The Relationship between State Regulations Related to Direct Care Staffing in Assisted Living and Residents’ Outcomes
Authors: Thomas K. , Cornell P. , Zhang W. , Carder P. , Smith L. , Hua C. , Rahman M. 
Published: August 2020

Research ObjectiveAssisted living (AL) communities are licensed and regulated by states, which vary dramatically in their requirements. Little is understood about how states’ approaches to regulating AL are associated with residents’ health outcomes. The objective of this study was to examine if states that implemented changes to their regulations related to staff training and direct care staffing levels in AL witnessed reductions in rates of hospital admissions among AL residents.Study DesignRetrospective cohort study using 100% Medicare claims, MedPAR, and assessment data. Data on AL regulations, over time, were identified using techniques from legal epidemiology, qualitative content analysis, and text mining. Two separate linear probability models and a difference in difference framework were used to examine the association between acute care hospitalization and changes in regulations pertaining to staff training (model 1) and direct care staffing levels (model 2), adjusting for time trends, resident characteristics (i.e., age, sex, race, dual‐eligibility, chronic conditions), and state‐license fixed effects.Population StudiedWith the Medicare Master Beneficiary Summary File and a methodology to identify Medicare beneficiaries residing in large AL communities (25+ beds), we identified a cohort of 889 154 Medicare beneficiaries enrolled in traditional Medicare and residing in 10 825 continuously operating, large AL communities between 2007 and 2017.Principal FindingsDuring this 11‐year period, six states changed their staff training requirements and two states changed their regulations pertaining to direct care staffing levels. On average, AL residents had 0.0168 (SD = 0.128) hospitalizations per month. A change in state regulations to increase or establish minimum staffing levels was associated with a reduction in the probability of hospitalization during the month of −0.0025 percentage points (95%CI = −0.004–0.000). A change in state regulations that introduced or increased requirements for staff training was associated with a reduction in the probability of hospitalization during the month of −0.0020 percentage points (95%CI = −0.004–0.000).ConclusionsThe policy effects represent clinically important differences of approximately 12% in the mean monthly hospitalization rate. These results suggest that changes in state regulations requiring staff training and minimum direct care staffing levels are associated with reductions in hospitalization among AL residents.Implications for Policy or PracticeStates are responsible for regulating AL. These findings set the stage for additional exploration into the optimal regulatory environment to ensure optimal outcomes for AL residents. As AL continues to care for an increasingly vulnerable population of residents, over 40% with a diagnosis of dementia, it is essential to understand the impact of regulations pertaining to direct care staffing on the care provided in these settings.Primary Funding SourceNational Institutes of Health.