D04 - AMDA Position Statement on Assisted Living

Introduction

The American Medical Directors Association (AMDA) was founded on the premise that physician inclusion in long term care is essential to the delivery of quality care. The purpose of this statement is to address the appropriate roles of physicians in assisted living residences (ALR) in this country. Only through carefully crafted public policy, standards of practice, and ongoing quality assurance processes can the delivery of quality care to residents of ALRs be assured.

Background

Assisted living residences are growing in popularity among the elderly and disabled in this country. For many elderly who need only assistance with some activities of daily living, an ALR can be an ideal setting. The types of services offered by ALRs vary across the continuum of long term care, from community-living and senior home settings to more facility-like settings that provide nursing and, in some cases, skilled nursing care to its residents. Compared to ALR residents five to ten years ago, the types of individuals moving into ALRs today are increasing in age and frailty and have more healthcare and cognitive problems. Unfortunately, the clinical service needs of many ALR residents are not being met by the services provided in many ALRs. Moreover, there are no federal regulations governing the operation of these facilities, and state regulation varies widely.

Today’s ALR residents’ care needs are strikingly similar to the acuity level of nursing home residents of 20 to 30 years ago. The clinical care needs of ALR residents now include a wide range of services, spanning from skilled nursing to nutritional and psychosocial services. In 1974, Medicare regulations began requiring physician medical directors to oversee care and make visits to nursing facilities on a regular basis in response to perceived quality of care problems. The OBRA 1987 nursing home reform regulations resulted from studies, hearings, and media accounts reporting poorly trained staff, inadequate services to meet the needs of the residents, and considerable variation across the states in both the regulations designed to protect the health and safety of vulnerable elders and in state enforcement of those standards.[1]  Taking a lesson from history, it is important to recognize the ALR population today is parallel to the population of nursing homes almost 30 years ago.

AMDA members know firsthand the dangers of inappropriate care in ALRs. A 2002 survey of AMDA members revealed the number one impediment to delivering quality care to our members’ patients in ALRs was that they were too sick for the facility—the facility was not equipped to handle the complex nature of the patients’ illnesses and, in many cases, were forced to discharge them to a more appropriate setting that provided a safety net of care (e.g., a nursing home or skilled nursing facility). Such situations may be overcome if the ALRs contract with clinical professionals qualified to oversee the appropriateness of admissions and delivery of care to residents, thus minimizing the need for those residents to move from their homes.

Additional impediments faced by AMDA members delivering care to assisted living patients include: minimal or no clinical staff coverage; no medical records or mechanisms for storage of them; unlicensed/untrained staff providing care for sick residents; lack of or poor quality medication management; and lack of or incorrect information to families at admission or discharge.

From August 2001 to April 2003 AMDA participated in the development of the Assisted Living Workgroup (ALW) report Assuring Quality in Assisted Living: Guidelines for Federal and State Policy,

State Regulations, and Operations (April 2003). The ALW was a result of the U.S. Senate Special Committee on Aging directive to create a coalition of diverse organizations for the purpose of developing guidelines for improving assisted living services in this country. AMDA’s involvement in this process and our members’ concerns about quality of care in ALRs prompted the development of this position statement and a plan of action for the continuation of AMDA’s efforts to educate policy makers and the public about ALR care.

Positions

While there are criticisms of the impact of OBRA ’87 regulations, there is no doubt that the presence of physician care and oversight has made a positive impact on quality of care in nursing homes. Accordingly, AMDA members feel that ALRs need additional clinical requirements to improve quality care in this setting.

AMDA recognizes and supports assisted living operators’ and consumers’ desires to maintain a philosophy of service delivery that is designed to maximize individual choice, dignity, autonomy, independence, and quality of life. Our members’ concerns focus on the reality that many individuals moving into ALRs are cognitively impaired and/or have multiple illnesses that require some type of physician oversight and care—the type of care that is not currently required and non-existent in ALRs in most states.

To remedy these circumstances, AMDA believes that ALRs should adopt more precise requirements for assessing and monitoring the clinical needs of residents and the delivery of medical care in ALRs as follows: appropriate staffing of ALRs; mandatory storage of medical records and documentation for applicable residents; physician and pharmacist review of medication administration; and a clear process for informing residents’ physicians of a significant change in health status. In addition, ALRs must consider clinical oversight of the delivery of care in order to avoid the many possibilities of unpredictable clinical needs that could arise during a resident’s stay, especially given the multiple illnesses of residents.

As reported in a recent study by the National Academy for State Health Policy, state policy trends in assisted living appear to be moving toward the delivery of more health care services.[2] However, states are not making the logical progression of requiring ALRs to provide more physician care, medical director oversight or consultation in ALRs. AMDA urges ALR providers to consider their clinical staffing needs when providing or adding health-related services to their residents. Input from physicians with long term care experience, knowledge of the principles of geriatric medicine, and an understanding of ALR philosophy can be invaluable in this regard.

Depending on the services provided to its residents, ALRs should consider consulting with other health care professionals as well. They include consultant pharmacists, social workers, registered dietitians, and activity professionals.

At AMDA’s most recent annual symposium, our membership expressed deep concern about patient safety and quality of care in ALRs and pledged to continue efforts to address the issue.  To that end, AMDA plans to continue working with other stakeholder organizations to develop clinical guidelines and identify best practices to aid federal and state government in establishing a safety net of quality care for the vulnerable elderly who currently reside in ALRs.

Conclusion

Regarding the improvement of quality clinical care in assisted living residences, the policy of the American Medical Directors Association is as follows:

• Establish a common national definition for assisted living that is recognized by federal and state policy makers;
• Develop systems in ALFs that recognize the importance of physician involvement in maintaining the highest quality of care of ALF residents;
• ALRs should consider consulting with physicians as well as other health care professionals such as consultant pharmacists, social workers, registered dietitians, and activity professionals with long term care experience, a knowledge of the principles of geriatric medicine, and an understanding of ALR philosophy when determining the appropriate oversight of resident care;
• Develop clinical guidelines and best practices to aid federal and state policy makers in establishing a safety net of quality care for the vulnerable elderly residing in ALRs.
• Recognizing the blurred margin between the skilled nursing facility level of care and that of the emerging ALRs, adapt some of the key principles such as quality indicators, incident and accident analysis by facility, polypharmacy reduction, monitoring of nutritional integrity and functional capacity and hospitalization circumstances to name a few.

The specific role and responsibilities of physicians in ALRs should be delineated as follows:

• Assist the ALR in ensuring that residents have appropriate physician coverage and ensure the provision of physician and health care practitioner services;
• Assist the ALR in developing a process for reviewing physician and health care practitioners’ credentials;
• Provide specific guidance for physician and health care practitioner performance expectations;
• Assist the ALR in ensuring that a system is in place for monitoring the performance of health care practitioners;
• Facilitate feedback to physicians and other health care practitioners on performance and practices.
• Assist ALR with resident assessment and development of the clinical component of the service plan, when necessary.

Clinical Care

• Participate in administrative decision-making and the development of policies and procedures related to resident care and medication management;
• Participate in administrative decision- making on staffing levels, coverage, licensing and training requirements for resident-care staff;
• Assist in developing, approving, and implementing specific clinical practices for the ALR to incorporate into its care-related policies and procedures, including areas required by laws and regulations;
• Review, respond to and participate in federal, state, local and other external inspections; and
• Assist in reviewing policies and procedures regarding the adequate protection of residents’ rights, advance care planning, and other ethical issues.

Quality of Care

• Assist the ALR in establishing systems and methods for reviewing the quality and appropriateness of clinical care, medication management and other health-related services and provide appropriate feedback;
• Participate in the ALR’s quality improvement process;
• Advise on infection control issues and approve specific infection control policies to be incorporated into ALR policies and procedures;
• Assist the facility in providing a safe and caring environment with optimal levels of family and community involvement;
• Assist in the promotion of employee health and safety; and
• Assist in the development and implementation of employee health policies and programs.

Education, Information, and Communication

• Promote a learning culture within the facility by educating, informing, and communicating;
• Assist the ALR in developing medical information and communication systems with staff, residents, families and others
• Assist in establishing appropriate relationships with other healthcare professionals
   

[1] Hawes, C. (1996). Assuring Nursing Home Quality: The History and Impact of Federal Standards in OBRA-1987. The Commonwealth Fund. Page 2.

[2] Mollica, R. (2002). State Assisted Living Policy: 2002. Portland, ME: National Academy for State Health Policy. Page 18.