Chances are at some point in your life you have been turned off by a discourteous hotel receptionist, an indifferent server at a restaurant, or a poorly trained salesperson at a clothing store. As a result, we might complain to our friends or on social media – or possibly notify the management of our bad experience. We may take our business to competitors with the expectation of receiving better service. However, we would rarely indict all hotels, restaurants, and clothing stores as deficient and needing reform as a result.
Why am I even talking about this?
Recently, there was an editorial in the New York Times (NYT) in which the author, Geeta Anand, dismisses assisted living as a viable long-term care alternative.
As I read the article, I found the author’s arguments lacking and plagued with many exaggerations and distortions that I think marginalized the effectiveness of her piece. I believe her critique of the industry relied on a few highly selective and negative anecdotal examples that didn’t even reference any first-person experiences. Importantly, I think it also missed the opportunity to share some alternative conclusions that a great deal of actual research shows.
The author’s premise is that “the dream that we can grow old while being self-reliant and live that way until we die” is a lie foisted on American elders by a financially motivated assisted living industry. Most older persons disagree and believe that their quest for self-reliance is achievable. However, they sometimes recognize that staying put or aging in place in their current homes is not a pathway to their achieving independence because both residential upkeep and self-care become too challenging.
But they are also not interested in succumbing to nursing home occupancy and losing their self-dignity and their ability to control how they live. For these folks, assisted living residences offer a promising alternative where they benefit from a safe living environment, offering supportive services and care, yet in an autonomous home-like place where they have stimulating and enjoyable social, educational, and recreational opportunities.
So yes, assisted living providers financially have benefited from an aging population of seniors, but it was because they offered this older demographic a way for them to cope with both their housing and care needs. And the emergence of this long-term care option in the 1980s and its steady growth thereafter help explain why nursing home occupancy rates (at least in the U.S.) are down rather than up, even with the explosive growth of the age 75 plus population.
The Assisted Living Alternative Comes in All Shapes and Sizes
Perhaps surprisingly, talking about assisted living is not straightforward because these housing-care options do not look or operate the same. They also have different names—such as personal care homes, board and care, supportive housing, and residential care.
These places can range from small mom and pop board and care residences in large older houses that accommodate less than 5 residents to corporate-owned and operated modern buildings that accommodate over 250 older residents. Assisted living residences can be in freestanding buildings but also share space with memory care centers and nursing homes located in the same building or on a campus setting. Some are physically beautiful and well-appointed, and others are simply plain and minimal. As I have said before, “If you have seen one assisted living residence, you have seen one assisted living residence.” Unfortunately, in this NYT editorial, all assisted living residences were pigeonholed into a single and uncomplimentary category.
In an attempt at clarification, Dr. Joan Hyde (U. Mass. professor and assisted living CEO) and myself referred to the U.S. assisted living option in this way:
“A group-oriented residential care setting not licensed as a nursing home that provides on both a scheduled and an unscheduled basis the housekeeping, meals, personal assistance, medication management, and health/nursing-related services required by older persons who have experienced physical and/or cognitive health declines.”
The Author’s Depiction Distorts
I think that the NYT editorial does a good job confusing its readers. The author argues that assisted living is appropriate for older people who “don’t need much assistance” but in fact the evidence says otherwise.
The majority of assisted living occupants need at least some help with everyday activities.
Walking, bathing, eating, toileting, dressing, and/or getting in and out of a bed or a chair are just some examples. Most assisted living residences provide oversight and cueing of medications. Indeed, these are the very reasons why they move into assisted living in the first place.
As well, over 4 out of 10 (40%) display symptoms of Alzheimer’s disease or other forms of dementia, while another 30% have less serious cognitive/memory impairments, although no immediate diagnosis of dementia. The majority has one or more chronic health conditions, such as arthritis, hypertension, Parkinson’s, or other debilitating conditions that require monitoring and medication.
In addition to misreading the need for assisted living, the author also criticizes assisted living residences because “they put their money into the physical plant” making them “gorgeous.” While this may be true, she implies that aesthetics are a bad thing. She is apparently unaware that physical design is far more than just appearances. The architectural and design features of residential care accommodations have been shown to contribute significantly to the residents’ positive outlook on life and an active lifestyle. Just as importantly, careful design can minimize falls and encourage social interaction.
This is not to say that physical design is more important than the services offered by assisted living. According to Laurence J. Pino, Esq., CEO of Tuscan Gardens Senior Living Communities in Florida and author of Reinventing Senior Living: “Every senior living provider knows that while the appearance of our buildings attracts residents, it’s the quality of care which keeps them.”
This may be news to the NYT author who is convinced that assisted living residences offer their older residents only “minimal help.” In practice, this option provides far more assistance than what the senior living industry refers to as “independent living,” which primarily offers access to meals and recreation.
In the U.S., a national study reported that virtually all assisted living residences help older persons with their unmet personal care needs (e.g., bathing, dressing, walking, and toileting). They also offer therapeutic services like speech, physical, and occupational therapy, pharmacy services, medication management, counseling, and yes, nursing services when appropriate and permitted by state law — but on an intermittent basis — rather than the 24-7 skilled service regimens of nursing homes. Many assisted living residences also offer different levels of personal care in recognition that some older occupants have more severe limitations and health issues than others. Once again, we must be careful about generalizing — not all assisted living residences offer these services — older consumers and their family members must consider their options carefully.
Where I do agree with the author is that these services, along with housekeeping, meals, recreation, social activities, transportation, and an attractive ambiance — don’t come cheap.
In 2018, the average monthly cost of assisted living in the U.S. was $4,000. But these costs vary dramatically depending on the state of residence with monthly fees ranging from about $2,800 to over $9,000. And unless you include yourself among the small percentage of Americans who have long-term care insurance or who qualify for Medicaid (because of your very low income), these are all out-of-pocket costs. Dedicated memory care accommodations for those with dementias, such as Alzheimer’s or other cognitive diseases, are even more expensive — tack on another $1,500 to $2,000 per month.
If Not Assisted Living, Where Should I Live and Get Care?
That’s a fair question, but first a reality check: Securing needed help is challenging and expensive wherever you live.
If you stayed in your current home and wanted to hire a home health aide to work 44 hours a week — which still might result in evening or weekend care gaps — your out-of-pocket costs would be on average over $4,000 a month. And you would still be responsible for the meals, rent, taxes, insurance, and upkeep of your current house or apartment. And if you require skilled nursing home care—and do not qualify as poor—expect to pay on average twice this amount.
A failure to compare the benefits and costs of alternative care solutions is one of the reasons why the NYT’s editorial is so misleading, and I believe irresponsible. The experts tell us that old age can be one of the best stages in our lives — because we have the flexibility and wisdom to spend our remaining time as we prefer. This is absolutely true, but unfortunately, bad things can also happen in old age. We are at increased risk of chronic health problems, challenging recoveries from hospital stays, the onset of physical limitations, the loss of valued confidants, and even more sadly, the wrath of dementia. But older people must cope with these assaults on their well-being and autonomy no matter where they live.
The not so easy-to-answer question is whether older persons can cope with the challenges of old age more effectively in their own homes.
Sure, staying put is far more feasible if you can afford to pay for two full-time caregivers working around the clock. But most of us do not have this financial capability.. The unbridled enthusiasm for older persons remaining in their current homes is especially shortsighted if family members are unavailable or cannot provide regular help, or not uncommonly, their energy and health simply give out. A major reason for why frail seniors can delay their transitions to assisted living is the herculean caregiving efforts of their spouses and daughters. That is why the author’s contention that assisted living would not “relieve the [caregiving] pressure on my sister, who works full time while raising a daughter” is inconsistent with everything we know.
Moreover, even with the best homecare, older persons remaining in their own dwellings will often miss out on the social, educational, and recreational activities available in assisted living. This void cannot be dismissed lightly. Research points to the loneliness of older persons as a significant factor increasing the likelihood of their health problems and even increasing their risks of getting Alzheimer’s disease.
Despite these aging in place challenges, the NYT’s author concludes: “But assisted living, even memory care units, often aren’t the right place for people with dementia.” Really? So, what I am wondering is where she believes this care nirvana may be? And yes, it is true that assisted living inevitably includes “lots of old people dying left and right”— because they are top heavy with chronologically very old occupants. The residents who now enter assisted living residences are typically in their late 80s.
So, if the author of this editorial criticizes the care offered in assisted living, she must also recognize the inadequate and incompetent assistance that older persons receive in their own homes. Our newspapers are filled with horror stories of older persons left stranded in their homes by geographically remote, indifferent, or inept family members and by irresponsible guardians.
Is Better Regulation the Answer?
The NYT editorial gives the impression that assisted living is unregulated because of absent federal oversight, but nothing could be further from the truth. In the U.S., this long-term care option is governed by state, not federal laws and regulations — and these are hardly “minimal rules.” Moreover, to deal with their increasingly frail occupants, state governments are continually strengthening their regulatory requirements.
It is true that how assisted living is regulated depends on where you live since every Canadian province and U.S. state has its own rules. Inevitably this results in different admission and retention guidelines, staff training requirements, staff-resident ratios, residents’ rights and responsibilities, medication policies, grievance policies, and allowable nursing services. And without doubt, in the United States, the regulatory environments in some states are more protective and stricter than others. For example, about 38 states require assisted living residences to have a licensed nurse on staff or available, while 13 states do not. So, most definitely, older consumers and their families should be aware of their state’s requirements, but that is a far cry from suggesting that assisted living residences operate outside the law or without stringent licensing or regulation.
Now, it might appear obvious that anytime we can get additional oversight for anything that impacts a person’s life, it is a good thing. But the reality is more complicated.
For example, it is often true that better trained and licensed staff would assure a higher quality of care. However, this would be costly for providers and would drive up the price of this alternative. The unfortunate result: This option would become financially out of reach for many middle-income seniors who if they had to remain in their own homes might have great difficulty coping with their health problems and limitations.
How much oversight to provide is unclear for a less apparent reason. To distinguish their assisted living residences from highly regulated nursing homes, their operators give residents more choices about their care regimens in order to maximize individual independence, autonomy, and quality of life. However, this often means making difficult tradeoffs, such as providing more relaxed rules on resident conduct and supervision that could jeopardize their safety.
The Bottom Line
At the end of the day, assisted living residences can be an excellent and sometimes the only option to help support an aging loved one. Sure, there are some great ones, some good ones, and certainly bad ones. But according to assisted living CEO, Pino, those worst-performing assisted living “simply don’t survive and are taken over by those operators who care.”
No matter the circumstances, family members must stay involved even after their loved ones become assisted living residents. They cannot shirk their oversight duties because their advocacy responsibilities are crucial to ensuring that their loved ones receive the best care possible.
Perfect long-term care options do not now exist. And certainly, there is room to improve the quality of care offered in today’s assisted living. However, I believe that to negatively broad brush a whole industry is just not justified or right.
It’s not fair to all the committed individuals who have dedicated their time and energy to caring for our elders on our behalf. I think that if the author, Geeta Anand, is totally honest, her problem with assisted living may be much more fundamental. She possibly has difficulties accepting that old age is sometimes accompanied by debilitating conditions that demand more than home care. And she can’t acknowledge that most of us do not look forward to nursing homes as the final step where we spend our lives.
Stephen M. Golant, Ph.D., is a leading national speaker, author, and researcher on the housing, mobility, transportation, and long-term care needs of older adult populations. He is a Fellow of the Gerontological Society of America, a Fulbright Senior Scholar, and Professor Emeritus at the University of Florida. A prolific author, Golant has written or edited over 140 papers and books; his latest, Aging in The Right Place, is published by Health Professions Press. Earlier with co-author Dr. Joan Hyde, he published The Assisted Living Residence: A Vision for the Future (The John Hopkins University Press). Contact him at golant@ufl.edu.
This post was originally published on Booming Encore and has been reprinted with permission.
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