting an attractive option for older adults in need of long-term care. One of the greatest challenges faced by assisted living residents is the payment model. It is expensive to live in assisted living communities in the United States. According to the National Center for Assisted Living, the median monthly rate for assisted living is $4,000. Many assisted living communities have a base rate for basic care and services and then have an ala cart menu of services that result in additional fees. The vast majority of assisted living communities are paid for using personal financial resources, long-term care insurance benefits, and/or family member contributions. Individuals with lower incomes and savings may be eligible to use Medicaid to cover some of the cost of care associated with assisted living, depending on the state Medicaid program. Medicaid waiver programs for assisted living often have long waiting lists. Until public funds are more readily available to pay for assisted living, residents who could have been cared for in assisted living communities at almost half the cost will require a nursing home where Medicaid funding is guaranteed. Many assisted living communities provide access to some onsite medical care and services, but the quality of these services varies. Assisted living facilities are primarily staffed by direct care workers who may or may not be licensed as nursing assistants. The larger assisted living facilities may have a registered nurse on staff at least some of the time, but most assisted living communities use a delegated nurse model of care. Assisted living communities’ access to social workers, consultant pharmacists, behavioral health specialists, and other consultants is also limited in most states. As noted by the Society’s Assisted Living Subcommittee, there is also a lack of medical direction in most assisted living communities. Some medical practices actually specialize in the provision of medical care to assisted living communities, and some of the best ones that I have encountered use an interdisciplinary team approach, consisting of mostly nurse practitioners and physician assistants for medical care needs with the support and guidance of physicians, a licensed clinical social worker, and a consultant pharmacist who may provide services to several assisted living facilities. Please share with us some of the things you love about assisted living communities and what you would like to see change. Dr. Galik is editor in chief of Caring for the Ages. The views the editor express are her own and not necessarily those of the Society or any other entity. Dr. Galik is a nurse practitioner in LTC- and community-based settings through a clinical practice with Sheppard Pratt Health System. She is a professor at the University of Maryland School of Nursing, where she teaches in the Adult-Gerontology Primary Care Nurse Practitioner Program and conducts research to improve care practices for older adults with dementia and their caregivers in long-term care. She may be reached at [email protected] .