American Assisted Living Nurses AssociationOFFICIAL SECTION OF THE OFFICIAL SECTION OF THE

American Assisted Living Nurses Association

A Clearer National Picture ofAssisted LivingJosh Allen, RN, C-AL

Chair, American Assisted Living NursesAssociation

Assisted living has evolved as both a care settingand a philosophical movement over the pastseveral decades in the United States, growingout of the residential “board and care” modeland a desire for a more homelike and person-centered environment than was offered byskilled nursing facilities. As the evolution andmaturation of assisted living has unfolded, pro-viders, advocates, professionals, and thosestudying the industry have often been facedwith a lack of reliable national data other thenthe information collected through industrytrade association membership surveys and thelike.1 In recent years, we have seen a notableshift in the availability research and data tar-geted at assisted living as academic and govern-mental agencies have become increasinglyaware of the important role this setting playsin meeting the needs of the growing populationof older adults in the United States.

A significant recent contribution to this grow-ing body of research is the 2010 National Surveyof Residential Care Facilities (NSRCF). Thisfirst-ever national data collection effort collectedinformation about the characteristics of residen-tial care facilities across the country, includingassisted living communities and board and carehomes. The data collected paint a clearer pictureof assisted living from a national perspective, in-cluding the number of communities, the numberof residents being served, the types of servicesbeing offered, and the usage of Medicaid to coverthe costs of assisted living.

The Survey Process

NSRCFcollecteddataon2302 facilities and8094current residents. The survey was conducted be-tween March and November 2010 by the CentersforDiseaseControl andPrevention’sNationalCen-ter for Health Statistics in partnership with several

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other offices and agencies within the US Depart-ment for Health and Human Services.2

After being refined through a pilot study andpretest, the survey was conducted using in-person interviews with facility directors anddesignated staff. Residents were not interviewedas part of the survey; rather, resident data werecollected from the director and staff interviews.

Who Was Surveyed?

Oneof the challengeswhen researching assistedliving is the wide range of terms and definitionsused to describe the setting. Fortunately, the Na-tional Center for Health Statistics (NCHS) wascareful to develop criteria that would include thespectrum of what constitutes “assisted living”across the country, including small, medium, andlarge providers. Specifically the criteria stated that

To be eligible for this study, residential care facil-ities are places that are: licensed, registered,listed, certified, or otherwise regulated by thestate; have fourormore licensed, certified, or reg-istered beds; provide roomandboardwith at leasttwomeals a day and around-the-clock on-site su-pervision; and help with personal care such asbathing and dressing or health-related servicessuch asmedicationmanagement. These facilitiesserve a predominantly adult population. Facili-ties licensed to serve the severely mentally illor the developmentally disabled populations ex-clusively, and facilities that do not have any cur-rent residents, are excluded. Nursing homes arealso excluded unless they have a unit or wingmeeting the above definition and residents canbe separately enumerated.2

Normally I prefer to use the term “community”when referring to an assisted living setting, butfor the purpose of clarity and to be consistentwith the NSRCF terminology the term “facility,”is used in this article.

Findings

As of this writing, the NCHS has released a databrief summarizing preliminary findings focusedprimarily on facility data, as well as public-use

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data files. Both of these resources as well as addi-tional anticipated data briefs can be accessed atwww.cdc.gov/nchs/nsrcf.htm. Following are keyfindings as summarized in the NCHS data brief.3

� In 2010, residential care facilities (RCFs) num-bered 31,100, and provided 971,900 beds.

� Approximately one-half of RCFs were small fa-cilities with 4 to 10 beds (50%). The rest weremedium facilitieswith 11 to 25beds (16%), largefacilities with 26 to 100 beds (28%), and extralarge facilities with more than 100 beds (7%).

� When the number of residents that RCFs wereserving at the time of interview was comparedby facility size, small facilities were found toserve 10% of all residents in RCFs and mediumfacilities served 9% of residents, whereas largeRCFs served 52% of all residents in RCFs andextra large RCFs served 29%.

� Ownership type, chain affiliation, and geo-graphic location of RCFs varied by facility size.

� Approximately 82% of RCFs were private, for-profit facilities, and the remaining 18% wereprivate, nonprofit facilities or were owned bystate, city, or local government (data notshown). Small RCFs were more likely to befor profit (91%) than larger RCFs.

� Approximately 38% of RCFs were chain affili-ated. As facility size increased, the proportionof chain-affiliated facilities grew: extra largeRCFs, for example, were almost 3 times aslikely (65%) as small RCFs (23%) to be ownedby a chain, group, or multifacility system.

� Small (89%) and extra large (93%) RCFs weremost likely to be in a metropolitan statisticalarea (MSA), whereas medium RCFs were leastlikely to be in an MSA (65%).

� Approximately 4 in 10 RCFs served residentswho were receiving long-term care (LTC) ser-vices paid by Medicaid.

� Overall, 43% of RCFs had at least 1 residentwho had some or all of his or her LTC servicespaid by Medicaid.

� Similar proportions of small (45%) and large(40%) RCFs served residents who were receiv-ing LTC services paid by Medicaid.

� Extra large RCFs were least likely (32%) toserve residents whose LTC services werepaid by Medicaid.

� The types of services offered at RCFs varied byfacility size.

� Nearly all RCFs provided basic health monitor-ing (96%), incontinence care (93%), social and

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recreational activities within the facility(99%), special diets (93%), and personal laun-dry services (99%).

� The provision of occupational and physicaltherapy increased with size of facility, whereasthe provision of skilled nursing services did notvary by facility size (38%e40%).

� Small RCFs were less likely to provide socialservices counseling (24%) and case manage-ment (51%) than larger RCFs. Medium RCFswere also less likely to provide case manage-ment (57%) than larger RCFs.

� Extra largeRCFsweremost likely (91%) andme-diumRCFswere least likely (73%) to offer trans-portation to medical or dental appointments.

Several of these key findings are of particularnote, including the large percentage of “small” fa-cilities, the use ofMedicaid that ismore extensivethan many industry observers previously as-sumed, and the relatively low reported provisionof nursing services. Forthcoming data briefs onresident characteristics and a more thoroughevaluation of the public-use data files may lendgreater insight into these areas of note.

The NSRCF was a one-time data collection ef-fort, but fortunately the NCHS has reported thatgoing forward assisted living as well as nursinghomes and home care, and hospice will be in-cluded in a survey of LTC conducted every otheryear. Currently titled the National Study of LongTerm Care Providers, the survey is intended to“enable efficient and timely monitoring of the di-verse and evolving field of LTC and to help ad-dress the nation’s information needs to informfuture LTC policy.”4

About AALNA

The American Assisted Living Nurses Associa-tion is the only national nonprofit associationdedicated exclusively to nursing in assisted liv-ing. Operated by nurses, for nurses, the missionof AALNA is to promote effective nursing prac-tices in assisted living such that nurses as wellas residents benefit. Learn more about AALNAat www.alnursing.org.

References

1. Spillman BC, Black KJ. The size of the long-term care

population in residential care: A review of estimates and

Geriatric Nursing, Volume 33, Number 3

methodology. Prepared for US Department of Health and

Human Services, Assistant Secretary for Planning and

Evaluation, Office of Disability, Aging, and Long-Term

Care Policy. Washington, DC: Urban Institute; 2005.

2. Moss AJ, Harris-Kojetin LD, Sengupta M, et al. Design and

operation of the 2010 National Survey of Residential Care

Facilities. Vital Health Stat 1(54). Washington, DC:

National Center for Health Statistics; 2011.

3. Park-Lee E, Caffrey C, Sengupta M, et al. Residential care

facilities: a key sector in the spectrum of long-term care

providers in the United States.

4. National Study of Long-Term Care Providers.

National Center for Health Statistics. Available at

Geriatric Nursing, Volume 33, Number 3

http://www.cdc.gov/nchs/nsltcp.htm. Cited on March

28, 2012.

JOSH ALLEN, RN, C-AL, is a Registered Nurse with more

than 20 years of experience in assisted living and residen-

tial care. Josh is the Board Chair of the American Assisted

Living Nurses Association, Napa, CA, and represents

AALNA as the Chairperson of the Center for Excellence in

Assisted Living.

0197-4572/$ - see front matter

� 2012 Published by Mosby, Inc.

doi:10.1016/j.gerinurse.2012.03.011

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