Response to the Commentary: Assisted Living: Optimal Person–Environment Fit

Assisted living (AL) represents a key part of the continuum of long-term care providers in the United States, with approximately 811,550 residents and 28,900 facilities as of 2016 (Harris-Kojetin et al., 2016). In their State of the Science Commentary, “Assisted Living: Optimal Person–Environment Fit,” Siegel et al. (2021) describe just how vulnerable residents of AL communities are, with most residents having multiple chronic conditions and functional limitations. Unfortunately, in 2020, the combination of congregate settings and frail residents meant that AL communities were particularly vulnerable to COVID-19. As of September 2020, estimates were that approximately 40% of COVID-19 deaths were in long-term care (LTC) settings, including AL communities (Kaiser Family Foundation, 2020). The U.S. experience is similar to that of congregate care homes in other countries, with a recent estimate that 46% of COVID-19 deaths were accounted for by care home residents (Comas-Herrera et al., 2020).

The Commentary points to ways that responding to COVID-19 would be especially challenging in AL, because of the model itself and the scarcity of data. Because AL is regulated at the state level, information on COVID-19 in AL is variable by state. As of August 2020, 19 states were identifying cases or deaths in AL (True et al., 2020). The incomplete information means we do not know whether infection control procedures are working or whether the racial and ethnic disparities we have seen in other settings related to COVID-19 are also found in AL.

Responding to the pandemic required policy changes in AL communities, including staff training, infection control procedures, visitor policies, and access to personal protective equipment (PPE). The Commentary describes the state variation around administrator licensure and minimal requirements to have health professionals available. This finding suggests that in all likelihood, many AL administrators were making these COVID-19 procedure decisions without a clinical background.

The authors describe the uneven staffing requirements across states, including limited hours of RNs and limited training for direct care workers (Siegel et al., 2021). Although 31 states require training in infection control, only 13 have robust infection control policies and procedures. It was in this context that AL staff were expected to provide the same level of infection control as those in hospitals or nursing homes where staff would have had more training and access to more resources, including PPE. A better understanding of the efficacy of infection control training and policies in states that have such requirements would be useful as the field moves forward with a greater focus on infection control.

In addition, as the Commentary reports, families and visitors play an important role for individuals residing in AL (Siegel et al., 2021). As COVID-19 isolation measures set in, most communities placed significant restrictions on these visitors. These policies created confusion for residents, isolation, and worry from family members. The authors describe families as providing “instrumental care, routine monitoring and management of health status, advocating for older adults’ care needs and intervening as needed, and routine communication and coordination with AL staff and other providers” (Seigel et al., 2021, p. 7). It would be extremely informative to have a more concrete understanding of the role of the family in care delivery and outcomes, and the impact of the absence of family assistance during the COVID-19 crisis.

The authors emphasize that most of the research on AL is descriptive, cross-sectional, or from convenience samples. As for health information technology (HIT), although it is “widely adopted in health care settings, electronic health records are not yet widely used nor comprehensive…” (Siegel et al., 2021, p. 6). If there were greater adoption and/or interoperability of HIT in long-term care settings with other health care settings, there might be better care coordination and a greater opportunity for more complex research. This adoption of HIT would provide enormous potential for improving the quality of care and developing greater understanding around resident outcomes.

From a research perspective, it would have been helpful during the COVID-19 pandemic to have regular reporting across all states, with detailed information on race and ethnicity and chronic conditions. The disparate health outcomes from COVID-19 have refocused the field on issues around health equity. The Commentary reports that Black Medicare beneficiaries are underrepresented in AL, are more likely to have a lower income, and are “more likely to reside in facilities with fewer services, and have higher chronic disease burden than White Medicare beneficiaries in AL” (Siegel et al., 2021, p. 7). Greater research on the experience of minority populations within AL communities, access to care, and cultural competency will be important to ensure that individuals from all backgrounds have access to the long-term supports and services that meet their needs.

Finally, many of the references in the Commentary cited work by Harris-Kojetin et al. The long-term care field, and AL in particular, owes a great deal of gratitude to Dr. Lauren Harris-Kojetin, who passed away in January 2020 after a long battle with cancer. Dr. Harris-Kojetin was the chief of the Long-Term Care Statistics Branch at the Center for Disease Control and Prevention’s National Center for Health Statistics (NCHS). At NCHS, she led the implementation of the 2010 National Survey of Residential Care Facilities and the initiation of the biennial National Study of Long-Term Care Providers (renamed in 2020 as the National Post-Acute and Long-Term Care Study [NPALS]). These surveys now provide a regular federal source of data, which has helped inform the field broadly. Dr. Harris-Kojetin was incredibly intelligent, passionate, and diligent, and her efforts ensured that the residential care sector would continue to have regular surveys. We have a great deal of information on residential care/AL thanks to Dr. Harris-Kojetin’s work.