Article Archive
November/December 2015

Promoting Nursing in Assisted Living Facilities
By Leslie Ledbetter, RN, DNP, AGPCNP-BC, and Dale Pelton, MBA, FACNHA
Today's Geriatric Medicine
Vol. 8 No. 6 P. 28

The large baby boomer population is contributing to rapid growth in assisted living facilities (ALFs) in the United States. More than 33,000 ALFs are currently in operation, yet this number may be unable to meet the growing demands of the increasing geriatric population. The number of elderly aged 85 and older is expected to increase to 19 million by the year 2050.1 This statistic supports the theory that people aged 85 and older are expected to be the fastest-growing segment of the geriatric population.2 The US Census Bureau reports that every eight seconds, a baby boomer turns 60 and by 2030, 20% of the United States is expected to be aged 65 or older.3 The geriatric population has superseded the average growth rate of the country's population and their medication management and medical needs must be addressed in a timely manner so that they can remain in their own homes and require fewer hospital admissions.2

To prescribers, practice in an ALF presents unique situations that are not seen in other areas of medicine. Medical providers who are practicing primary care within patients' apartments in an ALF setting struggle with the myriad chronic health concerns and the difficulty created by the lack of adequate nursing staff support within the facility to carry out complex orders.

A phenomenal occurrence has been observed throughout ALFs in the past decade as these facilities are admitting residents with more complicated diagnoses and comorbidities; the acuity level and complex diagnoses typical of nursing home patients has shifted downward and is being seen much more frequently in ALFs. Thus, facilities are required to attempt to cope with and care for more complicated medical problems among the elderly, often with limited personnel resources.

Increased Levels of Care Required
This essentially means that ALFs are admitting residents who, by virtue of their medical conditions, would previously have more likely belonged in the "nursing home" realm, based on their complex diagnoses and higher need for one-on-one care. ALFs have always operated under the premise that residents should require minimal assistance with daily needs and medication management. However, as the growing elderly population continues to live longer with extended lists of complex diagnoses, there is no other place for these individuals to live unless they move to a nursing home. Optimizing drug therapy for the elderly population is difficult but is an essential part of caring for these individuals.

The aspect of greatest concern in treating these serious chronic conditions is that there is a significant lack of nursing staff within ALFs to help monitor residents who are taking numerous medications. While some ALFs have only one nurse (LPN or RN) overseeing the management of the entire assisted living community, it is not uncommon for facilities to have no onsite nurse, depending on state regulations. Rather than nurses administering medications to residents, medical technicians—individuals who have undergone a certain amount of training based on state requirements—often administer medications to individuals in ALFs; however, their limited training results in a lack of ability and judgment to handle the growing demands of the elderly population's medication regimens. This should be a point of concern for any prescriber working in these types of elderly communities, as this increases the risk of medication errors and drug interactions going undetected and/or unreported. Adverse drug reactions in this patient population result in nearly 30% of their hospitalizations.2

Competent Oversight
Polypharmacy, a major concern among geriatric patients, carries numerous risks that should be monitored by competent nursing staff. Medical technicians are not trained to handle situations with polypharmacy and may not be equipped with the knowledge of the need to notify the provider of any potential or ongoing issues with medications. Statistics show that medication use increases dramatically with age: More than 75% of individuals aged 60 and older use at least two prescription medications, and 37% of the geriatric population use five or more medications.4 As a result, the risk of adverse drug reactions increases exponentially as patients age.

The heightened risk of drug reactions and interactions make the elderly more vulnerable and susceptible to adverse drug events. Appropriate staffing must be factored into facilities' populations and treatment needs. While there is a clear division between the definitions of nursing homes and ALFs, it is important to recognize the growing need for nurses in ALFs. Because the populations within these facilities continue to more closely approximate those of nursing homes because of the high incidence of chronic conditions such as congestive heart failure, chronic kidney disease, and cancer, the prescribing provider must take great caution in adding or changing medications because of the frequent lack of skilled and trained medical staff.

The provider must consider the skill set of the medical technicians within ALFs. Complex orders should not be given via these personnel because there exists a much higher risk of medication errors. For example, a patient with recent history of congestive heart failure needs to be monitored frequently with specific orders to follow, including daily weights, Lasix 40mg bid, KCLor 20 mEqs bid, and giving extra dose of Lasix if weight increases by five pounds within 24 hours. This may seem like a valid simple order, but in an ALF, medical technicians are not trained to assess patients and implement such complex orders.

Consider another example of a patient who requires sliding-scale insulin coverage, along with the timed insulin doses throughout the day. Medical technicians do not have the knowledge of the gravity of insulin treatment, and doses are often miscalculated or missed. These types of patients require frequent and routine follow-up by the primary care provider and possibly by home health nurses to check on a patient throughout the week.

Nurses' completion of pharmacology courses and mastery of the basic concepts of pharmacodynamics and pharmacokinetics as part of their training allows better medication supervision for residents who are more at risk for complications. "After five prescribed medications, the percentage of patients with adverse effects nearly doubles, and once nine prescriptions are breached, there is a 100% risk of an adverse drug event."5 This statistic should alarm both providers and directors of ALFs since many of the residents are considered to be within these prescription ranges. With more trained personnel such as onsite nurses, many rehospitalizations can be avoided and patients may able to remain in their own homes as long as there is an urgent follow-up visit from the patient's medical provider.

The crux of the problem with having nurses administer medications rather than being placed in a management-type role within an ALF is cost. Employing an LPN or RN is far more expensive than utilizing medical technicians; however, the safety of patients receiving multiple medications is compromised by limited knowledge among medical technicians. One recommendation to alleviate this issue and at the same time decrease the amount of staff turnover is to hire an individual as a medical technician with the goal of being provided the education to become an LPN. The staff member would be required to sign a contract with the facility so that paying for his/her education is worth the staff's and facility's efforts and investment. Providing the individuals with the extra education and degree will increase the facility's competent staff to handle more complex patients. Also, because staff turnover is a significant issue within ALFs, retaining staff for a certain contracted amount of time will help alleviate the revolving door that sees medical technicians migrate from one facility to the next.

Focus on Nursing
Having a greater nursing presence in ALFs will ensure better patient care, safety, and ability to meet the facility's goals. It may also increase the adherence to state regulations and policies. It may also decrease the possibility of future litigation between families and ALFs, since nurses' knowledge level related to medications utilizes their skills as more than simply medication passers. Because a patient may have a primary physician at the ALF but may also see various specialists, a good relationship between the primary prescriber and nurse at the facility creates the perfect opportunity to frequently review the medication record and make changes accordingly in order to prevent adverse drug events and falls.

There is much debate over how ALFs should be structured, but the systems within those facilities need to acquire more of a nursing focus. The safety of residents should be the single most important factor and the one of the major influences of patient safety is the number of medications a patient takes. Active partnership between in-house primary care providers and nurses would facilitate positive patient outcomes, as well as attaining the facilities' goals. Nurses administer medication in both nursing homes and skilled nursing facilities, and because ALFs care for patients with more chronic conditions and who take multiple medications, there should be no reason for medication administration by personnel other than nurses.

— Leslie Ledbetter, RN, DNP, AGPCNP-BC, is an adult/gero nurse practitioner in ALFs in Tucson, Arizona, and is cofaculty at Arizona State University.

— Dale Pelton, MBA, FACNHA, is executive director for a Brookdale Senior Living facility in Tucson and an experienced hospital administrator, executive director of planning for emergency medical services, and an adjunct professor in a number of colleges and universities.

1. Statistics/data — America's growing elderly population. National Center on Elder Abuse website. Accessed June 25, 2015.

2. Atkinson S. Geriatric Pharmacology — The Principles of Practice and Clinical Recommendations. Eau Claire, WI: PHC Publishing Group, an imprint of PESI Healthcare; 2012.

3. 2012 national population projections. US Census Bureau website.

4. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. Centers for Disease Control and Prevention website. Updated September 2, 2010. Accessed June 25, 2015.

5. Denham MJ. Adverse drug reactions. Br Med Bull. 1990;46(1):53-62.