Beware the Gray Zone: Caring for Sicker Senior Living Residents

Acuity levels may seem well defined on paper, but as seniors age, health care needs can change and leave some senior living residents in a grey area.

One survey revealed 87% of senior housing operators acknowledged acuity levels in assisted living have risen, but 45% of respondents said they were not sure how to respond. 

Acuity creep, the term to describe gradual increases in acuity that may require a change from a resident’s current level of care, is on the rise, and senior housing operators are facing tough choices to deal with the trend. While experts say it’s a multi-faceted challenge, there are steps providers should take to address acuity creep and reduce some of the serious risks.


A huge risk

When acuity levels rise in residents, it’s not always obvious and can happen over a long period of time. This blurs the lines of whether senior living operators are able to keep residents at their current care levels, especially in assisted living, where moderate care has a wide spectrum. 

“Perhaps the most obvious risk of acuity creep is that a resident’s cognitive or physical abilities decline to the point at which facility staff becomes unable to adequately care for them,” Ross Holland, a vice president of Lancaster Pollard, wrote in a recent report.

Operators are put in the position of clearly defining when it may be the right time for a resident to move to a facility that can better serve their health needs versus keeping occupancy rates steady.

“The biggest risk on the litigation side is that facilities get trapped in a scenario between stretching the boundaries of what their licensing allows them to do and risk losing residents,” Holland told SHN. “That’s a hard thing to deal with.”

Matt Murer, attorney and chair of health care at Polsinelli, says operators dealing with acuity creep might not react until a resident reaches a health crisis. And doing nothing before this point can end up doing a lot of harm to both residents and operators.

“If you were to ask providers if they have residents who are declining, they would all say yes,” says Murer. “But they haven’t reached that crisis point yet, which is why you see such a difference between the numbers and having a plan in place.”

Situations can become even more complicated when older adults don’t want to leave their current facility when their health care needs change, and operators don’t want to lose residents.

“What’s unspoken in this discussion is that usually the resident is very happy and wants to stay in the community,” says Murer. “In the whole discussion about what is right and the risk, the happiness and the satisfaction of the resident doesn’t get enough attention.”

However, even if residents want to stay in a community, that does not mean that senior living providers should simply sit on their hands. In fact, the worst response from providers dealing with acuity creep is a nonresponse, says Holland.

“They know it [acuity creep] is there, and oftentimes what will happen is if a facility isn’t entirely sure how to react, then it may be that they end up doing nothing,” says Holland. “That’s when it starts to become a little bit more difficult to manage the safety of your residents and also to keep yourself protected from litigation.”

Adding services to accommodate residents’ rising acuity and address acuity creep can also present a greater challenge than operators might realize. This method can increase the risks and the financial obligations for operators.

“One of the problems you can run into with acuity creep is if you start offering more services because you want to keep people there,” says Murer. “Once you state you are going to provide that service and you represent those individuals, then you get into a place where you better be providing care appropriately and on time.”

A line in the sand

Holland argues that one of the best ways for providers to mitigate the risks of acuity creep is to pursue higher levels of care licensure and invest in the proper staff who can consistently measure residents’ acuity to ensure the right care. Senior housing operators with more trained personnel like skilled nurses can react to acuity declines before any discrepancy in the right level of care becomes a problem. 

“At the end of the day, if you’re staffed appropriately, with people who understand the level of residents that you have, they’re the ones who are going to be able to spot things before they become a real issue,” says Holland.

However, this solution comes with a cost and may not be financially practical for some operators, as they can face numerous challenges when adding more services, staff or licensure levels.

“For some people, if they want to bring in an additional level of licensure, sometimes it’s just not possible because the building doesn’t meet the building code requirements,” says Murer. “Sometimes it’s not financially feasable because you would have to change your entire staffing model.”

Licensure levels also vary state by state, which can also make regulating and defining acuity levels more unclear, particularly in assisted living settings where residents may employ private aides whose care may mask obvious declines. Rising acuity levels have sparked some debate over the need for stricter regulations that more clearly define acuity levels consistently in assisted living.  

At this point, both Murer and Holland agree that thefts way for operators to reduce their risks is to have a clear plan in place that can address acuity creep early.

“There’s nothing wrong with providing care on a continuum basis,” says Holland. “It’s just being able to define those lines clearly and staffing appropriately that can really help stop a lot of these problems before they start.”

While drawing the line in the sand is a challenge, as more senior operators acknowledge acuity creep is a problem, having a designated care path in place becomes all the more essential.

“Having a clear understanding of what you want your community to provide—what it is you are promising the families and the residents—and then living up to and managing those expectations with a plan in place when people bump up against what you’ve established, are the right limits and will serve anyone well,” says Murer.

Written by Amy Baxter 

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