Assisted living: redefining the continuum.

Once upon a time, assisted living was perceived as an "alternative" service filling the gap between independent living on one end of the continuum, and full-blown skilled nursing home care on the other. No longer.

In the past few years, the increased need for long-term care - as well as evolving consumer preferences and the desire to contain national health care costs - have changed the ways that long-term care is delivered. Now we are seeing changes that are leading to a "blurring of the lines" between formerly separate; fixed points on the long-term care spectrum, such as traditional nursing home care, and residential alternatives such as assisted living. Already, for example, more hospitals and nursing homes are venturing into either subacute care or assisted living, and more independent and assisted living residences are offering nursing care.

As we all know, U.S. census statistics show a huge growth in the 85+ population. It is estimated that this age group will increase as much as 39.3% in this decade alone. Among these Americans, as many as half will need assistance with at least one activity of daily living. The dramatic growth in this segment of the population has led to an increased pressure on health care in general, and long-term care in particular. The result of this pressure is the creation of a diversified spectrum of long-term care alternatives.

As residents are living longer and healthier, they are staying in independent living settings longer. With the trend toward aging in place has come the increased pressure for providers to offer higher levels of services.

According to the Assisted Living Federation of America's Overview of the Assisted Living Industry: 1996 by Coopers & Lybrand LLP, the average length of stay in assisted living residences has crept up to nearly 2.5 years. While the average number of ADLs for residents at the responding facilities remained about the same as in the previous Overview three years before (at about 3.0), the level of acuity for the overall resident population was markedly higher. For example, nearly half of the residents at surveyed residences (48.3%) had some form of cognitive impairment, compared to 42% in the 1993 survey. Fewer residents needed help with medication reminders, but the percentage of residents requiring dispensing of medication increased dramatically - from 52% in 1993 to 69.9% three years later.

Whereas the development of daily incontinence used to be an indicator that a resident needed to move on to another setting, the percentage of the population in the surveyed residences who require assistance with daily incontinence has doubled - from 15% in 1993 to 30.2% in 1996.

Clearly, this is an indication that a move to "the next level" of care does not necessarily require moving on to another provider. It can just as often mean remaining in the same room, apartment or campus while the provider adjusts to the resident's new requirements.

In addition to the blurring of lines between different levels of care in assisted living, the industry is also serving an increasingly diverse population. While the vast majority of residents are still frail, elderly persons with some level of health care needs, assisted living is also becoming the environment of choice for those with Alzheimer's or other dementias. About 30% (29.3%) of responding residences in the 1996 Overview reported having dedicated Alzheimer's units. In addition, some providers are serving non-elderly adults with physical or mental disabilities.

Then there is managed care. While the direct involvement of managed care in assisted living is still in the future, the demands of managed care have contributed to the blurring of long-term care as a whole. Hospitals and sub-acute care facilities are discharging people sooner and sicker - some of whom are now going to nursing homes. Meanwhile, residents who traditionally would have been cared for in nursing homes are placed in or are choosing assisted living.

Finally, another factor of change in long-term care has been consumer demand, which has driven the popularity of assisted living from the start. As a result, considerable growth has taken place in most long-term care settings, resulting in a range of services available to consumers in a variety of models. For example, assisted living services can be found in nursing homes, luxury high-rise complexes, gracious manors, converted public buildings and single family homes. Services can range from help with only the basic activities of daily living, to more intensive assistance traditionally found in nursing homes.

So what is the provider relationship, then, in the continuum that now includes nursing homes and assisted living residences? Needless to say, there will always be a need for 24-hour, intensive, skilled nursing care. However, as the elderly move up - and now down - the long-term care spectrum according to their changing health care needs, there is no longer a clear line indicating where a person's needs can best be met.

There will continue to be room for a wide array of choices, as long as long-term care providers wish to remain responsive to consumers' needs. Innovative partnerships will continue to be created between home health, assisted living and nursing homes to produce solutions that will best meet an individual's needs and preferences. What is critical for the continued success of both the assisted living and nursing home industries is to look for ways to support each other as necessary partners in the ever-evolving long-term care spectrum.

Thomas H. Grape is President of Benchmark Assisted Living in Wellesley Hills, MA. He is a member of Assisted Living Federation of America's Board of Directors and serves as Chairman of ALFA's Regulatory Committee.