ENGAGE Spring 2024

Know your PAST to plan your FUTURE - The History of ALFs

by Gail Matillo, MPA | President/CEO, Florida Senior Living Association

Have you ever wondered why assisted living is such a popular option for seniors who want to remain as independent as possible while enjoying the autonomy, dignity, choice, freedom, and camaraderie that comes with community living? For this article, we wanted to take a deep dive into where we’ve been to know where we’re going and what the future holds for it. Times are changing, assisted living is changing, and we all know the next 25 years will be a great baby boomer explosion of the 65+ population.

A HISTORICAL OVERVIEW

“Well, why aren’t you doing something to help people like me?”

This powerful question from Dr. Keren Brown Wilson’s mother, Jessie Richardson, turned out to be a defining moment for Dr. Wilson, who would eventually establish the assisted living model of long-term care in this country – and the world.

Dr. Wilson was a graduate student in gerontology when she heard her mother’s words of frustration, and Richardson was then a 65-year-old woman who had survived a stroke and was living in a nursing home.

“In the early days, nursing homes were stripped-down hospitals and people were in a ward. They were told when to go to bed. They were told when to get up. They were told what to eat,” explained Dr. Wilson. “My mother was unable to bathe herself, cut up her food or take her medication, but her focus was on having her own place so she could have a life.”

Since that question posed by her mother, Dr. Wilson has spent her entire professional career working with frail, low-income elders. She also founded the Jessie F. Richardson Foundation to focus on improving conditions for vulnerable older adults in developing areas and the communities in which they live.

After becoming a professor of gerontology at Portland State University, Dr. Wilson wanted to provide health care services to the elderly in low-income housing, allowing those seniors to remain at home. But the state of Oregon wouldn’t help pay for the services, and at that time, the only services Medicaid would cover were those provided in traditional nursing homes. This had the effect of medicalizing old age in the United States.

“In the nursing home, residents were told what they could and couldn’t do. They had no autonomy, which was very dehumanizing,” said Dr. Wilson. “My mother was poor – a Medicaid client – and there were not many choices for her. But she had a simple vision: a small place with a little kitchen, a bathroom, and a place for her favorite things. No

one could make her get up, turn off her favorite soaps or ruin her clothes. She could be Jessie again, a person living in an apartment instead of a patient in a bed.”

Authorities believed elderly residents would be unsafe if they had more control of their lives. But Wilson and her husband, gerontologist Michael DeShane, believed they could create a safe place for elders to live a life worth living with choice and independence.

“No one really believed we could give nursing care in a non-nursing setting,” remembers Wilson. “No one believed people would be safe. People were convinced we would kill residents.”

The couple borrowed several million dollars to build a facility, and against the odds, Wilson’s vision of assisted living was born. Not only did that early facility serve lower income people for a flat rate, but the pilot study also showed residents had better health outcomes than those who lived in nursing homes.

This new model of care for the elderly earned significant national media coverage and Wilson was soon approached by Wall Street investors to take the idea public. For the next few years, she oversaw the building of hundreds of assisted living facilities across the US, with 3,000 employees in 18 states. Her original idea is now the model for assisted living worldwide.

About the same time (1981) Paul and Terry Klaassen were dissatisfied with the American options for senior care and were searching for an alternative to the sterile, hospitallike environment of a nursing home. They founded Sunrise Senior Living to pioneer a new residentcentered model of elder care based on an assisted living model in the Netherlands where Paul Klaassen’s grandmother lived. Their community opened in Virginia and was based on a simple but innovative vision: to create alternative living options for seniors that emphasize quality of life and envisioned a loving, warm community filled with compassionate caregivers and happy residents.

THE EVOLUTION OF ASSISTED LIVING

For nearly 30 years, assisted living has grown to serve more than 1.2 million older adults. Half of assisted living residents are at least 85 years old, and about 70 percent of assisted living residents are female while the remaining 30 percent are male.

INTERVIEW WITH OREGON TRAILBLAZER "ALFS HAVE MORE OPTIONS FOR CARE AND SERVICES"

Dr. Keren Brown Wilson, generally reported as the founder of today’s assisted living communities, recently spoke with FSLA staff about her philosophy. She created the ALF model because she wanted to create a new way for seniors to remain independent and respected while also being able to receive the level of care they required.

Her first ALF community, Park Place in Portland, OR, opened in 1981 and is considered the first modern assisted living facility. It offered residents private rooms with doors that locked, 24-hour staffing for medical emergencies and community areas for social interaction.

Dr. Wilson believes it takes three important elements to build a successful community – environment, service, and philosophy. Her approach was driven by an early sociologist

who studied the competence environmental press theory, a model that explains how the interaction between an individual’s level of competence and the demands of their environment can affect residents’ behavior, well-being and overall health. The theory suggests that when the level of environmental demand exceeds an individual’s level of competence, they may experience stress, anxiety and difficulty adapting to their surroundings. On the other hand, when the level of demand in the environment matches an individual’s level of competence, they may experience a sense of accomplishment and fulfillment.

According to Dr. Wilson, if ALFs create an environment that supports people’s ability to function, they will thrive in that environment. For example, when pets are allowed in a facility, this environmental change will increase a resident’s functionality because they will have to care for the pet.

The same is true for the overall philosophy of assisted living: when a resident has greater control of their space, including which services are received, when and how, the resident is more motivated to use their space with greater functionality. The environment is premised on being the most supportive and adaptable for the highest level of function at the highest level, in contrast to the more medically oriented model where the resident is a patient, being cared for according to an institutional schedule.

“In the future, residents will want more freedom to organize their services differently and demand more choices,” said Dr. Wilson. “I used to hear people say they’d rather be dead than living in a nursing home, and that feeling of dread means we must do a better job with education and a demonstration of normalcy.”

There is still confusion today about the differences between nursing homes and assisted living because originally, nursing home providers

were the only options. They would take a wing of the facility and call it assisted living. In some cases, nursing home providers would also create independent living, home care, hospice, and pharmacies. This structure allowed them more control over the market area and allowed them to avoid talking about how most states didn’t allow any model considered to be assisted living.

“The difference between nursing homes and assisted living, to me, is clear: assisted living must have space shared only by choice,” explained Dr. Brown. “It must have variable service delivery and it must have a philosophy that is resident centered –resident choice – resident control.”

The concept of managed risk or negotiated risk in assisted living was designed to allow people to participate in decisions about how much risk they wanted in their daily lives. However, this concept isn’t widely accepted by the industry, regulators, and the public at large.

Robert Applebaum, a professor at Scripps Gerontology Center at the University of Miami, succinctly explained that what people want for themselves is autonomy, but what they want for those they love is safety.

This safety-based motivation is a significant influence over the people who are charged with making sure residents are safe, and the industry doesn’t accept much ambiguity about

what’s okay and what’s not okay, even when the person is fully cognizant. This struggle will likely continue to be present at some level in the longterm care industry for the foreseeable future.

Another challenge facing the industry in the next decade is transition. There are very few options for seniors between the ages of 50 and 80 who may need assistance but aren’t quite ready to move into a facility. While more technology may be an answer, a proactive transition earlier in life may also be preferable, rather than waiting for a person’s health to decline and their circumstances to dictate the decision.

Dr. Wilson suggested another option might be for states to invest in assisted living, using state bonds with returns to attract investors instead of a Medicaid model.

This would potentially create new models of care that recognize many people will not qualify for Medicaid but are not able to cover services and care out of pocket. Something between these two settings will likely attract boomers, and collaboration with regulators and advocacy for residents is key to further progress.

“I never want to fully retire. I plan to cut back somewhat, but I plan to work as long as I can,” said Dr. Wilson. “In the end, I’d like to be remembered as someone who cared about those who had less than they needed to live comfortably."

“I believe much is expected of those to whom much is given,” she continued.

“We always are able to do more than we think we can. And I just want to do as much as I can.”

Forbes, https://www.forbes.com/health/senior-living/assisted-living-statistics/; Historical Evolution of Assisted Living in the United States, 1979 to the Present | The Gerontologist | Oxford Academic (oup.com); https://doi.org/10.1093/geront/47.Supplement_1.8; Keren Brown Wilson, Historical Evolution of Assisted Living in the United States, 1979 to the Present, The Gerontologist, Volume 47, Issue suppl_1, December 2007, Pages 8–22, https://doi.org/10.1093/geront/47.Supplement_1.8; www.sunriseseniorliving.com