As­sisted-liv­ing fa­cil­i­ties re­sist change, fail­ing to pro­vide med­i­cal care on site

The Buffalo News - - NATIONAL NEWS - By Paula Span

The pa­tient moved into a large as­sisted-liv­ing fa­cil­ity in Raleigh, N.C., in 2003. She was younger than most res­i­dents, just 73, but her daugh­ter thought it a safer op­tion than re­main­ing in her own home.

The woman had been fall­ing so fre­quently that “she was end­ing up in the emer­gency room al­most ev­ery month,” said Dr. Shohreh Taavoni, the in­ternist who be­came her pri­mary care physi­cian.

“She didn’t know why she was fall­ing. She didn’t feel dizzy – she’d just find her­self on the floor.” At least in a fa­cil­ity, her daugh­ter told Taavoni, peo­ple would be around to help.

As the falls con­tin­ued, two more in her first three months in as­sisted liv­ing, ad­min­is­tra­tors fol­lowed the pol­icy most such com­mu­ni­ties use: The staff called an am­bu­lance to take the res­i­dent to the emer­gency room.

There, “they would do a CT scan and some blood work,” Taavoni said. “Ev­ery­thing was OK, so they’d send her back.”

Such ping-pong­ing oc­curs com­monly in the na­tion’s nearly 30,000 as­sisted-liv­ing fa­cil­i­ties, a catchall cat­e­gory that in­cludes ev­ery­thing from small fam­ily-op­er­ated homes to cam­puses owned by na­tional chains.

It is an ex­pen­sive, dis­rup­tive re­sponse to prob­lems that of­ten could be handled in the build­ing, if health care pro­fes­sion­als were more avail­able to as­sess res­i­dents and pro­vide treat­ment when needed.

But most as­sisted-liv­ing fa­cil­i­ties have no doc­tors on site or on call; only about half have nurses on staff or on call.

Thus, many symptoms trig­ger a trip to an out­side doc­tor or, in too many cases, an am­bu­lance ride, per­haps fol­lowed by a hospi­tal stay.

Twenty years af­ter the ini­tial boom in as­sisted liv­ing – which now houses more than 800,000 peo­ple – that ap­proach may be shift­ing.

Early on, as­sisted-liv­ing com­pa­nies planned to serve fairly healthy re­tirees, of­fer­ing meals, so­cial ac­tiv­i­ties and free­dom from home main­te­nance and house­keep­ing – the so-called hos­pi­tal­ity model.

But from the start, the as­sisted-liv­ing pop­u­la­tion was older and sicker than ex­pected.

Now, most res­i­dents are over age 85, ac­cord­ing to gov­ern­ment data. About two-thirds need help with bathing, half with dress­ing, 20 per­cent with eat­ing.

Like most older Amer­i­cans, they also gen­er­ally con­tend with chronic ill­nesses and take long lists of pre­scrip­tion drugs – and more than 80 per­cent need help tak­ing them cor­rectly.

More­over, “these places be­came the pri­mary res­i­den­tial set­ting for peo­ple with de­men­tia,” said Sh­eryl Zim­mer­man, an ex­pert on as­sisted liv­ing at the Univer­sity of North Carolina at Chapel Hill.

But per­suad­ing most oper­a­tors to pro­vide med­i­cal care likely will not hap­pen with­out a fight. They have built their mar­ket­ing strate­gies on look­ing and feel­ing dif­fer­ent from the dreaded nurs­ing home, and they ob­ject to “med­i­cal­iz­ing” their com­mu­ni­ties.

“They don’t want the liability,” said Dr. Alan Kron­haus, an in­ternist who, with Taavoni (they are mar­ried), started a prac­tice called Doc­tors Mak­ing House­calls in 2002.

The fa­cil­i­ties also “live in mor­tal fear of bring­ing down heavy-handed fed­eral reg­u­la­tion,” he said. That can hap­pen when Medi­care and Med­i­caid, which cover most res­i­dents’ health care, get in­volved.

Doc­tors Mak­ing House­calls pro­vides one ex­am­ple of how as­sisted liv­ing can of­fer med­i­cal care.

The prac­tice dis­patches 120 clin­i­cians – 60 doc­tors, plus nurse-prac­ti­tion­ers, physi­cian assistants and so­cial work­ers – to about 400 as­sisted liv­ing fa­cil­i­ties in North Carolina.

“We see pa­tients of­ten, at length and in de­tail, to keep them on an even keel,” Kron­haus said. By con­tract­ing with labs, imag­ing com­pa­nies and phar­ma­cies, the prac­tice can pro­vide most of the med­i­cal care for more than 8,000 res­i­dents, on site and around the clock.

Work­ing with a lo­cal emer­gency med­i­cal ser­vice, he and his col­leagues re­ported in a 2017 study that the prac­tice could re­duce emer­gency room trans­fers by two-thirds.

The Lott As­sisted Liv­ing Res­i­dence in Man­hat­tan, on the other hand, re­lies on a sin­gle geri­a­tri­cian, Dr. Alec Pruch­nicki, to pro­vide med­i­cal care for most of its 127 or so res­i­dents.

If they’re feel­ing sick, a fam­ily mem­ber calls or the res­i­dent just knocks on the door of “Dr. P’s” base­ment of­fice.

Nearby Mount Si­nai Hospi­tal em­ploys him and pro­vides emer­gency ser­vices when needed.

Of­ten, they are not. In 2005, Pruch­nicki re­ported at med­i­cal con­fer­ences, he de­creased hos­pi­tal­iza­tions by a third.

“I can’t be in the only place in the coun­try where this would work,” he said.

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