Assisted living facilities (ALFs) are non-medical care facilities also referred to as residential care communities, “board and care,” or congregate living (FLAHCA, n.d.). They provide full-time living arrangements in the least restrictive and most home-like setting. These types of facilities can be broadly described as offering non-institutional residential care as opposed to the institutional care provided by nursing homes (Toth et al., 2020). The assisted living market size in the United States is valued at more than $80 billion (GVR, 2021).
Facilities can range in size from one resident to several hundred (FLAHCA, n.d.). Nationwide, residential care communities range in capacity from 4 to 518 licensed beds, with an average of 35 licensed beds. More than 80% are for-profit facilities, the majority chain-affiliated (Harris-Kojetin et al., 2019). They typically serve people who need help with daily activities and some healthcare services but do not need around-the-clock skilled nursing services.
Residents of assisted living facilities usually live in their own apartments or rooms and share common areas. They have access to services, including up to three meals a day; assistance with personal care; help with medications, housekeeping, and laundry; 24-hour supervision, security, and on-site staff; and social and recreational activities (NIA, 2017, May 1).
An assisted living facility can be an attractive alternative to skilled nursing—especially when people are still largely independent. However, this segment of older adult care has grown so rapidly and with so little oversight that people who need more care than an assisted living facility can provide must either pay for additional services or go without.
A steady decline of the number of people moving into institutional care facilities and instead moving to some sort of assisted living is due to at least three factors: (1) the high costs of residing in a nursing facility, (2) state Medicaid programs enacting policies to shift long-term care services away from the nursing facilities to the community, and (3) people’s desire to stay in their own homes (Toth et al., 2020).
A caregiver and older woman in an assisted living facility. Source: NIA/NIH.
Most assisted living facilities are not required to have nurses, nursing assistants, or doctors on staff but are required to be licensed by the state. Typically, a few “levels of care” are offered, with residents paying more for higher levels (NIA, 2017, May 1).
Non-institutional residential care facilities are rapidly becoming a source of care for older adults with Alzheimer’s disease and other dementias. On any given day in 2016 (latest available), more than 800,000 residents lived in nearly 30,000 residential care communities throughout the United States. Nationally, more than 40% of residential care residents were diagnosed with dementia (Sengupta & Caffrey, 2020).
Residential care communities are increasingly serving residents with other complex needs. In 2016 (latest available), approximately 30% of residents had depression, 35% had heart disease, and 18% had diabetes. While all residents in residential care communities may need services and supports, residents with dementia have a greater need for mental health services (Sengupta & Caffrey, 2020). In terms of activities of daily living, more than half of residents in assisted living facilities need help with bathing, walking, and dressing, while nearly half require help with toileting (NCAL, 2016).
Since its inception, assisted living ideally has emphasized consumer dignity, autonomy, and choice as well as privacy and a homelike environment. However, the assisted living landscape is rapidly changing; these settings increasingly house residents who have aged in place in assisted living or who had entered with a higher acuity level. Today, assisted living residents are older, require more care, and may resemble nursing homes residents in acuity (Kelly et al., 2018).
In Florida there are approximately three thousand assisted living facilities and about half of the residents are over the age of 85 (FLAHCA, 2020, December 1). Four types of assisted living licenses are available from the state (standard, extended congregate care, limited nursing services, and limited mental health). A facility must have a standard assisted living facility license to operate in Florida. The other three licenses can be added if the facility wishes to provide services designated outside the spectrum of a standard assisted living facility license (FLAHCA, n.d.). Care facilities are grouped as follows:
- ALFs (residential facilities that provide direct physical assistance with or the supervision of the activities of daily living, medications, and other similar services) overall house ~110,000 Florida residents. From https://www.floridahealthfinder.gov/reports-guides/assisted-living.aspx.
- ALFs with ECC (extended congregate care) house ~20,000 Florida residents.
- ALFs with LMH (limited mental health) house ~12,000 Florida residents.
- ALFs with LNS (limited nursing services) house ~35,000 Florida residents. (FLAHCA 2020, December 1)
In general, for admission to an ALF, a resident must be an adult, be capable of performing day-to-day living activities with supervision or assistance, not require 24-hour nursing supervision, be free of stage II, III, or IV pressure sores, be able to participate in most social and leisure activities, be ambulatory, not display violent behavior, and be able to take their own medication, with assistance of staff if necessary. An ALF can accommodate special dietary needs and provide mobility services. A resident may be discharged if he or she is no longer able to meet these criteria or is bedridden for more than seven days (FLDOEA, 2016).
COVID-19 and Assisted Living
Given their congregate nature and population served, assisted living facilities are at high risk for the spread of COVID-19 and other infectious diseases among their residents. Older adults with underlying medical conditions are at increased risk for severe illness. Experience with outbreaks in nursing homes has demonstrated that residents with COVID-19 may not report common symptoms such as fever or respiratory symptoms; some may not report any symptoms (CDC, 2020, May 9).
Additionally, older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms and may instead experience less-common symptoms such as new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Identification of symptoms consistent with COVID-19 should prompt isolation and further evaluation for COVID-19. Unrecognized asymptomatic and pre-symptomatic infections can contribute to transmission in these settings (CDC, 2020, May 9).