Residential Care/assisted Living Research Articles

Do end-of-life outcomes differ by assisted living memory-care designation?

Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end-of-life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory-care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL). Prospective cohort of 15,152 fee-for-service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory-care and general RC/AL residents. Two-part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents. The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory-care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory-care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory-care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two-part models showed that decedents in memory-care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02). We find a higher mortality rate and higher rate of hospice use among memory-care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life.

State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life.

Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.

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

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) group differences between residents relocating from acute/post-acute facilities (e.g., hospital, rehabilitation facility) and community-based residences, and (2) the relationship between previous location and depression within the first year of relocation. The 921 (35%) residents relocating directly from acute/post-acute facilities were more likely to have depression (p < .001) and poorer outcomes on select health and psychosocial variables. After controlling for covariates, relocating directly from an acute/post-acute facility significantly related to depression (OR = 1.22). Findings highlight opportunities to improve routine screening and transitional care for this subpopulation of RC/AL residents at heightened risk for depression.

Exploring Path Models of Disablement in Residential Care and Assisted Living Residents.

This study examined the relationships between individual and environmental factors and physical activity, and between physical activity and functional limitations and disability in residential care/assisted living (RC/AL) residents. Participants completed questionnaires and physical performance tests, and wore the Fitbit Motion Tracker® to capture physical activity. Model fit was analyzed using two-level path models with residents nested within RC/AL settings. Model parameters were estimated using the MPlus robust maximum likelihood method. A multilevel model with good fit (root mean square error of approximation = 0.07, comparative fit index [CFI] = 0.91) showed that persons with greater exercise self-efficacy were more physically active, and persons who were more physically active had better physical function and less disability. Setting-level factors did not significantly correlate with physical activity or disability. Although environmental factors may influence physical activity behavior, only individual factors were associated with physical activity in this sample of RC/AL residents.

Differences in assisted living staff perceptions, experiences, and attitudes.

Research within residential care/assisted living (RC/AL) settings has shown that the attitudes of personal care (PC) staff toward their organization and its residents and families can affect the quality of resident care. This article describes the perceptions, experiences, and attitudes of PC staff and their supervisors, and considers these data in the context of non-hierarchical staffing patterns-a philosophically expected, yet unproven tenet of RC/AL. Using data collected from 18 RC/AL communities, these analyses compared the characteristics, perceptions, experiences, and attitudes of PC staff (N = 250) and supervisors (N = 30). Compared to supervisors, PC staff reported greater burden, frustration, depersonalization, hassles, and feeling significantly more controlling of, and less in partnership with, families (p < 0.05). Because the PC staff experience is crucial for resident outcomes, more work is needed to create an environment where PC staff are less burdened and have better attitudes toward work and families.

Fall Prevention and Monitoring of Assisted Living Patients: An Exploratory Study of Physician Perspectives

Explore physician perspectives on their involvement in fall prevention and monitoring for residential care/assisted living (RC/AL) residents. Exploratory cross-sectional study; mailed questionnaire. Four RC/AL communities, North Carolina. Primary physicians for RC/AL residents. Past Behavior and future Intentions of physicians with regard to (1) fall risk assessment and (2) collaboration with RC/AL staff to reduce falls and fall risks among RC/AL residents were explored using Theory of Planned Behavior (TPB) constructs. Predictor variables examined (1) physicians' views on their own responsibilities (Attitude), (2) their views of expectations from important referent groups (Subjective Norms), and (3) perceived constraints on engaging in fall prevention and monitoring (Perceived Behavioral Control). Physicians reported conducting fall risk assessments of 47% of RC/AL patients and collaborating with RC/AL staff to reduce fall risks for 36% of RC/AL patients (Behavior). These proportions increased to 75% and 62%, respectively, for future Intentions. TPB-based models explained approximately 60% of the variance in self-reported Behavior and Intentions. Physician's involvement in fall prevention and monitoring was significantly associated (P < .05) with their perceptions of barriers and facilitators-ease, time, reimbursement, and expertise. This study provides first data on physician beliefs regarding their involvement in fall risk assessment of RC/AL patients and collaboration with RC/AL staff to reduce fall risks of individual patients. Challenges to physician involvement identified in our study are not unique or specific to the RC/AL setting, and instead relate to clinical practice and reimbursement constraints in general.

Physician Perspectives on Fall Prevention and Monitoring in Assisted Living: A Pilot Study

To investigate physician perspectives on their own role and the role of residential care/assisted living (RC/AL) staff in fall prevention and monitoring among RC/AL residents. Exploratory cross-sectional study. Mailed questionnaire. RC/AL communities. Primary physicians (N = 36) for residents of 4 RC/AL communities in North Carolina. Theory of Planned Behavior constructs were used to measure physician attitudes, perceived expectations, and perceived barriers to conducting fall risk assessments, medication reviews for potential side effects related to falls, and working with RC/AL staff to reduce falls and fall risks among RC/AL residents. Physicians expressed strong support for conducting fall risk assessment of patients in RC/AL communities, believing that these assessments were likely to uncover risks that might be preventable; however, they reported conducting such assessments for only 47% of their RC/AL patients. They believed RC/AL staff had greater responsibility than they did for conducting these assessments, although they believed the staff had less expertise to do so. Further, they believed they were significantly (P < .05) more likely than RC/AL staff to take specific actions to reduce fall risks among individual patients. Physicians supported working with RC/AL staff to reduce fall risks, but expressed concerns about the usefulness and amount of communications from RC/AL staff about residents identified at high risk for falls. This study provides the first data on physician perspectives on an important issue of quality care and quality of life in RC/AL communities-fall prevention and monitoring among RC/AL residents. Findings point to the need for greatly improved communications between primary physicians and RC/AL staff about residents at high risk for falls and responsibility for conducting fall risk assessments.

Preferences Versus Practice: Life-Sustaining Treatments in Last Months of Life in Long-Term Care

To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST. After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility. The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states. Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that. Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034). Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.

Practical Depression Screening in Residential Care/Assisted Living: Five Methods Compared With Gold Standard Diagnoses

To test the accuracy of five practical depression screening strategies in older adults residing in residential care/assisted living (RC/AL). Cross-sectional screening study. Four RC/AL communities in North Carolina. A total of 112 residents aged > or =65 and 27 staff members involved in their care. Direct care staff was trained in and completed the Cornell Scale for Depression in Dementia, modified for use by long-term care staff (CSDD-M-LTCS). They additionally responded to a one-item question "Do you believe the resident is often sad or depressed?" and the Minimum Data Set Depression Rating Scale (DRS). Residents responded directly to the Geriatric Depression Scale (15-item version; GDS-15) and the Patient Health Questionnaire, 2-item version (PHQ-2). A geriatric psychiatrist performed gold standard diagnostic interviews using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Sensitivities and specificities were calculated for all instruments at predetermined cutpoints. Gold standard diagnoses yielded 14% prevalence of major or minor depression. The CSDD-M-LTCS and one-item screen completed by caregivers failed to significantly discriminate depressed cases. The DRS yielded high specificity (0.85) but low sensitivity (0.47). For the two resident reported measures, the PHQ-2 had a sensitivity of 0.80 and specificity of 0.71, and the GDS-15, 0.60 and 0.75, respectively. Measures completed by caregivers failed to adequately detect depression. Of the measures completed directly by residents, the PHQ-2 seems to have the best mix of brevity, sensitivity, and ease of administration.

The Context of Religious and Spiritual Care at the End of Life in Long-term Care Facilities

Despite the increasing numbers of Americans who die in nursing homes (NHs) and residential care/assisted living (RC/AL) facilities, and the importance of religious and spiritual needs as one approaches death, little is known about how these needs are met for dying individuals in long-term care (LTC) institutional settings. This study compared receipt of religious and spiritual help in four types of LTC settings: NHs, smaller (<16 beds) RC/AL facilities, traditional RC/AL facilities, and new-model RC/AL facilities. Data were also available for religious affiliation of the facilities, size, and provision of religious and hospice services. Controlling for such factors, the importance of religion/spirituality to the decedent was the strongest predictor of the decedent's receipt of spiritual help. In addition, new-model RC/AL facilities were significantly more likely to provide help for religious and spiritual needs of decedent residents than other RC/AL types, but did not differ significantly from NHs.

Dying with dementia in long-term care.

To better understand the experiences and potential unmet need of persons who die in long-term care. We conducted after-death interviews with staff who had cared for 422 decedents with dementia and 159 who were cognitively intact and received terminal care in U.S. nursing homes (NHs) or residential care-assisted living (RC-AL) settings. We conducted family caregiver interviews for 293 decedents. We noted no differences between decedents with and without dementia in terms of pain, psychosocial status, family involvement, advance care planning, most life-prolonging interventions, and hospice use. Dying residents with dementia tended to die less often in a hospital, have less shortness of breath, receive more physical restraints and sedative medication, and use emergency services less frequently on the last day of life. Persons with dementia dying in RC-AL settings tended to have more skin ulcers and poorer hygiene care than nondemented persons in RC-AL settings. In comparison with persons dying with dementia in NHs, those in RC-AL settings tended to be restrained less often, have emergency services called more often on the day of death, and have family more satisfied with physician communication. These results suggest that the overall quality of care for persons dying with dementia in long-term-care settings may not differ markedly from that provided to persons who are cognitively intact. Similarly, large discrepancies in the overall quality of palliative care for persons with dementia in RC-AL facilities and NHs were not identified. However, numerous specific areas for care improvement were noted.

Cognitive Screening for Dementia and Mild Cognitive Impairment in Assisted Living: Comparison of 3 Tests

Compare diagnostic characteristics of brief cognitive screening tests in residential care/assisted living (RC/AL) residents. Cross-sectional study involving a comprehensive clinical examination to ascertain a consensus diagnosis of probable dementia, no significant cognitive impairment, or mild cognitive impairment (MCI), including both amnestic and non-amnestic subtypes. Fourteen RC/AL facilities in North Carolina. Participants were 146 RC/AL residents, aged 65 years or older, who did not have diagnosed cognitive impairment. Diagnostic characteristics of the Mini-Cog, the Mini-Mental State Exam (MMSE), and a new 50-point test based on expanding selected MMSE items (MMX). Overall, 55/146 (38%) participants were diagnosed with probable dementia, and 76 (52%) met criteria for MCI (most non-amnestic). Both the Mini-Cog and the MMSE showed high sensitivity and negative predictive value for dementia, but had relatively low sensitivity and negative predictive value for MCI. The Mini-Cog had low specificity and was less accurate as a dementia screen than either the MMSE or MMX. Reliability and validity data for the MMX were satisfactory, and it performed better as a screening test for MCI than either the MMSE or Mini-Cog. Although the MMSE and Mini-Cog are both sensitive to dementia, modest specificity and positive predictive value may limit their utility as screening tools. Preliminary MMX data suggest it improves screening for MCI compared to the Mini-Cog or MMSE, while providing a similar level of screening for dementia. Further work is needed to identify suitable instruments for cognitive screening across the range of MCI and dementia.

June’s Troubled Transition: Adjustment to Residential Care for Older Adults With Dementia

In research on dementia care and housing transitions, only rarely are residents themselves present as active informants. This is a costly omission, inasmuch as manifestations of dementia, perceptions of care settings, and residents' experience of such transitions are both complex and highly variable. In this article, drawn from a larger study of the social organization of care in residential care/assisted living (RC/AL), we develop a detailed, ethnographic narrative that combines first-person reflections by, and observational data on, a single resident--a focal case. The account suggests that for older adults with mild to moderate dementia, awareness of serious impairment among coresidents can be both distressing and stigmatizing. We further argue that assumptions about and attributions of dementia by staff members, compounded by immediate demands of caregiving, may create a self-fulfilling prophecy resulting in residents' resistance and withdrawal. The case also suggests that, to the extent this interactional dynamic is present, distinctive goals in RC/AL, such as enhanced self-determination among residents, are undermined.

Physical Performance Characteristics of Assisted Living Residents and Risk for Adverse Health Outcomes

Researchers know little about the physical performance ability of residential care/assisted living (RC/AL) residents and its relationship to adverse outcomes such as fracture, nursing home placement, functional decline, and death. The purposes of this article are to (a) describe the functional characteristics of RC/AL residents, (b) examine the relationships between resident- and facility-level characteristics and physical performance, and (c) determine the predictive value of physical performance for adverse outcomes. Data came from 1,791 residents in 189 RC/AL facilities participating in the Collaborative Studies of Long-Term Care. At baseline, residents were tested on four performance measures (grip strength, chair rise, balance, and walking speed), and other resident- and facility-level information was collected. Adverse outcomes were measured over 1 year. Average grip strength was 14 +/- 7 kg, 61% of residents walked <0.6 m/s (M = 0.41 m/s), 26% could perform five chair rises, and only 19% could perform a tandem stand for a least 1 s. Multivariable analyses showed that more cognitive and functional impairment, depressive symptoms and comorbid conditions, and for-profit ownership were associated with poorer physical performance. Controlling for individual characteristics, we found that better performance on the four physical performance measures was associated with a reduced risk of nursing home placement, fracture, and decline in function over 1 year. Simple performance measures identify modifiable functional deficits and suggest targeted interventions to prolong independent mobility and aging in place in RC/AL facilities.

Symptom Experience of Dying Long‐Term Care Residents

To describe the end-of-life symptoms of nursing home (NH) and residential care/assisted living (RC/AL) residents, compare staff and family symptom ratings, and compare how staff assess pain and dyspnea for cognitively impaired and cognitively intact residents. After-death interviews. Stratified random sample of 230 long-term care facilities in four states. Staff (n=674) and family (n=446) caregivers for dying residents. Interview items measured frequency and severity of physical symptoms, effectiveness of treatment, recommendations to improve care, and staff report of assessment. Decedents' median age was 85, 89% were white, and 77% were cognitively impaired. In their last month of life, 47% had pain, 48% dyspnea, 90% problems with cleanliness, and 72% symptoms affecting intake. Problems with cleanliness, intake, and overall symptom burden were worse for decedents in NHs than for those in RC/AL. Treatment for pain and dyspnea was rated very effective for only half of decedents. For a subset of residents with both staff and family interviews (n=331), overall ratings of care were similar, although agreement in paired analyses was modest (kappa=-0.043-0.425). Staff relied on nonverbal expressions to assess dyspnea but not pain. Both groups of caregivers recommended improved application of treatment and increased staffing to improve care. In NHs and RC/AL, dying residents have high rates of physical symptoms and need for more-effective palliation of symptoms near the end of life.

Residential Care/Assisted Living Staff May Detect Undiagnosed Dementia Using the Minimum Data Set Cognition Scale

To estimate the sensitivity, specificity, and reliability of the Minimum Data Set Cognition Scale (MDS-COGS) in screening for undetected dementia when completed by direct care staff in residential care/assisted living (RC/AL) facilities and secondarily to determine the prevalence of dementia in the sample. A cross-sectional study in which staff were trained to complete the MDS-COGS. Research interviewers and a neuropsychologist obtained information on each participant. Two neurologists reviewed the data and examined the participant, rendering a probable diagnosis of dementia/non-dementia diagnosis. MDS-COGS results were compared with the neurologists' determination. Fourteen RC/AL facilities in North Carolina. Data were collected from 50 staff on 166 residents without a diagnosis of dementia. In addition to the MDS-COGS, measures included a comprehensive neuropsychological battery. Depression and other neuropsychiatric symptoms were also assessed. Neurologists determined that 38% of participants had probable dementia. An MDS-COGS cutpoint of 2 was highly specific (0.97) but not very sensitive (0.49) for dementia. Test-retest and interrater agreement for a negative screen were high (88% and 93%, respectively). The MDS-COGS is a simple, brief screen that RC/AL staff can complete. It will identify with high specificity a subset of residents with undetected dementia, allowing rapid identification of those likely to need dementia care. Caution needs to be exercised in light of its low sensitivity, because some with milder dementia will not be detected. Further work is needed to determine whether staff can and will use the MDS-COGS as a trigger for more-thorough assessment and to guide care and improve outcomes.

Physician Communication with Family Caregivers of Long‐Term Care Residents at the End of Life

To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions. Retrospective study of family caregivers of persons who died in LTC. Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities. One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death. Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician-family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96). Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities. Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying.

Assisted Living Policies Promoting Autonomy and Their Relationship to Resident Depressive Symptoms

The objective of this study is to determine the relationship between facility policies regarding autonomy and depression among residents of residential care/assisted living (RC/AL) facilities. A stratified sample of RC/AL facilities in Florida, Maryland, New Jersey, and North Carolina participated in the study. Patient characteristics for individuals 65 years and older were obtained from medical record reviews and in-person interviews. Facility administrators provided data on facility characteristics. Data on 1,098 residents were used to examine the relationship between facility policies as measured by domains of the Policy and Program Information Form and resident depressive symptoms and its factors as measured by the Cornell Scale for Depression in Dementia. Generalized estimating equation regression analysis was used to examine this relationship and control for other explanatory variables and clustering. Among the policy variables examined, only the degree to which residents were involved in facility administration was consistently associated with depressive symptoms. Greater resident influence over facility policies and involvement in facility administration was significantly associated with lower levels of depressive symptoms. Resident control over their daily activities, the facility's tolerance for disruptive behavior, and the extent to which facilities had formal mechanisms for defining expected behavior were not significantly associated with levels of depressive symptoms. Although some facilities provide residents with opportunities to select activities or meal times, these policies were not associated with depressive symptoms. However, results are consistent with the hypothesis that resident involvement in facility administrative decision-making is associated with fewer depressive symptoms. Future research should explore the causal nature of this relationship and might provide guidance for policy and practice.

Hospice Attitudes among Assisted Living and Nursing Home Administrators, and the Long-Term Care Hospice Attitudes Scale

To examine the attitudes of residential care/assisted living (RC/AL) and nursing home (NH) administrators toward hospice and to assess facility and administrator characteristics related to those attitudes. Two exploratory factor analyses of the Hospice Attitudes Questionnaire using principal factors with a promax (oblique) rotation were conducted. One was in a sample of 390 RC/AL and NH administrators from four states (Florida, Maryland, North Carolina, and New Jersey) and the other included NHs from this and a second sample (n = 244). Association between facility and administrator characteristics and administrator attitudes towards hospice were examined among the 146 RC/AL administrators. Exploratory factor analysis in the full sample resulted in the 12-item Long-Term Care Hospice Attitudes Scale (LTC-HAS) with four component subscales: (1) emotional and spiritual support (three items, alpha = 0.83); (2) quality of care (four items, alpha = 0.78); (3) rapidity of death (three items, alpha = 0.66) and (4) end-of-life care coordination (two items, alpha = 0.73). The overall alpha for the 12-item scale was 0.81. When exploratory factor analysis was conducted on the NH data only, a three-item subscale related to financing and billing (alpha = 0.66) also emerged. Four facility and three administrator characteristics that were significantly related to hospice attitudes included state, facility type, facility age, affiliation with another level of care; and age, race, and nurse training. Findings from this paper provide insight about RC/AL facility and NH administrators' attitudes towards Hospice using scale data, an area with limited research. They indicate positive attitudes toward Hospice care coordination, and that Hospice should supplement, as opposed to replace, the care provided by facilities. Findings also suggest areas where targeted outreach and further study may be recommended.

The Relationship Between Psychiatric Disorders and the Ability to Age in Place in Assisted Living

Residential care/assisted living (RC/AL) has become a popular long-term care option in the past decade, in part because these settings offer residents a more home-like environment than nursing homes (NHs) while still offering supervision and assistance to meet individuals' personal and healthcare needs. One of the goals of RC/AL is to facilitate residents' ability to age in place by providing access to needed services and thereby delaying NH admission. This article explores individual and facility-level characteristics associated with discharge from RC/AL to NH with particular attention to persons with a psychiatric disorder. A Cox proportional hazards model was used to examine the risk factors associated with discharge from RC/AL to NH for a nonrandom sample of 366 residents in 37 RC/AL facilities in one state. Thirty-two percent of residents sampled had a psychiatric disorder. Residents with a psychiatric disorder were 1.78 times more likely to discharge to a NH. Other factors significantly associated with discharge from a RC/AL to NH included age (older), being married, more hospitalizations, for-profit ownership status, and part of a NH or continuing care retirement community. This article identifies both facility and individual characteristics that increase the likelihood of RC/AL residents discharging to NHs. Given that one of the main findings is that persons with a psychiatric disorder are at increased risk of discharge to NH, there is a need for improved provision of services for this population in RC/ALs to reduce premature discharge to NHs and to support aging in place in RC/ALs.