Why Covid-19 Could Be A Watershed Moment for Enhanced Assisted Living

In response to Covid-19, some assisted living providers around the United States are reevaluating their health care offerings and taking steps to increase their clinical capabilities. As the senior living value proposition shifts toward health care, regulations may need to change to keep up.

Massachusetts is a prime case in point. There, Covid-19 created a state of emergency in which the governor expanded the scope of services that can be provided in assisted living communities. Now, there is an effort to ensure that these changes become permanent.

Other states are ahead of the curve, having in the past created licenses that allow assisted living providers to offer more robust clinical care than is allowed in standard AL, and is different than what is offered in specially designated memory care communities. And senior living companies in these states, such as New York and Wisconsin, report advantages in being able to offer so-called “enhanced assisted living.”


These advantages include the ability to extend length of stay for some residents. Enhanced assisted living also brings marketing benefits that might become more pronounced during and after the Covid-19 pandemic.

In short, assisted living providers arguably have more incentive than ever before to pursue advanced licensure in states where it exists, and to push for expanded scope of care in states where regulations keep assisted living in a more strictly social model.

Let nurses be nurses

Even prior to Covid-19, assisted living operators in Massachusetts were pushing state lawmakers to pass a bill allowing for “common sense health services” to be provided in AL communities. These services include administering injections such as insulin, providing wound care, managing oxygen, and applying ointments or drops.


Then came the pandemic, which hit the Northeast hard in the spring. With Massachusetts in a state of emergency, Gov. Charlie Baker exercised special authority to allow assisted living nurses to provide an expanded array of services, including some that were included in the “common sense” legislation.

This was a matter of necessity, given that assisted living communities were in a state of lockdown; family members or outside health care professionals could no longer come in to provide residents with some needed care. And, the pandemic made it risky for assisted living residents to leave the building for care at a doctor’s office or hospital.

The governor’s action has proven valuable, according to Brian Doherty, president and CEO of the Massachusetts Assisted Living Association (Mass-ALA). Oxygen management, for instance, has been important in the context of Covid-19.

“That’s been very important, as residents sometimes returned to the assisted living residence after they’d been discharged from the hospital and were recovering from Covid,” Doherty said. “Many residences have found oxygen management to be one of the priority services that they enable their nurses to provide.”

Now, Doherty and other industry advocates in the Bay State are pushing to make these pandemic-related changes permanent. Doing so requires that the state legislature take action, as the flexibilities granted under Gov. Baker’s executive action will expire when the Covid-19 emergency ends.

The Common Sense Health Services bill was reported favorably by the state government’s Joint Committee on Elder Affairs and is now being considered by the Health Care Finance Committee, Doherty said. Its passage is particularly crucial given continuity of care issues that are in play, should the current flexibilities expire.

“We’re deeply concerned that once the state of emergency is lifted and the guidance is retracted, residents who have been receiving this care in-house and often at no additional charge will find their care plan disrupted,” Doherty said.

There are also reasons why expanding the allowable scope of care in assisted living would benefit residents but also provider companies, he said.

For one, there is an increasingly pressing need for senior living at a more affordable price point; currently, some residents are having to pay out-of-pocket to have outside home care professionals come in for services that could be done at a lower price point by an assisted living staff member. In some cases, assisted living residents may even be forced to relocate to a skilled nursing facility (SNF) to receive basic care that is well within the skill set of nurses in assisted living, Doherty said.

Also, allowing caregivers in assisted living to practice more fully within the scope of their licenses should make these settings more appealing places to work, which is important in light of ongoing labor challenges.

“One assisted living executive who operates in multiple states told me frankly that Massachusetts is the only state that his company operates in where a nurse isn’t allowed to be a nurse,” Doherty said.

That is, nurses often come to assisted living from other settings where they were able to provide services consistent with their license; in AL, by contrast, they sometimes see residents in need of help that they are not authorized to provide, despite having the know-how and licensure to do so.

“It puts those nurses in a situation where they have empathy for the residents … and wish they could provide more help, that they’re qualified to provide,” Doherty said.

Should the bill pass, assisted living providers would submit their plans for service provision to the state’s Executive Office for Elder Affairs, which would determine which providers to authorize. Not every assisted living facility would be expected to offer all or any of the expanded types of care, and Doherty believes that consumers will benefit from having a diversity of choices in terms of what type of assisted living community to choose.

The hope is that the pandemic created an inadvertent test of expanded assisted living services, and that providers have proven that they can safely and effectively operate at this level of care.

“Something that has been given a trial run and been successful during the pandemic, we hope will be provided as an option for consumers in the years ahead,” Doherty said.

Benefits and challenges of enhanced assisted living

Given that assisted living is regulated at the state level, there is variation across the United States in terms of how these communities are licensed and what types of care are allowed — and the guidelines can be complicated. A state-by-state summary of these rules and regulations compiled by the National Center for Assisted Living (NCAL) ran to nearly 400 pages last year.

So, while providers in states like Massachusetts are pushing to raise the bar on clinical services in assisted living, providers in other states — such as New York and Wisconsin — have long been able to offer more sophisticated types of health care.

West Allis, Wisconsin-based Heritage Senior Living and St. Ann’s Community in Rochester, New York, both take advantage of advanced licenses to offer what they term “enhanced assisted living” — and both providers report similar operational approaches and benefits from doing so.

New York offers a standard Assisted Living Residence (ALR) designation as well as an Enhanced Assisted Living Residence (EALR) option. The “enhanced” license allows for an assisted living community to provide assistance with needs such as incontinence or mobility limitations, as long as a resident does not need 24-hour medical or skilled nursing care. There are currently 19,810 ALR beds and 9,147 EALR beds in the Empire State, according to Stephen Hanse, president and CEO of the NYS Health Facilities Association/NYS Center for Assisted Living.

“I think it is beneficial to have enhanced assisted living residences,” Hanse told SHN. “If you start at an assisted living facility that has licensed enhanced beds, there is the opportunity for the resident to age in place.”

This ability to support aging in place for longer periods of time was part of the calculus that St. Ann’s went through when deciding to offer enhanced assisted living, Jennifer Blackchief, vice president of housing and strategy officer, told SHN. The nonprofit serves about 3,000 seniors each year across a variety of settings, including an assisted living community with 75 beds. Of those, all are licensed for standard assisted living, with 15 also licensed for enhanced AL and 24  licensed for memory care.

After evaluating what needs often trigger a move from assisted living to skilled nursing, St. Ann’s identified the inability to self-manage equipment such as oxygen and catheters, as well as the need for assistance in ambulating. These services became cornerstones of St. Ann’s enhanced assisted living offering, while the provider opted against accommodating more complex needs such as IVs.

“Just because you have an EALR doesn’t mean you have to provide everything you are allowed to provide,” Blackchief emphasized, noting that an important responsibility for the provider is explaining clearly to potential residents what services are and are not available in enhanced assisted living.

Although offering enhanced assisted living has undoubtedly extended length of stay within assisted living, boiling that down to an average number of days, weeks or months is difficult and likely would fail to capture the true complexity of the situation, Blackchief said. That’s because there is wide variability, with some residents able to stay in assisted living for a short while longer and other stays being extended more dramatically. However, there are “countless examples” of stays in assisted living that have been positively lengthened thanks to the EALR license, she said.

The situation is similar for Heritage Senior Living. Wisconsin offers two different assisted living licensures: residential care apartment complex (RCAC) and community-based residential facilities (CBRF). The RCAC license limits personal, supportive and nursing care to four hours per day, whereas the CBRF designation allows for as much daily service as is needed for residents with needs up to intermediate nursing care, although there are limits on how much skilled care can be rendered.

Across Heritage’s portfolio of 15 communities, some are standalone RCAC, some are standalone CBRF and — more recently — the company has favored a continuum of care model with independent living, standard assisted living and enhanced assisted living, Vice President of Quality and Clinical Operations Amanda Runnoe told SHN.

Like at St. Ann’s, offering enhanced assisted living does help extend length of stay for Heritage by providing an option for existing residents who have escalating needs. About a quarter of residents receiving enhanced AL services transition from lower levels of care at Heritage, with the balance being directly admitted to that enhanced level of care, Runnoe estimated.

In addition to the length of stay benefit, offering enhanced assisted living allows Heritage to serve a larger client group, she noted. But, providing enhanced services also comes with operational complexities and costs. For instance, Heritage’s staffing ratios typically increase from 1 staff member per 12 to 15 residents in RCAC to 1 staff member per every 6 to 8 CBRF residents.

At both Heritage and St. Ann’s, residents typically pay out of pocket for assisted living, including enhanced assisted living, and added charges help cover the additional costs of the higher care level. At St. Ann’s, enhanced assisted living residents pay an additional $30 a day, although Blackchief has heard of other providers taking different approaches. For instance, a provider might build the costs of enhanced care into standard monthly fees across the whole AL community, preventing additional charges down the road.

At St. Ann’s, the biggest challenges stem from balancing the advanced health care needs of EALR residents with the fundamental value proposition of assisted living as a vibrant, social environment, according to Blackchief.

Staff at St. Ann’s strive to enable EALR residents to participate in the social life of the community; offering 15 EALR beds, and intermingling them with standard ALR beds rather than separating them into a different wing, supports that socialization goal while allowing St. Ann’s to maintain a hospitality-forward assisted living experience overall. Communities with a higher proportion of EALR beds necessarily tend to have a more clinical vibe, Blackchief noted.

Staffing the enhanced assisted living program also involves more training, as well as identifying and supporting caregivers who have the skills to provide this level of care. For instance, St. Ann’s might have a specialized team for ostomy care, and a larger team trained in transfers and ambulation, which is a more common need.

St. Ann’s has not aggressively marketed its enhanced assisted living program but does explain the offering to potential residents.

“Where I find it to be valuable is, consumers are much more educated than they have been in the past,” Blackchief said. “I can remember 20 years ago creating checklists for families, so they would know what to ask when they toured competing facilities. I’m finding now, when families come, they already have those tools, they have more access to data, so I’ve found people referencing our enhanced license and asking questions about it.”

In the Covid-19 era, consumers are more concerned than ever about the clinical capabilities at a potential assisted living facility and may be more attracted to options that could defer a move to skilled nursing, given media reports of Covid-19 outbreaks in nursing homes.

“Unfortunately, the media has not displayed skilled nursing oftentimes in a good light,” Runnoe noted.

Consumers may find enhanced assisted living an attractive option, given the blend of more advanced clinical care with the hospitality model of assisted living, she thinks. Blackchief also believes it’s reasonable that enhanced assisted living will be viewed even more favorably than in the past by consumers.

“This might be the time where … providers are reevaluating their own position on what they think the market will respond to,” she said. “I think we’ll all market ourselves differently, but I can’t say it will drastically change at St. Ann’s, because we do already strike a balance between holding ourselves out as a social model but provide top-notch care.”