The Nurse Practitioner in Assisted Living Communities


Vol. 16 •Issue 3 • Page 55
The Nurse Practitioner in Assisted Living Communities

A Role Poised for Growth

Assisted living is the fastest growing segment of the senior care industry, with more than 1.4 million older adults now residing in assisted living communities (ALCs). Although the industry is diverse in terms of ALC size, services and staffing, some characteristics can be generalized.

Since the early days of the industry more than 25 years ago, assisted living has focused on providing an alternative living environment for older adults who need assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). IADLs encompass transportation, shopping, laundry, managing medications, etc. Dramatically different from the institutional-looking setting of a nursing home, ALCs have a residential feel ranging from homey to fairly opulent. The emotional environment of ALCs introduced a new paradigm: Assisted living overwhelmingly embraces what has come to be known as the social model.

Within this social model, ALC residents are afforded tremendous autonomy, personal choice and freedom — elements largely lacking in most skilled nursing facility (SNF) environments. Socialization and dining experiences are well developed in ALCs. Health and health care are not the focus; wellness is.

The ability to provide personal care and limited health care services to older adults within a social model, is aided by two other distinguishing factors: regulation and payer source. For decades, SNFs have had the burden of state and federal regulations. ALCs, on the other hand, have had no federal regulation and are subject to limited, widely varying state regulations. More than 90% of ALC residents pay from insurance plans or personal resources, whereas the bulk of SNF residents use Medicaid dollars to pay for care and services. These attributes have been significant in the ability of the assisted living industry to maintain a social model.

Current Trends

Current trends in assisted living reflect the changing nature of the industry. Residents who came to ALCs as generally healthy, primarily ambulatory older adults requiring limited to moderate assistance have aged and become more frail, sometimes requiring extensive assistance. It is not uncommon to see ALC resident using canes, walkers, wheelchairs or even mechanical lifts for assistance with mobility. In addition, the prevalence of ALC residents with dementia now ranges from about one-third of the population to as much as half. In response, dementia-specific assisted living communities have been introduced.

Liability issues in ALCs reflect the increasing frailty of the residents. State regulations have increased in the area of staff training, specification of services allowed, and requirements for resident care-related data gathering (e.g., assessment). Assisted living providers have responded to these changing trends in a number of ways, including adding health care team members and implementing enhanced training and risk management programs. Some ALCs have expressed concern about encroachment of a medical model and have held fast to the social model roots of the industry. There is lively debate about which is the best model for assisted living.

Expert Opinions

In 2006, the American Medical Directors Association (AMDA), a physician group historically focused on SNFs, convened a group of geriatric care experts to discuss the need for enhanced health care services and oversight in assisted living facilities. This group comprised AMDA members as well as representatives from a fairly broad range of national geriatric organizations and some hands-on providers, including me.

It is important to note that no federal regulations require a medical director for an ALC, and very limited state regulations address this issue at all. If an ALC has a medical director, it is generally by choice. One of the issues discussed at the AMDA meeting was whether the presence of a medical director in an ALC would prompt a shift away from the social model; many participants expressed concern about this possibility.

There seemed to be general consensus that a designated “health care leader” at each community was a good idea. This professional would have responsibility for oversight of health-related issues and could be a nurse practitioner, an RN, a medical social worker, or someone else with adequate training. Since ALC residents typically continue their relationships with their primary care providers, some group members worried that there may be concern about loss of those relationships if a medical director took over resident health care. Others believed that having the regular presence of a medical director or health care leader would facilitate more efficient response to health concerns and provide for better overall health among the residents. The language of the group shifted from “medical director” to “health services director,” fueled by belief in the critical foundation of the ALC industry’s social model. The significance of AMDA’s interest in assisted living should not be ignored.

Why NPs Fit the Bill

With their focus on a blended model of care, NPs demonstrate a convergence of social and medical models and would seem to be ideal candidates for the role of health services director in ALC settings. NPs with gerontologic education and experience are well versed in common geriatric concerns such as polypharmacy, falls and fall prevention, incontinence and the like. They look at their patients holistically within the framework of nursing — the diagnosis and treatment of human response to actual and potential illness — yet they can provide primary care and health care oversight.

Potential NP Roles

Potential roles for NPs in ALCs include the following:

  • primary care management
  • specialty practice in incontinence
  • mental health care including behavior management
  • wound management
  • medication therapy management services (MTMS) for Medicare D recipients (Section 1860D-4c)
  • staff, resident and family education
  • risk management (e.g., designing fall risk reduction programs)
  • administration.

    For primary care or specialty visits in ALCs, NPs would need to bill the resident or Medicare Part B directly. Reimbursement to NPs and physicians for health care visits in ALCs increased in 2007. Some ALCs may be open to paying fees for other services, but this would have to be negotiated with the individual ALC. The table accompanying this article shows codes and reimbursement rates for common services performed by NPs in assisted living facilities.

    Putting It Into Practice

    The health characteristics of ALC residents closely mirror those of SNF residents. Just as NPs have made a difference in the care of SNF residents, they play a beneficial role in ALCs.

    Sharon Roth Maguire is a gerontologic nurse practitioner who is senior director of health care and resident services at Brookdale Senior Living in Milwaukee. She is chairwoman of the Clinical Quality Executives Roundtable of the Assisted Living Federation of America, a clinical assistant professor of nursing at Marquette University in Milwaukee and a past president of the National Conference of Gerontological Nurse Practitioners.

    For Further Reading and Information

  • National Conference of Gerontological Nurse Practitioners (NCGNP) special interest group on assisted living. Visit NCGNP’s Web site (, and find the group on the Members Only practice links page.

  • Assisted Living Consult. This bimonthly journal focuses on clinical and practice issues in assisted living centers. Visit

  • Lyketsos CG, et al. Effect of dementia and treatment of dementia on time to discharge from assisted living facilities: the Maryland Assisted Living Study. J Am Geriatr Soc. 2007;55(7):1031-1037.

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