In my long career as an internist, I was fortunate to work in all settings of care for the first 26 years of my career and then focused on post-acute and long-term care (PALTC) practice the last 21 years. Though much of the latter time was focused on care in the skilled nursing facility (SNF) and continuing care retirement community (CCRC) settings, my personal experiences in small board-and-care homes (like assisted living communities [ALCs], also licensed as RCFEs = Residential Care Facilities for the Elderly) led me to favor referral of friends and family to this setting. While these homes are not as closely supervised and regulated as SNFs or even larger ALCs, I believe these homes can provide more personalized and appropriate care than provided for long-stay residents in SNFs and the larger ALCs, and at a lower cost.  I realize these are generalities, but here are some advantages of this model.

1. The monthly cost is usually all-inclusive without multiple additional al la carte fees. When a higher level of care is required (common for hospice patients), the added fee tends to be all-inclusive.

2. Staff usually work 12-hour shifts with staff to patient ratios of 1 staff to 3 or 4 residents, compared to 8-hour shifts and 1-12 or higher common in the other settings of care. 

3. With staff spending more time with fewer clients and families, they quickly learn about their clients’ preferences, interests, capacities, incapacities, and become aware of changes of condition sooner than in the other settings.

4. “Home cooking” is done in the kitchen with residents’ requests commonly accommodated. 

5. When a change of condition occurs, it tends to be identified much sooner, allowing family and providers time to assess and appropriately intervene.  

6. My 97-year-old mother-in-law has lived in a small home since the end of 2020. During this time, my wife has frequently visited her and the other residents. She knows their interests and encourages their pursuit. She connects with other families and helps them solve problems and enjoy the other residents. 

7. When I made site visits to these facilities for new hospice patients or subsequent FTF (Face to Face) regulatory visits, I could interview a staff person with detailed questions about the status of my patient without having to first find the information in the facility computer.

8. I commonly followed patients with advanced dementia in this setting who were high risk for complications due to immobility, aphasia, dysphagia, progressive weight loss, and cognitive distortions. Yet falls, aspiration pneumonia, and pressure injuries were rare. Cognitive problems were easier to address by non-pharmacologic approaches due to ready participation by families and the staff’s extensive knowledge of their residents. For my hospice patients I commonly was able to fine tune trials of psychotropic meds usually resulting in less medication use.  

Sadly, acute hospital staff and the public rarely consider these homes as an option due to the perception that persons unable to be discharged home are best served in SNFs or large ALCs with memory care units. The latter typically have an attractive marketing component that tends to emphasize hotel-like accommodations and assumed high-quality care. For SNFs, patients with a qualifying stay are referred for rehab, which may include patients who qualify for hospice with limited rehab potential, but instead are offered hope they might stabilize while receiving rehab (with or without palliative care).  

However, If I were in the acute hospital unable to be discharged home or qualified for hospice and without an SNF qualifying admission, I would prefer to have my care in a small home with expertise caring for my problems without becoming a burden to my family. For the acute hospital discharge planning team, identifying a cadre of small homes with this capacity  may speed up the discharge process and result in discharges with happier patients and families. I also predict the rehospitalization rate would be comparable or better than the traditional discharge options. 

I look forward to the work of this ongoing CALTCM focus group and hope studies can be done in the future to help discharge planners, patients, and families identify the best care setting option(s) after acute hospitalizations or ER visits with complicating significant functional loss. For those interested in joining our monthly calls, please contact the CALTCM Executive Office at [email protected].