At 85 years of age at admission, today's typical assisted living resident is older than he used to be and more dependent on healthcare staff.

It's likely he's in need of a walker or cane to ambulate, and he probably requires nursing assistance to perform various ADLs. There's also a good chance he's living with a chronic condition such as diabetes or COPD and is resigned to such daily regimens as insulin intake or inhalation therapy.

Despite his more extensive needs, he's also probably voiced a desire to enter an assisted living or similar residential setting as opposed to skilled care, said Paul Williams, senior director of government relations for the Assisted Living Federation of America (ALFA), Alexandria, VA.

"In general, the stigma is still that nursing homes are institutional and that people lose control over their lives once they enter them," Williams said. "Even though the state of acuity among today's assisted living residents is certainly greater, they still want to be able to exercise decisions in all other aspects of their lives. And that's always one of the attractions of assisted living."

Whether or not a facility can accommodate an individual, however, is often based on his acuity level and state regulations, Williams explained.

"Regardless of what the individual or family may want, if state regulations say they need a higher level of care, then they may have to move into a nursing home, sometimes despite their wishes," he told ADVANCE.

These lines, however, can often become blurred.

Who's Acceptable?

While ALFA is supportive of each resident's right to choose the care setting they desire, the organization also acknowledges that some state laws and regulations prevent residents from having that choice, Williams said.

"It's an informed choice that should be made by the resident, family, physician and provider," he said. "All should agree that the needs and desires of the resident can be met in the assisted living community. There are communities that provide light-to-moderate care but won't house Alzheimer's residents; however, there are some that strictly treat those with Alzheimer's."

State regulations are quite varied. For instance, Vermont sets a standard for discharging residents who are at a "very high" acuity level and have specific restrictions when it comes to admitting residents, said Kay Jarvis, human resources director at Cathedral Square Corp., South Burlington. Those requiring a ventilator or respirator are not permitted in assisted living, nor are those with stage III or IV ulcers. The exclusion list also includes those who need nasopharyngeal, oral or tracheal suctioning as well as those unable to transfer from a bed or chair (or to ambulate) without being assisted by two or more people.

However, the Green Mountain State does allow residents who become more acutely ill after admission to remain, provided they don't "pose a serious threat to self or other residents that cannot be resolved through care planning."

This clause has changed the way long-time AL nurses like Mary Brooks, LPN, care for residents. "With assisted living, you might think the care stays the same, but it doesn't - it changes every day," said Brooks, a charge nurse at Cathedral Square Corp. "We see residents who aren't as independent as they used to be - people who rely on intervention with their physicians and dietary staff; routine assessments on their skin, oxygen saturation and lung sounds; and wound care."

This includes an insulin-dependent resident Brooks cares for who's on continuous oxygen, takes Coumadin and needs regular labs drawn.

"I don't think it would have been possible for us to care for her 15 years ago; she would have needed to be in long-term care," Brooks said.

In Florida, where Williams says the admission restrictions are more flexible because certain facilities can be licensed to provide extended congregate care (a recognized higher level of care), residents can be bed-bound for as many as 14 consecutive days and still be retainable. Connecticut takes a more laissez-faire approach, allowing facilities to develop their own admission and discharge criteria as long as it doesn't "impose unreasonable restrictions and screen out people whose needs may be met."

Tougher Than the Rest

Some of the more restrictive East Coast states include Delaware, where residents can't "require more than intermittent or short-term nursing care," and Rhode Island, where residents "must not require medical or nursing care as provided in a healthcare facility but who (as a result of choice and/or physical or mental limitation) require personal assistance, lodging and meals, and may require the administration of medication."

Rhode Islanders must also be capable of "self-preservation in emergency situations, unless the residence meets a more stringent life-safety code" in order to be admitted.

Then there's the situation in Pennsylvania where all assisted living facilities still fall under the auspices and regulations of personal-care homes, which follow lower standards.

However, at ADVANCE's press time, standards in the Keystone State were set for change, with 2,800 assisted living regulations written by the state's Office of Long Term Living awaiting approval of the Independent Regulatory Review Commission. The group's responsible for reviewing agency regulations to ensure they're in the public's interest and consistent with legislative intent.

Once these regulations become official, AL facilities will have to gain licensure to admit high-acuity residents. Until that time, however, facilities will be able to welcome those who seek "personal assistance or supervision for a period exceeding 24 hours [and] do not require the services in or of a licensed long-term care facility, but . require assistance or supervision with ADLs."

For now, all administrators must write detailed descriptions of the services they intend to give and how they'll meet residents' needs safely upon each admission, said Ken Hook, MSW, personal care home administrator at Independence Court of Quakertown, PA. But beyond that, admissions are still basically at the discretion of administration.

Just a Myth?

Hook also contends when administrators decide to accept high-acuity residents, they assume a responsibility to provide their communities with sufficient, adequately trained staff as well. He also believes the alleged rise in acuity among assisted living residents is a bit overblown.

"I've been doing this a long time, and I see the same people todayI saw years ago," he said. "Yeah, some people have higher acuity than others, but what you're really seeing are elderly people who have issues associated with aging."

Jolene Salls, RN, a nursing supervisor at Shell Point Retirement Community, Fort Myers, FL, agrees. Though the average age of her 113 residents has gone from mid-70s to 80 and older in the past 10 years, the facility hasn't had to modify admissions criteria.

"We haven't really seen a rise in acuity as our residents have gotten older," she said. "Our residents are pretty much self-sufficient and require minimal assistance. They're still very much independent, and we pride ourselves on trying to keep people as independent as we possibly can."

At Independence Court, Hook said part of the reason he's able to keep his resident population consistently at 100-percent capacity (115 people) is due to having at least one nurse (usually an LPN)onsite 24/7. He contends it's difficult for every facility to follow the same protocol.

"The state does not require it," he said. "So, it depends on how much money you have to spend on staff, to be honest."

Still, in Hook's eyes all facilities in the Keystone State must adequately train staff to care for those whose health is compromised. Orientation at his facility lasts at least 1 week depending on the employee's prior work experience but job training is considered ongoing, he said. "And we have CNAs who are trained to give meds, which frees up our nurses to care for those who may have higher acuity needs," Hook added.

Activities Against Acuity

Those interviewed by ADVANCE also agreed that offering varied recreational events is a sure way to keep residents healthy. For instance, Independence Court residents can participate in an 8-hour activities program 7 days per week, Hook said.

"We try to keep people in the activity room all day if we can," he explained. "It's their choice of course, but we encourage them. Our residents also like to go shopping. They go to [local stores] as long as they're not a wander risk."

At Cathedral Square, a resident-services coordinator manages morning exercise programs and offers typical indoor/outdoor events, Brooks said. Similarly, Shell Point offers "sit-ercise," which enables residents to perform light workouts without being on their feet, Salls said.

When More Help's Needed

Assisted living facilities also should be obligated to employ outside services when their acute residents wish to remain in their care but need more hands-on assistance and supervision, Williams said. One solution is offering wellness programs.

At Cathedral Square, residents have 24/7 access to nurses who oversee medication administration. Those residents who want to self-administer meds are assessed and can do so if the nurse and primary-care provider are in agreement.

"This has had a huge impact on folks because they feel reassured that they can connect with somebody about any questions they may have," Jarvis said. "It's designed to be a preventive measure in response to the growing trends of people aging. We want to cut down on emergency room visits, medication errors and be proactive so people can live independently, be safe and have their health needs met."

Still, many residents are eventually going to require, or maybe even desire, skilled care, Hook contests. So, facilities need to recognize when a nursing home is the best option.

"It's an administrator's job to listen to staff when they raise concerns about residents," he said. "Usually, the transition to skilled care will occur after an illness or hospital visit, but we can provide hospice care here if someone's reaching the end of their life and everyone's in agreement to keep the resident with us."

Joe Darrah is associate editor at ADVANCE.