Annals of Long Term Care

Those who recognize the issues facing long-term care as being systemic will deal with them systematically. Not by trying to alter the environment, but by accommodating to it. And we’re talking here not just about nursing facilities. The challenges facing assisted living are equally daunting. Yes, it is true. Assisted living has enjoyed an almost meteoric rise in public acceptance and utilization. Almost too much so. Its popularity in the long-term care marketplace was such that, for a brief period, supply of the product clearly exceeded demand. Occupancy levels dropped precipitously. And many companies and individual facilities were tossed onto the dustbin of economic history. But the beauty of free enterprise is that markets do self-correct. Indeed, bankruptcy is very therapeutic (except, of course, for those actually immersed in Chapter 11). It adjusts price, supply, and demand almost painlessly (again, other than for those for whom the pain is very immediate and personal).

So, why worry? Well, to understand why you should worry, you have to delve just a bit into the history of assisted living. You have to understand the genesis of its popularity. Yes, assisted living did attract a following among those looking for more palatable long-term care services. But were we really seeing acceptance on the part of seniors (and their families) of assisted living as their product of choice? Or is it more likely that assisted living was seen simply as the lesser of two evils when compared to nursing homes?

Like it or not, what we might really be talking about here is an overwhelming popular aversion to facility-based care, no matter what the setting. Say what you will about public perceptions of nursing homes, the average senior’s aversion stems less from the issue of facility quality than from an unwillingness to confront the realities of aging. A facility whose primary purpose is to deal with the frailties and illnesses accompanying aging is not likely to be embraced by its customers. Forget what it’s called.

Assisted living facilities are, after all, not all that different from nursing homes in terms of their customers’ frailty. I’ve taken my share of brickbats for having offered some years ago a definition of assisted living as “a nursing home with a chandelier.” But the phrase was never meant to belittle assisted living. Rather, it is simple shorthand for the reality that assisted living facilities deal with exactly the same residents as did the nursing home of yore (then called an intermediate care facility [ICF]). Thus, my description of assisted living facilities as “nursing homes.” While assisted living facilities have had to attract residents in a highly competitive market, nursing homes did not—thus the “chandelier.” The customers remain the same—the same level of activities of daily living (ADL) dependencies, the same incidence of cognitive impairment. While preferring the ambience of assisted living over the institutional flavor of the traditional nursing home, most customers still see assisted living for what it really is: a healthcare provider whose purpose lies in caring for the elderly and the needs attendant to aging.

Today’s assisted living resident, has, indeed, become the nursing home resident of yesteryear. The Assisted Living Federation of America’s recently published 2006 Overview of Assisted Living¹ clearly demonstrates the increasing acuity of assisted living residents, while a comparable article by Frederick Decker² at the National Center for Health Statistics shows equally significant changes in the characteristics of nursing home residents. The implications for the future of assisted living stemming from this mutually reflective “morphing” are significant.

Assisted living is no longer “hospitality” (assuming it ever was). It is healthcare, pure and simple. Admittedly, it’s healthcare with a difference.