Are assisted living communities (ALCs)—established as a social model—seeing sicker patients, and what are they doing about it?According to Kimberly Vermilyea, RN, chief operating officer, post-acute segment, at Signature HealthCare, “Many assisted living facilities are serving residents with higher acuity, and I don’t think it’s a bad thing. This is a homelike environment where people have a tremendous feeling of being in their own home. And I think we sometimes forget how much having your own home contributes to your psychological well-being.”
However, Vermilyea hopes that ALCs don’t overestimate or oversell what they can do clinically to fill units. At Signature, she says, they have a corporate foundation to provide resources and education for their ALCs.
Alec Pruchnicki, MD, physician in residence at Lott Residence, an assisted living facility in New York City, says, “There is always a conflict between the social and medical model in assisted living.” To maintain an emphasis on social while providing clinical services, Lott Residence has all of its medical offices, exam rooms, and equipment in the basement—basically out of sight to visitors and residents.
“When you come in and walk around, it looks like a regular apartment building, not a nursing home,” he says. However, a growing number of residents need the clinical services offered there.
“I have seen residents getting sicker, and we are bringing in more services to accommodate the growing acuity,” Pruchnicki says. For example, Lott Residence has brought in more physical therapy services, and it is hoping to bring a cardiology group into the community to do regular testing with cardiologists and technicians on site.

Managing Transitions

Pruchnicki and his team understand the value of smooth transitions to managing sicker residents. “We try to improve communications between settings as much as possible,” he says. “Our social workers act as case managers, and they are in touch with hospital staff when a resident goes to the emergency room or is admitted.” This is important as “some people outside of this setting don’t understand how we work, what services we provide, and what limitations we have,” he says. This can result in residents coming back to Lott when they are still very sick.

“Communication at all levels is key to keeping things from falling through the cracks,” he says.

In theory, Pruchnicki says, “We have guidelines and policies about who we can care for. All of our residents are supposed to be ambulatory. If a patient is too sick for standard services, they should be in a nursing home. However, often the resident or family is resistant to the move.” The community could go to court over this; however, that can be time-consuming and leave the resident at risk and create burdens for staff in the meantime.

Pruchnicki suggests that ALCs make it clear on admission exactly what services are available and at what point they won’t be able to care for a resident. People may forget over time, he says, so it might be helpful to put it in writing.

There are ways to increase the medical presence in the ALC without huge additional investments in money or capital, he says. For example, “You can go to nearby hospitals or an area medical group and suggest an arrangement where a physician comes to your facility on a regular basis or sets up an office there. It takes some time and effort, but the end result can be a mutually beneficial arrangement,” he says.

“You can’t underestimate the value of a clinical presence. Our residents are on the cusp. A little primary care can go a long way to keeping them out of the hospital.”