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