Pathways into assisted living communities: Admission limitations and assessment requirements across the United States

Abstract

Objectives:

Limitations to admission play a critical role in shaping the composition of residents within licensed assisted living (AL) communities.

Design:

We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations.

Setting and Participants:

AL regulations and licensed AL communities across all 50 states in 2018

Methods:

We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those which impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission.

Results:

The largest group of ALs (28% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than eight out of every ten licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment.

Conclusions and Implications:

The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (e.g., health, mental health, cognitive). While future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policymakers to better understand the options in their state and how various AL licensure classifications compare to one another.

Brief Summary:

Limitations to admission and assessment requirements shape the composition of residents within any type of assisted living (AL) community and we identified nine groups of licensed AL communities across the United States with differing admission limitations.

One of the hallmark regulatory requirements of the 1987 Nursing Home Reform Act was the Pre-Admission Screening and Annual Resident Review (PASARR), a process of care applied to all new admissions into any state-licensed nursing facility (NF) receiving Medicare and Medicaid reimbursements.¹ The goal of PASARR was to limit individuals, particularly those with diagnosable forms of serious and persistent mental illness, from being admitted into a licensed NF that cannot provide necessary services and protections.² PASARR implementation involves a comprehensive needs assessment upon admission, which researchers have linked to numerous process and outcome improvements among NF residents such as a decade-long (1989–1998) reduction in inappropriate prescribing of antipsychotic medications and related resident harms.^3,4,5 Meanwhile, the number of licensed assisted living (AL) communities continues to increase, and current estimates suggest more than 900,000 individuals reside in AL communities across the United States on any given day.⁶ While admission limitations into AL communities and corresponding assessment requirements previously have been identified, researchers have not determined how they are defined across all fifty states nor resolved how they are applied to different AL licensure classifications within any given state.^7,8 In this paper, we seek to improve our understanding of who is limited from being admitted into licensed AL communities across the United States and identify the types of assessments required to make such determinations.

Assisted Living Licensure and Admission Limitations

In 2001, as AL communities assumed a growing role in providing long-term residential care across the United States, a Congressional hearing was held to investigate issues raised regarding care quality and resident safety.⁹ Following this, the Assisted Living Workgroup (ALW) consisting of administrators, clinicians, housing leaders, public officials, researchers, and resident advocates was charged with evaluating AL operations and produced 110 recommendations to promote nationwide standards of care.¹⁰ Among these, the ALW recommended states offer at least two licensure classifications based on residents’ health and mental health care needs (Assisted Living Workgroup, Definition of Assisted Living, Part C: Levels of Care. p14).

Compared to singular licensure schemes, multiple licensure classifications promote flexibility to address differences among resident needs and channel admissions into the most appropriate residential setting.¹¹ By differentiating licensure classifications such as one based on health needs and another based on mental health needs, states can assign distinct regulations pertaining to care requirements, staffing, environmental features, and other operational processes intended to support the provision of the highest practicable level of quality care.¹² In the case of the licensure classification pertaining to health needs, a state may require care processes such as medication management be offered. For a classification pertaining to mental health, a state may require staff training for the care of residents with serious and persistent mental illness.

While some states did not yet license AL communities when the ALW report was published in 2003, a recent analysis found all 50 states now offer multiple licensure classifications for AL communities.¹³ Researchers also have determined how such multiple licensure approaches have served to uphold varying regulatory approaches to services and staffing. For example, Street and her colleagues¹⁴ examined AL licensure classifications in Florida and documented how communities were governed by different requirements pertaining to the provision of medical and behavioral care services. Other work has linked AL licensure classifications across the United States with varying staffing level requirements and associated these observed differences with resident hospital admissions.¹⁵ Another recent study associated explicitly supportive AL regulations pertaining to hospice care with increased likelihood AL residents received hospice at end of life.¹⁶ Researchers also have associated dementia-specific licensure with lower rates of hospitalization and long-term nursing home stays among residents with ADRD.¹⁷

Admission Limitations and Assessment Requirements

The ALW also recommended that assessments of physical health, medical conditions, functional status, behavior, mental health, and cognitive status be completed at the time of admission into any licensed AL community.¹⁰ The ALW contended that such comprehensive assessments would produce information needed to make more accurate determinations concerning admission limitations for individuals with a diagnosed medical condition, a skilled nursing care need (e.g., gastric feedings, intravenous care), an identified communicable disease (e.g., tuberculosis), a mobility impairment preventing safe evacuation, neuropsychiatric symptoms of dementia (e.g., aggressiveness, harm to others), a serious and persistent mental illness and/or a cognitive impairment. Recent accounts indicate 46 states require an assessment at admission (or within two weeks) and 37 states require assessment of cognitive function in particular.¹⁸ It remains unclear the extent to which regulations concerning admissions limitations and assessment requirements vary across the different AL licensure classifications issued across and within the 50 states. By illuminating differences among these regulations, we inform decision-making among health care providers as well as residents and their family caregivers who otherwise may be challenged to distinguish among licensed AL communities.

Research Questions

In this study, we answer two questions: (1) what admission limitations have been linked to AL licensure classifications offered across the United States and (2) what are the assessment requirements associated with different approaches of limiting admission into the multiple licensure classifications across the United States.

Methods

In previous work, our team used health services regulatory text analysis to source regulations from Nexis Uni and then record the presence or absence of requirements (e.g., care practices, staffing) specific to each AL licensure classification offered within each state.^13,15,16,17 In this study, we relied on documented admission limitations and assessment requirements to assess the proportion of all licensed AL communities regulated by such provisions. This research was not defined as Human Subjects Research by our Institutional Review Board.

Sample

Our study included 165 licensure classifications used by the 50 U.S. States in 2018 to regulate AL communities serving 25 or more older adults. These licensure classifications covered 31,840 AL communities with a total capacity for 1,248,485 residents. Licensure classifications specific to smaller AL communities (less than 25 beds) were omitted from the analysis as these residences often are defined as adult foster home or board and care homes, and are considered to be inherently different from AL.⁶

Measures

After sourcing all relevant regulations, we identified admission limitations using our method of health services regulatory text analysis.¹³ We asked a total of 6 questions concerning the presence or absence of admission limitations (coded dichotomously 1 = yes; 0 = no) cited by the ALW and observed in prior research. We then aligned responses into four categories: limitation based on a health need, a specified behavior, mental health condition, and/or cognitive impairment (Table 1). We aligned admission limitations based on specific medical conditions, physical care needs and mobility limitations into a single category as preliminary text review indicated states that upheld one of these limitations often required the others. A behavior limitation reflected whether the licensure required AL communities to limit individuals from admission who presented a specified behavior such as aggression, noting that such a limitation does not prevent an AL community from admitting persons with a mental health condition or cognitive impairment who do not present the specified behavior at time of admission. A mental health limitation reflects whether the licensure classification precludes admission of persons diagnosed with a serious and persistent mental health condition. Limitations based on cognitive impairment reflect whether a licensed AL is required to limit admission of people diagnosed with Alzheimer’s disease, a related dementia and/or who are experiencing substantial problems with thinking and memory at the time of admission. We then assessed the presence or absence of 4 clinical assessment requirements recommended by the ALW and supported by other research,¹⁹ and sorted these into three categories: health, mental health, and cognition (Table 1).

Table 1:

Limitations to admission and assessment requirements

Limitation Type	Example
Health	Does the license’s definition of scope of service limit the admission/retention of individuals with specific medical health conditions or needs? Does the license limit admissions based on physical care needs (e.g., activities of daily living)? Does the license limit admissions based on mobility (e.g., ambulation)?
Specified Behavior	Does the license’s definition of scope of service limit the admission/retention of individuals with behavioral expressions associated with ADRD or mental illness?
Mental Health	Does the license’s definition of scope of service limit the admission/retention of individuals with mental health condition(s)?
Cognitive Impairment	Does the license require communities to limit the admission/retention of people with ADRD?
Assessment Type	Example
Health	Does the license require ALs to assess physical status at admission? Does the license require ALs to assess ability to ambulate/mobility at admission?
Mental Health	Does the license require ALs to assess mental health or condition at admission?
Cognitive	Does the license require ALs to assess cognitive status at admission?

Analysis

We used the following schema to identify groups of licensed AL communities: no admission limitations; admission limitation based on medical condition, physical status, or mobility limitation; admission limitation based on a specified behavior only; limitation based on mental health condition only; limitation based on cognitive impairment only; as well as the combinations of these four. We then assessed the number of AL communities and their bed capacity licensed under rules corresponding to each category to estimate the prevalence of these different regulatory approaches across the United States. We also categorized states according to whether all licensure classifications upheld the same admission limitations, and whether we observed within-state variation. For each group, we identified requirements concerning the assessment of health, mental and/or cognitive status at admission, and describe the proportion of each group required to conduct at least one type of assessment, specifically considering requirements pertaining to cognitive status.

Results

Among 165 AL licensure classifications governing larger AL communities (25+ beds) in 2018, we identified 17 that had no provisions limiting admission across the four dimensions we investigated. These licensures govern a total of 3,539 AL communities (11.17%) across 11 states. We identified 67 licensure classifications that only required AL communities to limit admission based on health (medical condition, physical status or mobility limitation), governing 9,196 communities (28.9%) across 26 states. Only 3 licensures restricted admission based on a mental health condition, and these governed 193 communities in the state of Indiana. We did not identify any licensures that limit admission based solely on a specified behavior or cognitive impairment.

The majority of AL communities across the United States obtained licenses with two or more admission limitations (59.4%). The most common of these limited admission across all four dimensions (health, behavior, mental health, and cognitive status) and governed 7,526 AL communities (23.6%) in four states. Admission limitations based on health and mental health conditions governed 6,165 (19.4%) AL communities in six states. Limitations based on health, behavior, and mental health status governed 3,394 (10.7%) of licensed AL communities in nine states. The remainder of licensed AL communities were required to limit admission based on resident health status, behavior, and cognitive impairment (N=854; 2.7%), both health status and cognitive impairment (N=524; 1.6%), or both health status and behavior (N=449; 1.4%).

We found fifteen states have different admission limitations across licensure classifications. For example, Arkansas issues five AL licensure classification types: three of these require communities to limit admission based on health status only, another one limits admission based on health and behavior status, and the fifth limits admission based on named conditions. Thirty-five states offer multiple licensure types but apply the same admission limitations to all AL communities within the state. For example, Vermont issues four different AL licensure classifications, but across all of them, requires communities to limit admission based on health status only. Washington governs AL via six licensure classifications, which all limit admission based on health, behavior, mental, and cognitive status.

In regard to required assessments at admission (see Table 3), we observed that 82.2% of licensed AL communities without any regulatory admission limitations are required to conduct a health assessment but only 40.5% are required to conduct an assessment of cognitive status. For those AL communities that are required to limit admission based on health status, 90.8% are required to assess health status and 65.6% are required to conduct a cognitive assessment. Almost all of the AL communities with multiple admission limitations require a health assessment and many also require a mental health assessment. Cognitive assessments were not consistently required among these communities, even when the licensure specifically limited admission of persons with cognitive impairment.

Table 3:

Number of AL communities and bed capacity by admission limitations and required assessments

	Required assessment
Admission limitations	None	Health assessment only	Health and mental health assessment	Cognitive assessment only	Medical and cognitive assessment	Health, mental health, and cognitive assessment	% Any assessment	% Cognitive assessment
No limitations at all
Number of communities (n=3539)	629	1,280	195	12,03	232	0	82.2%	40.5%
Number of bed capacity (n=157,538)	10,606	70,357	11520	50,753	14,302	0	93.3%	41.3%
Limitations based on health status only
Number of communities (n=9,196)	848	1,291	1,027	18	456	5,556	90.8%	65.6%
Number of bed capacity (n=432,105)	47,503	56,144	63,304	1167	31,642	233,115	89.0%	61.4%
Limitations based on mental health status only
Number of communities (n=193)	0	0	0	0	0	193	100%	100%
Number of bed capacity (n=18,540)	0	0	0	0	0	18,540	100%	100%
Limitations based on health, behavior, mental health, and cognitive status
Number of communities (n=7,526)	0	48	7,229	0	0	249	100%	3.3%
Number of bed capacity (n=203,870)	0	2,114	184,849	0	0	16,907	100%	8.3%
Limitations based on health and mental health status
Number of communities (n=6,165)	287	0	3,153	0	2,568	157	95.3%	44.2%
Number of bed capacity (n=202,139)	12,835	0	117,642	0	66,488	5,174	93.7%	35.5%
Limitations based on health, behavior and mental health status
Number of communities (n=3,394)	28	67	1,167	0	870	1,262	99.2%	62.8%
Number of bed capacity (n=144,249)	552	3,303	56,937	0	50,131	33,392	99.6%	57.9%
Limitations based on health, behavior, and cognition status
Number of communities (n=854)	59	795	0	0	0	0	93.1%	0%
Number of bed capacity (n=31,146)	1,150	29,996	0	0	0	0	96.3%	0%
Limitations based on health and cognition status
Number of communities (n=524)	0	0	0	0	244	280	100%	100%
Number of bed capacity (n=21,556)	0	0	0	0	10,944	10,612	100%	100%
Limitations based on health and behavior status
Number of communities (n=449)	0	59	125	0	33	232	100%	59.0%
Number of bed capacity (n=37,342)	0	5,429	8,094	0	2,301	21,518	100%	63.8%

Discussion

In this study, we identified nine groups of admission limitations aligned with AL licensure classifications across the United States. These groups range from those licensed AL communities that impose no admission limitations to those that limit admission based on health, behavior, mental, and cognitive status. The group that has no limitations on admission represents more than one of every ten AL communities across the United States. While somewhat striking at first glance, these communities may be subjected to other licensure requirements (e.g., minimum staffing, required services) that serve to effectively substitute for a lack of admission limitations.²⁰ These states also may not establish explicitly defined admission limitations because upholding such regulations does not support inclusive and flexible entry into residential housing. Indeed, if a state agency defines AL communities as a form of housing, then they may be subject to stipulations included in the federal Fair Housing Act precluding landlords from asking tenants about their health.²¹

Alternatively, a much larger group of licensed AL communities, nearly three of every ten across the United States, limits admission of persons based on health status but do not impose any other admission limitations pertaining to behavior, mental health, or cognitive status. While this regulatory approach may effectively distinguish AL communities from nursing and other types of residential communities that offer ongoing medical services and/or skilled nursing care and also assure that residents may be able to ambulate and evacuate in case of emergency, additional research is needed to associate admission limitations with resident population characteristics. Since these communities are not required to limit admission based on behavior, mental, or cognitive status, this may explain why the composition of their resident populations may be quite heterogeneous.⁶

Another large group of AL communities, nearly one of every four, are licensed under the most comprehensive admission limitations covering health, behavior, mental health, and cognitive status. Another group, consisting of one of every five AL communities, are required to limit admission based on health and mental health status. When combined, communities required to uphold multiple admissions limitations represent more than half of all licensed AL across the United States. It would seem such efforts to use multiple admission limitations are more likely to be implemented in states with larger markets (e.g., California, Florida) as admission limitations may be used to channel residents and distinguish communities. However, we found multiple admission limitations were applied in states with smaller markets as well (e.g., Alabama, South Dakota).

State Variation

The most complex regulatory approach in which multiple licensure classifications were linked with varying admission limitations was implemented in fifteen states. In these states, the market of licensed AL communities is regulated in such a way that distinct licensure classifications and corresponding admission limitations may minimize heterogeneity in resident composition across communities. In contrast, the majority of states (N=35) issue multiple licensures but link the same admission limitations to each, although we also observed states took different approaches in which some only linked health limitations to all classifications offered by the state (e.g., Vermont) whereas others applied all four limitations to all licensure classifications (e.g., Washington).

Assessment Requirements at Admission

While the majority of communities governed under an AL licensure that imposes no admission limitations are required to conduct a health assessment at admission and nearly half are required to conduct a cognitive assessment, whether these required assessments are used to limit admission remains at the discretion of these AL communities. In contrast, health assessments certainly are required when admission limitations include health status and mental health assessments are used among a large portion of these AL communities as well. Furthermore, almost all of the AL communities with multiple admission limitations required a health assessment and many of these also required a mental health assessment. However, cognitive assessments were less common, even when the community limited admission based on cognitive status.

With more than four of ten older AL residents living with ADRD,²² omission of a required cognitive assessment at time of admission is noteworthy. The absence of this particular regulation may reflect concerted efforts from advocacy and provider organizations that consider AL communities to be ideally suited to care for those who do not present long-term healthcare needs, mobility limitations, problematic behaviors or serious and persistent mental illness.²³ Such an approach also reflects the conceptualization of AL as market-based residential care that facilitates self-direction among residents.

Even so, we suspect many AL communities complete some sort of cognitive assessment prior to resident admission and use this information to identify particular care needs and negotiate service contracts,²⁴ especially within those AL communities that offer “memory care” or special programs for persons living with cognitive impairment.²⁵ Nevertheless, the lack of a required cognitive assessment warrants further consideration as some AL communities may admit residents with unobserved thinking and memory problems that soon manifest as care needs that cannot be fully met.^26,27 Research is needed to understand if these particular AL communities may be more prone to admitting residents who end up being discharged quickly when their needs exceed staff resources or when they become a threat to others.

Limitations

We offer a snapshot of the AL regulatory framework being upheld across the United States. We did not determine how these regulations shape the composition of residents within licensed AL communities or individual outcomes. Future research is needed to determine if the resident composition of these communities do, in fact, vary in any meaningful way based on efforts to channel admissions through required limitations and assessment requirements (e.g., measured with demographics, use of Medicaid). Moreover, as AL communities increasingly resemble NFs in terms of resident care needs, future research should consider how exactly admission limitations and corresponding assessment requirements concerning health status are conducted and applied relative to those which govern NFs.²⁸ We also think it is critical to determine how admission limitations and assessment requirements are combined with required services, staffing and other care practices. Identifying the different combinations of state regulations and examining their relationship with individual outcomes stands apart as a critical research endeavor especially as AL communities continue to grow and diversify across the United States.²⁸

Conclusions and Implications

By documenting variation associated with licensure classifications pertaining to admission limitations and assessment requirements, we have illuminated a discrete regulatory approach in licensing AL communities that may contribute to substantive differences in resident composition and individual outcomes. These findings contribute to more informed decision-making as health care providers as well as residents and their family caregivers can now readily identify and choose to move into a licensed AL community by evaluating if and how corresponding admission limitations and assessment requirements are aligned with individual needs and preferences.

Table 2.

Classification based on required admission limitations and the associated number of AL communities and their bed capacity in each class

Admission limitations	Number of licenses	States	AL communities N(%)	Bed capacity N(%)
No health, mental, behavioral or cognitive limitations	17	AK, CT, DE, HI, ME, MN, MO, ND, NH, PA, SD (n=11)	3539 (11.1%)	157,538 (12.6%)
One Limitation
Limitations based on health status only	67	AR, AZ, IA, KY, MA, MD, ME, MI, MO, MS, ND, NE, NH, NJ, OH, OK, OR, PA, RI, SC, TN, TX, VA, VT, WV, WY (n=26)	9,196 (28.9%)	432,105 (34.6%)
Limitations based on mental health status only	3	IN (n=1)	193 (0.6%)	18,540 (1.5%)
Two or More Limitations
Limitations based on health, behavior, mental health, and cognitive status	9	AL, AR, CA, WA (n=4)	7,526 (23.6%)	203,870 (16.3%)
Limitations based on health and mental health status	10	FL, GA, KS, NC, NM, SD (n=6)	6,165 (19.4%)	202,139 (16.2%)
Limitations based on health, behavior and mental health status	42	IA, IL, MA, MT, NJ, NY, WI, WV, WY (n=9)	3,394 (10.7%)	144,249 (11.6%)
Limitations based on health, behavior, and cognition status	6	AL, CO, TN (n=3)	854 (2.7%)	31,146 (2.5%)
Limitations based on health and cognition status	4	ID, UT (n=2)	524 (1.6%)	21,556 (1.7%)
Limitations based on health and behavior status	10	AR, DE, LA, NJ, NV (n=5)	449 (1.4%)	37,342 (3.0%)
N	165		31,840	1,248,485