Assisted Living: Responding to Change and Instability

By Pamela D Wilson CSA, CG, MS, BS/BA

Anticipating what consumers will want in the future relative to assisted living and care communities is challenging. While statistics indicate a significant increase in the aging population because of aging baby boomers, will this result in more individuals moving into assisted living and skilled nursing communities or will baby boomers prefer to remain at home with care? Aging population statistics indicate that the number of individuals diagnosed with memory loss will increase; will this increase consumer demand for memory care only communities? How will the changes in healthcare policies and systems continue to affect consumers?

While research and statistics guide many decisions relative to future planning, what are other factors that result in change for assisted living communities? According to research, stability in assisted living is not the norm. Changes occur at multiple levels of person (residents, family members, staff or managers), collectivities (groups or types of residents, staff or managers), organizations (owners or corporations) and external environments (economies or competitors).1

How do families perceive these changes and how might assisted living communities respond to these factors while managing family expectations?

While the care industry speaks about the value of “aging in place,” this is not always practical in some assisted living communities as the care needs of older adults’ advances to include complex medical care. Other communities, with individuals diagnosed with dementia, are unable to care for residents with challenging behaviors. These factors usually mean that an individual, at some point, will be transferred to a higher level of care. Thus the promise of aging in place becomes a temporary situation until care needs change and the next move occurs. “The progression of physical or cognitive decline, resulting in growing care needs, is responsible for most departures from assisted living.” 2

Staff turnover is a well-known factor in the quality of care received by residents. Research indicates that stress related to supervisor support, self-esteem, burnout, and job satisfaction are major concerns for direct care staff that result in turnover. Care staff positions are typically low paying and require a basic level of skill, thus communities see these positions as “revolving doors” easily replaced. Without commitment by communities to offer continued training and support, high turnover, often in the range of 20-50% will continue to occur. By supporting care staff and instilling a sense of belonging or commitment, organizations may be able to reduce high turnover rates and in turn increase the quality and consistency of client care. Consistent staff increases family satisfaction by instilling confidence that loved ones receive care from someone familiar with their needs.

While residents and their families may often be dissatisfied with what appears to be constant changes in staff, the challenge in making a move to another assisted living community, likely to have similar issues, is a barrier to change. Additionally moves are stressful on older adults, especially those diagnosed with dementia. As a result many families accept ongoing changes in caregiving staff and attempt to make the best of the situation. Care communities experiencing frequent changes are best to be proactive in communicating staff changes, the benefits of these changes and to provide assurances to families that loved ones will continue to receive beneficial care.

When economic downturns occur, some assisted living communities downsize to essential staff or change their community profile to attract residents with dementia or special care needs in order to remain at a high census level. Other communities reacting to similar changes in the market may retain residents who require higher care levels (rather than requesting a move to a higher level of care) or change fee structures to incentivize new resident move-ins. This change in structure and profile is critical to allow current care communities to remain financially viable as new assisted living communities continue to be built nearby current communities.

Changes in profile and resident background may be unnerving to family members with residents in these communities who now see residents admitted who are unable to communicate with their loved ones. By mixing high care need clients with those who are more independent this changes the daily life and routine of residents already living in these communities. Some residents able to communicate and participate in activities find themselves feeling out of place or lonely because new residents are not able to carry on conversations or participate in activities. A higher demand is also placed on care staff to devote more time to residents with high care needs than time previously devoted to residents with lower needs who have been long time residents in the community. Care communities transitioning to a mixed resident profile must be mindful to meet the needs of current and new residents in order to maintain family satisfaction.

Changes in community profile affect potential customers considering the community; these changes also affect future resident move-ins. For example, a community with whom I work received negative feedback from potential family members visiting in the afternoon who identified that all residents were still wearing pajamas at 2 pm in the afternoon and questioned the actions of the care community. Other family members, looking for a higher functioning residence, while visiting communities were disappointed to find many residents propped up in wheelchairs sitting in front of the television – a vision frequently seen in nursing homes where residents sit in wheelchairs sleeping in front of the nurses’ station. A lack of activities is concerning to many family members who hope that their loved ones will become more engaged and active, rather than remain isolated as the result of a move to assisted living.

As the assisted living industry continues to change to due to economic, external and internal factors providers will be challenged to balance necessary changes while meeting the needs of prospective and current residents. Communication with the families of current residents regarding changes is critical to maintaining positive relationships and providing confidence to family members that their loved ones will receive beneficial and necessary care.


1 Morgan, L.A., et. al. (2014) The façade of stability in assisted living. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 69(3), 431-441. Doi:10.1093/geronb/gbu019 March 18, 2014.

2 Assisted Living Federation of America (ALFA) (2009) Overview of assisted living: American Senior Housing Association (ASHA), American Association of Homes and Services for the Aging (AAHSA), National Center for Assisted Living (NCAL), and National Investment Center (NIC). Retrieved June 16, 2012 from

3 Karantzas, Gery C. et. al., (2012) Intentions to quit work among care staff working in the aged care sector. The gerontologist Vol. 52 No. 4, 506-516, doi:10:1093/geront/gnr161 March 7, 2012.

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©2014 Pamela D. Wilson, All Rights Reserved.

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