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Forecast 2019
The medicine of assisted living: SNF/AL Lines Continue Blurring?

Forecast 2019<br />The medicine of assisted living: SNF/AL Lines Continue Blurring?

Editor’s note: This Forecast is the last of a five-part series assimilating some of the latest research and industry news about assisted living in the year(s) to come as we face the challenges of rising acuity, staff training and medication management, among others. They are organized around the business of assisted living, the medicine of assisted living and the people of assisted living (both caregivers and residents).

Care and clinical issues

Coming trends

Health care issues in assisted living will undoubtedly gain greater traction than ever in 2019, reflecting the concerns of Americans in general based on national polling.

As policymakers and pundits endlessly debate the mechanical issues, indisputable trends are beginning to emerge, and likely will begin to change the face of assisted living in the years to come.

Data released in December 2018 by the National Health Interview survey, for example, showed close to 10% of seniors age 75 to 84 — a key demographic — say they need help with activities of daily living (ADLs). About 20% of senior 85 and older claimed needing help with ADLs, according to the survey. According to the CDC, the percentages of seniors needing ADL assistance is increasing, as reported in McKnight’s Senior Living.

An interesting statistic came in a late 2018 survey by RetirementLiving.com, which found that while most people approaching retirement age plan to continue their golden years at home, nearly 75% of them said failing health would force them to move to assisted living. Questions about whether the industry will be prepared to care for an onslaught of health problems in an age of rising acuity still loom.

In its forward-looking document “Argentum 2025,” the organization identifies a number of opportunities in the years to come around memory care. Noting the expected increase in people living with dementia and the corresponding burden it will place on caregivers at home and elsewhere, Argentum states it will be imperative that the industry and its supporters:

  • Boost public understanding of Alzheimer’s and other dementias to enhance public awareness, reduce stigma, and support efforts to fund research.
  • Promote disease management to help prevent and slow the progression of Alzheimer’s in residents.
  • Encourage participation in scientific studies by encouraging residents and their families to participate in relevant clinical trials.
  • Support and expand dementia-friendly communities by working to offer resources and assistance to foster the spread of communities that recognize a person with cognitive impairment, to respect them and create environments that are friendly to them.
  • Develop and share best practices to continue to advance the senior living industry’s knowledge base and expertise in the field.

Of course, mental health issues will go beyond the all-consuming issues of dementia in the year to come.

In its Top Trends in Aging Services list for 2019, Health Dimensions Group points to the need for the long-term care industry to better managed psychosocial issues.

“While health systems and providers are addressing these non-medical factors as they work toward population health, hospitals continue to struggle with discharging patients who have complex psychosocial issues,” the report states. “As census continues to decline in skilled nursing and psychosocial issues climb, there will be an increase in discharge partnerships to transfer patients to post-acute settings to meet complex needs which have traditionally caused rapid discharge and readmission back to the acute-care hospital.”

As the long-term care industry continues grappling with issues around anti-psychotics and opioid medication, medicinal marijuana is getting a stronger look as a viable therapy for seniors in all settings, according to an article in McKnight’s Senior Living.

“As the legal use of marijuana for medical purposes becomes more widespread in states across the country, senior living community operators are encountering challenges with serving their residents while complying with the law,” the articles notes. Caregivers and pharmacists across the country continue to deal with laws and regulations that conflict with its legal use in certain circumstances.

Proper medication management and expert pharmacists can play a role in all these issues.

Standards and practices coming?

In late December, the International Association for Healthcare Security and Safety (IAHSS) released a survey revealing the top senior living safety concerns.

The top threats, according to the publication, “Violence and Security in Skilled Nursing/Assisted Care Facilities,” are resident aggression/violence, public aggression/violence, theft from residents and staff members, and elopement or wandering.

The Bureau of Labor Statistics, for example, has found that nursing and residential care facilities have shared the dubious distinction of having among the industry’s highest prevalence of nonfatal occupational violence.

“An elopement related claim has the second-highest average total amount paid, $388,048 per claim, of all assisted living claims types, according to CNA’s Aging Services 2016 Claims Report,” the IAHSS report notes. “Assisted living communities remain the senior living/long-term care setting with the highest number of elopement claims — 54.3% of the 46 closed claims in the report, compared with 45.7% for skilled nursing — and the highest average total paid for the type of claim. Across all settings, payments on elopement claims averaged $325,561, and in skilled nursing, they averaged $251,172.13.”

States should better monitor safety and welfare of Medicaid beneficiaries in assisted living
Hundreds of thousands of Medicaid beneficiaries receiving assisted living services can be vulnerable to abuse, neglect or exploitation. The Centers for Medicare & Medicaid Services oversees how states monitor such incidents, but its guidance has been unclear, according to a recent GAO report.

The GAO report spurred the Long Term Care Community Coalition LTCCC in late October 2018 to develop recommendations for best practices for the assisted living industry, including the need to address staffing ratios; staffing requirements for nurses, administrators and recreational activities directors; staff training; oversight and quality assurance; abuse and neglect; transfers and discharges; consumer information and disclosure; and public information regarding community ownership as well as survey reports and complaint investigations.

Other standards in the works

  • The National Center for Assisted Living has posted guiding principles for assisted living, which include initiatives around leadership, quality in assisted living and dementia care.
  • In late October 2018, Argentum unveiled a new Senior Living Standards Commission, which builds upon its existing quality initiatives to develop and maintain voluntary standards for senior living related to emergency preparedness, memory care, medication management and other aspects of resident safety.
  • In its “Argentum 2025” report, Argentum proposes a number of quality initiatives to: participate in the healthcare continuum by working with networks of providers within and beyond the health care sector so the industry can leverage its capabilities and support senior living residents across the continuum of care; encourage innovation by supporting the development of research and participating in longitudinal studies to assess and measure the effects of innovative practices in senior care; and share quality indicators and best practices throughout the industry and among other senior living advocates to ensure continuous improvement.
  • In late November 2018, healthcare REIT Welltower announced an effort to establish quality standards in assisted living. The report outlines the work of a national stakeholder group of assisted living operators, academics, industry representatives and family members of parents receiving assisted living care, according to Welltower. The group identified five key pillars, or domains, of care quality in assisted living that can serve as the basis for national standards and the development of a culture of quality measurement and improvement.

Regulatory issues to consider in 2019

In its “Argentum 2025” report, Argentum observes how rising resident acuity will significantly impact the senior living industry over the next 10 years. “Additionally, the senior living industry is seeing increased state regulatory changes with variances in regulatory models across the country,” the report adds. “The industry needs standards and professional certification programs to show its commitment to quality to the public, professionals and among employers.

Argentum proposes several regulatory initiatives in the coming year, including:

  • Supporting licensing and enforcement to protect residents and their families from unlicensed providers that harm consumers by offering substandard care, and that harm the reputation of the entire industry as well.
  • Advocating for state regulatory reform to ensure meaningful and consistent laws and policy.
  • Developing standards to demonstrate senior living’s commitment to excellence and develop a self-regulatory framework that is flexible and meaningful.

One major piece of regulation that will likely relieve pressure on assisted living operators in 2019 is the EPA’s decision to exempt the industry from rigid rules and stiff penalties around the disposal of pharmaceutical waste. Before the change, assisted living communities were prohibited from disposing of such waste in toilets and septic systems. Assisted living operators had argued its residents are free to purchase and manage their own medications, making such communities in conflict with the agency’s strict definition of a long-term care community.

Quality standards will be clear drivers of how the industry evolves as both SNFs and ALs compete for the same resident. To that end, working with a single preferred pharmacy can help reduce risk and increase efficiency, while ValueMed’s expert pharmacists can help establish the highest levels of quality in medication management and assist in staff training.

We hope you’ve enjoyed our Forecast 2019 series as we discussed the macro growth issues shaping the industry. If you missed any part of the series, you can find them all here.

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