Assisted Living: Another Frontier

(Figure 2) I know there is no need to convince you that the numbers of frail elderly are increasing at a significant rate. It is also a given that Congress and the state legislatures will continue to find ways to limit the funding of Medicare and Medicaid. This represents not only a concern over the escalating cost of health care, but a reassignment of social priorities. It has become much more politically correct to channel dollars into the care of pregnant women and children, therefore investing in the future of this country as opposed to its past. Health care and its funding represent a venue where the conflicts between aging boomers and their Generation-X progeny will be acted out and, I hope, resolved.Recent years have also witnessed the rapid, though not too creative, development of community services for the frail elderly and disabled. Many of these services have been unwittingly shaped to the medical model, assuming that the provider knows best, rewarding dependency and offering few truly independent choices. Access to services is often contingent on medical necessity, and it is rarely admitted that independent living could be a realistic option if nontraditional services such as personal care, chore services, or companionship were part of a comprehensive package. And assisted living promises to create that comprehensive package. The Medicare and Medicaid waivers that allow assisted living as an alternative to institutionalization have frequently been motivated by anticipation of lower costs, but the benefits go far beyond the dollars saved. Justification for assisted living can be found in generations of research. A study funded by the Robert Wood Johnson Foundation verified that the frailty and physical limitations of home care patients often were as severe as or worse than the characteristics of cases encountered in nursing homes. These elderly need care and living arrangements that protect them from isolation and loneliness, and that allow them to define loneliness and privacy from their own perspective. We also know that recipients of home care can become institutionalized despite the fact that they are maintained in the home. Other studies of the elderly tell us that the attention of people outside the patient's family often has a greater therapeutic effect than equal amounts of time from family members. And the debilitating effect of caregiver burden on families is widely publicized. Given all that we know about care of the aged and what we would like to provide, the challenge has been to create alternatives to nursing homes and traditional home care that allow "aging in place" and permit the individual to retain control over his or her life. Assisted living has been proposed as a best option for "aging in place." It is not a new option, but one that is growing in popularity among the frail elderly, who once had no option but to relinquish control and defer to professional biases and family directives. Such is its popularity, in fact, that it now requires consumer protection to assure its original intent is maintained. Assisted living is a social, not a medical, program. Independence, individuality, choice, privacy, and dignity are its mantra. The site administrator, the RN, and the resident each have responsibility to make this living arrangement work. Assisted living assumes that services typically provided in a nursing home can be offered in a residential setting, but at lower cost. Residents are rewarded with greater control over their lives. They are provided maximum opportunities to act on their preferences; their personal and decisional autonomy is not only encouraged but expected. The State of New Jersey has responded to the need for oversight of assisted living programs with regulations that have been labeled as the most progressive in the nation. These regulations place the RN at the center of the information system. By completing a comprehensive social, functional, and medical assessment, the RN starts the flow of resources into assisted living on behalf of the resident. Nurses are the gatekeepers to the system, and they decide which components of care may be delegated and which must be provided by professionals. But there are those who question whether nurses are ideally suited to this role. Many industry spokespeople see nurses as too entrenched in the medical model, too ready to act on behalf of their patients, and too full of preconceptions about the best means to an end. They believe that nurses will be unable to relinquish control-they will find it difficult to accept solutions to problems proposed by residents on their own behalf, or to disregard a problem if the resident refuses to own it. In fact, assisted living may not be about health at all, but about enabling residents to manage personal limitations, so that they can continue to live life on their own terms.