The Continuum of Care

By Robin Avery

Continuum of care refers to the range of senior housing and care options available, from independent living to assisted living and the nursing home. In certain circles, the continuum’s trio of options is humorously referred to as Go Go, Slow Go, and No Go. But there’s nothing funny about the challenges of providing for an aging population. In Colorado, those challenges include deficiencies afflicting the second and third stops on the continuum – assisted living and nursing homes, sometimes called skilled care. In this column I focus on the assisted living situation; a later column will take a look at nursing homes.

The math says it all: There are about 15,000 licensed assisted living beds in Colorado, enough for  roughly three percent of people over 65. If we raise the age to 75, the percentage climbs a little, to seven percent. If you’re 85 years of age, that 15,000 number is roughly 21%. Stated another way: If you’re an 85-year-old Coloradan, you have a twenty one percent chance of living in an assisted living community. And if assisted living isn’t an option for you, then that means a steady stream into nursing homes. This needs to change. Simple math tell us that over the next decade, as those over the age of 75 grows dramatically, assisted living capacity needs to expand by nearly 7,000 beds. At an average of seventy two beds per facility, that means 93 individual facilities will have to be built. Due to the lack of availability of credit, this demand isn’t currently being met.

For decades, independent living was (usually) followed by skilled care such as a nursing home or hospice. Assisted living is now the second step of the journey. The assisted living model is relatively new, not even a quarter century old. And although it’s now embedded in the common lexicon, most people, including healthcare providers, aren’t always familiar with what constitutes quality assisted living. Some older physicians have made it a lifelong habit to place their patients into nursing homes. Nursing homes certainly provide a benefit, but at a significant cost that I believe should be reserved for those who need expensive, daily and complicated medical treatment. Populating nursing home space with aging citizens who are perfect candidates for an assisted living setting does a disservice to both the aged and the healthcare system.

Colorado’s assisted living landscape is populated with campuses that vary widely in size and quality, from very large to small, and from first-class to the mediocre, and worse. In these communities, physicians, licensed nurses and therapists care for the medical or clinical needs of the residents. Most of the medical concerns are chronic in nature. But medical care is just the beginning; a well-run assisted living community must possess a creative, dynamic social component. It takes dedicated focus to maintain, motivate, entertain and satisfy a population with many people who struggle with depression or disabilities, or just plain lack of energy. When you enter an assisted living community, it’s a good sign if you see active, alert residents. It indicates they feel safe and engaged. It always struck me how smart residents are. They know before anyone else if staff is dysfunctional, uncaring, unprofessional or negligent. The easiest course of action available to them – is to hide. So there’s no better indicator of a first-class assisted living facility than numerous residents and staff buzzing about in a safe and comfortable setting. Some call it The Circle of Trust and Respect. Once management, staff and residents are engaged in the Circle, family members and the extended community can easily recognize it. It’s a wonderful thing to see. We also refer to this as “managing the energy under the roof.” It starts with trust and respect between management and staff, and between staff and staff. When management leads staff with competence, knowledge and compassion, and staff exhibit competent professionalism and friendliness, or at least civility, then residents relax and enjoy themselves.
How else can you identify an exceptional assisted living community? There are many components to the question and the answer not easily arrived at. As with all human organizations, it starts with ownership and management. Does the management have a well thought out vision and mission? Does it pursue that vision and mission day in and day out? Do the goals and objectives embodied in the vision and mission serve both residents and staff? Is the staff meeting all residents’ needs physically, nutritionally, psychologically, spiritually and socially?

It’s not too much to ask, but as an industry and as a society, we’re behind the curve meeting the coming challenges. For instance, the thirty-hour class now required for an assisted living administrator’s certificate is wholly inadequate. At minimum, there should be a required internship that takes place in a top notch facility. A minimum wage style stipend would be paid for by the state, and would reap many rewards. It’s a complicated business, and adequate training for positions of responsibility and accountability is vitally important. It’s also important that existing companies provide for Administrator-In-Training (AIT) opportunities to develop future leaders. It’s a “hearts and minds” business. Leadership has to have great skills in both areas.


Robin Avery is a Gerontologist, a Consultant to, and Developer and Operator of assisted living communities, with a Masters Degree from The Naropa University.

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