Assessment is at the heart of it all.

You really can't overemphasize the importance of resident assessment in managing long-term care communities. The delivery of services in the field of seniors housing and care begins with, and will always be critically dependent upon, the underlying resident assessment. It is the first of the four basic functions required in any long-term care setting, the others being planning, implementation, and follow-up. Assessment is number one not only chronologically but as an essential prerequisite to the others. Absent an assessment of the customer's condition, preferences, and needs, there can be little in the way of effective planning or service delivery.

And yet its implementation, particularly in assisted living, has been problematic at best. And that's really a shame.

I spent a year, as president of the Assisted Living Federation of America, doing battle with consumer colleagues on the Assisted Living Workgroup, established by the Senate's Special Committee on Aging. As you may have read in Richard Peck's report in the April issue ("The Assisted Living Workgroup--One Year Later," p. 28), its ostensible function was to develop guidelines for the 50 states in their regulation of assisted living. What a shame we ever got to that point! Had assisted living been doing its job--if assisted living had been even elementally focused on the essential prerequisites of long-term care--such a task force might not have been necessary. Now, given that group's process-oriented recommendations, assisted living is that much closer to being saddled with the same regulatory framework that has so bedeviled nursing facilities over the years.

Assisted living's failure to come to grips with the basics of assessment is a good example of ignoring the fundamentals. Assessment is, after all, more than a clinical tool. The assessment process will, for example, determine the degree to which the facility is adhering to its business model--the "niche" it is attempting to carve out in the marketplace. It will serve as the basis for pricing decisions. It will prove essential to cost-control efforts within the community. It can serve as a vital component of human resources management. In short, resident assessment is ignored (or performed badly) only at a community's peril.

The assessment process must start with a basic understanding of the unique nature of the customer. While less the case for independent living, some congregate care, and more youth-oriented skilled nursing, the resident in a seniors housing and care community is elderly (by federal definition, at least, over 65 years of age). Seniors, unlike their younger cohorts, are characterized by an array of problems--not just medical or even primarily physical. While perhaps physically frail, they are also beset by mental, psychological, social, and environmental challenges, all of which require a holistic approach to determining their needs and developing a plan of care and/or services designed to meet them.

This is what is referred to as the "geriatric" model of healthcare. It is distinguished by the fact that it can (and usually does) reflect interrelated domains of care, some of which are "health-related" only in the broadest sense of the word. Conventional internal medicine, focusing on organ systems and single diseases, is not well suited to the typical older patient, who may suffer from multiple chronic diseases, exhibit uncommon symptoms, and have functional problems with consequent psychosocial stresses. In the same vein, "geriatric" treatment emphasizes relieving symptoms and improving function, rather than curing the underlying pathology.

Therefore, the primary tool for determining the needs of a resident in a seniors care community must be holistic in nature. It begins where the conventional routine history and physical examination for the younger patient leaves off. The areas focused on in the resident assessment must reflect the multiple issues facing the resident, be they physical, mental, psychosocial, and/or environmental.

Interestingly, one finds this emphasis on joint care and service management to be one of the four standards promulgated by the National Association of Social Workers (NASW). NASW's standards begin with an emphasis on one of the overriding concerns of professionals in long-term care: the maintenance (if not, indeed, the enhancement) of customer self-determination. That, in turn, is buttressed by the recognition that the client's interest, as perceived by the client, is paramount. Finally, confidentiality and privacy are recognized as sacrosanct, to be preserved at all costs.

Isn't all this, after all, what assisted living is all about?

The "who" of assessment is as important as the "what." Here is where the concept of team assessment becomes critical. One of the management challenges facing all seniors housing communities is the tendency to foster "silo" mentalities, the compulsion of workers to concentrate on their own responsibilities and overlook the activities of others on the staff. The results can be disastrous for the customer and, consequently, for the community as a whole. As noted in my April column ("Leadership Is More Than Giving Orders," p. 24), only a caregiving team that is as holistic as the services and care they are to provide can successfully conduct a resident assessment.

What disciplines need to be represented on the assessment team? Well, the core specialties, of course, are nursing, medicine (as provided in the nursing facility), and social work (including activities professionals). Dieticians, dentists, pharmacists, and other therapy professions might also become involved on a periodic basis. The key, however, is to have the represented specialties be as reflective as possible of the conditions presented by the resident.

Perhaps most ignored and, at the same time, most critical is family involvement. No one is in a better position to describe the resident's condition than, if not the resident herself, members of the family. Not only will their involvement in both the assessment and the service plan make for a better product, it can forestall numerous political, legal, and marketing issues, as well.

Absent an interdisciplinary approach to the exercise, the true value of an assessment can never be realized. Is a resident's weight loss a clinical issue? Absolutely. But what are its causes? The appearance or taste of the food? Depression? The physical environment of the dining room? These and any number of possible other reasons can account for what is possibly only a physical manifestation of multiple issues. Only by combining the knowledge and training reflected in multiple disciplines is one likely to get at such root causes. The interdisciplinary team is not only more apt to isolate underlying problems but also to develop a care plan capable of dealing with them.

Having discussed the "what" and the "who" of assessment, let's move on to the "when." Fortunately, assisted living doesn't suffer under the constraints imposed by the federal government on nursing facilities; assisted living has, for the most part, had the latitude to do it right. Unfortunately, it hasn't made effective use of that latitude. It is the rare community, for example, that assesses its residents prior to admission, when it's most appropriate. Even when done prior to move-in, assessment has been as much a function of marketing as of wellness. This can be a recipe for a dissatisfied customer and perhaps even deeper troubles down the line.

Just as the assessment determines the care needs of the customer, so too will it determine the price of the service package. Any price established absent a comprehensive resident assessment is only fortuitously reflective of customer need. The risks of this are obvious. The news media are replete with stories and articles about customers made painfully aware of their financial liability only after their loved ones have been admitted to a facility. The short-term advantages of that approach will clearly be outweighed by the long-term disadvantages. Certainly, prior to execution of a contract, the community owes the customer its best assessment of the customer's needs and his/her financial consequences.

If done within the context of resident preferences, service needs, and fiscal reality, the well-constructed resident assessment can help ensure development of data-driven management systems that foster staff competencies and capabilities, promote product accountability and improvement and, ultimately, impact favorably on the business's profitability. The data I'm talking about are not simply "nice things to know," ascertained after the fact. These data stem from standardized policies and procedures whereby care is actually provided. Fostering such data is not the resident assessment's primary purpose, of course. But its focus on individualized care plans, and ensuring that the services provided (and corresponding payments) are oriented toward the specific needs of each customer, will provide a consistent and powerful trove of management data.

Too many communities let events dictate their resident mix, rather than establish admission policies by design. The character of a seniors housing and care community should be proactively determined by management, not by the circumstances of an increasingly frail resident population. Pertinent questions must be addressed--for example, how much mild and intermediate dementia will fit within your program? What level of ADL dependency is appropriate to your service package? What, if any, medical interventions do you anticipate handling? What approach to medication management fits within your philosophy of care? It is the resident assessment that will let management know, on a real-time basis, the degree to which the community is adhering to its business plan.

As it monitors the changing needs of its residents, facility management will have the luxury of an early warning system when residents begin to outstrip a community's capacity to provide care. It will know when to adjust services (and accompanying payments), as well as prepare for those circumstances when discharge is the only safe and viable option for both the resident and the community.

Perhaps of greatest importance to the very essence of successful, customer-focused long-term care, resident assessments help management avoid the constraints of "cookie-cutter" care in which "one size fits all." It avoids the sameness that comes from facility directed institutional care and places appropriate emphasis where it belongs: on customer preferences and needs.

And that lies at the very heart of the special mission claimed by assisted living. It is the source of its unique value, and should be recognized as such.

To comment on Dr. Willging's views, as expressed here, please send e-mail to [e-mail].