Assisted living is an arrangement of support somewhere between independent living and convalescent or nursing home care. Currently, more than 1 million occupants (residents) call 1 of the 30,000 assisted living residences (ALRs) in the United States ?home.?1 The average age of residents in the year 2000 was 80 years, and approximately two thirds were female.
The typical assisted living resident requires support with 2 activities of daily living.2 Some residents, however, harbor inaccurate perceptions about their own abilities, especially if some degree of cognitive impairment is present. Other residents, initially competent, may decline in abilities over time. Medication misadventures can have serious consequences for residents.
Assisted Living: Philosophy and Program
As a philosophy, assisted living stresses safe individual autonomy. The guiding principle is to create ?a residential environment that actively supports and promotes each resident?s quality of life, right to privacy, choice, dignity, and independence.?1
As a program, ALRs offer a service array that varies among residences. Most, however, generally include the following services:
? up to 3 meals daily
? assistance with activities of daily living
? housekeeping and laundry services
? residence- or community-based recreational activities
? medication-related health services
? social services ? scheduled and unscheduled special assistance
? 24-hour staffing for monitoring and oversight
Although medication-related services are provided, ALRs do not operate on-site medical clinics.
An ALR may appear to be 1 step between living in the family home and going to a nursing home, but in actuality (as seen above) ALRs offer many levels of care. Resident-centered supports are detailed in each resident?s individual service package, which describes the resident?s unique needs and choices. Many ALR directors emphasize that their facilities are not stepping stones to convalescent homes (10% of residents eventually return home), and they strive to avoid resident transfer to higher (and more costly) levels of care.2 Some ALR organizations do offer a care continuum, either operating or collaborating with long-term care facilities.1
Medication in the ALR
Assisted living residents invariably use prescription or OTC medications, and medication management is a common reason for ALR admission.1 Historically, ALR staff members did not administer medication. To avoid resident relocation to more comprehensive care solely for medication administration, many ALRs now do provide this service (as stated above).
ALR officials generally inform potential residents about their medicationmanagement policies. Policies should cover their staff?s capacity to assist with medications and their preferred drugdisposal methods. It is important for all disclosures to be written (and explained) in patient-friendly language.1
ALR Medication Issues
Residents require varying levels of help. Most ALRs find the tasks listed in Table 1 to be their greatest challenges.
Many ALR residents manage and self-administer their own medications. ALRs often require annual assessment of the resident?s ability to do so by a qualified licensed health professional. Health professionals familiar with the procedure may recommend medication reminders or supervised medication administration.
Ultimately, a decision whether or not to allow medication self-administration is made mutually by the resident (or the resident?s family), the ALR staff, and the health professional. Increased supervision is justified if significant physical, cognitive, or functional status changes occur or if the resident asks for additional help.1
If self-administration is approved, providing the ALR with a written list of all prescribed and OTC medications is the resident?s responsibility. Residents may ask their pharmacists to help with this sometimes-daunting task. ALR staff members will use the list if emergency situations arise. The resident should update this list annually, often during the yearly health assessment.1
ALR Medication Administration
If the ALR staff administers medication, all drugs (including OTC medications) require prescriptions. ALR staff members, however, may lack the expertise to evaluate possible interactions between prescription drugs and OTC medications or alternative/complementary supplements. ALRs generally develop processes to keep the primary care physician aware of the resident?s complete medication regimen.1
How do ALR medication assistive personnel (MAP) acquire expertise? To start, a high school education (or a graduate equivalency degree) and English language proficiency may be conditions of employment. Some ALRs allow MAPs to administer medications only after successful completion of an approved training course that includes a written and performance-based competency examination.1
Because the consequences of inappropriate medication use are potentially severe, ALRs create safeguards. Having a licensed nurse administer or supervise all medications for residents who need assistance may not be feasible. Staff members who provide medication support, however, need adequate training and supervision ?in other words, competence.1
The MAP?s job description identifies the nature and scope of medicationrelated responsibilities. Expanding expectations and duties call for more training, experience, and credentials. Duties for which the MAP is untrained or untested must be avoided. A good training program covers several performance objectives. It should start with ensuring that the MAP can demonstrate the 6 ?rights? of medication administration (right resident, right drug, right dose, right route, right time, right documentation). Table 2 lists other important performance objectives.1
Successful completion of any training program should be followed by relevant, regularly scheduled and as-needed in-service or continuing education by a qualified licensed health professional. Often, pharmacists educate MAPs to enhance and sustain confidence and competency, proficiency, and safety. Newly introduced medications and changes in policy or procedures are important topics. Pharmacists should remember that adult learners look for interactive, case-based information.1
The officials of many organizations that work with ALRs believe that, within the constraints of available technology and affordable care, medications for ALR residents should be provided in specialized packaging systems. These systems, generally adaptations of unitdose systems, promote safe, accurate, and efficient medication administration to residents. A consistent style of packaging throughout the residence simplifies medication administration for MAPs and can help older adults with special needs remain independent longer. Some systems may allow the return and reuse of unused medications, saving money for the resident.1
Licensure and Regulation
ALRs are regulated at the state level. Many states make distinctions between categories of assisted living to distinguish those that provide less intense services from those that offer a comprehensive array.
Federal mandates and regulations for assisted living are nonexistent. To remedy this, the US Senate Special Committee on Aging held hearings on assisted living in 1999 and 2001. As a result of these hearings, the committee requested that the industry make recommendations that would ensure quality services. Officials of nearly 50 organizations collaborated and presented a final report in 2003, The Assisted Living Workgroup Report to the US Senate Special Committee on Aging (available at www.alworkgroup.org). The report contains 110 recommendations ranging from finances to staffing. Not surprisingly, however, many of the recommendations were not unanimously endorsed by the industry.
A generation ago, children and relatives cared for aging elders at home. The care they provided was often admirable, but it is unrealistic to expect that everyone has the time, patience, or skill to care for an aging person. Families and elders now have another option.
Unlike their residents, ALRs are still maturing. Quality still varies among ALRs, and, until industry leaders formulate uniform standards, variability will continue. Pharmacists can help ALRs and their residents by understanding both assisted living philosophy and assisted living programs.
The views expressed are solely those of the authors and not those of any government agency.
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