As artificial intelligence becomes increasingly integrated into tools used by senior care and living providers, its uses can be broadly placed into two categories: data analysis and automating routine work.

Some of the best new AI tools that LTC providers should be aware of include the newly expanded Microsoft 365 Copilot and the website scena.ai, according to a new brief guide on AI from LeadingAge. 

The latter was used to generate the opening video at LeadingAge’s conference. 

“At its core, generative AI is a subset of AI that focuses on creating content, whether its text images, music or entire virtual worlds,” a digital avatar told the crowd. “With the right application, generative AI can assist in aging services.” 

While many of these AI tools, and their applications, have been widely available for months, organizations like LeadingAge have been working to advance adoption of these tools, because the LTC industry often lags behind other sectors in onboarding new tech, many healthcare experts have noted. 

Coming into this year, staffing shortages remain an ongoing issue for LTC providers, so the more administrative tasks an organization can devote to AI, the more existing staff and caregivers can focus on resident care.

As for data analysis, AI’s predictive power, which can help predict and prevent falls, was seen as one of the most promising tech innovations in LTC, according to a recent podcast panel for McKnight’s Market Leaders including AHCA President Mark Parkinson.

Seniors themselves may be more open to AI being used in their healthcare systems, or at least accept its presence, a recent report found.

In addition to listing some AI tools and providing a broad overview, the recent LeadingAge post also listed several AI guides for organizations to review, including a report from NetHope and a recent research study published in JMIR Aging.

Telehealth expansion has been supported by many healthcare and government leaders in the post-pandemic world, including President Biden, as a way to ensure everyone has access to coverage and essential health services.

However, adding broadband access to rural or underserved communities may not be a silver bullet that enables telehealth use in those areas, a new study shows.

This means that long-term care providers, particularly those in rural areas, need to make sure that digital literacy training and cultural factors are in place for telehealth use.

Study authors were most concerned with policymakers and whether they were viewing telehealth issues too narrowly.

While the study, which looked at 170,000 Wisconsin Medicaid beneficiaries, supported the idea that telehealth helped remove geographical barriers to important healthcare services, the researchers concluded that actual telehealth use is separated by what they termed the “digital divide.” This includes a mix of factors including age, ethnicity and tech literacy.

“Although telehealth expansion has been touted as a low threshold policy intervention to expand access to care,” the study authors wrote, “leveraging telehealth to improve access for underserved populations will require more nuanced attention to the specific mechanisms linking telehealth and health care utilization to avoid inadvertently deepening disparities for select populations.”

After the pandemic, those who adopted telehealth skewed older, urban and female, the study found. While the researchers held back on making a definitive conclusion for why this cohort would be more amenable to telehealth use, they speculated that it was broadly due to better knowledge and trust in the healthcare system. The study showed greater telehealth use for lower-income and education individuals — but only for audio-only interventions, which are only a small fraction of telehealth care.

While seniors are often slower to adopt new technology, it is not the older adults themselves who are hesitant to use telehealth, but rather clinicians who worry that telehealth visits are insufficient to address more complex medical needs, McKnight’s reported last year.

The assisted living sector touts itself as the most cost-effective option to provide quality-of-life care and services for the nation’s older adults. But that value comes at a cost, according to a new report.

Seniorly set out to determine how much assisted living communities actually cost and how those costs stack up against other options, including in-home care, by analyzing the average cost to consumers in all 50 states.

The price of assisted living, as with most business offerings, is increasing. Between 2021 and 2023, 30 states saw average costs for assisted living rise — with Wyoming (a 53% increase), West Virginia (46%) and New Hampshire (46%) seeing the biggest average increases, according to the report. The 2023 national average monthly cost of $4,401 is an 8% increase over 2021.

Costs charged to consumers actually fell in 15 states — Washington saw the biggest decline, at 16% — and remained relatively flat in six states, according to the report. 

The average monthly rent for assisted living communities ranged from $2,946 in Louisiana to $8,248 in New Hampshire, where it was almost double the national average. Average monthly costs were more than $5,000 in 10 states, most of them concentrated in New England and the Mid-Atlantic, whereas the most affordable states included Indiana ($3,695), Iowa ($3,420) and South Dakota ($3,378).

Middle market highlighted

The cost of senior living is shining a spotlight on options for the “forgotten middle,” those whose incomes are too low for them to be able to afford current private-pay senior living options but too high for them to qualify for federal assistance.

A recent Milken Institute report, released in partnership with the National Investment Center for Seniors Housing & Care and CVS Health, projected that almost three-fourths of the estimated 16 million middle-income older adults who will be aged 75 or more years will be financially unprepared to afford housing to meet their needs in 2033. Even with home equity, the Milken researchers found, only 39% of those middle-income older adults will be able to afford assisted living.

Another recent study from the Harvard Joint Center for Housing Studies, released last month, found that only 13% of adults aged 75 or more years who are living alone across 97 US metro areas can afford to move into an assisted living community without starting to cash in their assets.

A NIC-funded 2019 study by NORC at the University of Chicago found that 54% of middle-income older adults will lack the financial resources to pay for senior housing and care in 2029, calling for a combination of public and private efforts to address the looming crisis.

The Seniorly study in part used data from the US Census Bureau’s 2022 median annual household income for states and savings rates from the Bureau of Economic Analysis. In doing so, Seniorly estimated that it would take the average American 17.2 years to save for one year of assisted living. 

Using those data to look at the affordability of assisted living, Seniorly found that New Hampshire residents would need to save for 26.8 years to cover a single year of assisted living, with West Virginia (26.1 years), Mississippi (24.8 years), Wyoming (24.6 years) and Delaware (21.7 years) rounding out the top five states as far as timing. 

Maryland came out at the other end of the spectrum, with residents needing to save an average of 11.7 years to cover one year of assisted living costs, followed by Utah (12.3 years), Minnesota (12.3 years), Georgia (13.3 years) and Washington (13.4 years). 

In comparing assisted living with home care costs, Seniorly pointed to a report from Genworth Financial that put the monthly cost of a home health aide at $5,462, although wide variation exists between states. Minnesotans will pay the most for home care, with a median monthly cost of $7,333, compared with $3,472 for assisted living. West Virginia was the least expensive state for home health aides at $3,793 per month, compared with $4,846 average monthly rent for assisted living.

Some question value

The assisted living industry’s pricing structure and providers’ for-profit status were two topics examined in a New York Times and KFF article package in November. Costs also were discussed in a December Washington Post article package looking at the deaths of residents who had eloped from communities. 

Those and other lay media investigations into the assisted living industry led the US Senate Special Committee on Aging to launch a review of the industry, including questions to three large providers, and to schedule a Jan. 25 hearing based on “significant concerns” about costs, staffing levels and resident safety.

Developers behind a new veterans home are hoping the facility serves as a design model for how to accommodate “the personal technology ecosystem.” 

As seniors are rapidly adopting technologies like smartphones and wearable devices, senior care and living providers need to be increasingly sure facilities have the infrastructure for these tools, such as sufficient wireless connectivity and charging outlets. 

That can also include knowing which software and interoperable systems to utilize as well, as one report noted.

Engineers with the firm IMEG Corp., who helped build the new 138-bedroom veterans home in Augusta, ME, said it is especially important for new senior living projects to implement these innovations during the planning phase.

While IMEG is undoubtedly using the Maine example to broadcast its own consulting abilities, it is important for senior living providers to make sure they are working with designers so they are not spending more money retrofitting new buildings for technology after the fact, or scrambling to catch up with the latest trends. 

The Maine Veterans home has a gym equipped with virtual reality capabilities and other rehab tech tools, the developers touted. 

Other senior living facilities have taken on the “smart gym” design model, such as Blakeford Senior Life’s Nashville campus, which has equipment and software to help with personalized elderly fitness regimens, McKnight’s recently reported.

However, while many senior living facilities boast impressive tools and devices, from cleaning robots to VR headsets, an important aspect of the current tech ecosystem to keep in mind is how many personal devices new senior living residents bring with them — and what they expect to be able to use, the IMEG developers note.

The senior living industry has been notoriously slow to adopt new technologies, many experts have pointed out. Only 30% of senior living organizations had upgraded their network systems over a five-year period, according to a report from 2022. Other accounts suggest that even when adopting new tech, many senior living providers end up abandoning tools.

Not all senior living providers have the resources available to design or implement these tools on their own; this is particularly true for rural communities.

Many healthcare leaders, and even President Biden, have raised this point and called for more investment in resources and technology for underserved senior living populations.

The US Senate Special Committee on Aging is launching a review of the assisted living industry following recent articles in the Washington Post, which reported on the deaths of residents who wandered from communities, as well as the New York Times and KFF, which scrutinized an industry pricing structure that adds fees on top of basic charges to cover additional services, as well as rate increases and the for-profit status of most providers.

Committee Chairman Sen. Bob Casey (D-PA), who has scheduled a hearing for Jan. 25, sent letters dated Monday to the leaders of Brookdale Senior Living, Atria Senior Living and Sunrise Senior Living, asking them to address his “significant concerns” about costs, staffing levels and resident safety.

“Despite these high costs, residents in assisted living facilities have been put in harm’s way, leading to avoidable injuries and death,” Casey wrote in his letter to the large providers, detailing points made in the November Times/KFF articles and December Post articles. 

Assisted living communities primarily are regulated at the state level, but the committee frequently has used its authority to “examine private companies when concerns arise about potential health and safety, as well as financial risks posted to older adults,” the senator said.

“The Senate Special Committee on Aging has jurisdiction over the problems older adults face, including matters of maintaining older adults’ health, their ability to secure proper housing, and their ability to obtain care or assistance when needed,” Casey wrote. “As chairman, I have an interest in ensuring that older adults and people with disabilities are receiving high quality care, have access to proper housing and receive good value for their hard-earned dollars.”

Specifically, Casey asked the companies to provide information and documents no later than Feb. 5 detailing how they communicate the cost of services to residents and their families, rates they charge in each state, and their schedules of services and costs. Additionally, he asked them to provide information on average revenue per occupied unit for the past seven years, figures on the number of residents who have eloped or sustained injuries due to being left unattended, information about the accessibility of information about complaints and citations received by their communities, their policies and procedures for informing residents and families about accidents, applicable staffing requirements, and job titles and associated pay rates at their companies. 

“We look forward to reviewing and responding to Sen. Casey’s letter on the assisted living industry with candor and transparency,” Sunrise Senior Manager of External Communications Heather Hunter told McKnight’s Senior Living. 

Atria Senior Living provided a similar response.

“Our top priority is our residents’ well-being and safety,” an Atria spokesperson told McKnight’s Senior Living. “We look forward to providing information in response to Sen. Casey’s letter.”

Brookdale said it is aware of the letter from Casey.

“Brookdale values the relationships we have created with our hundreds of thousands of residents at communities across the country over the last decade, and we are committed to providing high quality care,” a spokesperson said. “We take seriously our mission of enriching the lives of those we serve with compassion, respect, excellence and integrity.”

Atria, Brookdale and Sunrise are some of the largest senior living operators in the country. On the 2023 ASHA 50 list issued by the American Seniors Housing Association, Brookdale topped the list of operators, and Atria came in at No. 2. Sunrise was No. 3. On Argentum’s 2023 list of largest providers, Brookdale was No. 1, Atria was No. 2 and Sunrise was No. 5.

This isn’t the first time that senators have called for an investigation related to assisted living. In one of the most recent actions, a bipartisan group of US senators, all members of the Aging Committee, in 2015 asked the Government Accountability Office to report on Medicaid oversight and quality of care in assisted living communities. Their request resulted in a 2018 GAO report.

That report contained a to-do list for the Centers for Medicare & Medicaid Services related to state reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities. Some federal lawmakers and consumer advocates, however, said that they would push for changes in assisted living because of the report’s findings.

‘Isolated incidents’

Senior living industry groups have called the number of deaths reported in The Post’s story a small fraction of the total number of assisted living and memory care residents, most of whom report high satisfaction with their communities.

“The Washington Post’s reporting featured isolated incidents that assisted living communities take very seriously,” Argentum President and CEO James Balda told McKnight’s Senior Living, adding that the elopement-related fatalities highlighted in the Washington Post stories are “exceedingly rare,” occurring with 0.0015% of more than 6.2 million residents served during the timeframe of the reports.

“Our communities look forward to demonstrating to the committee that as the nation grapples to care for our aging population, assisted living provides independence and dignity for seniors,” he said.

Argentum, Balda added, “strongly supports” state regulations already in place to investigate incidents and punish any wrongdoing, and he said that any fatality is “devastating for our staff, our residents and their families.”

Calling elopements rare while acknowledging that any resident injury is “truly tragic,” National Center for Assisted Living Executive Director LaShuan Bethea said she welcomes the opportunity to engage with the committee to “further their understanding of the assisted living profession, its oversight and our deep commitment to providing quality care.”

“The assisted living profession is committed to continuing to learn all that we can about dementia and the disease process to meet the ever-changing needs of our residents,” Bethea told McKnight’s Senior Living. “Policymakers, providers and other stakeholders should come together to find ways to advance memory care while honoring why seniors and their families love assisted living — by supporting their independence and autonomy in a home-like environment.”

Assisted living will continue to evolve with the nation’s changing needs, and regulations, staffing and training requirements must evolve with them, LeadingAge President and CEO Katie Smith Sloan told McKnight’s Senior Living.

“Our elected officials and other stakeholders must prioritize policies to support older adults and the professionals working in aging services to ensure equitable access to high-quality care in assisted living, as well as other care settings,” she said.

In a response to the original package of Washington Post stories, American Seniors Housing Association President and CEO David Schless said the stories “inaccurately” suggest that elopements in assisted living or memory care settings would not occur if there were federal oversight of the setting. He also said that the articles failed to recognize the contributions of the vast majority of frontline caregivers and other senior living professionals.

Schless called assisted living “highly regulated” by states that impose strict requirements, including licensure, and cover a broad range of provisions such as those Casey asked about in his letter to providers. Schless added that states are actively involved in updating and modifying regulations and statutes on an ongoing basis.

“The states are far more responsive than the federal government in addressing the needs of residents and their families to ensure innovative services and programs are available to meet their needs and those of a rapidly aging population, including those with Alzheimer’s and related dementias,” Schless said. 

ASHA, he said, also plans to respond to the committee with a rebuttal of the Post’s “misrepresentation” of the industry, providing information he said was overlooked in the reporting as well as information about the benefits and value of senior living.

Association leaders previously submitted letters to the editor to the New York Times and the Washington Post in response to their articles. Although The Post has not published letters from the associations, it did post a letter from Andrew Carle, lead instructor in senior living administration at Georgetown University. He said that the more than 6 million Americans affected by dementia and prone to wandering would be “exponentially safer” in assisted living communities than at homes in the greater community.

Industry quality initiatives

The industry has launched several initiatives focused on building consensus around assisted living quality measures, as well as infection prevention and control efforts. NCAL last week released its 2023 regulatory review report, which highlighted regulatory requirements across all 50 states. 

The Center for Excellence in Assisted Living, known as CEAL@UNC for the past year, itself was launched in 2003 as a result of a recommendation in the landmark Assisted Living Workgroup Report, delivered to the Senate Special Committee on Aging. 

In a recent podcast interview with McKnight’s Senior Living, Sheryl Zimmerman, MSW, PhD, the center’s executive director, called on all assisted living stakeholders “to be more mindful in a pragmatic, feasible way” across all of assisted living to address resident care needs.

“Most everyone involved in assisted living is aware there are opportunities for improvement,” Zimmerman told McKnight’s Senior Living. “The Senate Aging Committee delved into assisted living 20 years ago with the Assisted Living Workgroup Report, which led to the national Center for Excellence in Assisted Living, and as the executive director, I welcome the opportunity this brings to coordinate efforts to work towards excellence while providing person-centered care and quality jobs.”

LeadingAge, Argentum, NCAL and ASHA in June announced that they had joined with the National Association for Regulatory Administration to develop guidance for the industry and resources for operators, regulators, policymakers and other stakeholders. The groups, working together as the Quality in Assisted Living Collaborative, first turned their attention to the area of infection prevention and control, an issue brought to the forefront during the COVID-19 pandemic, with plans to address other issues.

NCAL also has its own National Quality Award program, based on the Baldrige Performance Excellence Framework. It recognizes assisted living providers that meet certain goals. The organization’s voluntary quality initiative for assisted living communities also has goals related to staff stability, customer satisfaction, hospital readmissions and the off-label use of antipsychotic medications.

The Joint Commission is planning to revise its infection prevention and control requirements for assisted living community accreditation as infection prevention and control regulations for the setting become more common at the state level.

The commission’s proposal focuses on the structures deemed essential to supporting quality and safety and outlines a framework for infection prevention and control programs. The suggested changes also more closely align with the the Centers for Disease Control and Prevention’s core infection prevention and control practices for safe healthcare delivery in all settings, according to the commission. 

A Joint Commission spokeswoman told McKnight’s Senior Living that the proposed revisions are a continuation of the wider infection prevention and control chapter rewrite initiative that spans all areas of accreditation.

“Broadly speaking, the goal of the IC [infection prevention and control] chapter rewrite is to align the IC standards and elements of performance more closely with law and regulation, eliminate the requirements that do not add value to surveys, and streamline the chapter,” the spokeswoman said. “The proposed revisions are currently in field review. Once approved, the revised IC chapter will replace current IC chapter requirements.”

Once the new requirements are implemented, commission-accredited assisted living communities will receive access to a new assessment tool that will outline the specific actions and processes they will need to take to meet them.

The Joint Commission is accepting comments on the proposal until Feb. 21 through an online survey.

The changes

Specifically, the changes cover assigning management responsibilities for infection prevention and control, including developing policies and procedures, coordinating competency-based training and risk management. They also require organizations to have written policies and procedures guiding infection prevention and control, including reporting duties to local and state public health authorities.

The Joint Commission also is deleting an existing performance improvement component of the accreditation program requiring assisted living organizations to provide incidence data to key stakeholders — leaders, licensed practitioners, nursing and staff members — about multidrug-resistant organisms, because it was determined to be out of scope.

The Joint Commission launched its assisted living community accreditation program in 2022 to bring “national, consensus-based standards” to the industry. Its standards address the environment, staffing, emergency management, dementia care, medication management, the provision of care and services, process improvement and more. The program also requires organizations to track and report on five standardized performance measures: off-label antipsychotic drug use, resident falls, resident preferences and goals of care, advanced care plans/surrogate decision-makers, and staff stability.

The Joint Commission also launched an assisted living community memory care certification program last year in collaboration with the Alzheimer’s Association, to promote consistent, high-quality dementia care in assisted living. 

Industry efforts

Indicative of the growing importance of infection control in assisted living, regulatory requirements related to infection control and emergency preparedness were an addition to the National Center for Assisted Living’s 2023 regulatory review report, released last week. The report noted that such regulations now are in place in a majority of states.

Industry groups devised their own guidance for infection control and prevention in 2023.

NCAL, Argentum, the American Seniors Housing Association and LeadingAge in June announced that they had joined with the National Association for Regulatory Administration to develop guidance for the industry and resources for operators, regulators, policymakers and other stakeholders. Infection prevention and control was the initial focus of the effort, called the Quality in Assisted Living Collaborative.

Other existing infection control efforts available to providers include the CDC’s Project Firstline training program for infection control and prevention, a certification for infection prevention and control professionals via the Certification Board of Infection Control and Epidemiology, and an infection prevention and control document produced by Argentum during the pandemic. Other than the Argentum document, however, most of those efforts are not focused on assisted living, and they are not strictly guidance.

And assisted living was an area where such focus was needed, according to a study published in December 2022 in JAMDA – The Journal of Post-Acute and Long-Term Care Medicine. That research found that infection control and preparedness in assisted living during the pandemic was hampered in part by limited clinical expertise and medical oversight of staff members and conflicting regulations and guidance for federal, state and local health agencies.

And in memory care settings, according to a study published in the June 2022 edition of the Journal of the American Geriatrics Society, a need existed “to bolster infection prevention capacity when caring for this especially vulnerable population.” 

Regarding overall quality, NCAL has its own National Quality Award Program, based on the Baldrige Performance Excellence Framework, that recognizes assisted living providers that meet certain goals.

NCAL also has a voluntary quality initiative for assisted living communities, with goals related to staff stability, customer satisfaction, hospital readmissions and the off-label use of antipsychotic medications.