Over the last decade, assisted living has emerged as an increasingly popular long-term care option. Within the continuum of long-term care, assisted living facilities typically provide a level of care between independent living and nursing homes for persons who need assistance with one or more ADLs, such as bathing or dressing. However, states vary in the term they use for assisted living—it appears in the licensing regulations of most states but some refer instead to personal care homes, boarding homes, residential care facilities, adult homes, and homes for the aged—and in the characteristics of the facilities encompassed by the term used. A 2002 study of assisted living policies in each of the 50 states and the District of Columbia showed that states differ in the facilities included under their assisted living regulations based on facility size, services provided, and whether or not the facilities offer specified types of accommodations such as private apartments. In addition, the study found that many states incorporate a distinctive philosophy of care in their regulation of assisted living facilities to emphasize residents’ choice, independence, dignity, and privacy. Specifically, 28 states have included an assisted living philosophy statement in their regulations, but specifics of the statements vary. Unlike nursing homes, which are subject to extensive federal regulations, assisted living facilities generally have considerable flexibility to determine the resident populations that they serve and the services they provide. As a result, assisted living facilities vary widely on both of these dimensions. Nevertheless, most facilities provide housing, meals, housekeeping, laundry, supervision, and assistance with some ADLs and other needs, such as medication administration. The majority of assisted living residents are between the ages of 75 and 85 and more than two thirds are females. About a quarter of assisted living residents need help with three or more ADLs. Eighty-six percent of residents require or accept help with medication. Facilities differ in the extent to which they admit residents with certain needs (including residents who meet the criteria for admission to nursing homes) and whether they retain residents as their needs change. For example, a 2000 study found that less than half of the assisted living facilities are willing to admit or retain persons who require assistance to transfer from bed to chair or wheelchair. This study also found that less than half of the facilities would admit or retain residents with moderate to severe cognitive problems. The type, size, and cost of assisted living facilities also vary widely. Some facilities are freestanding while others are located on a campus that contains multiple units offering different levels of care (such as nursing homes and independent living residences). Those built in the 1980s generally provide semiprivate accommodation while the newer facilities typically offer private apartments. Facilities range in size from a few beds to over a thousand. The average facility in a nationwide study had 53 beds. Many facilities are independently owned while others belong to regional or national chain corporations. Assisted living fees vary widely across and within states depending on the facility’s size, service, and location. For example, the average monthly base rate ranged from $1,020 in Mississippi to $4,429 in Washington, D.C., according to a recent industry survey. Residents often pay additional fees for special care units and other services, such as medication administration and transportation. Two thirds of assisted living residents pay out-of-pocket, but many states use Medicaid and other federal and state funds to help finance such care. As of October 2002, 41 states used Medicaid reimbursement to cover assisted living or related services for more than 102,000 people. The federal government exercises minimal oversight over assisted living, leaving to the states primary responsibility for ensuring that assisted living residents have adequate protections. Some states fulfill this responsibility by establishing licensing standards, inspection procedures, and enforcement measures. Nevertheless, the regulatory approaches to assisted living adopted by states vary widely in scope and structure. For example, some states delineate the services that assisted living facilities may or may not provide—sometimes with multiple tiers of licenses for more specialized care—while others grant broad flexibility to providers to meet the individual needs of residents and their families. All states have long-term care ombudsmen with potential jurisdiction over assisted living facilities. Among other things, ombudsmen may provide services to protect assisted living residents and resolve complaints that they file. Ombudsmen may monitor quality of care, educate residents about their rights, and mediate disputes between residents and providers. Prior GAO reports have addressed a number of consumer protection and quality of care issues that remain at the forefront of public concerns about assisted living. These reports raised questions about the adequacy of information available to prospective consumers to help them choose a facility that meets their needs. The 1999 report also discussed states’ varying approaches to oversight and the type and frequency of consumer protection and quality of care problems that state agencies identified. Given the wide diversity among assisted living facilities in the services they offer and the populations they are prepared to serve, prospective assisted living residents can have difficulty finding an appropriate—let alone the most appropriate—facility to meet their individual needs. Initiatives such as the Florida “Find-a-Facility” Web site and the Texas standardized disclosure statement help consumers make better choices by providing them the information they need in an easier-to-absorb format. Available studies and interviews with our experts indicate that consumers choosing among their assisted living options often lack the information they need to make a fully informed selection. The limitations in the information currently provided to consumers relate to both its substantive content and mode of presentation. To make appropriate choices among the wide range of facility options available in the market, consumers need to learn about facility services, costs, and policies that impact residents. Moreover, they need this information to be not only complete and accurate, but also presented in a timely way and in a form that they can understand. When consumers do not receive adequate information before selecting an assisted living facility, they are less likely to find a facility that can satisfactorily address their personal care needs. In making selection decisions, consumers rely on facility information that they receive in various ways, including marketing brochures, facility tours, and interviews with providers. Consumers also rely on the advice of family, friends, or health care professionals. Our 1999 report stated that marketing materials, contracts, and other written materials that facilities give consumers were often vague, incomplete, or misleading. Specifically, the report found that facilities’ written materials often did not contain key information, such as a description of services not covered or available at the facility, the staff’s qualifications and training, circumstances under which costs might change, assistance residents would receive with medication administration, facility practices in assessing needs, or criteria for discharging residents if their health changes. Subsequent studies, including the 2003 Workgroup report, as well as experts that we interviewed, indicate that consumers continue to have difficulty obtaining full disclosure of the information they need. In response to this deficiency, 18 states have instituted information disclosure policies, such as requirements on the use of uniform disclosure statements or the contents of written materials provided to prospective residents. Our expert interviews and the studies we reviewed identified information about staffing levels and qualifications, costs and potential cost increases, and facility policies regarding discharge criteria as critical to informed decision making. Consumers need to know, for example, whether a facility has staff to provide full 24-hour service to address recurring care needs, such as assistance administering medications, as distinct from a facility whose overnight staff is only available to deal with emergency situations. While some facilities reportedly disclose only aggregate staffing data, the most important information for consumers concerns the number of staff directly involved in providing care to residents. Expert interviews and reviewed studies also indicated that consumers do not always receive information clearly explaining the circumstances under which resident costs can increase. Similarly, according to a consumer advocate organization, providers do not always inform consumers about the circumstances under which they could be involuntarily discharged from their facility, even when state regulations dictate that residents must leave if their needs reach a certain level. The experts we interviewed underscored the importance of conveying critical information about assisted living choices in a way that consumers can readily absorb. The experts explained that prospective residents and family members often have difficulty grasping the information presented to them, especially when they have to make decisions quickly to address a crisis situation. Under these circumstances, consumers often do not know what questions to ask or how to assess and compare the responses that they receive in order to identify the facility that can best meet their individual needs. When consumers do not get complete and accurate information on the assisted living alternatives available to them, in a form that they can understand, they run the risk of choosing a facility that cannot adequately meet their personal care requirements. A likely consequence is that they will have to move again within a short time. Both consumers and providers benefit if they can minimize this risk by ensuring that the consumer has, and can use, the critical information relevant to making an informed choice among different facilities. In the summer of 2003, Florida’s Department of Elder Affairs (DOEA) launched its Affordable Assisted Living Web site to enhance public access to information on assisted living. One of its features is called “Find-a- Facility,” a search tool that allows anyone with internet access to identify those Florida assisted living facilities that match the preferences set by the user. The available options include geographic location, price range, housing configurations (such as private apartments), whether the facility accepts residents with government subsidies or certain disabilities, and clinical and social services offered. (For examples of the Web site pages, see app. II.) Once the user selects his preferences among the available options, the site generates a list of licensed facilities, with those most closely matching the chosen preferences ranked highest. For each of these facilities, the user can print out a one-page description that includes the facility’s contact information, number of beds, specific government subsidy programs it participates in, any specialized care licenses, and all of its entries on the list of selection options. Development of the Web site occurred through a collaboration of public and private entities.