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

American Assisted Living Nurses Association

Higher Acuity in Assisted Living isHere to StayJosh Allen, RN

American Assisted Living Nurses AssociationBoard Member

For as long as assisted living has existed in thelong-term care continuum, so, too, has the na-tional debate over resident acuity in thisresidential-based care setting. What type of resi-dent is appropriate for assisted living? How cannursing services be safely provided and coordi-nated? How much is too much? Providers, resi-dent advocates, regulators, and health careprofessionals have been asking these and otherquestions regarding resident acuity for years.Although the questions are valid and deserve an-swers, this assisted living nurse would argue thatthe debate today is not as much about how far topush acuity; rather, the better question is how canwe most effectively manage acuity?

Assisted living communities (and residentialcare homes) typically provide the least restric-tive, most cost-effective, andmost homelike envi-ronment for older adults who require care,services, and supervision beyond that whichcan be affordably provided in the home. Forthis reason assisted living has quickly becomethe preferred long-term care environment for el-der adults and their families, frequently chosenover more costly and institutionalized settingssuch as nursing homes. As residents have contin-ued to choose assisted living to meet theirlong-term care needs, the demand to meet higheracuity has grown:

� It is estimated that up to half of assisted livingresidents have some type of mild to moderatedementia.1

� Assisted living residents take on average 9medications per day.2

� Eighty-one percent of assisted living residents re-quire assistance with medication management.3

� Sixty-four percent depend on assistance withbathing.3

Rather than continue the worn-out debate overwhether higher acuity residents should be livingin assisted living communities, this article fo-cuses on strategies that can help assisted living

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nurses safely and effectively meet the needs ofthis challenging resident population.

Acceptance Is the First Step

The first step in effectively managing higheracuity is to accept that it is a part of assisted liv-ing. This doesn’t mean that nurses should simplyaccept any and every resident into their commu-nities. What it means is rather than fight acuityat every step, evaluate each resident and situa-tion individually. Work with the care team to de-velop a service plan with effective strategiesdesigned to meet the needs of the resident withinthe constraints of the community.

The key point here is to accept that higher acu-ity is here to stay. If nurses think that taking a jobin assisted living will allow them to relax and takeit easy without having to use the full extent oftheir knowledge and skills, they are incorrect. As-sisted living practice demands a nurse that cancreatively meet high-acuity needs with a some-times overwhelming level of autonomy.

Let the Regulations Be Your Guide

Assisted living is regulated at the state level (al-though some federal provisions, such as OSHA,do apply). For this reason, nurses must have a de-tailed working knowledge of the requirementsoutlined in their state’s assisted living codes,rules, and regulations. Every state handles assis-ted living differently, particularly when itcomes to the acuity issue. In some states, suchas California, there are detailed lists of prohibitedconditions spelled out in the regulations. In otherstates, such as Oregon and Washington, nursedelegation is used to address acuity on a resi-dent-by-resident and community-by-communitybasis.

Before attempting to decide “who can stay andwho must go,” a thorough review of state regula-tions must occur. These guidelines will form thebasis for acuity-based admission and retentiondeterminations. If, for example, Stage 3 and 4pressure ulcers are prohibited in assisted livingin your state, a resident with this condition couldnot legally be retained in the community.

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However, many states also have waiver or ex-ception processes that can complicate under-standing the true acuity limitations. Although onthe surface a particular condition or health careservice may be prohibited, if the regulations al-low for exceptions, it may still be possible to re-tain the resident. Hospice care is a commonexample. In many states, a resident who is receiv-ing care from a licensed hospice agency can re-main in the community while receiving fairlyadvanced care.

If You’ve Seen One Assisted LivingCommunity.

“If you’ve seen one assisted living community,you’ve seen one assisted living community.” Thisoft-used adage describes the realitydand one ofthe truly distinguishing characteristicsdofassisted living: every community isdifferentddifferent in terms of physical design,staff qualifications, activity programming, andresident acuity mix. Some assisted living commu-nities are designed to care for relatively high-functioning residents who require only minimalassistance with activities of daily living. At theother end of the spectrum are communities car-ing for heavily dependent residents with moder-ate to advanced dementia.

While regulations may create a ceiling on acu-ity levels, it is also up to providers to decidehow the organization will address acuity andthe level of service that they are willing andable to provide. This discussion and planningshould drive the development of organizationalpolicies and procedures that are designed to pro-vide the level of service to which the provider iscommitting.

Providers and nurses, however, must realizethat this is an ongoing and fluid process. Althoughit may be the original intention of a community tolimit acuity levels, as time goes by and residents“age in place,” it may be necessary to adapt toan aging resident population by providing addi-tional resources and services.

Is Everyone on the Same Page?

Perhaps one of the most important parts ofmanaging high acuity is open communication be-tween providers, residents, family, and otherstakeholders. Misunderstandings about what

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a community can or will do for a resident canlead to dissatisfaction and possible litigation.Clear disclosure by providers regarding the ser-vices available, pricing information, admissionand discharge criteria, and staffing informationcan help residents and their families make in-formed decisions before moving into a commu-nity and hopefully help them understand howthe community will respond when their conditionchanges.

As an example, if a resident’s diabetes worsensand he or she requires insulin injections, it is im-portant that the individual know in advance thatthe community does not have nurses on staff onthe weekends. Therefore, the resident will be re-quired to pay for additional nursing services toprovide the injections.

Negotiated risk agreements can take disclo-sure to the next level. Fifteen states and the Dis-trict of Columbia include some provision fornegotiated risk agreements in their assisted livingregulations.4 An appropriately implemented ne-gotiated risk process clearly articulates the resi-dent’s expectations as well as the capabilitiesand limitations of the community. Furthermore,it identifies the potential harm to the residentfrom refusal or noncompliance. Negotiated riskagreements can be a useful tool in addressing res-ident and family expectations and managing acu-ity, but there are legal limitations in how wellthey can protect providers. It is important to re-view both state regulations and organizationalpolicies before implementing negotiated risk.

Now Comes the Hard Part

Staffing is without question the most challeng-ing aspect of providing care and services to higheracuity residents. Staff must be sufficient in bothnumber and qualifications to provide the level ofcare and services to which the provider has com-mitted, and unfortunately there are no shortcutsto good staffing. There must be enough of staffmembers on hand, and they must have a sufficientlevel of skill and competency to meet the needsand expectations of your residents.

There are creative approaches to staffing thatcan help to lessen the financial burden on the orga-nization and subsequently the resident. For exam-ple, research from the Center for Excellence inAssisted Living and the University of North Caro-lina at Chapel Hill has shown that medication

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aides and technicians did not have a higher rate ofmedication errors with a moderate to significantpotential to cause harm than nurses.5 Additionally,many providers use less expensive dedicated foodservice staff to serve meals, rather than expectingcaregivers to act as “universal workers” who mustprovide all aspects of care and service.

Summary

Higher acuity is here to stay in assisted living.Consumers do not want to “transfer” to other an-other setting once they have made an assisted liv-ing community their home. It is the responsibilityof regulators, providers, advocates, and nurses towork together to continue to adapt the assisted liv-ing model of care to meet the needs and expecta-tions of an increasingly acute resident population.

References

1. Assisted Living Federation of America. The acuity

question. Available at www.ahcancal.org/ncal/resources/

Pages/ResidentProfile.aspx. Cited November 21, 2010.

2. Center for Excellence in Assisted Living. Medication

management in assisted living. 2008. Available at www.

theceal.org/reports.php. Cited November 21, 2010.

3. National Center for Assisted Living. Resident

profile. Available at www.ahcancal.org/ncal/

resources/Pages/ResidentProfile.aspx. Cited November

21, 2010.

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4. Meng MA. Negotiated risk agreements: protecting

autonomy, avoiding risk. Assisted Living Executive. 2007,

September. Available at alfa/alfa/Compliance_

Corner_5.asp?SnID538977559#introduction. Cited

November 21, 2010.

5. Center for Excellence in Assisted Living and the

University of North Carolina at Chapel Hill. Research

brief: medication administration in assisted living. 2009.

Available at www.theceal.org/reports.php. Cited

November 21, 2010.

About AALNA

The American Assisted Living Nurses Associa-tion is the only national nonprofit associationdedicated exclusively to nursing in assisted liv-ing. It is operated by nurses, for nurses. The mis-sion of AALNA is to promote effective nursingpractices in assisted living such that nurses aswell as residents benefit. Learn more aboutAALNA at www.alnursing.org.

JOSH ALLEN, RN is a registered nurse with more than 17

years of experience in assisted living and residential care.

He is the Executive Director of the American Assisted Living

Nurses Association.

0197-4572/$ - see front matter

� 2011 Published by Mosby, Inc.

doi:10.1016/j.gerinurse.2010.12.007

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