Resident transitions to assisted living: a role for social workers.
Abstract: This study explored key aspects of resident transitions to assisted living (AL), including the frequency and importance of preadmission resident education and the potential role of social workers in this setting. To examine the factors that may help or hinder resident transitions to AL, a written survey was administered to a statewide, geographically representative purposive sample of Medicaid Assisted Living Waiver providers (N = 28). Findings suggest a positive relationship between the availability of a social worker and the frequency and importance of resident preadmission education in several areas. Results also suggest a gap between what AL providers believe is important for resident transitions and what is actually happening in their facilities. Social workers may play a significant role in providing preadmission education and are well positioned to address the unmet psychosocial needs of residents and family members during the transition to AL. Future studies should specifically examine the contributing role of social workers during the period of adjustment to AL and the effect of social work services on the well-being of AL residents and families in AL settings.

KEY WORDS: assisted living; gerontological social work; transitions
Article Type: Report
Subject: Assisted living facilities (Services)
Frail elderly (Care and treatment)
Social workers (Practice)
Authors: Fields, Noelle LeCrone
Koenig, Terry
Dabelko-Schoeny, Holly
Pub Date: 08/01/2012
Publication: Name: Health and Social Work Publisher: Oxford University Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0360-7283
Issue: Date: August, 2012 Source Volume: 37 Source Issue: 3
Topic: Event Code: 360 Services information; 200 Management dynamics
Product: SIC Code: 8059 Nursing and personal care, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 309792872
Full Text: As the number of older adults increases across the United States, the demand for services to meet the needs of an aging population continues to increase. Assisted living (AL) is a rapidly growing industry, with the number of facilities outpacing the number of nursing homes across the country (Assisted Living Federation of America, 2010; Stevenson & Grabowski, 2010). AL settings typically provide 24 hours of supervision and assistance to residents with needs related to activities of daily living as well as a variety of health-related services such as nursing and physical rehabilitation (National Center for Assisted Living [NCAL], 2008). Although the use of AL represents a growing trend in long-term care, little is known about what makes a successful transition to the AL setting.

The transition to AL is of growing interest, as research suggests that residential relocation may become an increasingly common experience among older adults. Furthermore, the relocation to AL represents a significant residential change for older adults moving from the community to a more structured, congregate setting given that most AL residents (70 percent) move into AL settings from their own private home or apartment (NCAL, 2010). Although the majority of older adults prefer to live at home rather than in institutional care settings, if relocation is needed, AL is considered preferable to a nursing home (Eckert, Carder, Morgan, Frankowski, & Roth, 2009). Healthy and independent older adults may relocate to AL in anticipation of future needs, whereas others may transition to AL as a result of functional declines and/or cognitive impairments that necessitate such a move (Cummings & Cockerham, 2004). Understanding of the factors related to these transitions is important as relocation is a significant life challenge that requires skills and resources such as social support and psychological well-being (Kling, Ryff, Love, & Essex, 2003).

In this pilot study, we used both quantitative and qualitative methods to explore the transition experiences of AL residents, in this case from the perspective of AL providers. Although there is considerable research on transitional care for older adults in acute care settings (for example, hospitals), far less is known about the current needs of residents transitioning to residential long-term care settings such as AL. The findings from this descriptive, exploratory study provide valuable insight related to the frequency and importance of preadmission education for residents as well as the potential role of social workers in assisting residents with the AL transition. The perspective of AL administrators is an important strength of this study because they are highly involved in the resident admissions process and in providing oversight of the services and supports offered in AL settings. Furthermore, the findings from this study will extend research that examines the perspective of AL administrators related to resident transitions in these settings (Kelsey, Laditka, & Laditka, 2010; Mead, Eckert, Zimmerman, & Schumacher, 2005; Munroe & Guihan, 2005). Finally, this study contributes to the development of steps to improve the overall health and quality of life for older adults experiencing healthcare transitions, including the relocation to AL.



There are more than 36,000 AL facilities across the United States providing residential care and services to almost 1 million older and disabled adults (Mollica & Johnson-Lamarche, 2005). On the basis of demographic projections in the United States, there is a strong likelihood that AL will continue to play an important role in continuum of services provided to older adults and their caregivers. Moreover, the expected growth in the number of older adults with cognitive and/or physical impairments may potentially increase the utilization of AL as a viable alternative to the high cost of nursing home care. As a result of federal and state initiatives, long-term care service provision has expanded to include Medicaid waivers for providing AL services for individuals who would otherwise live in nursing homes. Roughly 41 states have implemented Medicaid coverage in residential care settings including assisted living (Mollica & Johnson-Lamarche, 2005). Although the vast majority of AL settings operate primarily through private pay reimbursement, there has been growth in the number of AL providers opting to participate in state Medicaid programs, with approximately 134,000 residents receiving AL services under Medicaid in 2009 (Mollica, 2009). However, there are concerns that inadequate Medicaid reimbursement policies may discourage AL provider participation in Medicaid waiver programs in the future (Carlson, Coffey, Fecondo, & Newcomer, 2010). Finally, there are also emerging concerns regarding the ability of AL settings to provide appropriate care for older adults with increasingly complex health care conditions (Zimmerman et al., 2005).

Transitions to AL

Transitions during older adulthood are often characterized as periods of higher overall vulnerability and risk, particularly when the transition involves a transfer between different residential and/or health care settings (Coleman, 2003; Naylor, Kurtzman, & Pauly, 2009). Transitions may occur in the form of health care transfers (for example, hospital discharge) or relocations from one level of care to another (for example, community setting to a nursing home). For older adults with multiple and complex medical needs, there is evidence that poor transitions may result in adverse consequences such as medication errors, hospital readmissions, and inadequate support for caregivers (Coleman & Boult, 2003; Graham, Ivey, & Neuhauser, 2009). Recent studies suggest that a lack of communication around a patient's care plan and inadequate preparation for care during the transition create difficulties for patients and caregivers (Coleman, 2003; Naylor & Keating, 2008). Past research on residential relocation among older adults indicates that level of expectation; knowledge of and about the transition; awareness of the meaning of the transition; and level of emotional, physical, and environmental stress are linked to transition outcomes (Schumacher & Meleis, 1994). In the case of AL, residents transitioning to these settings often have a variety of physical and psychosocial needs, as well as various levels of functional ability and independence. However, recent literature on relocating and transitioning to AL communities has suggested that "there are strategies to promote a 'good fit' between an assisted living facility's culture and a potential resident" (Kennedy, Sylvia, Banni-Issa, Khater, & Forbes-Thompson, 2005, p. 23), including the education of residents and their family members about staff, activities, and other residents in the AL community. Thus, preadmission education such as information about facility policies (for example, what the AL does and does not offer) may be important in assisting resident transitions to these settings and promoting a "good fit" between the resident and the AL setting.

Social Work and AL

There is growing interest in the role of social workers in providing services for residents and families in AL. Although the National Center for Assisted Living and Assisted Living Federation report that on average, full-time social workers are not employed in AL settings, approximately half of AL facilities are providing social services and/or casework to residents (National Center for Assisted Living, 2010). There is limited research related to the involvement of social workers in AL; however, studies suggest increased opportunities for social workers in these settings (Koenig, Lee, Fields, & Macmillan, 2011; Vinton, 2004). Zimmerman, Munn, and Koenig (2006) have suggested that the skills that social workers possess position them well for work in AL settings, particularly in providing services around decision making, the transition process, and ensuring quality of life for residents. Specific social work roles within the AL setting have been found to include: decision making and transition coordinator, resident advocate, mental health assessor/counselor, family social worker, and care planner (Koenig et al., 2011). Moreover, previous studies have suggested that social workers are well suited for practice in AL settings because of the congruence between the values of the social work profession and the guiding philosophy of AL in promoting dignity and self-determination (Spitzer, Neuman, & Holden, 2004; Vinton, 2004).

On the basis of the literature, the following three aims were developed for the present study:

1. To explore the key aspects of resident transitions to AL settings;

2. To examine the frequency and level of importance of preadmission education that residents receive related to AL policies and procedures;

3. To gain a better understanding of the role and value of social workers in AL settings.



This study used a mixed-method approach to explore the perceptions of AL administrators about the aspects of successful transitions to AL as well as the frequency and importance of resident education prior to AL admission. A written survey was administered across a midwestern state to a purposive sample of Medicaid AL waiver providers with the highest census representing all geographic areas of the state. AL providers with the largest number of Medicaid waiver residents in each designated aging service area were selected because they have the highest frequency of enrollment experiences (resident transitions) serving this target population. Thirty-seven surveys were distributed by mail between April and May of 2009. Twenty-eight providers agreed to participate in the survey, for a survey response rate of 76 percent. The study was approved by the institutional review board at The Ohio State University.


The survey consisted of 82 closed-ended questions. The survey instrument included respondent and facility characteristics as well as items that measured indicators important to transition success, the level of importance of successful transition indicators, the frequency of consumer education prior to admission, and the level of importance of consumer education prior to admission. Seventy-eight items positioned in four-point Likert-type scales ("very important" to "not important") assessed the level of importance of indicators for a successful transition and resident education prior to AL admission, as well as frequency of resident education prior to AL admission ("always" to "never"). A final open-ended question solicited additional information regarding aspects of a successful transition for AL waiver residents. The remaining survey items were categorical questions that addressed facility characteristics and administrator demographics. Questions related to transition success (for example, level of awareness of what to expect from the transition, level of realistic expectation about the transition, functional limitations, social support, and level of confidence about the move) were modeled after previous studies that identified successful transition outcomes (Coleman, 2003; Kennedy et al., 2005; Schumacher & Meleis, 1994). More specifically, survey items were chosen on the basis of a literature review that highlighted the need for further study in the following three areas: (1) preadmission resident education related to AL facility policies and procedures, (2) preadmission assessment of AL resident and family expectations, and (3) psychosocial needs of AL residents.

Data Analysis

Univariate and bivariate analyses were conducted in SPSS to provide descriptive data about the sample and to explore relationships between study variables. The constant comparative method as described by Lincoln and Guba (1985) was used to analyze open-ended responses to questions. Two researchers analyzed these responses independently using an iterative process of moving back and forth between the raw data and tentative codes. During this preliminary process, the researchers reached coding agreement of 90 percent, after which they discussed differences in coding. Subsequently, a second level of coding was performed to further develop subcategories and properties of codes and to finalize themes.


Of the AL providers surveyed, 21 (75 percent) reported a for-profit status, 6 (21 percent) described their facility as free standing, and 7 (25 percent) described their facility as a Continuing Care Retirement Community. The average census of AL facilities participating in the survey was 15.5 residents, with an overall range of 4 to 38. The majority of participants (60.7 percent) reported having at least a bachelor's degree in fields of study such as nursing (42.9 percent), social work (17.9 percent), business (14.3 percent), and gerontology (10.7 percent).

The indicators important to resident transitions according to AL providers are shown in Table 1. Findings suggest that on average, the following indicators are important to a successful transition: awareness of what to expect from the AL transition, level of expectation (for example, realistic), social support, functional limitations, mental health, feeling that the transition is his or her choice, level of self-confidence in ability to adapt to a new situation, and ability to communicate needs. However, the availability of a licensed social worker within the AL setting was perceived as having little importance (M = 2.74) in the successful transition of Medicaid waiver residents.

Although AL providers reported that most residents receive preadmission education (for example, information related to specific AL policies), there were areas of education that did not receive as much attention prior to admission (see Table 2). These included bowel and bladder training programs (M = 2.48), service tier assignment (M = 2.40), and the purpose and elements of a resident care plan (M = 2.30). Furthermore, findings indicated that service tier assignment (M = 2.04) and the purpose and elements of a care plan (M = 1.78) had the lowest average scores of level of importance in terms of preadmission resident education (see Table 3). For purposes of this study, service tier assignment was defined as the AL residents' overall level of care and subsequent facility reimbursement for those care needs. For instance, a resident with more complex medical needs who receives higher levels of hands-on care by AL staff will usually be assigned a higher service tier assignment. Also related to service tier assignment, the resident care plan identifies the resident care needs that are to be met by the AL provider, such as medication management, assistance with activities of daily living, memory care (for example, for residents with dementia), and nursing care services.

Correlations based on variability and previous literature were investigated to explore the relationships between variables. Of particular interest were the AL providers' perspectives on the frequency and importance of preadmission resident education. In the discussion of these statistics, Gay and Airasian (2003) are referenced to define low (r < .35), moderate (.35 [less than or equal to] r [less than or equal to] .65), and high (r> .65) correlations. The importance of the availability of a licensed social worker within the AL facility was moderately positively correlated with frequency of education about service tier assignment (r = .393, p < .05), importance of education about the resident care plan (r = .553, p < .01), and the importance of education around service tier assignment (r = .648, p < .01). In addition, the associations between profit status, AL facility type, and indicators of transition success were examined. The not-for-profit status of the AL was moderately positively correlated with resident awareness of what to expect from the AL transition (r = .471, p < .05). Free-standing AL facility type was highly correlated with the perceived importance of residents' ability to communicate needs with the AL facility (r = -.720, p < .01).

Twenty-two of the respondents also provided qualitative comments on what additional aspects of a successful transition were important for waiver residents. The most frequent response made by providers involved comments around financial policies of the waiver program and the impact of these policies on waiver residents. Many participants indicated a need to increase the monthly allowance of waiver residents because these residents have to pay premiums or co-pays for their prescription drug plans out of this allowance, unlike nursing home residents. Several participants also advocated for a change in the financial policy in order to allow residents to keep more of their monthly allowance.

In addition to suggestions related to the implementation and evaluation of AL waiver policies, written comments indicated a need for preadmission assessment that included the "physical and psychological compatibility" of the waiver resident with AL providers. Qualitative comments also suggested the need for a preadmission social service assessment and complete psychological history of residents to address "many underlying issues" that may emerge at admission to AL. Family visitation and support during the transition to AL and the need for family involvement during the transition process were also indicated as important by AL providers. Finally, several providers suggested that improved communication was needed for residents to understand what AL does and does not offer. In addition to resident communication, participants reported a need for improved communication with family members. For example, one provider remarked about a need to "make sure that the family and resident are on board with the policies and rules of the facility," and another stated "residents need to know the consequences of not adhering to assisted living rules." This participant's responses further suggested that residents need better information about the waiver program, including what was described by one participant as the "process of alternative placement when AL can no longer meet a resident's needs" and understanding of the "limitations of level of care." Overall, these findings indicate a need for improvements in the AL admission process that will enhance channels of communication between residents, families, and staff as well as strengthen continuity of care between AL and other health care settings.


Findings from this study suggest that according to AL providers, preadmission resident education is important but the actual provision of preadmission resident education may be limited or even absent. Our findings support other research indicating that prospective AL residents need to be web informed about their own health care needs and whether or not the AL provider has the capacity to meet those needs, including what specific services and amenities are provided by the AL facility (Ball et al., 2004). In particular, the relationship between profit status and indicators of transition success suggests that resident expectations are important to not-for profit AL providers in our study. In addition, resident communication appears particularly important to AL providers in free-standing buildings. Although AL providers suggested that it is important to educate resident about changes in AL eligibility, they also indicated a lower frequency of actually educating residents about what the AL waiver pays for and provides. This discrepancy is significant, as research suggests that residents and their families need more information and education about the services and supports that are provided in AL settings in order to set realistic expectations upon admission (Stone & Reinhard, 2007).

Another important finding was the limited provision of preadmission education related to residents' level of care and, ultimately, their ability to remain in their AL residence AL providers in our study reported that the areas of education perceived as least frequently received among waiver residents prior to admission included service tier assignment, the purpose and elements of a care plan, and bowel and bladder training programs. These findings are noteworthy, as these particular areas of education relate to resident health status and level of functioning upon admission to AL. A lack of preadmission education in critical areas such as care planning may result in residents and families not knowing about the potential for transfer or discharge as a result of changing health care needs. Research has suggested that certain resident characteristics are related to higher risk for discharge, including functional status (Bernard, Zimmerman, & Eckert, 2001; Phillips et al., 2003). Previous studies have also suggested that AL providers may not commonly provide information to prospective and/or new residents about discharge criteria (Mollica & Johnson-LaMarche, 2005), highlighting the lack of and need for preadmission education.

Finally, study findings provide further insight about the potential role of social workers in AL settings and the ways in which social workers may be involved in supporting resident transitions. Although AL providers perceived the availability of a licensed social worker within the AL as having little importance for transition success, the data indicated a positive relationship between the availability of a social worker and frequency and importance of education about service tier assignment as well as the importance of education about the resident care plan. These findings are notable in that they suggest that greater value is placed on the importance of preadmission education about the service tier assignment and care planning when a social worker is involved. Similar to other research that supports the role and function of social workers in long-term care settings (Simons, Shepherd, & Munn, 2008), our study suggests that social workers may be valuable to AL by providing preadmission education to residents and their families. In addition, qualitative findings identified the need for strong communication and additional psychosocial support for residents to ensure a successful transition. Consistent with the research of Koenig et al. (2011), social workers may contribute to the psychosocial care of new AL residents by providing counseling (for example, adjustment support groups) or referring residents to other outside professionals during the transition period.


Practitioners and researchers suggest that the growth in AL and needs of AL residents warrants increased social work involvement in these settings, particularly as social workers are "well situated to examine the risks and challenges associated with these [housing] transitions" (Burnette, Morrow-Howell, & Chen, 2003, p. 834). The findings from this exploratory study provide insight into the transition to AL and the potential value of social workers in addressing the preadmission education and psychosocial needs of older adults in these settings. In particular, there is a clear disconnect between what AL providers believe is important for resident transitions and what is actually happening in their facilities. The ability of residents to communicate their needs as a part of the transition to AL seems especially important to At. providers in free-standing facilities. This suggests that free-standing AL providers may have a specific need for social workers during resident transitions and that the role of social workers may be especially valuable in these types of AL settings. Social workers may also play a vital role in addressing the gaps in preadmission education that AL providers in our study identified and are well positioned to address the unmet psychosocial needs of residents and family members during the transition to AL.

The present study has some limitations. First, the data were collected from only 28 AL Medicaid waiver providers in one midwestern state. Therefore, generalizability to other AL types of settings and states is limited. Moreover, although the perspective of AL providers is important for better understanding resident transitions in these settings, the findings do not encompass the perspectives of older adults and their families in AL. Subsequent research should compare the views of residents, families, and providers in order to obtain a more comprehensive understanding of the transition experience. Second, the analysis is based on a relatively small sample during a single point in time. More research should be conducted to examine the differential perspectives of AL providers who do and do not participate in the waiver program. Future studies should also specifically examine the contributing role of social workers during the period of adjustment to AL and the effect of social work services on the well-being of AL residents and families during the transition to these settings. Further study of the impact of social work services on individual outcomes in the AL setting is needed to justify investment in social work staff by AL providers. The philosophical underpinnings and principles of the AL model of care such as resident choice, independence, dignity, and quality of life (Assisted Living Federation of America, 2010) support the current and future role of social workers in these settings. Ultimately, social workers may show their greatest value to AL providers by demonstrating the profession's on-going commitment to person-centered care and in meeting the psychosocial needs of older adults and their families.

doi: 10.1093/hsw/hls020


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Noelle LeCrone Fields, MSW, LISFV, is a doctoral candidate, College of Social Work, Ohio State University, Columbus. Terry Koenig, PhD, is associate professor, School of Social Welfare, University of Kansas, Lawrence. Holly Dabelko-Schoeny, PhD, is associate professor, College of Social Work, Ohio State University, Columbus. The authors thank Hope Roberts of the Ohio Department of Aging for her support and assistance with this study. Address correspondence to Noelle LeCrone Fields, College of Social Work, Ohio State University, 1947 College Road, Columbus, OH 43210; e-mail:

Original manuscript received January 10, 2012

Accepted February 1, 2012

Advance Access Publication October 11, 2012
Table 1: Indicators Important to Transition

Indicator                                             M      SD

Availability of licensed AL social worker            2.74   0.81
Social support from waiver case manager              1.64   0.68
Level of self-confidence                             1.63   0.56
Functional limitations (physical)                    1.57   0.63
Mental health problems                               1.56   0.64
Functional limitations (cognitive)                   1.50   0.58
Ability to communicate needs                         1.50   0.58
Social support from family/friends                   1.43   0.57
Feeling that the transition was his or her choice    1.39   0.63
Level of expectation (realistic)                     1.32   0.48
Social support from AL staff                         1.29   0.46
Awareness of what to expect from the AL transition   1.14   0.36

Notes: Responses were given on a four-point Likert-Type scale: 1
= very important,  2 = important, 3 = little importance, and 4 = no
importance. AL = assisted living.

Table 2: Frequency at Which Medicaid
Waiver Residents Receive Preadmission

Education Need                                        M      SD

Bowel or bladder training programs                   2.48   0.85
Service tier assignment                              2.40   0.84
Purpose and elements of a resident care plan         2.30   0.78
Eviction notices/appeals                             2.07   1.03
Role of the waiver case manager                      2.04   0.59
Meal tray delivery policy                            2.04   0.90
Part-time intermittent skilled nursing care          2.04   0.92
Role of AL management                                1.96   0.76
On-site ancillary services (podiatry, optometry)     1.96   0.85
What waiver does/does not pay for at the AL          1.92   0.92
Reasons justifying eviction                          1.92   0.96
Nonmedical scheduled transportation                  1.82   0.89
Role of AL nursing staff                             1.81   0.56
Pet policies                                         1.81   0.96
Maintenance services                                 1.79   0.88
Changes in eligibility for AL care                   1.79   0.88
Role of AL direct care staff (nurses aids)           1.78   0.58
Visitor and guest guidelines/policies                1.75   0.89
Religious activities/church                          1.74   0.76
Scheduled transportation for medical reasons         1.71   0.81
Meal preferences (selective menu, food choices)      1.70   0.77
Laundry services                                     1.64   0.87
Self-administration of medication                    1.63   0.84
Dining room policies (seating times, meal options)   1.62   0.74
Assistance with ambulation                           1.62   0.69
Smoking policies                                     1.61   0.83
Call light/emergency pull cord systems               1.61   0.79
Activity programs (outings, bingo)                   1.60   0.75
Types of care the facility can/cannot provide        1.60   0.79
Furniture provided/not provided by the AL            1.57   0.79
Assistance with personal hygiene/dressing            1.57   0.63
Assistance with toileting                            1.57   0.63
Where to express concerns/make complaints            1.56   0.75
Monthly allowable funds as per waiver guidelines     1.53   0.74
Assistance with bathing/showering                    1.50   0.64
Room amenities (cable, phone, air/heat)              1.46   0.69
Medication assistance (by nursing staff)             1.25   0.44

Notes: Responses were given on a four-point Likert-type scale: 1 = very
important, 2 = important, 3 = little importance, and 4 = no importance.
AL = assisted living.

Table 3: Level of Importance of Resident
Preadmission Education

Education Need                                      M      SD

Service tier assignment                            2.04   0.89
Bowel or bladder training programs                 1.93   0.86
AL building/room design                            1.79   0.57
Purpose and elements of a resident care plan       1.78   0.89
Location of AL                                     1.71   0.66
Pet policies                                       1.68   0.72
Visitor and guest guidelines/policies              1.64   0.68
Role of the waiver case manager                    1.63   0.74
Role of AL management                              1.54   0.64
Laundry/maintenance policies                       1.53   0.64
Room amenities (furniture, phone, TV)              1.46   0.51
Activity/religious programs                        1.43   0.50
Dining room/meal policies                          1.43   0.57
Eviction policies                                  1.40   0.63
Smoking policies                                   1.39   0.74
Transportation policies                            1.36   0.56
Role of AL nursing staff                           1.29   0.46
Role of AL direct care staff (nurses aids)         1.29   0.46
Nursing policies (medication, nursing care)        1.25   0.52
Call light/emergency pull cord systems             1.25   0.52
Changes in eligibility for AL care                 1.18   0.48
Monthly allowable funds as per waiver guidelines   1.14   0.36
Type of care the facility can/cannot provide       1.07   0.26
What waiver does/does not pay for at the AL        1.07   0.26

Notes: Responses were given on a four-point Likert-Type scale: 1 = very
important, 2 = important, 3 = little importance, and 4 = no importance.
AL = assisted living.
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