Hospice Trends: Assisted living offers opportunities for growth
Large hospice, assisted living companies connect
By Larry Beresford
One million people now reside in America’s 20,000 assisted living facilities. Most of them are frail and elderly, typically in their 80s, and in need of supervision and support. A significant number already are or eventually will be sick enough to meet clinical criteria for hospice eligibility.
Hospices have begun to provide care to residents of these facilities, most often in response to individual requests for service. But some observers view this setting as poised for dramatic hospice growth. As assisted living continues to expand in response to an aging population and its demand for less institutional alternatives to nursing homes, there could be huge partnering opportunities for hospices willing to learn the field and aggressively promote collaboration.
Assisted living is another key piece of the puzzle of guaranteeing full hospice access to dying Americans. There is also overwhelming support among consumers for the rights of terminally ill residents to remain in these facilities and for the role of hospices in helping residents achieve that goal, according to the results of recent focus group research.1
But in pursuing the opportunities, hospices will need to educate themselves about the differences between the assisted living facility and the nursing home, its near neighbor on the continuum of institutional long-term care. Hospices also must modify the approaches they have developed for partnering with skilled nursing facilities.
Wide differences now exist from state to state in regulatory environments and requirements for assisted living, with varying degrees of receptivity to hospice’s involvement in the facility. On the other hand, the assisted living philosophy emphasizes maximizing independence, dignity, choice, and quality of life in a safe, comfortable, homelike setting, suggesting obvious affinities with the hospice philosophy of care.
What is assisted living?
An assisted living facility is a congregate residential setting that provides or coordinates housing, personal services, and care, including up to 24-hour on-site support and assistance, as well as recreational activities, health-related services, and meals. Facilities may include private rooms, suites, or apartments and opportunities for living with roommates. Home health care and durable medical equipment are examples of external partners that routinely come into the facility to provide services to residents.
Assisted living facilities are not federally regulated but may be registered, certified, or licensed by relevant state agencies. Some state regulations tend to discourage residents who become homebound, terminally ill, and unable to provide any self-care from remaining in the facility. Historically, they would then be transferred to a higher level of care, such as a skilled nursing facility (SNF). In Florida, the regulations explicitly recognize the role of hospice in supporting residents who otherwise would no longer qualify for assisted living because of their higher care needs. Regulators in other states may grant the same recognition informally, on a case-by-case basis.
In partnering with assisted living, the hospice enrolls qualifying, consenting terminally ill residents onto the hospice benefit and cares for them as if they were living in their own homes. The facility, which most often is paid privately by the resident, continues to provide its supportive services, but typically at a lower level of professional supervision than would be expected in a SNF. The hospice may be held accountable for ensuring that enrolled residents are receiving the care they need. Hospice and assisted living staff need to clarify their respective roles and work together collaboratively, but the relationship can be conducted on a less formal basis than hospice-SNF partnerships. It may not even require a written contract.
"There is a wonderful synergy between assisted living and hospice," notes Sherrill Garvey, senior vice president of residential care for Sunrise Senior Living in McLean, VA, the country’s largest chain of assisted living facilities. Current interest in the hospice relationship reflects a growing focus in the field on living and dying "in place" when that is preferred by the elderly resident. In November, Sunrise announced a hospice preferred provider agreement with Vitas Healthcare Corp. of Miami, the country’s largest provider of hospice care.
The agreement with Vitas is designed to enhance access to hospice care for residents and families who choose this option and to encourage joint development of best practices for hospice care in the assisted living facility. But it is just the beginning of a larger emphasis on hospice for Sunrise, which operates more than 340 assisted living facilities with 40,000 beds in 34 states.
The company recently hired a national director of hospice care. Its hospice partnerships have three main components:
- education of Sunrise facility teams;
- communication;
- outcomes measurement.
In its locales where Vitas does not operate, Sunrise will develop a network of other preferred hospice providers willing to commit to the company’s proprietary standards of best hospice practice and to collect and submit quality outcomes data.
The Vitas-Sunrise agreement is the most explicit example of a hospice-assisted living partnership on a large scale. In most communities, the involvement of hospices in caring for assisted living residents happens at the request of the terminally ill resident or his/her family. However, there are signs that this may be just the tip of an emerging iceberg.
Emeritus Assisted Living of Seattle, another large national chain with 180 facilities in 33 states, is "primed to join with hospice," says Wendy McKenna, director of wellness services for Emeritus. "Hospice is big in our business plans, and hospice partnerships are a high priority. Our residents have told us that. Our company believes in great partnerships. Some of the supportive things that come from hospice are real perks, like grief counseling for our staff."
Although Emeritus has not yet developed preferred provider relationships with hospices, that could be a future direction, McKenna says. What has emerged so far are close working relationships at the local level, where hospice team members make a point of checking in with facility staff whenever they visit the resident. Emeritus also confirms the licensure of the hospice and its professional staff who visit the facility on the resident’s behalf and asks them to write progress notes for inclusion in its medical charts on patients.
Vitas recently developed educational materials for consumers and facilities. VistaCare, a large hospice chain based in Scottsdale, AZ, also sees important partnering opportunities, says CEO Richard Slager, who in a previous job ran an assisted living company.
"We’re working with assisted living facilities in all of our communities. The regulations don’t require a contractual relationship, but we do try to establish a preferred relationship. We see this field as a great opportunity, and if I were an operator of an assisted living facility, I’d also see it as a tremendous opportunity," Slager says.
How to make partnerships work
Experts in the field encourage hospices to seize the initiative in making contact, establishing partnerships, and working with facility operators and the relevant state agencies to address regulatory concerns. "Where relationships have flourished is where the hospice does active outreach to facility staff, for example, by offering to provide educational presentations and helping to relieve their anxieties about residents dying in place," McKenna says.
Even when the facility’s administrator is sold on the concept, other staff members may have their own fears and concerns that need to be dispelled with education about hospice philosophy and services. Education can clarify that hospice isn’t just for the final few days of life and that its involvement can minimize the need for hospitalization and discharge of long-standing residents when they become terminally ill.
Hospices need to talk through the barriers and concerns of facility staff, says VistaCare’s Carla Hughes. "You have to ask the right questions to find out the facility’s concerns and to help the operator have an A-ha!’ moment." Because the differences are so great among states and among individual facilities, the hospice needs to tailor its approach and its care plan to each facility, she adds. Also crucial are the willingness to provide continuous care when needed, prompt on-call response, home visits by the hospice physician, and grief support groups.
For Vitas, the involvement in assisted living facilities varies among communities. Its program in Broward County, FL, now has three full-time interdisciplinary teams covering assisted living, says Dierdre Lawe, executive vice president for strategic development for Vitas. "I give a lot of credit to a couple of our staff who really championed it," she notes.
"In states where we’re providing this service, we try to make sure we understand the regulations and meet them. A good hospice has to focus on the psychosocial-bereavement needs of the facility’s staff. That’s part of what we built into our agreement with Sunrise," Lawe says.
Assisted living is also getting attention in Congress, where in 2001 the Senate Special Committee on Aging, in response to quality concerns, convened the stakeholders and charged them with developing guidelines for ensuring quality of care for all assisted living residents. Draft recommendations by the Assisted Living Workgroup (www.aahsa.org/alw.htm) will be submitted to Congress in late April, specifically recommending that "when a terminally ill resident is receiving hospice care, transfer from an assisted living residence may not be required if the needs are being met."
For more information on assisted living, contact the Assisted Living Federation of America, 11200 Maples Mill Road, Suite 150, Fairfax, VA 22030. Telephone: (703) 691-8100. Web site: www.alfa.org.
Reference
1. Dixon S, Fortner J, Travis SS. Barriers, challenges, and opportunities related to the provision of hospice care in assisted-living communities. American Journal of Hospice and Palliative Care 2002; 19:187-92.
As assisted living continues to expand in response to an aging population and its demand for less institutional alternatives to nursing homes, there could be huge partnering opportunities for hospices willing to learn the field and aggressively promote collaboration.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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