I attended a session at the national conference of the Assisted Living Federation of America (ALFA) in which the topic of aging in place in assisted living was discussed. And I think the panelists may have missed the true definition of aging in place and where that takes place.
I was confused at first, not understanding the concept. To me, aging-in-place is about aging in MY place. But then I started to understand that this is about the assisted living facility as home and one in which you can stay for the rest of your life even as your health care needs and acuity progress.
That essentially means higher acuity residents and thus the rub with the nursing home industry. But first a little background.
Aging in place in assisted living is for people who may no longer be able to live in a single family home or an independent apartment. Assisted living residences operate with an aging in place philosophy. The shift is somewhat supported by trends in state policy though many states are not on board with the idea of "enhanced" assisted living.
States typically use one or more of five factors to establish admission/retention policies in assisted living residences:
- General condition
- Health related conditions
- Functional capacity
- Alzheimer's disease and dementia
- Behaviors
Literature suggests there are three models. The first seeks to admit and retain residents with high acuity levels. A second model is more focused on serving low to moderate acuity residents on admission but continues to serve residents as their needs increase. Acuity levels rise over time. The third model would admit residents with low to moderate needs and maintain policies that discharge residents as their needs increase regardless of the level of care allowed by the licensing regulations.
The essence of the debate is what is the right place for mom and dad. Panelists at ALFA suggest that assisted living is all someone needs and it is about resident choice, So if a resident can afford an R.N, to come in and provide skilled nursing services they should have the choice to do so. And if the resident is in the last stages of life then they should be able to have hospice to the very end in the assisted living facility.
Nursing homes would argue that there is a level of care that only they can provide,
Then it becomes a finger pointing exercise. The AL industry would say that nursing homes have the lobbyists and legislators in their pocket. State regulations favor nursing homes. And so on.
So part of this concerns the roadblocks to bringing in more services to assisted living, "enhanced" assisted living they call it.
This of course is a siloed discussion. We should be talking about what is right for a person. As a boomer, I believe that I will be able to age in my home. That I will retrofit it for safety and then the technology will progress so that I am monitored. I also believe I have some responsibility to keep myself healthy in mind, body, and spirit to the best of my ability. That I need to develop and nurture friendships and a support community. So in essence, I and my boomer neighbors will develop a NORC, a Naturally Occurring Retirement Community.
Supported by adult day, transport options, home health, PACE programs and medical homes, hopefully, I never have to set foot in a facility.
I am not naive. There will be people who simply cannot live alone and may willingly choose assisted living if they can afford it (let's not go there). So there is a place for assisted living and nursing homes and CCRC'S.
But consider a study published this week. The Journal of the American Geriatrics Society reveals that many older adults with dementia live and die in community settings rather than nursing homes. The researchers found that individuals with dementia go back and forth between care settings. The researchers also determined that a majority of care for those with dementia, even advanced dementia, is provided in the community by families. While it did not mention assisted living, it was alluded to in the words "care settings." Still, look at the final conclusion. Rightly or wrongly, appropriately or not, people are aging in THEIR place.
If we treat each care option as a separate entity, we miss the point that we all should be working together for the benefit of the person. And from the study above families need help.
When Highmark Blue Cross of Pennsylvania bought a hospital, I secretly applauded. Insurers have the best statistics about the health of the patient and they know what has to be done to keep someone well and out of the hospital. They can accomplish two goals - operational efficiencies and profits while keeping the population healthy. I believe Medicare Advantage programs operate around a similar philosophy. And as I write this, Aetna just announced it was forming a national accountable care organization (ACO).
For Highmark to have made that move they had to break out of a silo and a comfort zone. So at the very least the nursing home industry and the assisted living industry need to talk to each other. To really break this wide open, they need to blow up the model. Because while a good first step is to see how you mix acute populations and care for them together, the leap comes when you vertically expand the business model. You have to go deep vertically.
One of the first people I met at the conference works for a hospital that owns nursing and assisted living and home health and hospice.
And that is good. Still, the consumer is the ultimate decision maker. The leaders in the industry ten years from now will figure out how to move everything into the community. Just as hospital inpatient procedures and beds have shrunk, so too will the inventory of assisted living and nursing homes. The Greatest Generation may still follow old models of care. Boomers will not. And surprisingly since many of the attendees at ALFA are boomers themselves, they should be able to switch their perspectives to "what if this was me?" and make more strategic decisions on where to steer their organizations. Silo thinking and finger pointing are not solutions.
Perhaps this me versus them tone was one I chose to pick up on. It frankly rubbed me the wrong way on the first day. But it was by no means representative of the overall tone of the conference, where best practices in assisted living were testaments to the deep care people have for residents and the leading edge practices they bring to care. And providers across the continuum can learn much from their assisted living colleagues.
Learn more ~ or join the conversation!
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@ALFA
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