Podcast Takes Insightful Look at Changing Face of Assisted Living

Assisted living (AL) continues to be an important part of long-term care, but it has changed significantly over the years. These changes impact practitioners caring for older adults. A recent AMDA On-The-Go podcast, Palliative Care and Goals of Care in AL, offered tremendous insights on topics including framing goals of care conversations in AL and what palliative care and hospice care might look like in this care setting.

Here are just a few of the many insights from the conversation with Michael Nash, MD, CMD, and Katie O’Brien, MD, CMD:

• Increasingly, some AL communities have a physician and/or an advanced practitioner in the building several days a week, either making house calls or working in an on-site clinic. This is at least partly due to the increasing complexity of AL residents, many of whom have multiple chronic conditions.
• At the same time, the average age of residents has risen into the 80s, and up to 80% of residents need help with medications. About half of AL communities have round-the-clock dedicated nursing support, and this trend is growing.
• Practitioners who care for AL residents deal with increasing patient complexity and varying models of medical and nursing oversight. These models, in turn, determine how long a patient can stay in AL.  
• Practitioners often must walk a line between what the resident and family want and what is best for the resident. There often is a hesitancy on the part of residents and families to move someone into skilled nursing. They may want to stay in the AL community, even after their health declines and they need higher levels of care. As a result, practitioners must be advocates for the resident and help ensure they are in a setting where they will be safe and can thrive. 
• Increasingly, practitioners conduct anticipatory guidance and help residents plan for the future. This is key to ensuring smooth transitions between care settings. Palliative care plays a key role here, as anticipating individuals’ needs can help identify the types of palliative care they may benefit from. These conversations can be challenging and even uncomfortable. However, practitioners need to be prepared for these talks and help residents and families understand realistic expectations and goals of care. These conversations aren’t one-and-done; it is important to revisit them as a person’s diagnoses or conditions change. Ideally, these conversations must start before a crisis or health change occurs.
• It is often said that if you’ve seen one AL community, you’ve seen one. It’s important for the practitioner to know what services and supports each AL community they serve provides. This is key to determining what facilities are the best match for each individual. It is also essential for enabling residents to age in place and not bounce back to the hospital as much as possible.
• While it’s not the practitioner’s role to deal with finances, it is important for them to understand that residents and families often have misconceptions about what care and services—including palliative care—are covered by Medicare or Medicaid and which are paid out of pocket. They can help develop a financially feasible care plan and connect them with organizations or individuals who can help them sort out the finances.
• It is important to establish early palliative care plans, with an emphasis on managing symptoms and supporting caregivers. These plans should include anticipatory guidance about things like changing dietary or medication needs. It is also important to be proactive and work with building staff as part of the care team.
• As in skilled care, teamwork is essential in AL. The on-site staff work with residents every day and know them better than anyone. They see subtle changes early and are positioned to help address them before they necessitate an ER visit or hospital stay. Having home-based palliative care and a bridge to hospice can be helpful. 
• Hospice has a place in AL, both for patients with a slow decline and those near death. Hospice in AL allows residents to die in their homes. Again, it is important to know an AL facility’s capabilities to provide home-based hospice care and the ability for staff to communicate with hospice nurses.

Listen to the full discussion and many more enlightening insights on this topic.