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Health Care Services Use in Assisted Living:
A Time Series Analysis*
Kimberlyn M. McGrail,1,2 Meredith B. Lilly,1 Margaret J. McGregor,1,3 Anne-Marie Broemeling,1,4
Kia Salomons,1 Sandra Peterson,1 Rachael McKendry,1 and Morris L. Barer1,2
Cet article décrit le modèle réglementaire de la Colombie-Britannique pour l’aide à la vie autonome et était basée sur une
analyse des séries chronologiques qui a examiné l’utilisation individuelle des services de soins de santé avant et après leur
arrivée en résidence-services. Les 4 219 résidents étudiés dans résidences assistées étaient vieilles et surtout des femmes,
73 pour cent d’entre eux ayant une ou plusieurs principales maladies chroniques. L’utilisation des services de soins de
santé a eu la tendance à augmenter avant le passage à la vie autonome, de diminuer au moment du déménagement
(notamment pour les médecins généralistes, les médecins spécialistes, et les soins actifs), et de rester faible au cours des
12 mois de la période suivie. Ces effets positifs apparents ne sont pas insignifiantes; la cohorte de 1 894 résidents de la
vie assistée utilisaient moins de 18 000 jours de soins actifs dans l’année après, par rapport à l’année précédente, de leur
déménagement. La recherche dans l’avenir devrait examiner si et comment aide à la vie autonome affecte à long terme
les voies de soins de santé pour les personnes âgées et, finalement, comment leur fonction et la qualité de la vie sont
This article describes British Columbia’s regulatory model for assisted living and used time series analysis to examine
individuals’ use of health care services before and after moving to assisted living. The 4,219 assisted living residents
studied were older and predominantly female, with 73 per cent having one or more major chronic conditions. Use of
health care services tended to increase before the move to assisted living, drop at the time of the move (most notably for
general practitioners, medical specialists, and acute care), and remain low for the 12-month follow-up period. These
apparent positive effects are not trivial; the cohort of 1,894 assisted living residents used 18,000 fewer acute care days in
the year after, compared to the year before, their move. Future research should address whether and how assisted living
affects longer-term pathways of care for older adults and ultimately their function and quality of life.
Centre for Health Services and Policy Research, University of British Columbia
School of Population and Public Health, University of British Columbia
Department of Family Practice, University of British Columbia
Alberta Health Services
* Funding and access to data for this project were provided by the British Columbia Ministry of Health. We are grateful to our
colleagues at the Ministry, the Provincial Home and Community Care Council, the Council’s Standing Committee on Assisted
Living, and others who provided thoughtful comments on the research as it progressed. Thanks as well to the reviewers whose
careful reviews helped to improve the article. Any errors remain the responsibility of the authors.
Manuscript received: / manuscrit reçu : 14/09/2011
Manuscript accepted: / manuscrit accepté : 01/10/2012
Mots clés : vieillissment, services de soins de santé, aide à la vie autonome (idée)/résidence-services (résidence)
Keywords: aging, health care services, assisted living
Correspondence and requests for offprints should be sent to / La correspondance et les demandes de tirés-à-part doivent
être adressées à:
Kimberlyn M. McGrail, Ph.D.
Centre for Health Services and Policy Research
201-2206 East Mall
Vancouver, BC V6T 1Z3
([email protected])
Canadian Journal on Aging / La Revue canadienne du vieillissement 32 (2) : 173–183 (2013)
Canadian Journal on Aging 32 (2)
Older adults in Canada, as elsewhere, typically wish to
remain independent and living in their own homes for
as long as possible (Carstairs, & Keon, 2009; Premier’s
Council on Aging and Seniors’ Issues, 2006). When
people become frail and need assistance with activities
of daily living or with health conditions, remaining
at home is frequently possible if assistance can be provided through a combination of support from visiting
nurses, personal support workers, and family/friends.
Eventually, however, some people need more personal
assistance than is possible from home-based health
services; other people (or their families or caregivers)
may feel that living at home is no longer viable because
of safety or other concerns. And yet, these individuals may not need the intensity of services commonly
offered in long-term residential care facilities (nursing
Congregate housing, supportive housing, and assisted
living are among the Canadian “middle options”
between independent living (with some limited support)
in one’s own home, and living in a long-term care
facility (Canadian Centre for Elder Law, 2008). These
are relatively new “housing with care” phenomena,
originating in the 1990s. There is no consistency in terminology, formulation, or regulation within Canada
or beyond, but there are some common elements that
characterize assisted living: (a) on-site staff and allhours’ access to emergency services; (b) maximizing
of residents’ independence, autonomy, privacy, choice,
and dignity; and (c) provision of a home-like environment (Phillips, et al., 2003; Wright, 2004). Arrangements
in assisted living facilities vary, but the standard suite,
located within a supervised building, is usually private
and includes a bathroom and some kitchen capacity.
These independent apartments are sometimes part
of multiple acuity-level facilities designed to facilitate aging in place (Lum, Ruff, & Williams, 2005). These
facilities range from being fully privately funded to
fully publicly funded. Most provide a mix of options.
The British Columbia (BC) Ministry of Health services,
along with many other health system policy-makers,
supports community-based care that can simultaneously help individuals retain independence while
reducing the use of other health care services (BC
Ministry of Health, 2012). In particular, the Ministry
is striving to decrease needs for both residential longterm care and acute in-patient care, the two most expensive sites of care in the health care system.
The impact and burden on caregivers when individuals move to institutional forms of care such as assisted
living is well documented (Mittelman et al., 2006). In
addition, many studies have tried to create predictive
models for the likelihood of placement in institutional
Kimberlyn M. McGrail et al.
forms of care, most frequently nursing homes (Gaugler
et al., 2007; Miller & Weissert, 2000). Surprisingly little
research exists, however, on the impact of institutional
placement on the use of other health care services.
One study from Germany found that an increase in
acute hospitalizations preceded nursing home admission, followed by a decline of hospitalizations after
admission although not as far as the rate before the
increase (Ramroth et al., 2005). Another study found
that inappropriate medication prescribing declined
somewhat after admission to a nursing home (Dhalla
et al, 2002). No studies were identified that considered
the impact of facility placement on the use of physician
services, nor were any found that considered the impact
on service use after individuals moved into a facility
such as assisted living, which does not provide 24-hour
nursing care to residents.
The study described in this article aimed to fill that
gap, providing a first look at the use of assisted living
and use of health care services in the Province of British
Columbia, Canada.
Assisted Living in British Columbia, Canada
British Columbia was the first province in Canada to
regulate assisted living. In 2002, the BC Ministry of
Health Services and BC’s health authorities announced
a three-year plan for home and community care redesign
(BC Ministry of Health Services, 2002). The objectives included increasing the number of clients served
at home relative to those in facilities and reducing
the use of acute care beds by individuals who could
be served in the community. Criteria defining “complex
care” were set out in April 2002, and only those who
met these criteria were to be eligible for publicly funded
long-term residential (nursing home) care (BC Ministry
of Health, n.d.c). These changes created a potential
gap in care for people who were no longer able to live
independently in their own homes, but who did not
meet these more restrictive long-term care eligibility
criteria. Assisted living was conceived as a service
option that would fill this gap.
An approved assisted living facility in British Columbia
is “a premises or part of a premises in which housing,
hospitality, and … prescribed services are provided by
or through the operator to three or more adults who
are not related by blood or marriage to the operator”
(Community Care and Assisted Living Act, 2002). The Office
of the Assisted Living Registrar has jurisdiction over
all assisted living residences in British Columbia, regardless of the source of payment (public or private) for
those facilities (BC Ministry of Health, n.d.a).
By law (specifically the Community Care and Assisted
Living Act), assisted living operators in British Columbia
Assisted Living and Health Care Services
must offer five hospitality services: one to three meals
a day plus snacks; weekly light housekeeping; weekly
laundering of flat linens; social and recreational opportunities (leisure pursuits, social interaction, and community involvement); and a 24-hour emergency response
system. Assisted living facilities must also provide
at least one, and not more than two, “prescribed services”, as defined in section two of the Community
Care and Assisted Living Regulation (2008). These prescribed services are as follows: (a) regular assistance
with activities of daily living, including eating, mobility, dressing, grooming, bathing, or personal hygiene;
(b) central storage of medication, distribution of medication, administering medication, or monitoring the
taking of medication; (c) maintenance or management
of the cash resources or other property of a resident
or person in care; (d) monitoring of food intake or of
adherence to therapeutic diets; (e) structured behaviour
management and intervention; and (f) psychosocial
rehabilitative therapy or intensive physical rehabilitative therapy.
Although assisted living operators may offer all six
of these service areas as “support”, they may provide
only two at the “prescribed” level. The difference is
in degree. For example, operators may offer intermittent or occasional reminders about medications to
their residents as a “support” service, but organizing,
administering, and recording the taking of medication
is a “prescribed” service. The vast majority of assisted
living facilities in British Columbia have chosen to
offer assistance with activities of daily living and central
storage of medication ([a] and [b] above) as their two
prescribed services.
To be considered for public funding, candidates must
first be assessed by a case manager (often a registered
nurse or social worker) from one of the province’s
regional health authorities. The case manager uses
formal criteria to determine whether the individual has
a need for support and personal assistance, can no
longer live independently in the community, and is able
to make decisions on his or her own behalf (or lives
with a spouse who is able to do so) (BC Ministry of
Health, n.d.b). By implication, people with moderate
to advanced dementia or other forms of cognitive impairment and who do not have an able spouse are generally not considered suitable candidates for assisted
As of 31 March 2009, the end of our study period,
there were 6,436 assisted living units in 185 separate
physical residences in British Columbia. Of these,
4,351 units (69%) were publicly subsidized; the rest
were fully private-pay. These units were located in a
mix of fully private, fully publicly subsidized, and
mixed buildings.
La Revue canadienne du vieillissement 32 (2)
The data for this study were provided by the BC
Ministry of Health through Population Data BC (www. Virtually all (> 99%) of the records
used here arrive at Population Data BC with personal
health numbers attached, making this truly populationbased information. Each individual whose data were
provided to the research team was assigned a unique,
anonymous identifier making it possible to link and
track information about the individual across data
files and over time without revealing any identifying
information. Ethics approval for the study was obtained
through the University of British Columbia Behavioural
Research Ethics Board.
We accessed the following data files for each of the
fiscal years 2003/04 to 2008/09: (1) the registry file;
(2) continuing care data; (3) hospital separations;
(4) fee-for-service physician payments; (5) publicly
paid pharmaceutical information; and (6) vital statistics death information. The registry file is the central
demographics file, and it provided us with information on year and month of birth, sex, and variables –
part of the Johns Hopkins Adjusted Clinical Groups
case-mix system – which provide a summary measure
of health status (Reid et al., 2008). The continuing
care data files provided information on individuals’
admission and discharge dates from publicly funded
assisted living and whether they received publicly
funded home health services in the year prior to moving
to assisted living.
One of British Columbia’s five health authorities
switched to a new data reporting system, which meant
that we had information on assisted living clients who
were residents of that health authority only for 2004/05.
Like other health authorities, the one excluded after
2004/05 had a mix of rural and urban areas. It had
about 16 per cent of the total provincial population
and about 20 per cent of all assisted living units. A comparison of 2004/05 data showed that assisted living
residents from the excluded region were slightly older
and slightly more likely to be male, reflecting the
general demographic characteristics of that region, but
were not different in health status. The fact that this
information was missing thus decreased our sample
size but was not expected to affect the results or interpretation of these analyses.
The hospital separations file contained data on all
acute care separations (discharges and deaths) and
day surgeries at hospitals in British Columbia. The
fee-for-service physician data included dates of service
and physician specialty. For purposes of analysis, we
created four broad groupings of physicians: general
Canadian Journal on Aging 32 (2)
practitioners, medical specialists,1 surgical specialists,2
and laboratory/imaging specialists.3 This categorization
is consistent with previous analyses using these data
(see, for example, McGrail, Evans, Barer, Kerluke, &
McKendry, 2011).4 Pharmaceutical data were for publicly paid prescriptions only. Our focus here is on prescriptions for antipsychotics and benzodiazepines, two
drug classes that are associated with care quality among
older adults (Dhalla et al., 2002; Rochon et al., 2008;
Stevenson et al., 2010).
Study Population, Variables, and Analysis
This study included all British Columbians aged 65
and older who moved to a publicly funded assisted
living unit between 2004/05 and 2007/08 (subject to
the data limitations just described). We excluded people
(n = 5) who did not have a full year of observation in
the year prior to moving to assisted living. These data
reflect first admissions to publicly funded assisted
living, since the program’s start and our study period
coincided. Data from 2003/04 and 2008/09 were used
to assess health care services use before and after admission to assisted living. Analytic variables included
demographics (age, sex, vital status), health status, and
health care services use (physician, hospital, pharmaceutical). Details on construction of analytic variables
are provided in Table 1.
Health care services use before and after admission
to assisted living was examined using a single-cohort
time series approach (Shadish, William, Cook, &
Kimberlyn M. McGrail et al.
Campbell, 2001). We opted for this approach in order
to take advantage of the longitudinal nature of the
data and because it was not possible to create a robust
comparison group for the assisted living cohort. People
who enter assisted living are likely to be different, with
respect to unmeasured variables, from people who
do not enter assisted living. Those variables may also
influence health care services use, which would introduce confounding to any comparisons.
The time series analyses were limited to individuals
who could be followed fully for 12 months prior to
and 12 months after moving to assisted living. Creating this kind of balanced cohort ensures that any
trends observed are not attributable to differences in
underlying characteristics of the population at different points in the study period. This restricted the
cohort to people who did not die or transfer to residential care (a nursing home) within the first year after
their move. All utilization variables outlined in Table 1,
such as visits to a general practitioner and admissions
to acute care, were calculated on a monthly basis for
the twelve months prior to and twelve months following admission.
We modelled the data using segmented, ordinary,
least-squares regression (Wagner, Soumerai, Zhang, &
Ross-Degnan, 2002) in the form:
Yt = β 0 + β1 * time t + β 2 * move to AL t
+ β 3 * time after move to AL t + ε t
Table 1: Definitions of variables
Demographic variables
Use of health care services
Acute care hospitalizations
Health status
Six age groups, with age calculated at the time of the move to assisted living: 65–69, 70–74, 75–79,
80–84, 85–89, and 90 and older.
Measures of use included both likelihood (did or did not have a visit) and intensity, where intensity is
defined as the number of visits, and a visit is a unique combination of individual, provider, and date.
Included separations from acute in-patient care. Measures of use included both likelihood and intensity,
where intensity is the total number of days in hospital.
Two specific therapeutic classes were analyzed, benzodiazepines and antipsychotics (typical and
atypical), as these drugs are often indicators of quality of care in frail senior populations.
Measured using the Johns Hopkins ACG case-mix system (
viewDefinition.php?definitionID=102226), which assigns individuals to health status categories
based on the full set of diagnosis codes they receive from physicians’ visits and hospital stays over
the course of a year. Each diagnosis is aggregated to one of 238 “Extended Diagnostic Clusters”
that relate to body systems and conditions (e.g., dementia, asthma). Each diagnosis is also assigned
to one of 32 Aggregated Diagnosis Groups (ADG) based on several criteria including clinical
similarity and expected use of health care services such as follow-up visits or the likelihood of referral
to a specialist. For example, a diagnosis of “dermatitis” is considered a “time limited: minor”
condition. Eight of the ADGs are considered “major”, meaning they could be expected to have
a significant impact on the need for health care services.
Assisted Living and Health Care Services
La Revue canadienne du vieillissement 32 (2)
where Yt is the average health care services …
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