Table 2.

Comparison of Medical Care Provision in Three Settings: Private Residence, Assisted Living (AL), and Nursing Home (NH)^*

Activity or Process	Private Residence**	AL	NH
General perceptions of setting
Patient complexity or acuity	Lower than AL	Intermediate	Higher than AL
Family involvement	Higher than AL or NH	Similar to NH	Similar to AL
Trust and confidence in skills of care provider	Varies; generally high confidence in availability and low confidence in medical care skills	Varies; generally high confidence in nurse but concerns about nonnurse care providers and availability of ongoing oversight	High confidence; respondents appreciated that they could dependably speak with a nurse
Likelihood that telephone call represents serious problem	Low; often a trivial problem	Moderate	Higher
Making a diagnosis
Communication about patient problems	Greater trust in history from family than from AL staff	Varied confidence in care provider expertise and quality of information	Higher confidence in quality of information, because caller would always be “a real nurse”
Ordering tests (if problem presents in the evening)	Family to take patient to physician’s office the next day for laboratory tests and X-ray	Laboratory work done the next day by AL; urine dipstick and X-ray sometimes available at night	Laboratory work done the next day by NH; urine dipstick and X-ray sometimes available at night
Monitoring capability (including vital signs)	Family often unable to assess vital signs but will monitor for change in status more carefully than AL staff	Can assess vital signs, but monitoring may be unreliable or inconsistent, especially at night	More confidence in monitoring, especially of medications, than in AL
Therapeutic options and treatment provision
Available range of care options	Limited; similar to AL	Limited	Broader: includes intravenous fluids and antibiotics, nursing procedures
Rapidity of starting medications	If a pharmacy is open, family can obtain quickly	Pharmacy must deliver; if at night, cannot obtain a new prescription until morning	Pharmacy must deliver; however, some medications are available for emergency use
Likely management decision
If patient needs to see physician immediately	Send to emergency department	Send to emergency department	Send to emergency department
If patient needs to see physician the next day	Patient comes to physician office	Patient comes to physician office	Physician, nurse practitioner, or physician assistant goes to NH
Likelihood of transfer to hospital emergency department
With medical problem	High	High	Low
With acute agitation	Moderate	High	Low
Administrative and regulatory matters
Prescribing medications	Requires two telephone calls: one to family, one to pharmacy	Staff cannot take oral orders; prescribing requires up to three calls and a fax: telephone call to pharmacy, telephone call and faxed order to AL community, and often a call to family	May only require one telephone call to NH nurse (for oral orders); optional second call to family
Paperwork and documentation	Fewest regulatory and paperwork requirements	Highest regulatory and paperwork requirements; high volume of contact over telephone or fax, “many more faxes”	Regulatory requirements are “more doctor friendly” than AL; fewer telephone contacts and faxes than in AL

^*Results of qualitative analyses of responses of 165 physicians active in AL to open-ended questions about management of patients residing in private residences, AL, and NHs.

^**Private residence assumes that the patient is living with a reliable, nonmedical caregiver.