Article Archive
May/June 2020

Long Term Care: Safer Living Options in the Time of COVID-19
By Jason Bloome
Today’s Geriatric Medicine
Vol. 13 No. 3 P. 8

Small residential assisted living homes can offer a safer option than skilled nursing homes for older adults who require rehabilitation and long term care.

The US health care system is overwhelmed with patients with COVID-19, many of whom are older adults who require respiratory treatments that include the use of respirators, ventilators, inhalation therapy, and oxygen. Older residents in skilled nursing homes are a population especially vulnerable to developing serious illness or dying as a result of COVID-19. In 2017, there were 15,483 skilled nursing homes in the United States providing care to approximately 1.3 million residents. In the future, all Centers for Disease Control and Prevention (CDC) models predict a shortage of skilled nursing home beds, and in this time of COVID-19, a safer option may be small, four- to 10-bed residential assisted living homes (also called group homes, adult foster care, or board and care homes).

Many families concerned about COVID-19 are afraid of placing loved ones in the skilled nursing homes to which many residents transfer from hospitals for short-term rehabilitation. Every year, more than 2 million adults on Medicare are discharged to skilled nursing homes for rehabilitation services. In order to qualify for rehabilitation covered by Medicare in a skilled nursing home, an individual must have a hospital inpatient stay of at least three days and require occupational, speech/language, or physical therapy at least five days a week or skilled nursing care seven days a week. Although Medicare can pay for up to 100 days for rehabilitation, the average rehabilitation stay is 25 days.

After rehabilitation, some older adults no longer can return home and require long term custodial care (eg, help with dressing, bathing, incontinence; have dementia; and/or are nonambulatory and need help into and out of bed). For these patients, physicians can offer an alternative: Bypass the skilled nursing homes with direct hospital patient discharge to small residential assisted living homes where short-term rehabilitation is offered in the same setting in which the patient will receive long term custodial care. Although no care setting is impervious to viruses, families concerned about COVID-19 might prefer the advantages small residential assisted living homes have vs large 100-plus bed skilled nursing homes. In the United States, there are approximately 28,900 assisted living homes and, of these, 13,294 (46%) are small residential assisted living homes with four to 10 beds.

In general, residential assisted living homes would not consider accepting residents who test positive for COVID-19. Most residential assisted living homes in the United States are only licensed to provide 24-hour custodial care. They do not have isolation rooms, aren’t staffed with nurses, and can’t accept patients who require skilled nursing care (eg, those with gastrostomy tubes, IV tubes, or tracheostomies) including those with COVID-19 on ventilators and respirators. Therefore, as cases increase nationwide for COVID-19 patients who require specialized care, residential assisted living homes, unlike other care facilities, won’t see a reduction in bed capacity.

Skilled nursing homes are among the few settings, outside of hospitals, that can provide respiratory services for COVID-19 patients. About 16% of residents in skilled nursing facilities across the United States received respiratory treatment in 2017. When skilled nursing homes accept more patients with COVID-19, the risk of infection increases for current and incoming patients without COVID-19. Increasing the number of skilled nursing home beds for patients with COVID-19 will also reduce the available supply of beds for incoming patients who do not have COVID-19.

Infection Control
Residential assisted living homes can incorporate good infection control measures; these are easier to implement in small residential assisted living homes, where there are fewer residents and staff, a smaller volume of traffic generated by family visitations, and less surface areas to sanitize than in large skilled nursing homes. Having fewer patients facilitates efforts by care staff to monitor residents for possible signs of COVID-19, which include high temperatures, coughing, and respiratory issues and to put into place newly issued CDC and World Health Organization guidelines for assisted living homes compiled by the California Assisting Living Association.

Skilled nursing homes are often cited for having poor infection control measures. It’s estimated that more than 2 million infections occur in skilled nursing homes each year. Infection control deficiencies are the most common reported violation (39%), followed by food sanitation (36%) and accident environments (34%). In 2017, more than 39% of skilled nursing homes in the United States were cited for one or more deficiencies related to infection control. Poor infection control measures can hasten the spread of COVID-19 among residents in skilled nursing homes.

Residential assisted living homes are small and have fewer patients than do skilled nursing homes, which influences the quality of care and decreases the likelihood of the community spread of infections. Small residential assisted living homes are usually four- to six-bedroom houses that have four to 10 residents. In homes where some residents have private rooms, staff care for only three to six residents.

Skilled nursing homes have high patient densities and high occupancy rates that can increase the risk for community spread of COVID-19. In 2017, 4 out of 5 skilled nursing home beds in the nation were filled, with some states, such as New York, having occupancy rates as high as 90%.

The number of beds in skilled nursing homes affects the quality of care, with smaller homes having higher star ratings than larger nursing homes, according to the Centers for Medicare & Medicaid Services (CMS). In 2017, the average number of beds in skilled nursing homes in the United States was 108.

Activities of Daily Living
Residential assisted living residents, on average, require less help with activities of daily living than do skilled nursing home residents. Skilled nursing homes have short- and long-term residents who require skilled nursing care (eg, help with IVs or tracheostomies), and long term custodial care residents. On average, skilled nursing homes have sicker populations than those of residential assisted living homes. In settings with sicker residents, the spread of COVID-19 is particularly dangerous.

Staff-to-Resident Ratios
Residential assisted living homes have much higher staff-to-resident ratios than do skilled nursing homes. CMS correlates higher quality of care with care settings that have high staff-to-resident ratios. Although staffing requirements vary from state to state, most residential assisted living homes have one staff person per three to six residents.

Medicare has no minimum standard for staff-to-resident ratios in skilled nursing homes, but it does require that an RN be present for eight hours a day and a registered nurse or licensed practical nurse always be present at a facility. In April 2019, CMS changed the way it assesses skilled nursing home staffing by using published payroll records instead of depending on skilled nursing homes self-reporting. It found more than one-half of all skilled nursing facilities met the expected level of staffing less than 20% of the time during a one-year study and, as a consequence, downgraded 1,638 skilled nursing homes on Nursing Home Compare to one star—the lowest rating. Most homes were downgraded because their payroll records did not show any registered nurse hours for periods of four days or more or because they failed to produce payroll records or provide data that could be verified by an audit. An analysis of the payroll data found the average weekend staffing time per resident day was just 17 minutes for registered nurses, nine minutes for licensed practical nurses, and 12 minutes for nurses’ aides. CMS found in skilled nursing homes with lower staffing levels there were more infection control violations.

Rates of Patient Depression
Given the choice, most older adults would prefer to receive care at home, or, if this option is not possible, in a community-based care setting rather than in an institution. Small residential assisted living homes provide a familiar environment for people transferring from their own homes.

Residing long term in a skilled nursing home can affect a resident’s mental well-being, which can exact a toll on the physical well-being as well. The percentage of residents with depression in skilled nursing homes (49%) is twice as high as for residential assisted living homes (25%). Frequent family and friend visits can often help alleviate depression for skilled nursing home residents but, due to COVID-19, many states are beginning to restrict and even prohibit family visits.

Less Expense
Residential assisted living homes are less expensive than skilled nursing homes. As COVID-19 cases increase throughout the nation and cities close nonessential businesses, families face fiscal uncertainty and budget constraints. The cost of long term care settings for loved ones will be an important consideration.

The average nationwide cost for a residential assisted living home is $3,000 to $3,500 for a shared room and $4,051 for a private room. Private paid skilled nursing homes, on average, are $7,513/month for a shared room and $8,517 for a private room—about twice the cost of residential assisted living homes.

Doctors Can Lead the Way
Physicians should inform families about the option of bypassing skilled nursing homes for patients who require rehabilitation and long term custodial care. Families depend on physicians to give them good advice during a time of crisis and, as the nation is mobilizing to combat COVID-19, our doctors are on the frontlines. News reports about the insidious spread of COVID-19 have every family thinking twice before placing a loved one who requires long term custodial care in a skilled nursing home. For patients who require rehabilitation about to be discharged from hospitals to skilled nursing homes, physicians can offer families an alternative: Bypass the skilled nursing home with direct discharge to a residential assisted living home, where rehabilitation services can be imported into the same setting that provides long term custodial care. Small four- to 10-bed residential assisted living homes have many advantages when compared with skilled nursing homes and have their own part to play as COVID-19 forces us to leverage all parts of our health care system.

— Jason Bloome is owner of Connections – Care Home Referrals, an information and referral agency to care homes in Southern California. More information is available at