The demand for long-term healthcare services is reaching an all-time high, thanks in part to extended life expectancy and the overall graying of America. According to statistics compiled by the National Center for Assisted Living (NCAL), in the year 2000 approximately one in eight Americans reached the age of 65 or older; and by the year 2030, that figure is estimated to rise to one in five. As the population ages, the senior housing market continues to expand to meet the growing demand. From independent living to assistance with daily activities to full-scale monitored care, today's choices are driven by healthcare needs as well as lifestyle demands. This month Medical News will explore design options bridging the continuing care spectrum as well as health, safety, and legislative issues impacting senior living. Independent living communities are the first option for seniors. Basically a retirement community, this beginning level of senior housing typically includes amenities such as one prepared meal a day in the common dining area and weekly housekeeping services. Assisted living communities, the next level, offer the same basic features as retirement communities, with added assistance with personal care. Although the variety of services and level of care varies widely, most assisted living communities are designed to meet the needs of those residents requiring help with activities of daily living (ADLs) such as dressing, grooming, and bathing. These residential settings maximize independence by offering some assistance with ADLs without providing the skilled nursing care offered in a nursing home. Some assistance is also offered with individual medications if needed, but this differs according to individual state regulations. Seniors who require 24-hour nursing care progress to the next level to a nursing home, often referred to as a skilled nursing facility. The onsite medical staff sets these facilities apart from other types of senior housing. Nursing care is provided by a registered nurse (RN), or a licensed practical nurse (LPN) throughout the day, under the direct supervision of a medical director. These nursing facilities provide many of the same amenities found in other senior housing options, including personal care, supervision, assistance with ADLs and medications, and in addition, may offer other types of services such as respiratory therapy, physical therapy, and occupational or speech therapy. Kathleen Fix, MD, is the medical director of UAB Geriatric Health Center at Mount Royal Towers, a community that offers many levels of senior care in the same facility — Independent Living, Independent Living Plus, Assisted Living, and ActivCare® Alzheimer's unit. Mount Royal Towers is one of many assisted living communities and nursing facilities that also provides care for individuals with Alzheimer's disease and dementia. "When the residents first enter Mount Royal, their personal physician will recommend the level of care that they need," she says. "Residents can keep their private physicians if they like, and many do — if they have seen the same doctor for 30 years, we certainly don't want them to abandon that ship. In some cases residents will continue to see the in-house physician here as well as their personal physician. However, since we are specifically trained in geriatrics, most of our residents choose to transfer their care to the in-house physician." As the resident's health progresses or declines, they move to different levels of care within the facility. If hospitalization is needed at some point, Fix acts as a liaison to coordinate care with UAB and other area hospitals. Perhaps the fastest-growing trend in senior care is the emergence of separate facilities to provide care and housing specifically tailored to the special needs of Alzheimer's and dementia residents. This trend is fueled by recent figures released by the National Alzheimer's Association that state that over 4.5 million Americans suffer from the disease. These separate care facilities, called Specialty Care Assisted Living Facilities (SCALFs), provide services in a secured environment, with trained professional staff members who are skilled in handling the behavior associated with Alzheimer's or related dementia disorders. SCALFs typically have locked entrances, color-coded hallways designed to make it easier for residents to find their way, and monitored wandering paths for additional security. In the same manner as the skilled nursing facilities, the SCALF medical director and staff work closely with the residents, their family, and their personal physicians to develop a written individualized plan to outline the specific care each resident requires. Leanne Messer at Galleria Oaks Assisted Living, a SCALF community, says, "I love the fact that we specialize here. We are completely focused on our resident's special needs. And, we never have to worry whether the resident's condition needs to be diagnosed because they are already diagnosed by their physician before they arrive." Even when a patient has been diagnosed, and it is has been determined that he or she needs to be moved into a facility to receive additional care, it can be very difficult for many families to broach the subject of a nursing facility. "Many people will accept the suggestion better if it comes from a medical professional, rather than their son or daughter," says Michael Brewer, MD. "From a physician's standpoint, when I see that a family can no longer properly care for a family member, that is when I intervene. I have to ask, is the patient getting the care they need in the home? Also, in the case of an elderly parent, I have to consider the child — who is usually also a patient of mine — what is the strain of being a primary caregiver doing to their health, even their marriage? I explain that their son or daughter isn't trained to care for them, and there are any number of excellent facilities where they can live to receive the care that they need." All nursing homes and assisted living facilities are required to follow strict guidelines regarding patient care. "The state of Alabama requires that each resident must see a doctor at least once a month," says Jennifer Agee, administrator at Columbiana Health and Rehabilitation, a new skilled nursing facility that opened in December 2004. "Our medical director, Dr. Thomas Nolan, sees a certain number of residents each week, so by the end of the month he has seen each of our residents." Nursing homes are licensed and regulated by State Departments of Public Health and are individually certified by the State for Medicare and Medicaid. Each facility offers a staff of licensed and/or registered nurses, nursing aides, and administrators as required by licensing standards. Assisted living residences are also regulated by state and local governments. A recent NCAL survey reported that virtually all (99 percent) of assisted living residences are licensed and certified by the states in which they operate. What affect will the rapidly aging population have on the options that are available for senior care in the future? "The aging of the baby boomer generation will put a spotlight on senior care. Our generation doesn't suffer in silence," says Fix. "The face of nursing home care will need to be re-evaluated in the decade, with a renewed focus on chronic diseases, such as Alzheimer's Disease, heart disease, and osteoporosis." Chronic illness often leads to disability, which indicates that long-term care services, such as home healthcare, nursing homes, and assisted living facilities, will increase in importance. One-time interventions that correct a single problem will most likely be replaced with the ongoing management of multiple diseases and disabilities; doctors will increasingly be required to help their patients cope with their illnesses, rather than curing them. "Our goal in geriatric medicine is to help patients maintain the best quality of life possible and help them to function at the highest level they can achieve. For this we look at the patient's whole life, not just the medical problems he or she may face," she says. Each increased level of service also increases the costs associated with patient care. Sherri Young, admissions coordinator at Trussville Healthcare, says, "Most facilities accept Medicaid and Medicare, but not all facilities accept some of the other Managed Care plans like Seniors First and Health Spring. Families should check into the requirements of each facility very carefully." Agee agrees, adding, "Our industry is trying to prepare for the onslaught of senior baby boomers in the long term, but financial considerations factor heavily into the equation. All facilities of this type are dealing with Medicaid budget issues at the present time." "There is a growing movement toward a group home setting, often called congregate housing, for seniors," Fix adds. "This type of housing is set up more like a home than a nursing facility, and many seniors thrive in that type of setting. Studies are being conducted now to determine the cost-effectiveness of group housing. In-home healthcare is also going to become more prevalent, but this type of care can be very expensive because Medicare doesn't pay for medical professionals to come into the home. The reality is — it is expensive to get old in the United States."