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Expanding Long-term Care Choices for the Elderly

Identifying Users


Christine G. Williams, M.Ed., Director, Office of Health Care Information, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, MD.

Catherine Hawes, Ph.D., Professor, Department of Health Policy and Management, School of Rural Public Health, Texas A&M University, College Station, TX.

Despite an overall increase in the number of nursing facilities (NFs) and NF beds, beds per 1,000 people over age 75 declined by 17 percent between 1987 and 1996. Nonetheless, overall occupancy rates declined from 92.3 percent in 1987 to 88.8 percent in 1996, as more people sought care in alternative settings (their own homes, assisted living facilities, personal care homes). This has resulted in NF residents who are older and more functionally disabled. In 1987, 71.8 percent of NF residents received help with three or more activities of daily living (ADLs); by 1996, this percentage had risen to 82.9 percent (a 15.5-percent increase).

Ms. Williams pointed out that this trend of residents being older and more functionally and cognitively disabled will continue. Other expected trends include:

  • A sicker population in postacute or subacute care (resulting in greater need for skilled and rehabilitative care following hospitalization).
  • Potentially shorter stays.
  • Demographic changes in marital/family status and longevity.

To cope with some of these changes, almost one-fifth of NFs in 1996 had at least one special care unit, containing 6.8 percent of all NF beds; there are far more now. In 1996, the most common type of special care unit was for treatment of Alzheimer's and related dementias; other special care units include those for rehabilitation, subacute care, ventilator dependency, hospice, HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), and brain injury.

Ms. Williams asserted that although the NF population represents a small proportion of both the elderly population and the general population of people with disabilities, NFs will continue to be an important piece of the long-term Care (LTC) system. Frail individuals lacking financial resources or family caregivers will particularly need this option available.

The definition of assisted living varies across both States and facilities. In some States, assisted living is a distinct licensure category, while in others the term also covers traditional board and care homes.

A study of the characteristics of assisted living facilities (ALFs), which examined over 11,000 ALFs nationwide, found that:

  • Approximately one-half (48 percent) have been in operation 10 years or less.
  • Two-thirds have between 11 and 50 beds. Catherine Hawes noted that the newer ALFs tend to be larger.
  • Large facilities tend to offer more services.
  • Almost three-quarters of units are private (not shared by unrelated adults), and 62 percent have private, full bathrooms. Dr. Hawes commented that people rank having a private bath higher than they do a private bedroom.
  • Fifty-seven percent of units are single rooms, and 43 percent are apartments (defined as having a cooking space).
  • High-service ALFs are more likely to have retention policies for behaviors, transfers, wheelchair use, and nursing care needs than low-service ALFs.
  • The average annual basic price (excluding ancillary services) for high-service/high-privacy ALFs is $23,292; $22,068 for high-service/low-privacy ALFs; and $21,252 for low-service/high-privacy ALFs. Fewer than one-fifth of people over age 75 can afford this without spending down.

The critical factor in whether an ALF is low-service (i.e., 24-hour staff, two or more meals, housekeeping, and personal care) or high-service (low-service plus provision and/or arrangement of nursing care/monitoring) is that high-service facilities have a full-time registered nurse (RN) on staff. ALFs in which RN or licensed practical nurse (LPN) services are either not offered or are arranged through a home health agency also have much more restrictive policies on resident retention.

The distribution of ALFs by mix of services and privacy is as follows:

  • Fifty-eight percent have low or minimal privacy and services.
  • Eleven percent have both high services and high privacy.
  • Eighteen percent have high services and low privacy.
  • Twelve percent have high privacy and low services.

The study also found that the average length of stay in ALFs was 28 months. The most common reason for leaving was the need for more care (78 percent of cases); exhausted funds only accounted for 9 percent of those leaving. Nonprofit ALFs with multilevel campuses are the most likely to allow residents to age in place.

Dr. Hawes described aging in place as a "squishy" concept, determined in part by facilities and in part by State regulations, resulting in confusion for residents. Dr. Hawes stressed the need to educate potential residents and their family members (who typically have a major role in decisionmaking) about what to expect in an ALF and what to look for in a contract before signing.


Hawes C, Rose M, Phillips CD. A national study of assisted living for the frail elderly. Beachwood (OH): Myers Research Institute, Menorah Park Center for Senior Living; 1999 Nov.

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