Doctor in the house?
Most assisted-living facilities lack on-site or on-call medical staff
The patient moved into a large assisted-living facility in Raleigh, North Carolina, in 2003. She was younger than most residents, just 73, but her daughter thought it a safer option than remaining at 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 would just find herself on the floor.”
At least in a facility, the woman’s 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 that most such communities use: The staff called an ambulance to take the resident to the emergency department.
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 is common 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 might 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, and 20 percent with eating.
Like most older Americans, residents 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-chapel Hill.
About 70 percent of residents have some degree of cognitive impairment, Zimmerman’s studies have found. So residents can find it difficult to coordinate medical appointments and tests, and to travel to offices and labs, even when facilities provide a van.
“The assisted-living industry has to recognize that the model of residents going out to see their own doctors hasn’t worked for a long time,” said Christopher
Laxton, executive director of AMDA, a society that represents health-care professionals in nursing homes and assisted-living facilities.
His recent editorial in Mcknight’s Senior Living, an industry publication, was pointedly headlined: “It’s time we integrate medical care into assisted living.” AMDA is considering developing model agreements.
“There has to be more attention to medical and mental-health care in assisted living,” Zimmerman said in agreement. “Does everyone who falls really need to go to an emergency department?”
Lindsay Schwartz, an executive at the National Center for Assisted Living, a trade association, said in an email that “assisted living has certainly expanded its role in providing medical care over the years by adding nursing staff and partnering with other health care providers, among other ways.”
But persuading most operators to provide medical care probably 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, his wife, started a practice called Doctors Making Housecalls in 2002.
The facilities also “live in mortal fear of bringing down heavy-handed federal regulation,” Kronhaus 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 nursepractitioners, physician assistants and social workers — to about 400 assistedliving 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 transfers by two-thirds.
Spending time in emergency departments and hospitals often takes a toll on residents, even if their ailments can be treated. They get exposed to infections and develop delirium, and they lose strength from days spent in bed.
Perhaps that contributes to short stays in assisted living. Adult children often see these facilities as their parents’ final homes, but residents stay just 27 months on average, after which many move on to nursing homes.
Adding doctors to assisted living also could cause problems, advocates acknowledge; in particular, it might increase the alreadyhigh fees that facilities charge.
But something clearly must give.
“There can be health care
in assisted living without making it feel like a nursing home,” Zimmerman said.
Family members tell of frightened and confused residents arriving unaccompanied at emergency rooms, unable to give clear accounts of their problems. Kronhaus recalls a resident with dementia taken to the local ER by ambulance; discharged, she was sent home by taxi. The address she gave the driver was her former home, where neighbors spotted her and called the police.
By contrast, the North Carolina woman with a history of falls is doing well.
Taavoni discovered that her hypertension medications were causing such low blood pressure that she fainted. Reducing the dose and discontinuing a diuretic, Taavoni also weaned the patient off an anti-anxiety drug that she suspected was causing problems.
The falls and the related emergency department stopped. Doctors Making Housecalls is still caring for her, and for most of the neighbors in her assistedliving facility.