The variation among the different communities makes it difficult to establish a uniform definition of AL. The ALW developed the following definition:

Assisted living is a state regulated and monitored residential long-term care option. Assisted living provides or coordinates oversight and services to meet the residents’ individualized scheduled needs, based on the residents’ assessments and service plans, and their unscheduled needs as they arise [2].

Services required by state law and regulation must include but are not limited to:

One of the key differences between nursing communities and AL is that there are no federal regulations for AL. Each state has developed its own specific regulations, thereby avoiding onerous federal regulations that would likely lead to increased cost to both communities and residents. Some advocate that there would be potential benefit to federal oversight that establishes clearer and more uniform enforceable standards in order to maintain quality patient care and safety.

ALCs differ widely in size, capabilities of care, and philosophy. The adage “if you’ve seen one assisted living facility you’ve seen one assisted living facility” applies. Many are freestanding communities, while others may be part of a continuing care retirement community (CCRC) . Rooms are typically a private or semi-private studio and one- or two-bedroom apartments. As part of resident rights, recent proposals admonish private rooms for all AL residents. There are many corporate AL chains, with 78 % being for-profit, 20 % nonprofit, and 1 % government/other [1]. Sixty percent of ALCs serve 1–25 residents, 35 % have 25–100, and only 5.5 % have greater than 101; however, 71 % of all residents dwell in communities with more than 50 beds. Smaller communities tend to be newer than larger communities. In 2014, the largest chains were Brookdale Senior Living , Sunrise Senior Living , Evangelical Lutheran Good Samaritan Society , Emeritus Corporation , Five Star Quality Care , and Assisted Living Concepts . Most states in the West and Midwest, as well as a few northeast states (ME, PA, VI and VT) had higher use of residential care communities than the national average. Only in the West is there a comparable supply of residential care beds and nursing home beds per 1000 persons aged 65 and over, whereas nursing home beds far outnumber residential care beds in all other regions of the country [1].

Staffing in ALCs varies widely. There is no requirement for a nurse on site in ALCs. Seventy-five percent of ALCs provide social work services [1], with activities staff present more frequently in larger communities. Documentation and charting also varies, with state-specific regulations and scope of practice issues such as which AL staff, if any, are able to take verbal physician’s or other healthcare professional’s orders. State regulations and community-specific policies on which medical conditions may prohibit admission or give cause for discharge from an ALC vary. Ventilator dependency, stage IV decubiti, continuous intravenous fluids, and communicable airborne infections that require isolation may prohibit admission to AL. Most ALCs will admit residents with a moderate level of need for assistance, such as requiring help with or using wheelchairs (62–71 %). However, 44 % of ALCs will admit those who need assistance with transfers, and 53 % will not admit persons with moderate-to-severe dementia [3].

There is an increasing prevalence of dementia amongst AL residents. Zimmerman et al. [4] estimate that 71 % of AL residents have cognitive impairment (29 % mild, 23 % moderate, 19 % severe), and that 17 % of ALCs have dementia special care units, and 9 % dementia–specific units. A majority of residents with mild dementia go unrecognized by AL staff [4]. State regulations have begun focusing on dementia care especially related to resident safety, staff training, and provision of dementia-friendly activities. The Alzheimer’s Association has developed AL-specific criteria and guidelines for dementia care [5]. Practitioners may notice a phenomenon in dementia-specific units that if a significant number of residents with dementia are admitted in a similar stage, at about the same time, that as these residents “age in place” and their disease progresses, many will be discharged from the AL community to a nursing community or hospice in a short period of time as they begin to require more complex medical and behavioral or end of life care. If anticipatory marketing has not been done, the community may experience a significant drop in occupancy rates that results in an impending financial crisis. AL residents may receive hospice care and continue to reside in the ALC depending on state regulation and each community’s capabilities.

Three-quarters of residents are either entirely (22 %) or partially (49 %) responsible for making the decision to move into an ALC, while for other residents, their adult children, children’s spouse, or other family member commonly makes this decision. More than 70 % of residents move into an ALC from their own private home or apartment, and 60 % relocate within 10 miles of their previous permanent residence [6].

Similar to nursing communities, AL residents are typically female, white, with an average age of 87 years [6] and thus older than their nursing home counterparts [1]. The residents in AL do have increasing ADL needs [1] (Fig. 1) that generally correlate with declining overall health. This ADL dependency, though not as severe as those for nursing community residents, does exceed that seen in community-dwelling elderly. Data indicates that AL residents generally need assistance with two ADLs and have an average length of stay of 28 months.

AL residents often suffer from multiple medical problems. Half to three quarters have chronic conditions in three or more different general disease categories [7, 8]. As noted there is an increasing incidence and prevalence of dementia. Other common conditions include hypertension, heart disease, depression, arthritis, and osteoporosis [8].

Medication usage is an important issue in AL. Residents take an average of seven to eight prescriptions and two OTC medications daily, and 80 % require assistance with taking these medications [6]. Unlike skilled nursing communities, there is no federal mandate for a consultant pharmacist medication review, though many ALCs may provide this service. Use of over-the-counter medications, as well as alternative and herbal therapies are other potential concerns for the practitioner [9].

Overall, 60–90 % of residents are satisfied with their care in AL. The main two reasons residents leave the ALC are a change in health status or death. About 60 % move to a nursing community, 13 % move back home or to a child’s or relative’s home, 10 % transfer to another ALC, and 7 % go to a non-short-stay hospital [6]. Understanding resident admission and discharge patterns is helpful to physicians when they discuss with residents and families the option of AL as it relates to the resident’s care and illness trajectory.

There is no federal mandate that requires an ALC to have a medical director, although some organizations have established this position. The ALW did not reach a majority consensus when considering a recommendation that ALCs have a medical director, but did reach a consensus that an “external professional consultant” should be used. One-quarter to one-third of ALCs have acquired a medical director [6]. There is increasing use of models where physicians either alone or in combination with nurse practitioners and/or physician assistants visit residents at the ALC on a regular basis. In general, most attending physicians continue to see residents in their private office. ALCs usually do not have a well-established “medical staff.” Unlike nursing communities, where there are mandatory visits no less than every 60 days, AL residents are required to be seen at a minimum of once yearly. ALCs can contract with different services, including home health care and hospice agencies. Despite the lack of regulation in most states, a consultant pharmacist provides medication review and monitoring at 64 % of ALCs [6].

AL cost is significantly lower than that of a nursing community and is usually paid for privately with residents and families financing the majority of costs. Costs vary widely, depending on size of the AL residence, care requirements and geographic region (Fig. 2). The national median monthly rate in 2014 was $3500/month [10]. The national median yearly cost for a single ALC room was $42,000 (compared to a nursing home private room at $87,600) [10]. Fees usually include rent, meals and some level of basic services. Unlike the skilled nursing community, there are no Medicare payments to ALCs. But many states have developed Medicaid waiver programs under CMS to cover personal and skilled care services for qualified, low-income patients. Medicaid paid for at least some services for 19 % of all residents in 2010 [8]. Rendered services, not room and board charges, can be covered by Medicaid funds. These waivers are only available when a resident meets both the state’s criteria for being “nursing home eligible” and the Medicaid financial eligibility requirement. Residents may experience a long delay before receiving such a waiver and some ALC providers feel that they receive inadequate reimbursement under the waiver programs. Long-term care insurance is an occasional primary payment source. The lack of public funding for AL makes affordability a major concern for the future viability of the AL industry.

Another affordability concern is “a la carte” pricing policies at ALCs. ALC communities may charge extra when residents need additional help (i.e., a higher level of care/assistance) as illness progresses. Since many residents have limited funds, their families may be reluctant or even refuse to pay the increased fees and often subconsciously deny the existence of increasing frailty and medical risk.

Surprisingly, despite all these concerns about affordability, residents move out of an ALC due to financial reasons only 6 % of the time [6]. If a resident has to move out of the ALC for lack of funding, it is a difficult time for families. Not infrequently the resident is transferred to a hospital, which then assumes the responsibility of placing the resident at another healthcare community.

Readers are referred to Part IV Special Issues in Long Term Care, Chap. “Documentation and Coding”. Of note, the custodial care codes should be used (99324-99326 and 99334-99337) for ALC visits and not the home visit codes. AL coding uses Place of Service Code 13 . Also note that reimbursement for AL medical services is generally higher than equivalent codes for other sites of service, such as the office and nursing home settings, which can be a financial incentive for physicians to make resident visits at the ALC.