Residential Care Communities and Their Residents in 2010: a National Portrait March 2016

Residential Care Communities and Their Residents in 2010: A National Portrait March 2016

SERVICES AN • U M S U.S. Department of U A H & Health and Human Services

H T

A Centers for Disease Control

O and Prevention

R National Center for A P E

Health Statistics Authors & Production Contact Information

RTI International For e-mail updates on NCHS publication Galina Khatutsky, MS releases, subscribe online at: Catherine Ormond, MS http://www.cdc.gov/nchs/govdelivery.htm Joshua M. Wiener, PhD For questions or general information: Angela M. Greene, MBA, MS National Center for Health Statistics Ruby Johnson, MA, MS 3311 Toledo Road E. Andrew Jessup Room 5419 Emily Vreeland, BA Hyattsville, MD 20782

National Center for Health Statistics, Tel: 1–800–CDC–INFO (1–800–232–4636) Long-Term Care Statistics Branch TTY: 1–888–232–6348 Internet: http://www.cdc.gov/nchs Manisha Sengupta, PhD Online request form: http://www.cdc.gov/info Christine Caffrey, PhD Lauren Harris-Kojetin, PhD

All material appearing in this report is in the Khatutsky G, Ormond C, Wiener JM, Greene AM, Johnson public domain and may be reproduced or R, Jessup EA, Vreeland E, Sengupta M, Caffrey C, Harris- Kojetin L. Residential care communities and their residents in copied without permission; citation as to 2010: A national portrait. DHHS Publication No. 2016-1041. source, however, is appreciated. Hyattsville, MD: National Center for Health Statistics. 2016. Acknowledgments

The authors are grateful to Emily Rosenoff of The authors express their gratitude to the the U.S. Department of Health and Human directors and administrators of assisted living Services, Office of the Assistant Secretary for and similar residential care communities Planning and Evaluation (ASPE), Office of who took the time to participate in the Disability, Aging, and Long-Term Care Policy, National Survey of Residential Care Facilities for her continued support for this project. (NSRCF). The authors gratefully acknowledge The authors acknowledge the following the following organizations for their support National Center for Health Statistics staff toward the successful completion of the for their contributions to the NSRCF: Abigail NSRCF by encouraging participation in the Moss, Genevieve Strahan, Frederic Decker, survey: LeadingAge, formerly the American Iris Shimizu, Roberto Valverde, Anita Association of Homes and Services for Bercovitz, Lisa Dwyer, and Eunice Park-Lee. the Aging; American Seniors Housing The authors thank Nataliya Kravets from the Association (ASHA); Argentum (formerly Research Data Center of the National Center Assisted Living Federation of America); for Health Statistics for her analytic support. National Center for Assisted Living (NCAL); Center for Excellence in Assisted Living (CEAL); and the Board and Care Quality Forum. Table of Contents

Executive Summary � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8

Chapter 1 Introduction ...... 11 Chapter 2 Basic Community Characteristics ...... 13 Chapter 3 Resident Health and Health Care Services Use...... 22 Chapter 4 Dementia and Cognitive Impairment among Residents...... 32 Chapter 5 Services Offered by Residential Care Communities and Used by Residents . . . . 42 Chapter 6 Workforce...... 48 Chapter 7 Access and Affordability ...... 56 Chapter 8 Environment ...... 63

Definitions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �71 Data Sources and Methods � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �74 References � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �76 List of Figures

Figure 2-1 Percent distribution and number of residential care communities and residents, by bed size: United States, 2010 ...... 14 Figure 2-2 Percent distribution of residential care communities, by Census region and bed size: United States, 2010 ...... 15 Figure 2-3 Percentage of residential care communities, by location, ownership, chain affiliation, years in operation, and Census region: United States, 2010 ...... 16 Figure 2-4 Percent distribution of residential care communities, by bed size and years in operation: United States, 2010 ...... 17 Figure 2-5 Percent distribution of residential care communities, by co-location and continuing care community status: United States, 2010 ...... 18 Figure 2-6 Percent distribution of total annual industry charges for all residential care residents, by bed size: United States, 2010 ...... 19 Figure 2-7 Percent distribution of residential care community residents, by age, sex, race/ethnicity, education, and marital status: United States, 2010 ...... 20 Figure 2-8 Percent distribution of residential care community residents, by length of stay at time of survey: United States, 2010 ...... 21 Figure 3-1 Percentage of residential care community residents, by the 10 most common chronic conditions and age: United States, 2010 ...... 23 Figure 3-2 Percentage of residential care community residents, by memory limitations, behavioral symptoms, serious mental illness, intellectual and developmental disabilities, and age: United States, 2010 ...... 24 Figure 3-3 Percentage of residential care community residents, by incontinence, falls, walker and wheelchair use, and age: United States, 2010 ...... 25 6

Figure 3-4 Percentage of residential care community residents, by Figure 4-5 Percentage of residential care community residents, by assistance with types of activities of daily living (ADLs) and cognitive impairment or dementia status and use of age: United States, 2010 ...... 26 emergency department, hospital overnight, and nursing or rehabilitation facility in the past 12 months: United States, 2010 ...... 37 Figure 3-5 Percentage of residential care community residents, by assistance with number of activities of daily living (ADLs) Figure 4-6 Percentage of residential care community residents, by and age: United States, 2010 ...... 27 cognitive impairment or dementia status, living in facilities with various admission and discharge policies: United States, 2010. . . . 38 Figure 3-6 Percentage of residential care community residents, by need for help with types of instrumental activities of daily living Figure 4-7 Percent distribution of residential care community residents (IADLs) and age: United States, 2010 ...... 28 with cognitive impairment or dementia, by behavioral symptom status in the last 30 days and treatment status: Figure 3-7 Percentage of residential care community residents, by need United States, 2010 ...... 39 for help with number of instrumental activities of daily living (IADLs) and age: United States, 2010 ...... 29 Figure 4-8 Mean annual charges for residential care community residents with cognitive impairment or dementia, by Figure 3-8 Percentage of residential care community residents, by dementia care setting: United States, 2010 ...... 40 limitations in basic physical activities and age: United States, 2010 . . . . 30 Figure 4-9 Percent distribution of total annual industry charges Figure 3-9 Percentage of residential care community residents, by use for residential care community residents with cognitive of emergency department, hospital overnight, and nursing impairment or dementia, by dementia care setting: United facility or rehabilitation facility in the past 12 months and States, 2010 ...... 41 age: United States, 2010 ...... 31 Figure 5-1 Percentage of residential care community residents, by Figure 4-1 Percent distribution of residential care community residents, availability and use of selected health and long-term care by cognitive impairment or dementia status: United States, 2010 . . . . . 33 services: United States, 2010 ...... 43 Figure 4-2 Mean age and percentage of residential care community Figure 5-2 Percentage of residential care community residents, by residents, by cognitive impairment or dementia status and availability and use of selected supportive services: United resident characteristics: United States, 2010 ...... 34 States, 2010 ...... 44 Figure 4-3 Percent distribution of residential care community residents Figure 5-3 Percentage of residential care communities, by availability of with cognitive impairment or dementia, by dementia care medication management services: United States, 2010 ...... 45 setting and community bed size: United States, 2010 ...... 35 Figure 5-4 Percent distribution of residential care communities, Figure 4-4 Percentage of residential care community residents, by by vaccination practices and types, and percentage of cognitive impairment or dementia status and use of ADL vaccinated residents in residential care communities, by assistance, incontinence care, and skilled nursing services: vaccination type: United States, 2010...... 46 United States, 2010 ...... 36 7

Figure 5-5 Percent distribution of residential care communities, by Figure 7-4 Annual mean charges for residential care community stage of written plan for management of residents during an residents, by Medicaid enrollment and cognitive status: influenza pandemic: United States, 2010 ...... 47 United States, 2010 ...... 60 Figure 6-1 Percentage of residential care communities employing staff, Figure 7-5 Annual mean charge for residential care community by staff type and use of contract workers: United States, 2010 ...... 49 residents, by bed size: United States, 2010 ...... 61 Figure 6-2 Mean hours per resident per day, by staff type: United States, 2010. . . .50 Figure 7-6 Percentage of residential care communities where at least one resident moved out because of cost, by bed size: United Figure 6-3 Mean hours per resident per day, by staff type and bed size: States, 2010 ...... 62 United States, 2010 ...... 51 Figure 8-1 Percent distribution of residential care community residents, Figure 6-4 Percent distribution of residential care communities, by by living arrangements and bed size: United States, 2010 ...... 64 hours of initial formal training required of personal care aides: United States, 2010...... 52 Figure 8-2 Percentage of residential care community residents, by policies supporting a homelike environment and bed size: Figure 6-5 Percentage of residential care communities, by fringe United States, 2010 ...... 65 benefits offered to personal care aides and bed size: United States, 2010 ...... 53 Figure 8-3 Percentage of residential care community residents, by features of rooms and apartments and community bed size: Figure 6-6 Percent distribution of residential care communities, United States, 2010 ...... 66 by qualifications and background of residential care community directors: United States, 2010 ...... 54 Figure 8-4 Percentage of residential care community residents, by services offered that support a homelike environment and Figure 6-7 Annual turnover rates of residential care communities, by bed size: United States, 2010 ...... 67 staff type and bed size: United States, 2010 ...... 55 Figure 8-5 Percentage of residential care community residents, by Figure 7-1 Number of beds per 1,000 persons aged 85 and over, by participation in social activities at least twice a month and setting and Census region: United States, 2010 ...... 57 bed size: United States, 2010 ...... 68 Figure 7-2 Percentage of residents living in residential care Figure 8-6 Percent distribution of residential care community residents, communities, by admission and discharge policies: by visitors in the past 30 days and bed size: United States, 2010 ...... 69 United States, 2010 ...... 58 Figure 8-7 Percentage of residential care community residents living Figure 7-3 Percentage of residential care communities serving where volunteers provided social/religious activities, by Medicaid beneficiaries and percentage of residents using community bed size: United States, 2010 ...... 70 Medicaid to pay for long-term care services, by bed size: United States, 2010 ...... 59 Executive Summary Residential Care Communities and Their Residents in 2010: A National Portrait

Assisted living and similar residential care communities provide services to individuals who cannot live independently but generally do not require the skilled level of care provided by nursing homes. With the aging of the population, the number of individuals needing this type of care is expected to increase in the future. Residential care communities will likely continue to be an important part of the long-term care system as their numbers increase to meet the growing demand. Using data from the first-ever national study of residential care communities with four or more beds, the National Survey of Residential Care Facilities (NSRCF), this chartbook presents national findings on residential care communities and residents in the United States in 2010.

Chapter 2� Basic Community Characteristics

● There were 733,300 current residents living in 31,100 residential care communities in 2010 (Figure 2-1).

● Half of all residential care communities (50%) were small (4–10 beds). The rest were medium-sized (11–25 beds; 16%), large (26–100 beds; 28%), and extra-large communities (over 100 beds; 7%) (Figure 2-1).

● Residents of residential care communities were charged $28 billion for room, board, and services in 2010 (Figure 2-6). Residential Care Communities and Their Residents in 2010: A National Portrait 9 Chapter 1: Introduction

Chapter 3� Resident Health and Health Care Services Use ● Residents with cognitive impairment or dementia living in the dementia care unit of a community were charged $52,200. ● The 10 most common chronic conditions for residents living in residential care communities included, in descending order, Residents with cognitive impairment or dementia living in hypertension (57%), Alzheimer’s disease and other dementias residential care communities that exclusively served people with (42%), heart disease (34%), depression (28%), arthritis (27%), dementia were charged, on average, $53,700 (Figure 4-8). osteoporosis (21%), diabetes (17%), chronic obstructive Chapter 5� Services Offered by Residential Care Communities and pulmonary disease (15%), cancer (11%), and stroke (11%) Used by Residents (Figure 3-1). ● Almost all residents lived in residential care communities that ● Most residential care community residents received assistance offered assistance with activities of daily living (ADLs) (100%), with bathing (72%), followed by dressing (52%), toileting (35%), basic health monitoring (97%), and incontinence care (94%). and eating (22%) (Figure 3-4). Among the services studied, skilled nursing care (40%) and social ● Over one-third of residential care community residents (35%) services counseling (44%) were least commonly offered (Figure had had an emergency department visit and almost one-quarter 5-1 and Figure 5-2). (24%) had had an overnight hospital stay in the 12 months before ● Nearly all residents lived in residential care communities that the survey (Figure 3-9). provided social and recreational activities (100%); most also Chapter 4� Dementia and Cognitive Impairment among Residents provided transportation to medical appointments (84%) and stores (86%) (Figure 5-2). ● Sixty percent of all residents in residential care communities had symptoms indicating some level of cognitive impairment, and ● Among services offered by residential care communities, basic almost half of all residents (42%) were diagnosed with Alzheimer’s health monitoring (75%), assistance with ADLs (69%), and disease or other dementias (Figure 4-1). incontinence care (38%) were the top services most used by residential care residents (Figure 5-1) . ● Thirty-five percent of residents with cognitive impairment or dementia lived in residential care communities with dementia ● A majority of residential care residents had been vaccinated care units—14% in the dementia care unit and 21% in a non- against influenza in the 12 months prior to the survey (70%); 32% dementia care unit within the community (Figure 4-3). of all residents had received vaccination against pneumonia in the past 12 months (Figure 5-4). ● Thirty-seven percent of residents with cognitive impairment or dementia had a visit to an emergency department in the last 12 months, compared with 32% of residents without cognitive impairment or dementia (Figure 4-5). Residential Care Communities and Their Residents in 2010: A National Portrait 10 Executive Summary

Chapter 6� Workforce Chapter 8� Environment

● More than one-third of all residential care communities (37%) ● About three-quarters of all residents in residential care employed at least one RN; almost all communities (94%) communities (74%) lived in apartments or single rooms. The employed personal care aides (PCAs) (Figure 6-1). percentage of residents living in apartments was greater in communities with more than 25 beds (49%) than in communities ● On average, residential care community staff provided about 2 hours and 19 minutes of total direct care, but only about with fewer beds (10%) (Figure 8-1). 14 minutes of licensed nursing care, per resident per day ● Overall, 87% of all residents in residential care communities had (Figure 6-2). a bathroom located inside their room or apartment; 77% of all residents had doors that could be locked from the inside; and 44% ● Almost all residential care communities (96%) required formal PCA training prior to working at the community; almost two- had any cooktop, hot plate, oven, or microwave in their room or thirds of communities (64%) required training of less than 75 apartment (Figure 8-3). hours (Figure 6-4). ● In the 30 days prior to the survey, 42% of residents living in residential care communities received visitors at least several ● Turnover rates in residential care communities were highest for PCAs (38%) and lowest for directors (16%) (Figure 6-7). times a week, about one-fourth (26%) had visitors weekly, and one-third (33%) were visited less frequently, including almost one- Chapter 7� Access and Affordability tenth (9%) who had no visitors (Figure 8-6).

● Residential care communities on average provided 177 beds per 1,000 persons aged 85 and over (Figure 7-1).

● In 2010, the mean total charge per residential community resident nationally was $38,000 per year (Figure 7-4).

● The mean total charge per Medicaid resident was approximately $26,200 per year, which was $14,600 less than charges to non- Medicaid residents. Charges were not the amounts paid by Medicaid (Figure 7-4). 1 Introduction

Residential care communities are an important and largely underexamined component of the long-term services and support system, in part because the federal government provides only a modest proportion of direct funding via Medicaid and few federal regulations since regulation is mainly at the state level. Residential care communities may be especially appropriate for people with disabilities who need supervision, but not necessarily a lot of hands-on and skilled care, such as people with mid-stage Alzheimer’s disease. In 2010, the nation’s 31,100 residential care communities served primarily older people, as well as younger persons with physical disabilities—733,300 residents in all (Caffrey et al., 2012; Park-Lee et al., 2011). By comparison, in 2010, 15,682 nursing facilities provided services to 1,396,448 residents (American Health Care Association, 2010). As the population ages and the need for long-term services and supports grows (Johnson, Toohey, & Wiener, 2007), the demand for residential care communities is likely to increase.

To provide information about this critical component of the long-term services and supports system, this chartbook presents data from the 2010 National Survey of Residential Care Facilities (NSRCF) (Moss, Harris-Kojetin, & Sengupta, 2011). Findings from this report will be of interest to providers, consumer advocates, researchers, and federal and state policymakers. The NSRCF, a nationally representative survey of licensed or otherwise regulated residential care providers in the United States, collected a broad array of data on residential care communities and residents. Residential Care Communities and Their Residents in 2010: A National Portrait 12 Chapter 1: Introduction

Common names for these settings include assisted living facilities, residential care homes, personal care homes, residential care facilities, and adult family homes. The survey was conducted by the National Center for Health Statistics (NCHS) with support from the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, the Department of Veterans Affairs, and other federal agencies. Although the term “residential care facilities” was used in the name of the survey, many providers now prefer the term “residential care communities,” which is used in this chartbook. For more information on the 2010 NSRCF, see http://www.cdc.gov/nchs/nsrcf.htm. There is currently no plan to repeat the 2010 NSRCF in future years, but NCHS will continue to monitor residential care communities as part of the National Study of Long-Term Care Providers (NSLTCP) (Harris-Kojetin, Sengupta, Park-Lee, and Valverde, 2013). For more information on the NSLTCP, see http://www.cdc.gov/nchs/nsltcp.htm. Basic Community 2 Characteristics

This chapter describes characteristics of residential care communities and presents a demographic profile of the residents who live in them. It examines the size, geographical variation, operating characteristics, co-location with other settings, and annual industry charges of residential care communities. It also examines selected characteristics and length of stay of residents living there. Residential Care Communities and Their Residents in 2010: A National Portrait 14 Chapter 2: Basic Community Characteristics

FIGURE 2-1 Percent distribution and number of residential care communities and residents, by bed size: United States, 2010

Small (4–10 beds) Medium (11–25 beds) Large (26–100 beds) Extra large (over 100 beds)

100 7% (2,100)

29% (208,900) 80 28% (8,700)

60 16% (4,900) 52% Percent (381,800) 40

50% (15,400) 20 9% (67,000)

10% (75,700) 0 Residential care communities Residents (N=31,100) (N=733,300)

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● There were 733,300 residents living in 31,100 residential care communities in 2010. Half of all communities were small, with 4–10 beds. The rest were medium-sized (16%), large (28%), and extra large communities (7%). ● More than half of all residents (52%) lived in large communities, and 29% lived in extra large communities. Only 10% of all residents lived in small communities; 9% lived in medium-sized communities. Residential Care Communities and Their Residents in 2010: A National Portrait 15 Chapter 2: Basic Community Characteristics

FIGURE 2-2 Percent distribution of residential care communities, by Census region and bed size: United States, 2010

Small (4–10 beds)1 Medium (11–25 beds)2 Large (26–100 beds)3 Extra large (over 100 beds)

100 † †6 †8 5 †16 14 80 7 35 35

60 55

18 Percent 29 40 75

20 21 39 31

8 0 Northeast (N=2,600) Midwest (N=6,900) South (N=8,400) West (N=13,200)

1 Regions are significantly different from each other in the percentage of small facilities at p<.05. † Estimate does not meet standard of reliability or precision because the sample size is 30–59, or the sample size is greater than 2 Regions are significantly different from each other in the percentage of medium facilities at p<.05. 59 but has a relative standard error of 30 percent or more. 3 The Northeast and the West are significantly different from all other regions in the percentage of large facilities at p<.05. NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● There were 2,600 residential care communities in the Northeast, 6,900 in the Midwest, 8,400 in the South, and 13,200 in the West. ● The Northeast had the highest percentage of large communities (55%) compared with other regions. ● The West had the highest percentage of small communities (75%) compared with other regions. Residential Care Communities and Their Residents in 2010: A National Portrait 16 Chapter 2: Basic Community Characteristics

FIGURE 2-3 Percentage of residential care communities, by location, ownership, chain affiliation, years in operation, and Census region: United States, 2010

All residential care communities Northeast Midwest South West

100 93 91 86 82 81 79 81 80 76

64 64 63 62 60 56 56 47 49

Percent 38 39 40 33 31

0 Located within a metropolitan Privately owned, for-profit2 Chain affiliated3 10+ years in operation4 statistical area1 1 Differences between regions are significant at p<.05, except between Northeast and South. 3 Differences between regions are significant at p<.05, except between Northeast and West. 2 Differences between regions are significant at p<.05, except between Northeast and Midwest. 4 Differences between regions are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● The majority of all residential care communities (81%) were located in metropolitan statistical areas. This pattern was more common in the West (91%) and less common in the Midwest (64%). ● Eighty-two percent of all communities were owned by private, for-profit organizations. A lower percentage of communities in the Northeast and Midwest were for-profit (63% and 64%, respectively) than in the South and West (86% and 93%, respectively). ● Overall, 38% of all communities were owned by chains, with ownership highest in the Midwest. Almost half of all communities in the Midwest were owned by chains; in the Northeast and the West, chains owned about a third of residential care communities. ● Seventy-six percent of communities in the Northeast had been operating for 10 or more years, which was higher than in other regions. The West had the lowest percentage of communities (49%) that had been operating for 10 or more years. Residential Care Communities and Their Residents in 2010: A National Portrait 17 Chapter 2: Basic Community Characteristics

FIGURE 2-4 Percent distribution of residential care communities, by bed size and years in operation: United States, 2010

Less than 10 years 10 or more years1

100

†20 29 34 80 44 59

60 Percent 40 80 71 66 56 20 41

0 All residential care communities Small Medium Large Extra large (4–10 beds) (11–25 beds) (26–100 beds) (over 100 beds)

1 Differences between small, medium, and large bed size categories are significant at p<.05. NOTE: Estimates may not add up to totals because of rounding. † Estimate does not meet standard of reliability or precision because the sample size is 30–59, or the sample size is greater than 59 but has a relative standard error of 30 percent or more. SOURCE: CDC/NCHS, 2010 NSRCF.

● Overall, 44% of all residential care communities had been operating for fewer than 10 years. ● More than half of the small communities (59%) had been operating fewer than 10 years. Residential Care Communities and Their Residents in 2010: A National Portrait 18 Chapter 2: Basic Community Characteristics

FIGURE 2-5 Percent distribution of residential care communities, by co-location and continuing care community status: United States, 2010

100 100 Part of a continuing care 6 7 Co-located with independent retirement community 5 apartments and a nursing facility or rehabilitation facility 80 12 80 Co-located with a nursing facility or rehabilitation facility

60 60 Co-located with independent apartments Not part of a continuing care 94 Percent Percent retirement community 40 40 76 Freestanding communities

20 20

0 0 Co-location Continuing care retirement community

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Most residential care communities (76%) were freestanding. ● Twelve percent of all communities were co-located on the same grounds with independent living apartments, 5% were co- located with nursing facilities or rehabilitation facilities, and 7% were co-located with independent living apartments and nursing facilities and/or rehabilitation facilities. ● Only 6% of all communities were part of continuing care retirement communities—communities that offer multiple levels of care, such as independent living, residential care, and skilled nursing care, so that residents can remain in the same community as their needs change. Residential Care Communities and Their Residents in 2010: A National Portrait 19 Chapter 2: Basic Community Characteristics

FIGURE 2-6 Percent distribution of total annual industry charges for all residential care residents, by bed size: United States, 2010

Living in small communities (4–10 beds) 11% Living in medium communities Living in extra large ($3 billion) (11–25 beds) communities (over 100 beds) 7% ($2 billion) 31% ($9 billion)

51% ($14 billion)

Living in large communities (26–100 beds)

Total annual industry charges for all residents = $28 billion

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Residents of residential care communities were charged $28 billion for room, board, and services in 2010. ● Large communities accounted for 51% of the total annual industry charges ($14 billion), followed by extra-large communities, which accounted for 31% ($9 billion). ● Small and medium-sized communities accounted for 11% and 7% of the total annual industry charges, respectively ($3 billion and $2 billion). Residential Care Communities and Their Residents in 2010: A National Portrait 20 Chapter 2: Basic Community Characteristics

FIGURE 2-7 Percent distribution of residential care community residents, by age, sex, race/ethnicity, education, and marital status: United States, 2010

100

80 Ages 85 54 High school and over 59 education 63 Widowed 70 Female or less 60 Non- 91 Hispanic white Percent 40 27 Ages 75–84

More than 20 41 high school Not degree 37 9 Ages 65–74 30 Male widowed Under 11 age 65 9 Other 0 Age of residents Sex of residents Race/ethnicity Education of Marital status of residents residents of residents

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● More than half of all residents (54%) were aged 85 or over, and more than one-quarter (27%) were aged 75–84. Of the remainder, 9% were aged 65–74 and 11% were under age 65. ● Nine in 10 residents in residential care communities (91%) were non-Hispanic white, 7 in 10 residents (70%) were female, and about 6 in 10 residents (63%) were widowed. Fifty-nine percent of all residents had a high school education or less. Residential Care Communities and Their Residents in 2010: A National Portrait 21 Chapter 2: Basic Community Characteristics

FIGURE 2-8 Percent distribution of residential care community residents, by length of stay at time of survey: United States, 2010

0–3 months Over 5 years

9% 4–5 months 15% 9% 4–5 years

16% 14%

6–11 months

36%

1–3 years

The average length of stay was 2.7 years

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● At the time of the survey, residents had lived in their residential care communities an average of 2.7 years. ● About one-third of all residents (32%) had been living in their residential care communities for less than a year. ● More than one-third of all residents (36%) had been in their residential care communities for 1–3 years, 16% had resided there for 4–5 years, and 15% had been living in their communities for more than 5 years. Resident Health and 3 Health Care Services Use

This chapter describes resident health and functional status and the use of health care services for those living in residential care communities. The chapter describes common chronic conditions, functional limitations in basic and instrumental activities of daily living (ADLs and IADLs), use of assistive devices, and hospital and emergency department visits. Residential Care Communities and Their Residents: A National Portrait 23 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-1 Percentage of residential care community residents, by the 10 most common chronic conditions and age: United States, 2010 All residents Under 65 years 65 years and over Percent 0 10 20 30 40 50 60

57 Hypertension1 40 59 42 Alzheimer’s disease and other dementias1 12 46 34 Heart disease1 11 37 28 Depression1 39 26 27 Arthritis1 12 29 21 Osteoporosis1 5 22 17 Diabetes1 25 16 15 Chronic obstructive pulmonary disease (COPD) 17 15 11 Cancer1 5 11 11 Stroke 9 11 1 Differences between age groups are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● The 10 most common chronic conditions for all residents included, in descending order, hypertension (57%), Alzheimer’s disease and other dementias (42%), heart disease (34%), depression (28%), arthritis (27%), osteoporosis (21%), diabetes (17%), chronic obstructive pulmonary disease (COPD; 15%), cancer (11%), and stroke (11%). ● Hypertension, Alzheimer’s disease and other dementias, heart disease, arthritis, osteoporosis, cancer, and stroke were more prevalent among residents aged 65 and over than among residents under age 65. ● A higher percentage of residents under age 65 had depression, diabetes, or COPD than did residents aged 65 and over. Residential Care Communities and Their Residents: A National Portrait 24 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-2 Percentage of residential care community residents, by memory limitations, behavioral symptoms, serious mental illness, intellectual and developmental disabilities, and age: United States, 2010

All residents Under 65 years 65 years and over

60 57 56 53

40 39 40 38 36

30 Percent

20 20

10 8 4 3 1 0 Any memory limitations1 Any behavioral symptoms Serious mental illness1 Intellectual and in the last 30 days1 developmental disabilities1

1 Differences between age groups are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Over half of all residents (56%) suffered from memory limitations; the prevalence of memory limitations was higher for residents aged 65 and over than it was for residents under age 65. ● More than half of all residents under age 65 (53%) exhibited behavioral symptoms in the 30 days before the survey, almost 40% suffered from serious mental illness, and 20% had intellectual or developmental disabilities. ● Among residents aged 65 and over, 36% of residents exhibited behavioral symptoms in the 30 days before the survey, 4% had severe mental illness, and 1% had intellectual or developmental disabilities. Residential Care Communities and Their Residents: A National Portrait 25 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-3 Percentage of residential care community residents, by incontinence, falls, walker and wheelchair use, and age: United States, 2010

All residents Under 65 years 65 years and over

50 50 46

40 40 38

30 27 28

Percent 25 20 20 16 15 14 10 10

0 Was incontinent (any type)1 Fell in the past 12 months and sustained a Used a walker1 Used a wheelchair (any kind)1 hip fracture or other injury1

1 Differences between age groups are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost 40% of all residents had some type of incontinence (urinary or fecal) at the time of the survey. Incontinence rates were higher in residents aged 65 and over (40%) than in younger residents (25%). ● In the 12 months before the survey, about 15% of all residents experienced a fall with an injury. Falls with injuries were higher in residents aged 65 and over (16%) than in younger residents (10%). ● Almost half of all residents (46%) used walkers, and more than a quarter (27%) used wheelchairs. ● Walker and wheelchair use varied by age, with younger residents relying less on these devices than older residents. For example, only 14% of residents under age 65 used a walker, compared with 50% of residents aged 65 and over. Residential Care Communities and Their Residents: A National Portrait 26 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-4 Percentage of residential care community residents, by assistance with types of activities of daily living (ADLs) and age: United States, 2010

All residents Under 65 years 65 years and over

80 75 72

60 54 52 50

40 37 35 Percent 32

22 22 20 18 17 13 14

†4

0 Bathing1 Dressing1 Toileting1 Eating1 Transferring

1 Differences between age groups are significant at p<.05. † Estimate does not meet standard of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent or more. SOURCE: CDC/NCHS, 2010 NSRCF.

● Most residents received assistance with bathing (72%), followed by dressing (52%), toileting (35%), eating (22%), and transferring (13%). ● Compared with younger residents, a higher percentage of residents aged 65 and over received assistance with ADLs: three- quarters of residents aged 65 and over (75%) received assistance with bathing, more than half (54%) received help with dressing, 37% received help with toileting, and 22% received assistance with eating. Residential Care Communities and Their Residents: A National Portrait 27 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-5 Percentage of residential care community residents, by assistance with number of activities of daily living (ADLs) and age: United States, 2010

All residents Under 65 years 65 years and over

50 46

40 39 37 37 37 35

30 26 23 Percent 20 18

0 No ADLs1 1–2 ADLs 3+ ADLs1

1 Differences between age groups are significant at p<.05. NOTE: ADLs included were bathing, dressing, toileting, eating, and transferring. On average, residents received assistance with 1.9 ADLs; residential care community residents under age 65 years received help with fewer ADLs (1.2 ADLs) than residents 65 years and over (2.0 ADLs). SOURCE: CDC/NCHS, 2010 NSRCF.

● About three-quarters of all residents (74%) received assistance with at least one ADL; about one-third of all residents (37%) received assistance with three or more ADLs. ● Almost 40% of residents aged 65 and over (39%) received assistance with three or more ADLs, compared with 18% of residents under age 65. Residential Care Communities and Their Residents: A National Portrait 28 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-6 Percentage of residential care community residents, by need for help with types of instrumental activities of daily living (IADLs) and age: United States, 2010

All residents Under 65 years 65 years and over

100 93 87 87 80 81 77 80 75 75 73 74

63 60 56 Percent

40 34 35 28

0 Taking medications1 Managing money1 Shopping1 Housekeeping1 Using a phone1

1 Differences between age groups are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Most residents needed help with taking medications (87%), managing money (80%), shopping (75%), and housekeeping (74%); about one-third (34%) needed help using a phone. ● Compared with residents under age 65, more residents aged 65 and over needed help with all IADLs, except taking medications. Residential Care Communities and Their Residents: A National Portrait 29 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-7 Percentage of residential care community residents, by need for help with number of instrumental activities of daily living (IADLs) and age: United States, 2010

All residents Under 65 years 65 years and over

80 77 78

40 32 Percent

19 20 17

5 5 †3 0 No IADLs 1–2 IADLs1 3+ IADLs1

1 Differences between age groups are significant at p<.05. NOTE: IADLs included taking medications, managing money, shopping, housekeeping, and using a phone. On average, residents † Estimate does not meet standard of reliability or precision because the sample size is between 30 and 59, or the sample size is needed help with 2.2 IADLs; residential care community residents under age 65 years needed help with more IADLs greater than 59 but has a relative standard error of 30 percent or more. (2.3 IADLs) than residents 65 years and over (2.2 IADLs). SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost all residents had at least one IADL impairment; 5% of all residents reportedly had no IADL limitations. ● More than three-fourths of all residents (77%) had needs in three or more IADLs. ● Almost 80% of residents aged 65 and over (78%) received assistance with three or more IADLs, compared with 65% of residents under age 65. Residential Care Communities and Their Residents: A National Portrait 30 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-8 Percentage of residential care community residents, by limitations in basic physical activities and age: United States, 2010

All residents Under 65 years 65 years and over

97 100 94 94 92 90 87

80 76 70 65 62 62 60

Percent 39 39 40 40 36 37 27 28

0 Limitations in at least 1 of the Standing or being on Stooping, bending, or Reaching up overhead1 Using fingers to grasp or Sitting for about 2 hours1 5 basic physical activities1 feet for about 2 hours1 kneeling1 handle small objects1

1 Differences between age groups are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost 95% of all residents had limitations in at least one of five basic physical activities. ● Most residents had difficulty with standing or being on their feet for about 2 hours (92%); stooping, bending, or kneeling (87%); and reaching up overhead (62%). ● Almost 40% of residents had difficulty using their fingers to grasp or handle small objects (39%) and sitting for about 2 hours (36%). ● Compared with residents under age 65, a greater percentage of residents aged 65 and over had limitations in each of the five basic physical activities studied. Residential Care Communities and Their Residents: A National Portrait 31 Chapter 3: Resident Health and Health Care Services Use

FIGURE 3-9 Percentage of residential care community residents, by use of emergency department, hospital overnight, and nursing facility or rehabilitation facility in the past 12 months and age: United States, 2010

All residents Under 65 years 65 years and over

35 35

31 30

24 24 23

20 Percent

10 8 8

†4

0 Emergency department visits Hospital overnight stays Nursing facility or rehabilitation facility stays

† Estimate does not meet standard of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent or more. SOURCE: CDC/NCHS, 2010 NSRCF.

● Over one-third of residents (35%) had had an emergency department visit in the 12 months prior to the survey. ● Almost one-quarter of residents (24%) had had an overnight hospital stay in the 12 months prior to the survey. ● Eight percent of residents had had a nursing or rehabilitation facility stay in the 12 months prior to the survey. ● Differences in emergency department, hospital overnight, and nursing or rehabilitation facility use in the 12 months prior to the survey did not vary by age. Dementia and Cognitive 4 Impairment among Residents

This chapter includes information about residents with cognitive impairment or dementia living in residential care communities and the admission and discharge policies that affect them, the services they receive, and the charges for their care. Residential Care Communities and Their Residents in 2010: A National Portrait 33 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-1 Percent distribution of residential care community residents, by cognitive impairment or dementia status: United States, 2010

Residents with cognitive impairment and no dementia Dx

18% Residents without cognitive impairment or dementia 40%

42%

Residents with Alzheimer's disease or other dementias

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Eighteen percent of all residents in residential care communities had symptoms indicating various levels of cognitive impairment, but they had not been diagnosed with dementia by a physician or other health care provider. ● Forty-two percent of all residents had been diagnosed with Alzheimer’s disease or other dementias by a physician or other health care provider. ● Forty percent of all residents had neither symptoms of cognitive impairment nor a diagnosis of dementia. Residential Care Communities and Their Residents in 2010: A National Portrait 34 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-2 Mean age and percentage of residential care community residents, by cognitive impairment or dementia status and resident characteristics: United States, 2010

Residents with cognitive impairment or dementia Residents without cognitive impairment or dementia

Years 78 79 80 81 82 83 84

83 Mean age1 80

Percent 0 20 40 60 80 100

Female1 72 66

Non-Hispanic white 91 92

Widowed1 66 58

Medicaid 18 20

With 3+ ADLs1 60 30

1 Differences between residents with and without cognitive impairment or dementia are significant at p<.05. NOTE: ADL= activities of daily living. Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● The mean age of residents with cognitive impairment or dementia (83 years) was greater than the mean age of residents without cognitive impairment or dementia (80 years) in the residential care communities. ● Compared with residents without cognitive impairment or dementia, a higher percentage of residents with cognitive impairment or dementia were female, widowed, and in need of assistance with three or more ADLs. Residential Care Communities and Their Residents in 2010: A National Portrait 35 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-3 Percent distribution of residential care community residents with cognitive impairment or dementia, by dementia care setting and community bed size: United States, 2010 100 7 8 7 †3 3 14 18 Lived in residential care communities 80 that exclusively served residents with dementia 21 26 Lived in dementia care units within 60 residential care communities Lived outside the dementia care unit

Percent 87 within residential care communities 40 that had such a unit1 Lived in residential care communities 57 49 that neither exclusively served 20 residents with dementia nor had dementia care units1

0 Residents with cognitive impairment Residents with cognitive impairment Residents with cognitive impairment or dementia in all communities or dementia in small/medium or dementia in large/extra large (N=435,700) communities (4–25 beds) communities (over 25 beds) (N=96,400) (N=339,300)

1 Differences between residents with cognitive impairment or dementia living in residential care communities with 4–25 beds and † Estimate does not meet standard of reliability or precision because the sample size is between 30 and 59, or the sample size is communities with over 25 beds are significant at p<.05. greater than 59 but has a relative standard error of 30 percent or more. NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Overall, 57% of residents with cognitive impairment or dementia lived in residential care communities that did not exclusively serve people with dementia or have a dementia care unit. ● Thirty-five percent of residents with cognitive impairment or dementia lived in residential care communities with dementia care units—14% in the dementia care unit and 21% in a non-dementia care unit within the community. ● Only 7% of residents with cognitive impairment or dementia lived in communities that exclusively served residents with dementia. ● Among residents with cognitive impairment or dementia in communities with 4–25 beds, 87% lived in communities that neither exclusively served residents with dementia nor had a dementia care unit, compared with 49% of such residents in larger communities. Residential Care Communities and Their Residents in 2010: A National Portrait 36 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-4 Percentage of residential care community residents, by cognitive impairment or dementia status and use of ADL assistance, incontinence care, and skilled nursing services: United States, 2010

Residents with cognitive impairment or dementia Residents without cognitive impairment or dementia

80 77

60 52 48

40 Percent

20 18 16

0 Any ADL assistance1 Incontinence care1 Skilled nursing services1

1 Differences between residents with and without cognitive impairment or dementia are significant at p<.05. NOTE: ADL= activities of daily living. SOURCE: CDC/NCHS, 2010 NSRCF.

● More than three-quarters of residents in residential care communities with cognitive impairment or dementia (77%) received any ADL assistance, compared to 52% of residents without cognitive impairment or dementia. ● Almost half of residents with cognitive impairment or dementia (48%) received incontinence care, compared to 18% of residents without cognitive impairment or dementia. ● Sixteen percent of residents with cognitive impairment or dementia received skilled nursing services, compared to 10% of residents without cognitive impairment or dementia. Residential Care Communities and Their Residents in 2010: A National Portrait 37 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-5 Percentage of residential care community residents, by cognitive impairment or dementia status and use of emergency department, hospital overnight, and nursing or rehabilitation facility in the past 12 months: United States, 2010

Residents with cognitive impairment or dementia Residents without cognitive impairment or dementia

40 37

25 24

20 Percent

10 8 7

0 Emergency department visits Hospital overnight stays Nursing facility or rehabilitation facility stays in the past 12 months1 in the past 12 months in the past 12 months

1 Differences between residents with and without cognitive impairment or dementia are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Thirty-seven percent of residents with cognitive impairment or dementia had had a visit to an emergency department in the last 12 months, compared with 32% of residents without cognitive impairment or dementia. ● There were no significant differences by resident cognitive impairment or dementia status in hospital overnight stays and nursing facility or rehabilitation facility stays in the last 12 months. Residential Care Communities and Their Residents in 2010: A National Portrait 38 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-6 Percentage of residential care community residents, by cognitive impairment or dementia status, living in facilities with various admission and discharge policies: United States, 2010

Residents with cognitive impairment or dementia Residents without cognitive impairment or dementia

59 60 54

50 41 39 40 36 32 30

Percent 24

20 18

0 Had policies to not admit, or admit on a Had policies to discharge residents who Had policies to not admit, or admit on a Had policies to discharge residents case-by-case basis, residents who exhibit exhibit problem behavior1 case-by-case basis, residents who have who have moderate to severe cognitive problem behavior1 moderate to severe cognitive impairment1 impairment1

1 Differences between residents with and without cognitive impairment or dementia are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Thirty-nine percent of residents with cognitive impairment or dementia lived in residential care communities that had policies not to admit residents who exhibited problem behavior, compared to 24% of residents without cognitive impairment or dementia. ● Fifty-nine percent of residents with cognitive impairment or dementia lived in communities that had discharge policies for residents exhibiting problem behavior, compared to 36% of residents without cognitive impairment or dementia. ● Forty-one percent of residents with cognitive impairment or dementia lived in communities with policies not to admit residents who had moderate to severe cognitive impairment, compared to 54% of residents without cognitive impairment or dementia. ● Eighteen percent of residents with cognitive impairment or dementia lived in communities with policies to discharge residents with moderate to severe cognitive impairment, compared to 32% of residents without cognitive impairment or dementia. Residential Care Communities and Their Residents in 2010: A National Portrait 39 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-7 Percent distribution of residential care community residents with cognitive impairment or dementia, by behavioral symptom status in the last 30 days and treatment status: United States, 2010

Residents without behavioral symptoms Residents with behavioral 61% symptoms

48% 52% Residents with behavioral symptoms who received medications to control behavior or reduce agitation Residents with behavioral 39% symptoms who did not receive medications to control behavior or reduce agitation

NOTE: The denominator for this figure is the 60% of all residential care community residents with cognitive impairment or dementia. Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Among the 60% of residential care community residents with cognitive impairment or dementia, 52% had exhibited behavioral symptoms in the 30 days before the survey. ● Of residents who had cognitive impairment or dementia and had had behavioral symptoms in the 30 days before the survey, 61% had been prescribed medications to help control behavior or to reduce agitation. Residential Care Communities and Their Residents in 2010: A National Portrait 40 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-8 Mean annual charges for residential care community residents with cognitive impairment or dementia, by dementia care setting: United States, 2010

$60,000 $53,700 $52,200 $50,000 $45,700 $40,900 $40,000 $34,700

$30,000 Dollars

$20,000

$10,000

$0 All residents with cognitive Residents living in communities Residents living in dementia Residents not living in dementia Residents living in communities impairment or dementia that exclusively served residents care units within residential care units within residential care that neither exclusively served with dementia care communities communities that had such units residents with dementia nor had dementia care units

SOURCE: CDC/NCHS, 2010 NSRCF.

● In 2010, all residents with cognitive impairment or dementia living in residential care communities were charged, on average, $40,900. ● Residents with cognitive impairment or dementia living in communities that exclusively served people with dementia were charged, on average, $53,700, and residents with cognitive impairment or dementia living in the dementia care unit of a community were charged, on average, $52,200. ● Residents with cognitive impairment or dementia not living in the dementia care unit of a community that had such units were charged, on average, $45,700, and residents with cognitive impairment or dementia living in communities that neither exclusively served residents with dementia nor had dementia care units were charged, on average, $34,700. Residential Care Communities and Their Residents in 2010: A National Portrait 41 Chapter 4: Dementia and Cognitive Impairment among Residents

FIGURE 4-9 Percent distribution of total annual industry charges for residential care community residents with cognitive impairment or dementia, by dementia care setting: United States, 2010

Residents living in communities that exclusively served residents with dementia 12% ($2 billion) Residents living in communities that neither Residents living in dementia exclusively served residents care units within residential with dementia nor had 18% care communities 47% dementia care units ($3 billion) ($8 billion)

24% ($4 billion)

Residents not living in dementia care units within residential care communities that had such units Total annual industry charges for residents with cognitive impairment or dementia = $17 billion

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Of the total annual industry charges for residents with cognitive impairment or dementia, equaling $17 billion, 12% of the charges were for residents living in residential care communities that exclusively served residents with dementia. ● Residents with cognitive impairment or dementia living in a community with a dementia care unit—either in the dementia care unit (18%) or outside the unit (24%)—made up 42% of the total annual industry charges. ● Forty-seven percent of the total annual industry charges were for residents with cognitive impairment or dementia living in residential care communities that neither exclusively served residents with dementia nor had dementia care units. Services Offered by Residential Care Communities 5 and Used by Residents

This chapter describes the health and long-term care services offered by residential care communities and used by residents. Residential Care Communities and Their Residents in 2010: A National Portrait 43 Chapter 5: Services Offered by Residential Care Communities and Used by Residents

FIGURE 5-1 Percentage of residential care community residents, by availability and use of selected health and long-term care services: United States, 2010

Services offered in the residential care community where resident lived Services used by resident

100 97 100 94 89

80 75 69

Percent 40 40 38 31

20 13

0 Assistance with activities of daily Basic health monitoring Incontinence care Special diets Skilled nursing living (ADLs) SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost all residents lived in residential care communities that offered assistance with ADLs (100%) and basic health monitoring (97%). These services were also the ones that were most used by residents (69% and 75%, respectively). ● Around 90% of all residents lived in residential care communities that offered incontinence care (94%) and special diets (89%), with about one-third of all residents having used these services (38% and 31%, respectively). ● Forty percent of all residents lived in residential care communities that offered skilled nursing care, and 13% of all residents used these services. Residential Care Communities and Their Residents in 2010: A National Portrait 44 Chapter 5: Services Offered by Residential Care Communities and Used by Residents

FIGURE 5-2 Percentage of residential care community residents, by availability and use of selected supportive services: United States, 2010

Services offered in the residential care community where resident lived Services used by resident

100 99 100 90 87 86 84 80 80

59 60

45 44 Percent 39 40

20 16

0 Social/recreational activities Personal laundry services Social/recreational activities Transportation to Transportation to medical Social services counseling in the residential care outside the residential care stores/elsewhere appointments community community SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost all residents lived in residential care communities that offered personal laundry services (99%) and social and recreational activities in (100%) and outside (90%) the community; 87%, 80%, and 45% of all residents used these services, respectively. ● Most residents lived in residential care communities that offered transportation services to stores (86%) and medical appointments (84%); 39% and 59% of all residents used these services, respectively. ● Forty-four percent of all residents lived in residential care communities that offered social services counseling, and 16% of all residents used the service. Residential Care Communities and Their Residents in 2010: A National Portrait 45 Chapter 5: Services Offered by Residential Care Communities and Used by Residents

FIGURE 5-3 Percentage of residential care communities, by availability of medication management services: United States, 2010

Percent 0 20 40 60 80 100

Staff provided oversight and cueing 92

Staff prompted that it was time 79 to take medications

Staff assisted residents with opening bottles 78 and handing correct doses

Staff assisted residents by putting medications in the resident’s mouth and 66 handing the resident a glass of water

SOURCE: CDC/NCHS, 2010 NSRCF.

● Most residential care communities provided oversight and cueing of medications (92%); 79% prompted residents to take medications, and 78% helped with opening bottles and handing correct doses. ● Two-thirds of all communities (66%) helped residents take medications by putting medications in residents’ mouths and handing them water. Residential Care Communities and Their Residents in 2010: A National Portrait 46 Chapter 5: Services Offered by Residential Care Communities and Used by Residents

FIGURE 5-4 Percent distribution of residential care communities, by vaccination practices and types, and percentage of vaccinated residents in residential care communities, by vaccination type: United States, 2010

Influenza vaccination Pneumonia vaccination

80 70

62 60 54

Percent 32

19 20 18 13 10 10 8 4 3 0 Personal MD order for Community-wide Advance MD/NP orders Preprinted admission None of the four % of residents vaccinated in each resident1 standing orders1 for all residents1 orders1 practices listed1 the past 12 months1

1 Differences between influenza vaccination and pneumonia vaccination are significant at p<.05. Estimates may not add up to totals because of rounding. NOTES: MD=medical doctor; NP=nurse practitioner. SOURCE: CDC/NCHS, 2010 NSRCF.

● For influenza, more than half of all residential care communities (54%) had a personal physician order on file for each resident, 19% had community-wide standing orders, 10% had advance medical doctor or nurse practitioner orders for all residents, and 4% had preprinted admission orders. ● For pneumonia, almost two-thirds (62%) of residential care communities had a personal physician order for each resident, 10% had community-wide standing orders, 8% had advance medical doctor or nurse practitioner orders for all residents, and 3% had preprinted admission orders. ● Seventy percent of all residents had been vaccinated for influenza and 32% of all residents had been vaccinated for pneumonia in the past 12 months. Residential Care Communities and Their Residents in 2010: A National Portrait 47 Chapter 5: Services Offered by Residential Care Communities and Used by Residents

FIGURE 5-5 Percent distribution of residential care communities, by stage of written plan for management of residents during an influenza pandemic: United States, 2010

Yes, in progress

14%

No, not started 41%

45% 87%

Yes, completed

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost 60% of all residential care communities had started (14%) or completed (45%) a written plan to manage residents during an influenza pandemic. ● Forty-one percent of all residential care communities had not started a written plan to manage residents during an influenza pandemic. 6 Workforce

This chapter includes information on the types of staff working in residential care settings, staffing ratios in residential care communities (measured in hours per resident per day), staff turnover, and training required of and fringe benefits offered to personal care aides (PCAs). The chapter also provides information on residential care community directors’ backgrounds and qualifications. Residential Care Communities and Their Residents in 2010: A National Portrait 49 Chapter 6: Workforce

FIGURE 6-1 Percentage of residential care communities employing staff, by staff type and use of contract workers: United States, 2010

100 94

83 80

60 Percent 40 37 32

20 16

0 Personal care aides Administrators providing Registered nurses Licensed Contract workers hands-on care practical/vocational nurses (all staff types)

SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost all residential care communities (94%) employed PCAs. ● In 83% of all communities, administrators, directors, assistant administrators, or assistant directors provided some hands- on direct care (ADL and IADL assistance) to residents. ● More than one-third of all communities (37%) employed at least one RN; 32% of all communities employed any LPNs or vocational nurses. ● About 16% of all communities used contract staff to supplement their regular employees. Residential Care Communities and Their Residents in 2010: A National Portrait 50 Chapter 6: Workforce

FIGURE 6-2 Mean hours per resident per day, by staff type: United States, 2010

RN care LPN/LVN care PCA care Administrator/Director direct care

Hours 0.0 0.5 1.0 1.5 2.0 2.5

All direct care 0.08 0.16 1.81 0.27 (Total = 2.32 hours)

All licensed nursing care (RNs and LPNs/LVNs) (Total = 0.24 hours)

NOTE: RN=registered nurse; LPN=licensed practical nurse; LVN=licensed vocational nurse; PCA=personal care aide. SOURCE: CDC/NCHS, 2010 NSRCF.

● On average, residents received nearly 2.32 hours (about 2 hours and 19 minutes) of total direct care per resident per day—including nursing and personal care. ● Averaging across all residents, regardless of whether RNs, LPNs, or vocational nurses were on staff, communities delivered an average of 0.24 hours (14.4 minutes) of total licensed nursing care per resident per day. The average resident received 0.08 hours of RN care (about 5 minutes) and 0.16 hours (about 10 minutes) of LPN or vocational nurse care. ● The large majority of care provided was delivered by PCAs, who provided an average of 1.81 hours (about 1 hour and 49 minutes) per resident per day. ● On average, community administrators provided 0.27 hours (about 16 minutes) of direct care per resident per day. Residential Care Communities and Their Residents in 2010: A National Portrait 51 Chapter 6: Workforce

FIGURE 6-3 Mean hours per resident per day, by staff type and bed size: United States, 2010

Small (4–10 beds) Medium (11–25 beds) Large (26–100 beds) Extra large (over 100 beds)

4.0 3.63

3.0 2.54

2.0 Hours 1.63

1.25 1.31

1.0

0.35 0.16 0.12 0.15 0.18 0.17 0.13 0.11 0.07 0.05 0.01 0.0 RN care1 LPN/LVN care1 PCA care1 Administrator/Director direct care1

● Each resident in residential care communities with 4–10 beds received, on average, 0.16 hours of RN care per day, compared with 0.05 hours in communities with over 100 beds. ● PCAs provided 3.63 hours of personal assistance to each resident per day in communities with 4–10 beds, compared with 1.25 hours in communities with over 100 beds. ● Administrators and directors provided 1.31 hours of direct care to each resident per day in communities with 4–10 beds, compared with 0.11 hour in communities with over 100 beds. Residential Care Communities and Their Residents in 2010: A National Portrait 52 Chapter 6: Workforce

FIGURE 6-4 Percent distribution of residential care communities, by hours of initial formal training required of personal care aides: United States, 2010

None

4% More than 75 hours

22%

10% 64% 75 hours

Less than 75 hours

NOTE: The denominator for this figure is the 94% of all residential care communities that employ personal care aides. Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost all residential care communities (96%) required at least some initial formal training of personal care workers. ● Initial formal training requirements for PCAs were less than 75 hours in almost two-thirds of residential care communities (64%); another 10% required 75 hours of training. Twenty-two percent of all communities required more than 75 hours of formal training. ● Most communities (90%) provided ongoing in-service training for their PCAs (data not shown). Residential Care Communities and Their Residents in 2010: A National Portrait 53 Chapter 6: Workforce

FIGURE 6-5 Percentage of residential care communities, by fringe benefits offered to personal care aides and bed size: United States, 2010

All residential care communities Small (4–10 beds) Medium (11–25 beds) Large (26–100 beds) Extra large (over 100 beds)

98 100 97 92 89 84 83 81 81 80 71 72 66

60 54 50

Percent 38 40 40 35 37

21 20 8 7

0 Paid time off1 Health insurance for PCA/family1 Life insurance1 Pension1

1 Differences between bed size categories are significant at p<.05. NOTE: Figure indicates only the 94% of residential care communities that employ any personal care aides. SOURCE: CDC/NCHS, 2010 NSRCF.

● Paid time off was the most common fringe benefit (84%) offered to PCAs in all residential care communities. It was offered in 71% of communities with 4–10 beds and in almost all communities with 26–100 beds (97%) and over 100 beds (98%). ● Half of all communities that employed PCAs offered health insurance to their PCAs. About one-fifth (21%) of communities with 4–10 beds, 54% of communities with 11–25 beds, 83% with 26–100 beds, and 92% with over 100 beds offered health insurance. ● The percentage of communities that offered life insurance or pension benefits to PCAs increased with bed size, from 7–8% of communities with 4–10 beds to 81% of communities with over 100 beds. Residential Care Communities and Their Residents in 2010: A National Portrait 54 Chapter 6: Workforce

FIGURE 6-6 Percent distribution of residential care communities, by qualifications and background of residential care community directors: United States, 2010

Percent 0 20 40 60 80 100

Certified/licensed in managing facilities for older people 83 Not certified/licensed in managing facilities 17 for older people Tenure at residential care community: 12 Less than a year Tenure at residential care community: 59 Between 1 year and 9 years Tenure at residential care community: 29 10 years or more Under 2 years of residential care community/ 50 nursing facility experience before current position 2+ years of residential care community/ 50 nursing facility experience before current position

High school/some college education 38

College/postgraduate degree education 62

NOTE: Estimates may not add up to totals because of rounding. SOURCE: CDC/NCHS, 2010 NSRCF.

● More than 80% of all residential care community directors had certificates or licenses related to managing facilities for older people. ● Twelve percent of all community directors had been in their position for less than a year, 59% had been in their current position for 1 to less than 10 years, and 29% had been in their position for 10 years or more. ● Half of all community directors had had at least 2 years of experience working in residential care or in nursing facilities before their current position. ● Most community directors (62%) had college or postgraduate degrees. Residential Care Communities and Their Residents in 2010: A National Portrait 55 Chapter 6: Workforce

FIGURE 6-7 Annual turnover rates of residential care communities, by staff type and bed size: United States, 2010

All residential care communities Small (4–10 beds) Medium (11–25 beds) Large (26–100 beds) Extra large (over 100 beds)

50 45 41 40 38 38 39

33 32 30 31 30 30 27

22 22 Percent 20 20 19 16 15 15 11 10 7

0 Directors1 RNs1 LPNs/LVNs1 PCAs1

1 Differences between bed size categories are significant at p<.05. NOTE: RN=registered nurse; LPN=licensed practical nurse; LVN=licensed vocational nurse; PCA=personal care aide. Turnover rate is calculated across all residential care communities that employ a particular staff type. SOURCE: CDC/NCHS, 2010 NSRCF.

● Turnover rates in residential care communities were highest for PCAs (38%) and lowest for directors (16%). ● Annual turnover rates among PCAs were the highest of all staff types regardless of residential care community size; the rates ranged from 32% in communities with 4–10 beds to 45% in communities with 26–100 beds. ● Director annual turnover rates ranged from 11% in communities with 4–10 beds to 33% in communities with over 100 beds. ● RN annual turnover rates ranged from 7% in communities with 4–10 beds to 30% in communities with over 100 beds. 7 Access and Affordability

This chapter provides information on accessibility and affordability, such as adequate bed supply and reasonable waiting list times, admission and discharge policies, and prices. Residential Care Communities and Their Residents in 2010: A National Portrait 57 Chapter 7: Access and Affordability

FIGURE 7-1 Number of beds per 1,000 persons aged 85 and over, by setting and Census region: United States, 2010

Residential care communities1 Nursing facilities2

400 358

285 300 279 273 245

200 177 184 177

Number 164 131

100

0 All regions West South Midwest Northeast

1 Differences between regions in residential care community bed supply are significant at p<.05. Data on number of nursing facility beds obtained from the American Health Care Association: http://www.ahcancal.org/research_ 2 Differences between regions in nursing facility bed supply are significant at p<.05. data/trends_statistics/Documents/ST_rpt_STStats2011_20110906_FINAL_web.pdf NOTE: In each region, differences between residential care community bed supply and nursing facility bed supply are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● In 2010, residential care communities, on average, provided 177 beds per 1,000 persons aged 85 and over, ranging from 131 beds in the Northeast to 245 beds in the West. ● Nationally, there was an average of 279 nursing home beds per 1,000 persons aged 85 and over, ranging from 184 beds in the West to 358 beds in the Midwest (American Health Care Association, 2010). ● The supply of nursing home beds outnumbered residential care community beds in all regions except the West. ● Among the 29% of all residential care communities that reported having a waiting list, on average, 7 people were waiting for beds, and the average waiting time for admission was 153 days (data not shown). Residential Care Communities and Their Residents in 2010: A National Portrait 58 Chapter 7: Access and Affordability

FIGURE 7-2 Percentage of residents living in residential care communities, by admission and discharge policies: United States, 2010 Percent 0 20 40 60 80 100

88 Needed skilled nursing care on a regular basis 66 67 Exhibited problem behavior 46 Residents living in residential care 50 Had moderate to severe cognitive impairment communities that had 24 policies to not admit residents or admit on a 47 Were unable to leave the building in an emergency without help case-by-case basis 17 Residents living 41 in residential care Required end-of-life care 7 communities that had policies to discharge 20 Were regularly incontinent of urine or feces residents 17 15 Needed daily monitoring for a health condition 5

SOURCE: CDC/NCHS, 2010 NSRCF.

● Eighty-eight percent of all residents lived in residential care communities that had policies not to admit, or to admit on a case-by-case basis, people who needed skilled nursing care on a regular basis, 67% of all residents lived in communities with admission policies for problem behavior, 50% of all residents lived in communities with admission policies for those with moderate to severe cognitive impairment, 47% of all residents lived in communities with admission policies for those unable to leave the building in an emergency without help, 41% of all residents lived in communities with admission policies for those requiring end-of-life care, 20% of all residents lived in communities with admission policies for those regularly incontinent of urine or feces, and 15% of all residents lived in communities with admission policies for those needing daily monitoring for health conditions.

● About two-thirds of all residents (66%) lived in residential care communities that had a policy to discharge individuals if they developed a need for skilled nursing care on a regular basis, 46% of all residents lived in communities with discharge policies for problem behavior, 24% of all residents lived in communities with discharge policies for those with moderate to severe cognitive impairment, 17% of all residents lived in communities with discharge policies for those unable to leave the building in an emergency without help, 7% of all residents lived in communities with discharge policies for those requiring end-of-life care, 17% of all residents lived in communities with discharge policies for those regularly incontinent of urine or feces, and 5% of all residents lived in communities with discharge policies for those needing daily monitoring for health conditions. Residential Care Communities and Their Residents in 2010: A National Portrait 59 Chapter 7: Access and Affordability

FIGURE 7-3 Percentage of residential care communities serving Medicaid beneficiaries and percentage of residents using Medicaid to pay for long-term care services, by bed size: United States, 2010

Residential care communities serving any Medicaid beneficiaries1 Residential care residents using Medicaid to pay for long-term care services2

49 50 45 43 40 40

32 31 32 30 Percent

19 20 18 12 10

0 All residential care Small Medium Large Extra large communities (4–10 beds) (11–25 beds) (26–100 beds) (over 100 beds)

1 Differences between bed size categories are significant at p<.05. 2 Differences between bed size categories are significant at p<.05, except between small and medium bed size categories. SOURCE: CDC/NCHS, 2010 NSRCF.

● Overall, 43% of all residential care communities had at least one resident whose long-term care services were partially or fully paid for by Medicaid. Nineteen percent of all residents used Medicaid to pay for long-term care services. ● Almost half of communities with 4–10 beds (45%) and 11–25 beds (49%) served at least one resident whose long-term care services were paid for by Medicaid. Forty percent of communities with 26–100 beds and about one-third of communities with over 100 beds (32%) served at least one resident whose long-term care services were paid for by Medicaid. ● About a third of all residents in residential care communities with 4–10 beds (32%) and 11–25 beds (31%) used Medicaid to pay for long-term care services; 18% and 12% of residents used Medicaid in communities with 26–100 beds and communities with over 100 beds, respectively. Residential Care Communities and Their Residents in 2010: A National Portrait 60 Chapter 7: Access and Affordability

FIGURE 7-4 Annual mean charges for residential care community residents, by Medicaid enrollment and cognitive status: United States, 2010

$50,000

$40,800 $40,900 $40,000 $38,000

$33,800

$30,000 $26,200 Dollars $20,000

$10,000

$0 All residents Medicaid residents1 Non-Medicaid residents Residents with cognitive Residents without cognitive impairment2 impairment

1 Differences between Medicaid and non-Medicaid residents are significant at p<.05. 2 Differences between residents with and without cognitive impairment are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● In 2010, the mean total charge per residential care community resident nationally was $38,000 per year. ● The mean total charge per Medicaid resident was approximately $26,200 per year, which was $14,600 less than the mean total charge for non-Medicaid residents. Charges were not the amounts paid by Medicaid. ● On average, individuals with cognitive impairment were charged $40,900, which was $7,100 more than individuals without cognitive impairment. Residential Care Communities and Their Residents in 2010: A National Portrait 61 Chapter 7: Access and Affordability

FIGURE 7-5 Annual mean charge for residential care community residents, by bed size: United States, 2010

$50,000

$41,300 $40,000 $38,100

$33,000 $32,700

$30,000 Dollars $20,000

$10,000

$0 Residents in small residential care Residents in medium residential care Residents in large residential care Residents in extra large residential care communities (4-10 beds)1 communities (11-25 beds)1 communities (26-100 beds)1 communities (over 100 beds)1

1 Differences between bed size categories are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● In 2010, the annual total mean charge was about $33,000 for residents in residential care communities with 4–10 beds ($33,000) and for residents in residential care communities with 11–25 beds ($32,700). ● Charges increased to $38,100 for residents in residential care communities with 26–100 beds and to $41,300 for residents in residential care communities with over 100 beds. Residential Care Communities and Their Residents in 2010: A National Portrait 62 Chapter 7: Access and Affordability

FIGURE 7-6 Percentage of residential care communities where at least one resident moved out because of cost, by bed size: United States, 2010

60 57

39 40

30 28 Percent

20 16 16

0 All residential care Small Medium Large Extra large communities (4–10 beds) (11–25 beds) (26–100 beds)1 (over 100 beds)2

1 Differences between large and all other bed size categories are significant at p<.05. 2 Differences between extra large and all other bed size categories are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● In 2010, over a quarter of all residential care communities (28%) reported that at least one resident moved out because of cost. ● Almost three-fifths of communities with over 100 beds (57%) reported that at least one resident moved out because of cost, compared to 39% of communities with 26–100 beds and 16% of communities with 4–10 and 11–25 beds. 8 Environment

This chapter focuses on features of residential care communities that support a homelike, rather than an institutional, environment and offer access to the larger community beyond the residential care community. Residential Care Communities and Their Residents in 2010: A National Portrait 64 Chapter 8: Environment

FIGURE 8-1 Percent distribution of residential care community residents, by living arrangements and bed size: United States, 2010

Apartments Rooms for 2+ people Single rooms

100 10

80 42 49 43 60

Percent 27 40 23

48 20 32 28

0 All residents Residents living in small/medium Residents living in large/extra large (N=733,300) (4–25 beds) communities (26+ beds) communities (N=142,700)1 (N=590,600)

1 Differences between residents living in residential care communities with 4–25 beds and those in communities with over NOTE: Estimates may not add up to totals because of rounding. 25 beds are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Overall, 42% of all residents in residential care communities lived in apartments. More than one-quarter of all residents (27%) lived in rooms designed for two or more people, and nearly a third (32%) lived in single rooms. ● The percentage of residents living in apartments was greater in communities with over 25 beds (49%) than in smaller communities (10%). ● Of the residents who lived in communities with 4–25 beds, about half (48%) lived in single rooms and 43% lived in rooms designed for two or more people. Residential Care Communities and Their Residents in 2010: A National Portrait 65 Chapter 8: Environment

FIGURE 8-2 Percentage of residential care community residents, by policies supporting a homelike environment and bed size: United States, 2010

All residents Residents living in small/medium communities (4–25 beds) Residents living in large/extra large communities (over 25 beds)

99 99 96 100 93 88

80 76 71 67 66 63 62 59 59 59 60 47

Percent 40

0 Allowed to bring their own Allowed to bring their own Allowed to keep their own pet1 Allowed to eat meals Allowed to eat meals small furniture1 large furniture1 where they like when they like

1 Differences between residents living in residential care communities with 4–25 beds and those in communities with over 25 beds are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost all residents (99%) lived in residential care communities that allowed them to bring their own small furniture, 88% of all residents were allowed to bring their own large furniture, 71% of all residents were allowed to keep their own pets, and about 6 in 10 residents lived in communities in which they could eat their meals where they liked (63%) or when they liked (59%). ● Nearly all residents living in communities with over 25 beds were allowed to furnish their rooms or apartments with their own small furniture (99%) or own large furniture (93%), compared to 96% and 67% of residents in smaller communities, respectively. ● More than three-fourths of residents in communities with over 25 beds (76%) were allowed to keep their own pets, compared to 47% of residents in smaller communities. Residential Care Communities and Their Residents in 2010: A National Portrait 66 Chapter 8: Environment

FIGURE 8-3 Percentage of residential care community residents, by features of rooms and apartments and community bed size: United States, 2010

All residents Residents living in small/medium communities (4–25 beds) Residents living in large/extra large communities (over 25 beds)

100 95

87 85 80 77

60 54 52 46 44 Percent 40

20 9

0 Bathroom located inside room/apartment1 Doors that can be locked from the inside1 Any cooktop, hot plate, oven, or microwave in room/apartment1

1 Differences between residents living in residential care communities with 4–25 beds and those in communities with over 25 beds are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Overall, 87% of all residents in residential care communities had a bathroom located inside their room or apartment; 77% of all residents had doors that could be locked from the inside; and 44% had any cooktop, hot plate, oven, or microwave in their room or apartment. ● Almost all residents in communities with over 25 beds (95%) had rooms or apartments with bathrooms located inside their units, compared to over half of residents (54%) in smaller communities. ● Eighty-five percent of residents in communities with over 25 beds lived in rooms or apartments with doors that could be locked from the inside, compared to fewer than half of residents (46%) in smaller communities. ● Over half of residents in communities with over 25 beds (52%) had any cooktop, hot plate, oven, or microwave in their room or apartment, compared to 9% of residents in smaller communities. Residential Care Communities and Their Residents in 2010: A National Portrait 67 Chapter 8: Environment

FIGURE 8-4 Percentage of residential care community residents, by services offered that support a homelike environment and bed size: United States, 2010

All residents Residents living in small/medium communities (4–25 beds) Residents living in large/extra large communities (over 25 beds)

100 94 90 90 86 84 86 77 80 75 68

60 Percent 40

19 20 19 20

0 Social/recreational activities Transportation to Transportation to Transportation to outside the community1 stores/elsewhere1 medical appointments1 employment

1 Differences between residents living in residential care communities with 4–25 beds and those in communities with over 25 beds are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Almost all residents (94%) living in residential care communities with over 25 beds had access to social and recreational activities outside of the residential care community, compared to 75% of residents living in smaller communities. ● Most residents living in communities with over 25 beds had access to transportation to stores (90%) and medical appointments (86%), compared to 68% and 77%, respectively, of residents living in smaller communities. Residential Care Communities and Their Residents in 2010: A National Portrait 68 Chapter 8: Environment

FIGURE 8-5 Percentage of residential care community residents, by participation in social activities at least twice a month and bed size: United States, 2010

All residents Residents living in small/medium communities (4–25 beds) Residents living in large/extra large communities (over 25 beds)

60 53 50 49 50 43 39 40 38

30 Percent

20 12 10 7 5

0 Left the grounds1 Went out to movies/social events1 Attended day programs for social or recreational activities1 1 Differences between residents living in residential care communities with 4–25 beds and those in communities with over 25 beds are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Overall, 50% of all residents living in residential care communities left the grounds, 39% went out to movies or social events, and 7% attended day programs for social and recreational activities at least twice a month. ● Fifty-three percent of residents living in communities with 4–25 beds had left the grounds, compared to 49% of residents living in communities with over 25 beds. ● Forty-three percent of residents living in communities with 4–25 beds went out to movies or social events, compared to 38% of residents living in communities with over 25 beds. ● Twelve percent of residents living in communities with 4–25 beds had attended day programs for recreational or social activities, compared to 5% of residents living in larger communities. Residential Care Communities and Their Residents in 2010: A National Portrait 69 Chapter 8: Environment

FIGURE 8-6 Percent distribution of residential care community residents, by visitors in the past 30 days and bed size: United States, 2010

100 7 9 13

80 24 24 26 No visitors 60 Visitors several times/at least once 26 27 23 Visitors once a week Percent 40 Visitors several times a week Visitors daily 31 31 28 20

11 9 11 0 All residents Residents living in small/medium Residents living in large/extra large communities (4–25 beds)1 communities (over 25 beds)

● In the 30 days prior to the survey, 42% of residents living in residential care communities had received visitors at least several times a week, about one-fourth (26%) had had visitors weekly, and one-third (33%) were visited less frequently, including almost one-tenth (9%) who had had no visitors. ● A higher percentage of residents living in communities with over 25 beds had had visitors several times a week (31%) and visitors once a week (27%) compared to residents living in communities with 4–25 beds (28% and 23%, respectively). ● Among residents living in communities with 4–25 beds, 26% of them had had visitors several times or at least once in the past 30 days and 13% had had no visitors in that time period, compared to 24% and 7%, respectively, of residents living in communities with over 25 beds. Residential Care Communities and Their Residents in 2010: A National Portrait 70 Chapter 8: Environment

FIGURE 8-7 Percentage of residential care community residents living where volunteers provided social/religious activities, by community bed size: United States, 2010

100 88 90

80 73

60 Percent 40

0 All residents Residents living in small/medium Residents living in large/extra large communities (4–25 beds)1 communities (over 25 beds)

1 Differences between residents living in residential care communities with 4–25 beds and those in communities with over 25 beds are significant at p<.05. SOURCE: CDC/NCHS, 2010 NSRCF.

● Overall, 88% of residents lived in residential care communities where volunteers provided social or religious activities. ● Ninety percent of residents living in communities with over 25 beds had volunteers who regularly provided social or religious activities, compared to 73% of residents living in smaller communities. Definitions

Activities of daily living (ADLs): Receiving any verbally threatening other persons, including staff or assistance in five ADLs (bathing, dressing, transferring, other residents; being physically aggressive toward using the toilet, and eating) that reflect a resident’s other persons, including staff or other residents; capacity for self-care. A summary variable was created removing clothing in public; and making unwanted with four categories: no limitations, 1–2 limitations, sexual advances toward staff or other residents. and 3–5 limitations. For residents confined to a bed or Bed supply: Beds per 1,000 persons were calculated chair, the question about whether or not the resident by dividing the number of residential care beds by the received assistance with transferring was not asked in number of persons aged 85 and over, multiplied by the survey. For these analyses, the 12% of residents 1,000. who were chair- or bedridden were defined as receiving assistance in the transferring and summary Chain affiliation: Communities owned by a chain, ADL variables. The 2% of residents who had a toileting group, or multi-community system. A chain is more device, like an ostomy or catheter, or who were than one residential care community under common chairfast were defined as receiving assistance in the ownership or management; it may include residential toileting and summary ADL variables. care communities within a state or across multiple states. Behavioral symptoms: Exhibiting any of the following behaviors in the past 30 days: refusing to Charges: Total charge for the month before the take prescribed medicines at the appropriate time survey interview, including the basic monthly charge or in the prescribed dosage; creating disturbances and any charges for additional services. Annual total or being excessively noisy by knocking on doors, mean charge was calculated by multiplying the yelling, or being verbally abusive; wandering or monthly mean charge by 12. Total industry charges moving aimlessly about in the building or on the were derived from the weighted number of residents grounds; refusing to bathe or clean himself/herself; multiplied by the annual total mean charge. rummaging through or taking other people’s belongings; damaging or destroying property; Residential Care Communities and Their Residents in 2010: A National Portrait 72 Definitions

Chronic conditions: Ten most common chronic conditions that residents Instrumental activities of daily living (IADLs): Receiving any assistance were ever diagnosed as having by a doctor or other health professional, in five IADLs (shopping, managing money, using a phone, housekeeping, based on the survey respondent’s reference to the resident’s medical and taking medications). A summary variable was created with four record or personal knowledge of the resident. categories: no limitations, 1–2 limitations, and 3–5 limitations. Cognitive impairment: Based on the survey respondent’s reference to Length of stay: Derived from the month and year the resident first moved the resident’s medical record or personal knowledge of the resident, this into the residential care community and the month and year of the survey. includes residents who experienced problems in any of the following areas Limitations in basic physical activities: Whether a resident can perform in the 7 days before the interview: short-term memory, long-term memory, the following five activities without assistance and without equipment: or orientation (not knowing the location of room, not recognizing staff standing or being on one’s feet for about 2 hours; sitting for about 2 hours; names or faces, not knowing that he/she is in a residential care community, stooping, bending, or kneeling; reaching up over one’s head; and using or not knowing the season of the year). Limitations in any way, because of one’s fingers to grasp or handle small objects. difficulty remembering or having periods of confusion, were also included. Medicaid participation among residential care communities and Co-location with another care setting: Determined on the basis of residents: Residential care communities that were certified or registered provider self-report in response to the question, “Are any of the following to participate in Medicaid and residents who had had some or all of their types of places on the same property or at this same location?” Four types long-term care services paid by Medicaid during the past 30 days. If a of places were included: independent living; nursing home; rehabilitation, community reported not having any residents having their long-term care sub-acute, or post-acute unit in a nursing home; and hospital. Residential paid by Medicaid in the past 30 days, then the community was considered care communities were considered to be co-located with another care a non-Medicaid community. In residential care, Medicaid covers residential setting if one or more of these places was on the same property or at the care services but does not cover room and board charges. There is no same location. information in the National Survey of Residential Care Facilities (NSRCF) on Dementia: Ever been diagnosed as having Alzheimer’s disease or other what the Medicaid program paid for each individual resident. The survey dementia by a doctor or other health professional, based on the survey includes only information on total charges to individual residents. respondent’s reference to the resident’s medical record or personal Medication management: Ranges from general oversight and cueing to knowledge of the resident. actively putting medications in residents’ mouths and handing them water. Dementia special care units: A distinct unit, wing, or floor designated Memory limitations: Problems with short-term or long-term memory in as a dementia or Alzheimer’s special care unit within the residential care the 7 days before the interview. community. These are distinguished from residential care communities that exclusively serve adults with Alzheimer’s disease or other dementias. Metropolitan statistical area (MSA): A county or group of contiguous counties that contains at least one urbanized area of 50,000 or more Health care services use: Includes nursing home or rehabilitation facility population. An MSA may contain other counties that are economically and stays, overnight hospital stays, and emergency department visits during socially integrated with the central county, as measured by commuting. the 12 months before the interview (or since the resident had moved into the residential care community if he or she had been there less than 12 months). Residential Care Communities and Their Residents in 2010: A National Portrait 73 Definitions

Ownership type: Either of two types: (1) private, for-profit, and (2) other, Staffing ratios: Measured by hours per resident per day, ratios separately which includes private nonprofit and state, county, or local government by staff type (registered nurses, licensed practical or vocational nurses, ownership. The private, for-profit category includes publicly traded and personal care aides) and in total, when all direct care staff hours are corporations. combined. All staffing time estimates were calculated at the resident level and included only employed workers (not contract staff). Staffing ratios Region: Grouping conterminous states into geographic areas were calculated as the number of full-time equivalent employees for a corresponding to groups used by the U.S. Census Bureau. A listing of states given staff type × 35 hours/7 days/number of current residents. included in each of the four Census regions is available from http://www2. census.gov/geo/docs/maps-data/maps/reg_div.txt. Staff turnover: Calculated only for communities that employed that staff type. The turnover rate for each type of staff was calculated as the number Residential care bed: Licensed, registered, or certified residential care beds. of staff that left in the past 12 months divided by the number of that type Residential care communities: Assisted living facilities and similar of staff currently employed at the community. residential care communities (e.g., personal care homes, adult care homes, board care homes, adult foster care) that meet the study eligibility criteria provided in Data Sources and Methods. Size: Number of licensed, registered, or certified residential care beds (both occupied and unoccupied) in a residential care community: small (4–10 beds), medium (11–25 beds), large (26–100 beds), and extra large (more than 100 beds).

Skilled nursing services: Services essential to the maintenance or restoration of health, provided to sick or disabled persons by a registered nurse (RN) or a licensed practical nurse (LPN).

Social services counseling: Counseling related to obtaining and keeping benefits provided by programs such as Supplemental Security Income, Social Security, and Medicaid. Data Sources and Methods

Resident and residential care community data of residential care communities. For the 2010 for these analyses were from the 2010 National NSRCF, 3,605 residential care communities Survey of Residential Care Facilities (NSRCF). were sampled with probability proportional to To be eligible for the NSRCF, residential care community size. Interviews were completed communities must be licensed, registered, with 2,302 residential care communities, for a listed, certified, or otherwise regulated by the first-stage, community-level weighted response state; have four or more licensed, certified, or rate of 81%, which was weighted for differential registered beds; provide room and board with at probabilities of selection. In the second stage least two meals a day; provide around-the-clock of sampling, three to six current residents of on-site supervision; and help with personal care each community, depending on residential care such as bathing and dressing or health-related community bed size, were randomly selected. services such as medication management. These All data collected on sampled residents came residential care communities also must serve from interviews with residential care community a predominantly adult population. Residential staff who answered questions by referring to the care communities licensed to exclusively serve residents’ records or their own knowledge of the the mentally ill or developmentally disabled residents; residents were never interviewed. The populations were excluded. Nursing homes also second-stage, resident-level weighted response were excluded unless they had a unit or wing rate was 99%. A detailed description of NSRCF meeting the above definition and their residents sampling design, data collection, and procedures could be separately enumerated. is provided both in a previous report (Design and Operation of the 2010 National Survey of The 2010 NSRCF used a stratified two-stage Residential Care Facilities, November 2011) and probability sample design. The first stage was the on the NSRCF Web site: http://www.cdc.gov/ selection of residential care communities from nchs/nsrcf/nsrcf_questionnaires.htm. the sampling frame representing the universe Residential Care Communities and Their Residents in 2010: A National Portrait 75 Data Sources and Methods

Residential care communities are characterized by a large number Because estimates were rounded, individual weighted estimates of small communities (4–10 beds) that serve a relatively small may not sum to totals and percentages may not sum to 100%. proportion of residents. More specifically, 50% of residential care communities are small, but they serve only 10% of residents. Most The NSRCF has some limitations. The survey was designed primarily residential care community residents live in larger communities. to gather information on residential care communities serving To obtain a full understanding of residential care communities older people, as well as younger persons with physical disabilities. and their residents, we present data from two perspectives with As a result, the NSRCF excluded communities licensed to serve the different units of analysis. We show a limited number of residential mentally ill or the developmentally disabled populations exclusively. care community characteristics with the residential care community The detailed inclusion criteria also meant that other communities as the unit of analysis, such as Figures 2-1 and 5-5. The rest of the that may have met part of the definition but not all of the inclusion charts are more closely aligned with the number of residents served. criteria were also excluded. Because the NSRCF was designed to For these analyses, we match residents with the characteristics of provide national estimates, these data do not allow for state-level the residential care communities in which they live and present estimates. Although residential care is regulated by the states, and the residential care community characteristics with the resident differences in provider and resident characteristics may be similar as the unit of analysis. For these types of analyses, we refer to “the by state, the survey is not able to address these differences. The communities in which residents live.” This type of analysis can be NSRCF collected information on the characteristics of providers thought of as community analyses weighted by the number and as well as residents. However, residents were not interviewed type of residents. The unit of analysis (residential care community or and all resident data were based on proxy responses provided by residential care community resident) is noted in all figure titles and community administrators or designated staff. Thus, information on text bullets. residents is subject to errors in reporting by the administrators or designated staff. Differences among subgroups were evaluated using chi-square tests for categorical variables and t-tests for continuous variables. If chi-square tests indicated statistical significance, a post hoc chi-square procedure was used to make pairwise comparisons. Significant results from the post hoc procedure are reported here. All significance tests were two-sided using p<.05 as the level of significance. The difference between any two estimates is reported only if it is statistically significant. Data analyses were performed using the SAS-callable version of the statistical package SUDAAN 11.0.1 (RTI 2012). Cases with missing data were excluded from the analyses on a variable-by-variable basis. The percentage of weighted cases with missing data varied between 0.01% and 2.5%. References

American Health Care Association. (2010). LTC stats: Park-Lee, E., Caffrey, C., Sengupta, M., Moss, A., Rosenoff, Nursing facility patient characteristics report, December E., & Harris-Kojetin, L. (2011). Residential care facilities: A 2010. Washington, DC: American Health Care Association. key sector in the spectrum of long-term care providers in the United States. NCHS data brief, no. 78. Hyattsville, MD: Caffrey, C., Sengupta, M., Park-Lee, E., Moss, A., Rosenoff, National Center for Health Statistics. http://www.cdc. E., & Harris-Kojetin, L. (2012). Residents living in residential gov/nchs/data/databriefs/db78.htm care facilities: United States, 2010. NCHS data brief, no. 91. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db91.pdf

Harris-Kojetin, L., Sengupta, M., Park-Lee, E., & Valverde, R. (2013). Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/ nsltcp/long_term_care_services_2013.pdf

Johnson, R. W., Toohey, D., & Wiener, J. M. (2007). Meeting the long-term care needs of the baby boomers: How changing families will affect paid helpers and institutions. Washington, DC: The Urban Institute. Retrieved from http://www.urban.org/UploadedPDF/311451_Meeting_ Care.pdf

Kane, R. A., & Cutler, L. J. (2009). Promoting homelike characteristics and eliminating institutional characteristics in community-based residential care settings. Seniors Housing & Care Journal, 17(1), 15–37. Residential Care Communities and Their Residents in 2010: A National Portrait 77 References

Useful Links Other NSRCF Publications

National Survey of Residential Care Facilities (NSRCF) Greene, A., Wiener, J., Khatutsky, G., Johnson, R., & O’Keeffe, J. (2013). Medicaid in residential care. Washington, DC: Department of Health and Human Services, Assistant http://www.cdc.gov/nchs/nsrcf.htm Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. Retrieved from http://aspe.hhs.gov/daltcp/reports/2013/FacBenDif.pdf

NSRCF Data Products Karon, S., Wiener, J. M., Greene, A. M., Khatutsky, G., & Johnson, R. (2014). What factors Survey methodology, documentation, data dictionaries, and data files for the 2010 NSRCF affect residential care facility charges? Washington, DC: Department of Health and Human survey can be accessed here: http://www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. Retrieved from: https://aspe.hhs.gov/sites/default/files NCHS datasets for the 2010 NSRCF survey, in SAS, SPSS, and STATA languages, can be pdf/138356/RCFcharge.pdf found here: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/NSRCF/2010 Khatutsky, G., Wiener, J., Greene, A., Johnson, R., & O’Keeffe, J. (2013). Do services and staffing in residential care vary with resident needs? Washington, DC: Department of NSRCF Publications Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. Retrieved from http://aspe.hhs.gov/daltcp/ Data Briefs from the National Center for Health Statistics reports/2013/ResNeed.pdf

Park-Lee, E., Caffrey, C., Sengupta, M., Moss, A., Rosenoff, E., & Harris-Kojetin, L. Residential Moss, A. J., Harris-Kojetin, L. D., Sengupta, M., Park-Lee, E., Caffrey, C., Rosenoff, E., … care facilities: A key sector in the spectrum of long-term care providers in the United States. Greene, A. M. (2011). Design and operation of the 2010 National Survey of Residential NCHS data brief, no. 78. Hyattsville, MD: National Center for Health Statistics. 2011. http:// Care Facilities. National Center for Health Statistics. Vital and Health Statistics, 1(54). 2011. www.cdc.gov/nchs/data/databriefs/db78.htm Retrieved from http://www.cdc.gov/nchs/data/series/sr_01/sr01_054.pdf

Caffrey, C., Sengupta, M., Park-Lee, E., Moss, A., Rosenoff, E., & Harris-Kojetin, L. Residents Wiener, J. M., Feng, Z., Coots, L. A., & Johnson, R. (2014). What is the effect of dementia on living in residential care facilities: United States, 2010. NCHS data brief, no. 91. Hyattsville, hospitalization and emergency department use in residential care facilities? Washington, MD: National Center for Health Statistics. 2012. http://www.cdc.gov/nchs/data/databriefs/ DC: Department of Health and Human Services, Assistant Secretary for Planning and db91.pdf Evaluation, Office of Disability, Aging and Long-Term Care Policy. Retrieved from: Caffrey, C., & Park-Lee, E. Use of electronic health records in residential care communities. https://aspe.hhs.gov/sites/default/files/pdf/138371/RCFdementia.pdf NCHS data brief, no. 128. Hyattsville, MD: National Center for Health Statistics. 2013. http://www.cdc.gov/nchs/data/databriefs/db128.htm National Study of Long-Term Care Providers Resources Park-Lee, E., Sengupta, M., & Harris-Kojetin, L. D. Dementia special care units in residential care communities: United States, 2010. NCHS data brief, no. 134. Hyattsville, MD: National For more information on NSLTCP data products and publications, see http://www.cdc. Center for Health Statistics. 2013. http://www.cdc.gov/nchs/data/databriefs/db134.htm gov/nchs/nsltcp.htm SERVICES AN • U M SA DHHS Publication No. 2016-1041 U H & H T U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

E Centers for Disease Control and Prevention

National Center for Health Statistics T

T 3311 Toledo Road

A P E

Hyattsville, MD 20782