Beyond the Medication Pass: Attitudes, Ethics, Agency, and Antipsychotic Medications in Assisted Living/Residential Care

Background and Objectives As-needed (PRN) antipsychotic medication use (APU) among assisted living/residential care (AL/RC) residents is a controversial health policy issue. AL/RC care staff, families, clinicians, researchers, and policymakers disagree about PRN APU to manage behavioral expressions associated with residents’ dementia or cognitive impairment. Research Design and Methods Semistructured interviews among eleven direct care staff (n = 3), licensed nurses (n = 2), administrators/executive directors (n = 4), and consultant pharmacists (n = 2) currently working in Oregon AL/RC. Using situational analysis, we identify, describe, and visualize positions and ideologies by job role to theorize PRN APU decision-making. Results Three broad processes underlie APU to manage residents’ behavioral expressions: justifying PRN APU, moralizing APU, and balancing local practices (eg, managing behavioral expressions, respecting individuals) with nonlocal practices (eg, professional authority). People involved in the situation of APU in AL/RC describe positive and negative justifications, and personal moral positions that frame PRN antipsychotics or nonpharmaceutical interventions as “right” or “wrong,” driving various approaches to behavior management. Participants described a converse orientation between perceived level of agency within and proximity to the situation of APU. Those most closely involved, or local, to the situation of passing medications (eg, direct care staff and nurses) expressed less agency compared with nonlocal physicians and policymakers, who are not involved in the day-to-day practices within AL/RC. Discussion and Implications This study raises practice and policy implications regarding APU in AL/RC settings. Care staff roles, ethical considerations, and perceived agency inform decision-making on whether to use antipsychotic medications. Participants described costs and benefits associated with both PRN APU and nonpharmaceutical interventions when responding to AL/RC residents’ behavioral expressions. Participants’ experiences emphasize the interactions across multiple levels of care. Balancing regulatory goals with resident-centered practices underscores the need for a system-level perspective, extending beyond direct care staff passing antipsychotic medications to residents

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are primarily responsible for noncompliance, (2) unclear parameters place direct care workers in a role paradox, and (3) there is a persistent disconnect about when to seek qualified expertise before requesting psychotropic medications. AL/RC-specific mechanisms for medication prescription and administration are necessary to improve the structure and processes of care. Policymakers might consider how regulations unintentionally incentivize task-oriented versus person-centered care practices

Evaluation of the LiveWell Method: Final Report

The LiveWell Method uses a practice-based framework to improve the quality of life for people living and working in long-term care settings, including assisted living and memory care. It is designed to improve teamwork, communication, and morale by helping staff organize, track, measure, and improve daily operations. This evaluation is informed by the LiveWell Method’s “bottom-up and top enabled” approach, which engages and empowers direct care staff and administrators to create a more democratic and transparent workplace. In addition, the evaluation included questions to assess LiveWell’s core values, such as creating care innovations, nurturing dignity, creating community, and honoring elders, as well as organizational frameworks such as “lean thinking” and “human-centered design,” and trauma-informed practices

Differential Health and Social Needs of Older Adults Waitlisted for Public Housing or Housing Choice Vouchers

Affordable housing is an important form of income security for low-income older persons. This article describes characteristics of older persons waitlisted for either public housing or a housing choice voucher (HCV) (previously Section 8) in Portland, Oregon. 358 persons (32% response rate) completed a mailed survey with questions about demographics, health and housing status, food insecurity, and preference for housing with services. Findings indicate that many waitlisted older persons experienced homelessness or housing instability, poor health, high hospital use, and food insecurity. Public housing applicants were significantly more likely to report lower incomes, homelessness, and food insecurity than HCV applicants. We conclude with policy implications for housing and health agencies that serve low-income older persons

Does Assisted Living Provide Assistance and Promote Living?

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have worsened; regulations have become complex; the need for consumer support, education, and advocacy has grown; and financing and accessibility have become insufficient. Together, these factors have limited the extent to which today\u27s assisted living adequately provides assistance and promotes living, with negative consequences for aging in place and well-being. This Commentary provides recommendations in four areas to help assisted living meet its promise: workforce; regulations and government; consumer needs and roles; and financing and accessibility. Policies that may be helpful include those that would increase staffing and boost wages and training; establish staffing standards with appropriate skill mix; promulgate state regulations that enable greater use of third-party services; encourage uniform data reporting; provide funds supporting family involvement; make community disclosure statements more accessible; and offer owners and operators incentives to facilitate access for consumers with fewer resources. Attention to these and other recommendations may help assisted living live up to its name

Wage and Cost Study of Oregon Assisted Living and Residential Care Providers, 2022

Senate Bill 703 directed Oregon Department of Human Services (ODHS) to conduct a study of licensed residential care (RCF) and assisted living (ALF) facilities, including those with a memory care (MC) endorsement, to evaluate: a) Total cost to provide care to residents, b) the sufficiency of the Medicaid reimbursement paid to facilities to meet the total cost of care, and c) the average compensation paid to direct care workers by the facilities by geographic region. ODHS contracted with the Institute on Aging (IOA) at Portland State University (PSU) to conduct a study to achieve these three objectives. In the fall of 2022, IOA developed and conducted the study in collaboration with ODHS staff, with multiple opportunities for input from community partners, including consumer advocates and direct care worker partners, long term care trade associations, and attendees of the Long-Term Care Facility Provider Workforce Recovery Workgroup. This report describes the findings of the resulting study, which uses multiple data sources, including data collected by IOA from over 150 ALF/RCF providers and Medicaid reimbursement data provided to IOA by ODHS. Prepared for: Oregon Department of Human Services Office of Aging and People with Disabilities A study completed by the Institute on Aging at Portland State University with funding from and in partnership with Oregon Department of Human Service

Extreme Heat Vulnerability among Older Adults: A Multi-level Risk Index for Portland, Oregon

Background and Objectives Extreme heat is an environmental health equity concern disproportionately impacting low-income older adults and people of color. Exposure factors, such as living in rental housing and lack of air conditioning, and sensitivity factors, such as chronic disease and social isolation, increase mortality risk among older adults. Older persons face multiple barriers to adaptive heat mitigation, particularly for those living in historically temperate climates. This study measures two heat vulnerability indices to identify areas and individuals most vulnerable to extreme heat and discusses opportunities to mitigate vulnerability among older adults. Research Design and Methods We constructed two heat vulnerability indices for the Portland, Oregon metropolitan area: one using area scale proxy measures extracted from existing regional data and another at the individual scale using survey data collected following the 2021 Pacific Northwest Heat Dome event. These indices were analyzed using principal component analysis (PCA) and Geographic Information Systems (GIS). Results Results indicate that the spatial distribution of areas and individuals vulnerable to extreme heat are quite different. The only area found among the most vulnerable on both indices has the largest agglomeration of age- and income-restricted rental housing in the metropolitan area

Oregon Community-Based Care Survey: Assisted Living, Residential Care, and Memory Care

In Oregon, community-based care (CBC) communities include assisted living (AL), residential care (RC), and memory care (MC) communities. These settings provide residential, personal care, and health-related services, primarily to older adults. As the population of Oregonians aged 65 and older is estimated to increase from 16 percent in 2015 to nearly 23 percent in 20501, the availability of CBC settings will continue to be an important source of long-term services and supports. This report provides an in-depth look at Oregon’s CBC settings. Because no central dataset of CBC services, staff, and residents is available, as opposed to nursing facilities, information for this report was collected using a questionnaire that CBC providers (e.g., administrators, directors) were asked to complete. CBC settings provide long-term services and supports to many older Oregonians and their families. These services include daily meals, housekeeping and laundry, assistance with personal care needs, medication administration, monitoring of health conditions, communication with residents’ health care providers, and social and recreational activities. Of the 517 AL, RC, and MC communities licensed as of fall 2016, 60 percent (308) returned a questionnaire. The data described in this report are based upon these 308 communities unless noted otherwise. The goals of the project described in this report included: Describe assisted living, residential care, and memory care community characteristics, including staffing types and levels, policies, and monthly charges and fees Describe current residents’ health and social characteristics Compare current results with prior Oregon surveys and national studies of similar setting types to identify changes and possible trends Compare setting types for differences that might affect access, quality, or cost

Climate Change Policies and Older Adults: An Analysis of States’ Climate Adaptation Plans

Background and Objectives As climate change drives more frequent and intense weather events, older adults face disproportionate impacts, including having the highest mortality rates from storms, wildfires, flooding, and heat waves. State governments are critical in deploying local resources to help address climate change impacts. This policy study analyzes states’ climate adaptation plans to assess the methods through which they address the impact of climate change on older adults. Research Design and Methods This study uses content analysis to analyze available climate change adaptation plans for all U.S. states for strategies designed to increase resilience of older adults to impacts of climate change. Results Nineteen states have climate adaptation plans, of which 18 describe older adults as a population group with specific health impacts and risks factors. Four categories of adaptation strategies for older adults include communications, transportation, housing, and emergency services. State plans vary in terms of the risk factors and adaptation strategies included. Discussion and Implications To varying degrees, states’ climate change adaptation planning address health, social and economic risks specific to older adults, as well as strategies for mitigating those risks. As global warming continues, collaborations between public and private sectors and across regions will be needed to prevent negative outcomes such as forced relocation and other social and economic disruptions as well as disparate morbidity and mortality

Estimation of Excess Mortality Rates Among US Assisted Living Residents During the COVID-19 Pandemic.

The devastating effects of COVID-19 among older adults residing in long-term care settings have been well documented.1 Although much attention has been paid to COVID-19–associated mortality in nursing homes,2 less is understood about its effects on assisted living residents. Most assisted living residents are aged 80 years or older and many have multiple chronic illnesses, making them highly susceptible to poor outcomes of COVID-19.3 This study examines the excess mortality among a US cohort of assisted living residents during the COVID-19 pandemic