What are the differences between a nursing home and an assisted living facility? Many people would be surprised at how these two have become more similar than different over the past 15 years, with assisted living facilities accepting residents with more physical, psychiatric, and cognitive problems than they have in the past.
In 2015 about 1.3 million U.S. adults lived in about 15,600 skilled nursing facilities. That same year, there were approximately 29,000 licensed assisted living facilities in the U.S., with about 800,000 residents.
Nursing homes are typically best suited for people who require significant personal and nursing care, including:
- Being bed-bound
- Having fractures or wounds that are not healing
- Having multiple medical problems, like diabetes, heart disease, and congestive heart failure
Nursing homes may also be appropriate for people who need 24-hour care and supervision related to dementia. Only about 10% of nursing home residents can walk without assistance and more than 60% receive psychotropic medications.
Assisted living facilities are best suited to people with higher levels of functioning and independence who can benefit from social activities, exercise, and wellness programs. The main philosophy of assisted living is providing residents with varying levels of choice and independence in a homelike environment.
Cost and Payment
As a residential service with 24-hour care, nursing homes remain the most costly option for long-term institutional care, with fees now approaching and some even exceeding $100,000/year. Most of those costs are covered by the Medicaid program, contributing to fiscal crises in many states.
In contrast, the majority of assisted residents pay from their own financial resources, although 41 states offer waiver programs that allow low-income residents to live in assisted living.
Regulations and Staffing
Nursing homes are generally regulated by the federal government, while assisted living facilities are regulated by the states. In a sign that assisted living facilities are caring for more complex residents, at least half of the 50 states updated their assisted living regulations by 2018.
Annual staff turnover remains high in both settings, and while a nurse must be on-site 24 hours per day in a nursing day, in assisted living that may not be the case. Tennessee, for example, requires only that a nurse be available as needed.
While in a nursing home it is taken for granted that nurses administer medications, in assisted living facilities things are murkier. In some states, the laws are vague regarding which staff members may assist with medications, and nearly half the states permit registered nurses to delegate the administration of oral medications to aides. Residents with diabetes requiring insulin or pain conditions requiring narcotics may not be able to receive these medications from assisted living staff.
Alzheimer’s and Dementia
Both nursing homes and assisted living facilities have high rates of Alzheimer’s disease and other kinds of dementia. Both settings have upwards of two-thirds of residents with dementia or significant levels of cognitive impairment.
Sixty percent of nursing home residents with dementia are in the moderate and severe stages. The rates are approximately the same in assisted living. Because of the high rates of dementia in assisted living, many states now have enhanced standards for the care of assisted living residents with dementia.
Some facilities have what’s called a “memory loss unit” or a “secure dementia program.” This type of care is generally designed for those who are in the middle stages of dementia where they would benefit from activities that target that cognitive level. Often, these programs have their entrances and exits secured since some people with dementia wander and are at risk of elopement.