Those demanding Baby Boomers … they impact, change and challenge the system at every lifestage. In the 60s they were outspoken in their criticism of the government. By the 90s, they'd elected the first president from their own generation. In 2020, they are fully capable of again raising their voices, in a loud protest if the system isn't prepared to offer the array of senior services and lifestyle options, they are sure to demand. In truth, the industry is already getting a taste of what Boomers will expect for themselves as members of the nation's largest generation are now reviewing housing and service options on behalf of their parents. Nursing homes … or skilled nursing facilities … have been around a long time for those with the highest level of needs. However, assisted living and continuing care retirement communities (CCRCs) are relatively new options that have evolved over the last couple of decades as a growing number of seniors have hit a mid-point between wanting or being able to maintain their own home and requiring around-the-clock care. "The major difference is the type of care and the frailty of the elder," says Paul J. Williams, director of state affiliate relations for the Assisted Living Federation of America (ALFA). With the nation's increasing life span comes a new perception of what being "elderly" really means and how it varies from individual to individual. By the age of 80, some need considerable assistance with multiple activities of daily living (ADLs) such as dressing and hygiene. For others, the only assistance required is help getting a good tee time for their latest round of golf. "There is a large number of people in the general public who may think of assisted living as a nursing home or nursing home junior," notes Williams. "That's where our education component has to come in." Whereas a skilled nursing facility is primarily a medical model and reserved for those with greater healthcare needs, assisted living and CCRCs tend to be much more of a community model of care. Unlike skilled nursing facilities, Williams says in the assisted living setting residents are really in charge of living their lives as independently as they would be at home but with wraparound services available to them. "The place a senior most wants to be is at home," says Williams. "We understand that, and we want to see care delivered in the least restrictive environment, and that's the home. "However," he continues, "when care is no longer appropriate at home, an assisted living community is a great next step." Before opting for an assisted living community, however, potential residents and their families need to make a checklist of what is important and affordable. It is also wise to recognize that unless opting for a CCRC with increasing levels of care, the senior will most likely have to move again in a few years as their medical needs or dependency on help increases. "Particularly with assisted living, before you ever decide to move in, you need to see what the triggers are that would cause you to be discharged," counsels Doug Pace, director of assisted living and continuing care for the American Association of Homes and Services for the Aging. Pace, who served as the co-facilitator of the Assisted Living Work Group that was formed in 2001 by the Senate's Special Commission on Aging, says the relatively young industry has really begun looking at its future and focusing on impact issues. The work group's resulting 281-page document, which is available online at www.alworkgroup.org, outlined a long list of recommendations including the formation of the Center for Excellence in Assisted Living. At a summit meeting last December, providers and related organizations began tackling issues such as dementia care, staffing concerns, admission and discharge criteria for assisted living facilities and medication management. "As the industry matures, you start to get more sophisticated," points out Williams. In addition to addressing administrative concerns, Williams notes, "The assisted living profession is doing a lot better job of being able to capture resident preferences." He adds assisted living facilities and certainly CCRCs are adopting principles from the hospitality industry. It's these amenities and services that most interest the Baby Boomers. "The average age to enter assisted living is around 83 or 84 so we have approximately 15-20 years before the Boomers hit," Williams says. However, the industry isn't waiting for the age wave to crest before taking action. Instead, Williams states, the industry is trying to evaluate current services and anticipate changes. For example, Baby Boomers are generally more health conscious and are expected to require more fitness equipment and programming. They aren't afraid of technology and will want Internet access. They may not want breakfast at 8 a.m. but instead may prefer to sleep in and dine at 9 or 10 o'clock. "As a profession, we're looking at ways to adapt our communities," Williams notes. It's not just assisted living and CCRCs that are re-examining how services are delivered. Pace notes the "culture change movement" aims to reinvent some aspects of skilled nursing facilities. "Because of the regulations that have been put in place, it has grown up as an institutional system," Pace says of traditional nursing home care. The new approaches, he continues, seek "to change the culture to a more residential-centered care environment." Models such as the Greenhouse Project in Mississippi and Wellspring out of Wisconsin along with the well-known Eden Alternative (see box) utilize a variety of tools to integrate the concepts of resident-directed care. By creating smaller housing units, empowering front-line staff to make decisions and bringing in plants and animals, these culture change models seem to be improving both resident and staff morale. Pace and Williams both stress the importance of offering a variety of options in varying price ranges and care models to ensure that every senior has the opportunity to find the best fit for their specific needs in a safe, cheerful environment. "We will continue to promote all avenues to ensure our residents now and our residents in the future have the greatest degree of independence, integrity and choice of settings," Williams concludes.