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National Assisted Living Quality of Life Study – Phase I: “Who’s Living Where…And Why It Matters”

Andrew Carle, MHSA Executive-in-Residence/Director George Mason University – Program in Senior Housing Administration

#ALFA2014

Overview: Part I: George Mason University

– Department of Health Administration & Policy – Program in Senior Housing Administration

Part II: AL “Quality of Life” Study

Part III: Strategic Need

Part IV: Study Design/Key Findings

Part V: Implications/Next Steps

I. GMU/Dept. Health Admin & Policy George Mason University: • Largest university in VA

• 33,000+ Students • Nationally Ranked

• USN&WR: “#1 School to Watch” (2010 & 12)

• Princeton Review: #1 Diversity • $130M Research

Department of Health Administration & Policy: • College of Health and Human Services (3,100 students) •“Top 20” Graduate Programs in Health Administration (2014)

• Nationally Recognized Faculty

• Health Policy/Medicare/ACA

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Program in Senior Housing Administration:

First academic program dedicated exclusively to Senior Housing Administration (2001):

Undergraduate: • Bachelor of Science Health

Administration - Concentration in Senior Housing Admin (BS-SHA)

Graduate: • MHA/Graduate Certificate SHA • “Executive Seminars”

http://seniorhousing.gmu.edu

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Part II: National Assisted Living “Quality of Life” Study

Objectives:

Phase I: • Identify and measure key

“Quality of Life” (QOL) indicators for a “typical” AL resident

Phase II: • Compare to “Peer Acuity

Seniors” living at home

Hypothesis:

AL residents will have better QOL indicators than “peer acuity seniors” living at home, with either no or limited assistance:

• Hospitalizations • Re-hospitalizations

• Falls/Injuries • Medication Errors • ADL/IADL Compliance • Cognition/Depression • Nutrition

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Part III: Strategic Needs (4)

1. Consumers (Media) & Regulators:

• Industry has relied on anecdotal evidence of “quality” to defend itself

• Need to move from 31,000 individual communities to “Senior Housing Industry” providing proactive, tangible, measurable benefits to aging populations

From “Youth” to “Adult” stage in Product Life Cycle

2. Accountable Care Organizations (ACO’s):

• Ability to document cost savings in health care system

• Today: • Re-hospitalizations

• Tomorrow: • Hospitalizations

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Strategic Needs…

4. LTC Insurance: • Growing industry requiring documented contribution of covered products and services:

– Future version of CLASS Act may offer additional opportunities

3. Medicaid: • Home and Community Based Services (HCBS) initiatives only compare “living at home” services vs. skilled nursing care

• Potential to document value of AL services as a primary component of HCBS, vs. “living at home”

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Part IV: Study Design/Findings

Data Resource:

National Survey of Residential Care Facilities (NSRCF): • 8,094 Residents; 2,302 Communities

• Included group homes and communities of 4+ beds, but excluded those serving only adults with severe mental illness or developmental disabilities

• Facilities Data Brief • December 2011 • Size, Ownership, Multi-facility

• Residents Data Brief • March 2012 • Demographics, Health Status,

Physical Functioning 8

Study Phases: Phase I: Secondary Data Analysis

Key Objectives: 1. Examine characteristics of residents in NSRCF dataset

Q: What represents a “typical” assisted living resident?

2. Identify statistically significant differences among AL residents and/or AL communities I.e. “Peer” group by resident and community type

Timeline: • Oct. 2012 to Jan. 2014

Phase II: Survey Design, Data Analysis, Synthesis

Key Objectives: 1. Identify and recruit sample population of at-home “Peer Acuity Seniors”

2. Conduct data collection, analysis; synthesize, disseminate findings

Estimated Timeline: • June 2014 to May 2016

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Key Issue – Phase I: What represents a “typical” AL resident?

1. Are NSRCF residents statistically similar for ALL characteristics across ALL types of communities?

i.e. “Homogenous” • Residents in all

communities are essentially the “same”

2. Are NSRCF residents statistically DIFFERENT in characteristics (resident mix), but equally distributed across ALL types of communities?

• Ex: The mix of Non-MC vs. MC residents is essentially the same in all communities

3. Are NSCRF residents significantly different in BOTH resident mix and type of communities? • If so, what represents the

“majority”?

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Principle NSRCF Data Categories Researched:

• Resident Demographics

• Resident Health Status/Acuity

• Resident “Risk” Factors

Sunrise Senior Living - Fair Oaks, VA

NSRCF Community Characteristics: • Small Communities 4-10 Beds (50% communities/10% residents)

• Medium 11-25 Beds (16% communities/9% residents)

• Large/X-Large 26–100+ Beds (35% communities, 81% residents)

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Overall Findings: Demographics The majority of AL residents are 85+ years old, female, Caucasian, widowed, and have lived in the community for 1-3 years. They moved into the community from a private “home”, and are non-Medicaid/private pay.

Characteristic Percent Age 85+ 54% Female 70% Caucasian 91% Widowed 62% Previous Residence: Private Home 74% Non-Medicaid/Private Pay 80%

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Overall Findings: Health/Acuity The majority of AL residents have multiple chronic conditions, with hypertension, Alzheimer’s/dementia, and CHF as the top 3 conditions. They require an equal amount of assistance with either 1-2 or 3-5 ADLs. A minority of residents have a development disability or severe mental illness (SMI).

Characteristic Percent

Multiple Chronic Conditions (2-10) 76%

- Hypertension 57%

- Alzheimer’s/Dementia 42%

- Congestive Heart Failure (CHF) 34%

1-2/3-5 ADL Limitations 37%/37%

Developmental Disability 3%

Severe Mental Illness (e.g. Schizophrenia) 8% 13

Overall Findings: Risk

A minority of AL residents are reported to have fallen (with injury), visited an emergency room, or been hospitalized overnight, during the past year.

Characteristic Percent

Falls with Injury 15%

ER Visit 35%

Overnight Hospitalization

24%

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Findings of Interest (1): Residents of large communities were more likely to be age 85+. Residents of small communities were nearly three times more likely to be age 65 or younger and non-Caucasian, and two times more likely to utilize Medicaid.

Characteristic

Small (4-10)

Medium (11-25)

Large (26+)

Less than 65 23% 21% 8%

85+ 43% 45% 56%

Non-Caucasian 21% 12% 7%

Medicaid 32% 31% 16%

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Findings of Interest (2): Larger communities had significantly more residents with 2-3 chronic conditions, including CHF, Hypertension, and Osteoporosis. They were more likely to have a reported incident of either a fall with injury or ER visit during the past year.

Characteristic Small (4-10) Medium (11-25) Large (26+)

2-3 Chronic Conditions

44% 46% 52%

- CHF 25% 30% 36% - Hypertension 50% 54% 58%

- Osteoporosis 15% 18% 21%

Fall with Injury 9% 14% 16% ER Visit 28% 33% 36%

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Findings of Interest (3): Small/medium communities had more residents with 3-5 ADL limitations, developmental disabilities, SMI, Alzheimer’s, or depression. On a percentage basis, small communities had five times more residents with a developmental disability than large communities, and 1.3 times as many with Alzheimer’s Disease.

Characteristic Small (4-10) Medium (11-25) Large (26+) 3-5 ADL’s 62% 37% 34%

Dev. Disabled 10% 7% 2%

Severe Mental Ill 13% 15% 6%

AD/dementia 53% 40% 41%

Depression 36% 31% 26%

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Findings of Interest (4): Smaller communities were more likely to have residents who “often/sometimes” exhibited difficult behaviors, including creating disturbances, being verbally threatening, physically aggressive, or removing their clothes. They were more likely to require medications to control behavior.

Characteristic Small (4-10) Medium (11-25) Large (26+)

Create Disturbance 26% 19% 14%

Verbally Threatening 14% 12% 10%

Physically Aggressive 13% 10% 7%

Removed Clothing 7% 4% 3%

Requires Medication(s) to Control Behavior

35% 26% 19% 19

Part V: Phase I Implications/Next Steps • Communities of different sizes are serving different

populations, yet are often viewed in the aggregate as “assisted living” by consumers, media, and policy makers • Should there be multiple and clearly defined licensing

categories? “Specialty” vs. “Senior”?

• Is the “split” small community mix of younger residents with DD/SMI, in combination with older residents with Alzheimer’s/dementia, appropriate? • Are these “Memory Care only”

communities? • “Co-housed” residents?

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Next Steps - Phase II:

How do we identify “peer acuity” seniors living at home, in order to compare to the “typical” assisted living resident?

- Via public solicitation? - Via government agency (Ex: Area Agency on Aging)? - Via “lost leads” (clinically/financially appropriate but did not

move-in)?

To which measures do we compare?

- One year forward? - One year back?

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Is assisted living improving “quality of life”? Better than alternatives?

THE TIME TO ANSWER THESE QUESTIONS HAS ARRIVED.

Publication:

“Resident Characteristics and Chronic Health Conditions”. 2014 Seniors Housing & Care Journal (October)

Thank You!=========

Andrew Carle, Executive-in-Residence George Mason University Program in Senior Housing Administration (E) acarle@gmu.edu (P) 703-993-9131 (W) http://seniorhousing.gmu.edu

#ALFA2014