Assisted Living vs. Skilled Nursing: It's a Mothra vs. Godzilla thing

Although they lack the fearful abilities of the monsters of Japanese sci-fi fame, skilled nursing and assisted living providers are similar to those fictional creatures in their mutual distrust and shared desire to enter the other's turf.  The 2012 ALFA (Assisted Living Federation of America) Conference convened last week in Dallas saw a continuation of this 25 year struggle, which began when the nascent assisted living facility (ALF) industry first emerged as a viable housing alternative for older adults.

Walk into any ALF community in the United States and one quickly notices how often they resemble their skilled nursing counterparts of 15 and 20 years ago. The average ALF resident is now much older and much likelier to have significant cognitive and physical limitations. Therefore, it is no surprise that "choice" was a big theme at this year's conference. Stephanie Handelson, president & COO of Benchmark Senior Living captured the mood well by saying:

"Never give up on aging in place. The worst thing you can do is pull a person out of [their residence] and put them elsewhere where the care is no better--and the outcome is worse."

To my mind, the question remains unanswered as to which model can best care for what type of resident. From the ALF perspective, its (almost exclusive) reliance on private paying residents who are increasingly more interested in remaining at home (with HCBS) is propelling its need to keep current residents. However, ALFs warily avoid violating the state regulations which force higher acuity residents to relocate to a skilled nursing setting.

It is no surprise that the largest national association of assisted living facilities uses the term "senior living centers" rather then assisted living facilities when referring to this level of care. Removing "assisted" reflects the perceived need to be viewed as offering a continuum of care with few (or no) restrictions.

In Illinois there are 303 ALFs (comprising 13,470 unites) and in a prior post (here) I commented on how the relatively lax regulatory framework in Illinois (in comparison to other states) enables Illinois ALF providers to admit and retain residents who (in other states) would be forced to reside in a skilled nursing center. However, to accommodate these higher acuity residents an ALF provider must increase licensed (e.g. RN) staffing which can significantly increase expenses (and thus increase costs to their price sensitive clients). In contrast, the vast majority of skilled nursing facilities accept Medicaid which allows their residents to rely on public assistance when their (or their families) private resources are exhausted.

Meanwhile, SNF providers are quick to defend current restrictions placed on ALF admission criteria as well as discharge criteria. Realizing that their historic reliance on a "medical model" of care is inhibiting their ability to compete for residents, culture change (as posted here) and other person-centered care initiatives are more important than ever in SNF providers pursuit of market share.

No doubt, the struggle will intensify as the baby-boom generation ages. What do you think? Which provider will win greater market share?

Learn more on Twitter @aginginchicago







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  • Very interested in this topic as a health services researcher. Would love to have contact with people with experience and perspectives on this issue. Working now on a fire safety project. Please contact me if you are interested in fire safety in assisted living at

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    Bruce Lederman has over 25 years experience in the senior care field as a direct care provider and thought leader. Bruce was CEO and president of his own firm that operated skilled nursing facilities in Illinois. He is a former nursing home administrator and has consulted to numerous elder care providers on planning for strategic growth as well as process improvement. Recently he served as board chair of CJE SeniorLife, a leading non-profit elder care provider in the Chicago area. Bruce is currently employed as chief strategy officer for a company providing skilled nursing services in communities throughout Illinois and Missouri.

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