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Assisted Living National Update

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National Trends and Legislation
in Assisted Living plus
Ethical Marketing
April 13, 2010
Shane Osborne
National Center for Assisted Living
Assisted Living Properties
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living
• Average years open = 13.3
• Properties have an average 54 units.
• Average monthly cost = $3,022 or $36,264 annual (single occupancy.)
• Average monthly cost dementia care unit = $4,200.
• Ownership of operating units

59% Private For Profit

12.6% Publicly Held For Profit

25.7% Non-profit

1.3% Government sponsored
• 97% Sprinkled in common areas & 96% sprinkled in all rooms.
• 100% Smoke detectors in common areas & 99% in all rooms.
Assisted Living Residents
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living
• Average Age = 86.9
• Average Age at Move-in = 84.6
• 73.6% Female; 26.4% Male
• Average Income = $27,260
• Average Assets (including home) = $431,020
• Median Income = $18,972
• Median Assets (including home) = $205,000
Prior Residence
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living
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

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
Private home/apartment
Nursing home
Retirement/IL
Family residence
Different ALF or group home
70%
9%
9%
7%
5%
Assisted Living Residents
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living
• Average Length of Stay = 28.3 months
• Median Length of Stay = 21 months
• Average annual resident turnover = 42%
• 62% within 10 miles of their previous residence.
• 22% of residents made the decision to move
independently; 49% partially involved; others
made the decision for resident 25% of the time.
Health Conditions
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living

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
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
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Hypertension
Arthritis
Alzheimer’s/Dementia
Coronary Heart Disease
Depression
Osteoporosis
Macular Deg./Glaucoma
Diabetes
Stroke
66%
42%
38%
33%
30%
27%
19%
17%
14%
ADL Dependence
ALF Data from 2009 ALFA, ASHA, AAHSA, NCAL & NIC Survey
•
•
•
•
•
ADL
Bathing
Dressing
Toileting
Transfer
Eating
ALF
64%
39%
26%
19%
12%
NF
96%
90%
84%
80%
53%
• 81% of ALF residents need help with meds.
(Average 9.9 meds daily – 7.6 prescriptions and 2.3 OTCs)
Other Care Issues
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living
• Residents need assistance with 4.5 IADLs on average
with 4 out of 5 needing help with housework,
laundry, medications, transportation and meal
preparation
• 54% use a walking device (cane, walker, etc.) and 22%
use a wheelchair
• 31% bladder incontinent; 14% bowel incontinent
• 92% of communities arrange for /provide hospice care
Residents Moving Out
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living
 Nursing home
59%
 Home
9%
 Another ALF
11%
 Relative’s home
5%
 Hospital (other than short term)
7%
 Independent living
4%
 Hospice
2%
 Other
4%
One-third (33%) of residents die in the assisted living
setting.
NCAL’s Policy Priorities
• Keeping Regulation of Assisted Living at
the State Level
• Navigating National Health Care Reform
• eg. Implementation of Class Act and Employer Mandates
• Medicare Part D Co-Pay fix
• Arbitration
• Employee Free Choice Act
• Keeping assisted living included in the CMS
definition of HCB settings
State Regulatory Trends
• Twenty-two states reported AL regulatory/Medicaid
policy changes in 2009. Eight states made major
changes or overhauled rules. Trends:
• Higher standards for Alzheimer’s/dementia care.
• Life safety, emergency preparedness.
• Disclosure & staff training.
• Medication management.
NCAL State Regulatory Review
available at : www.ncal.org
State Regulatory Trends (2)
Additional focal points of policy change:
• Criminal Background Checks
• Resident assessment/service plans.
• Medicaid policy.
• Move-in/move-out rules.
• Reporting requirements.
• Resident rights.
NCAL State Regulatory Review,
2010 edition available
March 2010 at: www.ncal.org
Medicare Part D
• Medicare Part D Co-Pay Legislation
− Partial Fix included in health care reform legislation.
− Will eliminate Part D co-pays for dual eligibles in home
and community based settings covered under Medicaid
waivers - includes about 60% of assisted living dual
eligible population.
− NCAL took leadership on this issue and lead coalition of
national stakeholder groups.
• NCAL will seek a fix for dual-eligibles in assisted
living settings not covered by this legislation.
Medicaid and Assisted Living
• Rates often inadequate.
• Payment for AL Incomplete (housing, food,
utilities not covered; SSI check insufficient to
fill gap.)
• Many recent Federal initiatives, regulations
tend to exclude AL.
• NCAL study of State Medicaid rates, payment
issues released in last October.
NCAL Medicaid Payment & Policy Study
“State Reimbursement Policies and Practices in
Assisted Living”
Available at www.ncal.org.
Study sponsored by NCAL and done by Robert Mollica,
independent health policy researcher, formerly on staff of National
Academy for State Health Policy.
Methodology:
Updates Residential Care and Assisted Living Compendium: 2007
prepared for ASPE.
Source:
State web sites; Electronic survey; Telephone calls with staff
responsible for HCBS programs.
Data collected March – June 2009.
NCAL Medicaid Payment & Policy Study
Key Findings:
• AL Medicaid coverage is growing again (up 9%
between ’07 and ’09) after drop between ’04 and ’07 -now about 131,000 nationally.
– Medicaid covers about 13% of AL residents (compared to
about 63% of NH residents).
• 37 states use 1915(c) HCBS waivers; 13 provide
coverage directly under Medicaid state plans; 4
include it in 1115 demonstration programs; and 6 use
state general revenues. States may use more than one
funding source.
– Oklahoma began Medicaid waiver coverage in AL in 2009
NCAL Medicaid Payment & Policy Study
• Tiered rates the most common methodology for
reimbursing assisted living providers (19 states). Flat
rates are used in 17 states.
• 23 states cap the amount that may be charged for
room and board.
• 24 states supplement the beneficiary’s federal
Supplemental Security Income (SSI) payment of
$674, which states typically use as the basis for room
and board payment. SSI combined with state
supplements ranges from $722 to $1,350 a month
depending on the state. Some states provide no
supplement.
NCAL Medicaid Payment & Policy Study
• 25 states permit family members or third parties to
supplement room and board charges.
• 23 states require apartment style units; 40 allow units to be
shared; and 24 allow sharing by choice of the residents.
• Screening for mental health needs is performed by case
managers and assisted living community staff in 9 states;
by case managers only, in 10 states; and by assisted living
staff only, in 9 states.
• Mental health services are arranged by assisted living
communities in 16 states; case managers in 20 states; and
may be provided directly by assisted living communities
in 3 states.
NCAL Medicaid Payment & Policy Study
Trends: The shift to HCB settings
• Medicaid nursing facility census: 896,495 in Dec. 2008:
– 8.3% less than Dec. 2001.
• Number of assisted living residents receiving Medicaid LTC
services: 131,000 in 2009:
– 43.7% more than in 2002.
• Medicaid spending for NH care is still much greater, but
spending for HCB care is growing much faster:
– From FY 2001–2007, Medicaid spending for HCB care rose 81.5%
while spending for NH care rose 9.8%.
– In FY 2007, $16.7 billion spent on HCB care v. $46.9 billion for NH
care.
LTC Housing Supply:
Beds Per 1,000 People 65 and Older
Licensed
AL/RC
NFs
U.S.
25.7
44.1
Oregon
45.3
25.5
Michigan
36
36.4
Alabama
15.2
42.1
Oklahoma 19.4
61.5
Source: “State Medicaid Reimbursement Policies and Practices in Assisted Living,” Robert
Mollica, National Center for Assisted Living/AHCA, September 2009. Available at
www.ncal.org.
HCBS as a Percentage of Medicaid Long
Term Care Spending
Percent
HCBS
U.S.
31%
Oregon
57%
Michigan
19%
Alabama
13%
Oklahoma 29%
Source: “State Medicaid Reimbursement Policies and Practices in Assisted Living,” Robert
Mollica, National Center for Assisted Living/AHCA, September 2009. Available at
www.ncal.org.
Key questions
• How will federal Medicaid rules define
community settings?
• Will declining state revenues limit AL rates?
− If so, are ALFs likely to drop out?
• Will AL contribute to further decline in NF
use?
• As Congress contemplates further stimulus of
HCB care, what role will AL play?
• Should federal housing subsidies be
considered?
Employee Free Choice Act
AKA, the Union Card Check Bill
• Would allow unions to organize without a secret
ballet election. Employees would just need to sign
a card.




Takes away privacy.
Would affect every union in the country.
Takes away the election process.
Requires binding arbitration.
• President Obama has promised to sign the card check
legislation into law.
• NCAL opposes this bill, which was reintroduced in
both the House and the Senate on March 10, 2009.
Arbitration Legislation
• The legislation would eliminate the use of predispute arbitration agreements by all LTC facilities
nationwide.
• Reintroduced in March 2009 in both the House and
Senate. The Fairness in Nursing Home Arbitration
Act also applies to assisted living.
• In 2008, it passed the House and Senate Judiciary
Committees, but did not make it to the floor of
Congress.
• President Obama has said he would sign the measure
into law.
• NCAL/AHCA opposes the legislation.
Three Federal Agencies Working on
National Assisted Living Study
• Largest examination of assisted living by
the Federal Government
 Pilot Tested in 2009
 National Field Survey begins in April 2010
 Findings Published in 2011
• Agencies involved include:
− Office of the Assistant Secretary for Planning and
Evaluation (ASPE)
− National Center for Health Statistics (NCHS/CDC)
− Agency for Healthcare Research & Quality (AHRQ)
AHRQ’s Consumer Disclosure Initiative
• In July 2008, AHRQ launched the Assisted Living
Disclosure Collaborative. This 18-month project will
result in a tool that would allow consumers to
compare and select assisted living communities
around the country.
• Final model tool was completed in December 2009
and will be pilot tested in 2010 in Phase II.
• Phase III work will begin in 2010 and focus on the
consumer piece of the this initiative.
• NCAL will continue to actively participate in this
AHRQ initiative.
NCAL Life Safety Initiatives
• Concern among fire marshals, experts about
decreased ability of AL population to evacuate
without assistance is challenging current life
safety standards. NCAL taking proactive steps.
• National Fire Protection Association committee
has just accepted NCAL Life Safety Code
proposals for existing buildings.
• NCAL also soon will submit proposal for new
construction to International Building Code
committee.
• Objectives: Ensure safety; avoid shift to
institutional standards, costly retrofitting;
harmonize two major codes impacting AL.
Federal Regulation of AL?
• Trend toward AL residents with more health needs and
more residents with dementia is leading states to increase
AL regulation, increasing pressure for greater uniformity
of state regulation.
• Many leaders in the new Congress are on record as
supporting greater federal oversight of AL (e.g. Henry
Waxman, Pete Stark).
• Most in public policy circles agree that assisted living
could be one headline away from federal oversight.
• NCAL will be at the table if a debate over federal
regulation occurs.
Federal Agencies with
Assisted Living Initiatives
• Centers for Medicare & Medicaid Services (CMS)
 Defining HCB Settings
• HHS Office of Inspector General (OIG)
 State Oversight of Waiver Providers
 Examining AL Providers’ Use of Home Health
• Environmental Protection Agency (EPA)
 Disposal of Unused Drugs
 Energy Use and Energy Star Programs
Litigation Trends
Source: “CNA: Reducing Risk in a Changing Industry: CNA
HealthPRO Aging Services Claims Analysis 2004-2008,” CNA
Financial Corporation, 2009.
General trends:
• Frequency of incurred aging services claims (reported
claims with an indemnity and/or expense payment)
stable from 2004 to 2008.
• Severity of closed claims is increasing.
• SNFs have highest average severity within not-forprofit segment, followed by CCRCs.
• AL facilities have highest average severity within forprofit segment, followed by SNFs.
Litigation Trends (2)
Most Frequent Allegations
at AL Facilities*
Resident fall
45.9%
Abuse
10.3%
Improper care
8.8%
Pressure ulcer
7.2%
Unsafe environment of care
6.7%
*Source: CNA: Reducing Risk in a Changing Industry, 2009.
Litigation Trends (3)
Allegations at AL Facilities – Highest
Average Total Paid for Closed Claims*
Elopement
$337,344
Pressure ulcer
$276,612
Failure to monitor
$240,517
Improper care
$214,815
Abuse
$203,229
Resident fall
$202,415
*Source: CNA: Reducing Risk in a Changing Industry, 2009.
Litigation Trends (4)
Injuries at AL Facilities – Highest
Average Total Paid for Closed Claims*
Death
$308,564
Pain and suffering
$236,377
Amputation
$188,080
Sexual assault
$184,918
Head injury
$148,650
Co-morbidities
$147,817
*Source: CNA: Reducing Risk in a Changing Industry, 2009.
Looking Ahead: What is Clear
•
•
•
•
•
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E-Prescribing
Electronic Health Records
More on-line disclosure of information
New service models and delivery sites
Increasing acuity
Increased state oversight
Staffing challenges
Looking Ahead: What is Unclear
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Uniform assessments
Uniform outcome measurements
LTC financing reform
Federal regulation
Legal changes
How CMS will define HCBS settings
The declining economy’s impact on assisted
living
Surviving the Recession
• Nationally, occupancy levels have only decreased by
1% so the impact of the downturn has been minimal.
• New building is slow because of the lack of capital.
• The Unknowns:
 Have we hit the bottom of the downturn?
 Will the decline in housing prices mean that our
residents will spend down more quickly?
 If unemployment continues to rise, will more
unemployed adult children keep their parents at home?
The Power of
Ethical Marketing
The LTC Continuum
AL
NF
Sub
Acute
Remember To Be Realistic.
Ask Yourself…
• Where do I want to live when I’m 85?
 Nursing home
 Assisted living facility
 Your own home
Attitudes and Perceptions
Kaiser Family Foundation Research
• 35% think nursing homes do a good job of
serving health care consumers.
• 50% think assisted living providers do a good
job of serving health care consumers.
Driving Forces in the
Long Term Care Marketplace
• The “Age of the Elderly” & senior affluence.
• Growing desire to stay at home longer is leading to higher
resident acuity at move-in.
• The lines have blurred among provider types and that trend
will continue.
• Consumers are more educated and have access to more
information especially via the Internet.
• More public dollars flowing to home- and community-based
settings.
• Boomers are in the driver’s seat.
• Seniors are more independent physically and mentally.
Seniors’ Impressions Of Moving
Seniors relocating face:
 Giving up their own home
 Making new friends
 Fear of losing personal control
 Realizing a decline in doing things for
themselves
 Changing familiar routines
 Severing of emotional attachments
(Journal of Gerontological Nursing, Oct. 2004)
New Residents’ Greatest Fears
• Fear of losing independence is #1
• Fear of losing privacy
• Fear of losing control
• Food
− When will I eat?
− Where will I eat?
− What will I eat?
Resident Feelings
• It is normal for the residents to feel:
 Angry
 Fearful
 Frustrated
 Hurt
 Sad
 Insecure
Common New Resident Questions
•
•
•
•
•
•
•
What furniture can I bring?
Who will give me my medicine?
Will “they” tell me what to do?
How will I get to the dining room?
Will they have food like I cook at home?
Who will I sit with?
Is my family going to leave me?
Admission
• Recognizing liability triggers.
• Identifying situations that create unrealistic
expectations of care, service and outcome.
• Establishing a protocol to involve nursing
management and the physician when
necessary.
Recognizing Liability Triggers
• What family members say about a resident
• How family members ask questions about
the facility
• Their perception of assisted living
• Their expected outcome
Admission Protocol
• Use the admission process to identify
potential exposures.
• Involve nursing and physician.
• Identify needs of supporting family
members.
• Document all communication.
Ask Yourself -Do the financial incentives for the
marketing staff invite increased risk
or decrease my profit potential?
LITIGATION
State Litigation
• Medicaid Fraud Control Units
 Expanded authority with jurisdiction over nonMedicaid residential care settings
 Knowledgeable about LTC
• Use consumer protection laws
 Deceptive trade practices
 False advertising
 Consumer fraud prevention
State Litigation
• Most states have similar consumer
protection laws
− Steep fines + damages + attorney’s fees
− Additional liability if elderly or disabled
− Allow for civil actions
− Injunction authority
• State attorneys general are close-knit,
political and copy each other
• Applies to all long term care facilities
“An Ounce of Prevention…”
 Review materials
 Contracts/Admission Agreements
 Marketing Brochures
 Advertising
 Train staff
 Address problems and complaints ASAP
 Self-monitor
Reasons Family Members Give For Suing
Source: Tra Beicher, Risk Manager
•
•
•
•
“I just couldn’t get them to listen to me.”
“I knew something was wrong…”
“I didn’t know this was going to happen.”
“My [Mom/Dad/Aunt] just kept getting
worse and worse.”
• “They didn’t even apologize.”
Key Factors That Drive Families to Sue
Source: Tra Beicher, Risk Manager
1. Attitude of staff
2. Lack of communication
3. Unmet resident and family expectations
Set Realistic Expectations for Residents
and Families
• Communicate reality: Families don’t see
many conditions as terminal.
• Talk openly about physical and mental
decline.
• Explain services that are not available.
• Know and explain that the environment
won’t fix all resident/family problems.
• Provide clear information about how to
complain.
Three Things To Do Now
• Teach staff to apologize
• Give the family something
tangible
• Attach someone to the problem
NCAL’s
The Power of
Ethical Marketing
Disclosure
Builds trust between the residence
and the consumer
 Admission and Discharge Policies
 Contracts
 All Fee Schedules
The Power of the Written Word
• Opportunity to Showcase
• Accuracy
• Consistent with Spoken Word
• Periodic Review and Comparison
The Power of the
Spoken Word
Perception is
Reality
The Power of the Spoken Word
The Tour
 Professionalism
 Balanced Presentation
 Effective Listening
 Personalized
The Power of the Spoken Word
• Staff Involvement
• Resident Involvement
• Consistent with Written Materials
Disclosure and Dementia Care
MetLife Mature Market Institute 2009 Findings
• 59% of ALFs provide dementia care with 52%
charging an additional average $1,304 per
month.
• 29% of nursing homes surveyed had separate
dementia units and only 10% charge an
additional fee. Those that did charged an
average of $10 more per day.
Customer Referral Form
Tour Name:
_____________________________________________________
Address:
_____________________________________________________
City, State and Zip:_____________________________________________________
Telephone:
_____________________________________________________
Referral Source: (circle one)
Physician
Family Member
Clergy
Social Worker
Telephone Book
Friend
Drive-By
Newspaper Ad
Area Agency on Aging
Hospital
Licensing
Other: ______________
Prospective Resident Information:
Name:
____________________________________________________
Current Living Situation (circle one):
Lives Alone
Assisted Living Facility
Nursing Home
Other
Needs Assistance With:_______________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Follow-Up Needed For: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Staff Signature:
_____________________________________________________
Date: ________________
Resident/Family Inquiry Form
Name:
_____________________________________________________________________________________________
Telephone:
_____________________________________________________________________________________________
Nature of Inquiry: (circle one)
Complaint
Suggestion
Feedback
Other
Comments:________________________________________________________________________________________________
__________________________________________________________________________________________________________
Action Taken:______________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Action Requested:__________________________________________________________________________________________
__________________________________________________________________________________________________________
Staff Signature:_____________________________________________________________________________________________
Date: ______________________________________________________________________________________________________
The Power of the Internet
• User-Friendly Website
• Current Information
• Virtual Tours = In-person Tours
• Privacy Issues
• American Marketing Association’s
Code of Ethics
AMA’s Internet Code of Ethics
• Support professional ethics to avoid harm by
protecting the rights of privacy, ownership
and access.
• Adherence to applicable laws and
regulations.
• Awareness of changes in regulations related
to Internet marketing.
AMA’s Internet Code of Ethics cont.
• Effective communication to organizational
members on risks and policies related to
internet marketing.
• Organizational commitment to ethical
internet practices communicated to
employees, customers, and relevant
stakeholders.
The Power of the Community
• Goodwill
• Genuine Interest
• Positive Impact
• Sincerity
The Power of Teamwork
ALL STAFF COUNT !
• Education and Training
• Staff Empowerment
• Approval to say “I Don’t Know”
• Follow up
• Unified Customer Focus
Teamwork Cont.
Customer Service
 Telephone etiquette
 Listening skills
 Presentation skills
 Affect and expression
 Body language
Fair Housing Act
Prohibits discrimination based on:

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
Race
Religion
Color
Sex
Disability
Familial status
National origin
Americans with Disabilities Act
• Prohibits discrimination based on physical or
mental handicap in public accommodations
operated by private entities.
• 800/514-0301 (voice) or 800/514-0383 (TDD)
Integrating FHA and ADA
• Terminology
• Photographs
• Equal Housing Opportunity Logo
• Fair Housing Policy Statement
• Staff Training
AMA’s Code of Ethics
• Responsibility of the Marketer
• Honesty and Fairness
• Rights and Duties
• Organizational Relationships
Checklist for Staff
_______ Does your written marketing material fully disclose in
plain language your services and amenities?
______ Does your marketing material promise or allude to
services that your residence is not able to provide?
______ Have you reviewed your written marketing material on a
yearly basis and any time your state regulations change?
______ Have you incorporated customer-based marketing skills
into your residence’s employee orientation program?
Checklist Cont.
______
Have you trained your staff about the marketing
materials?
______ Is your website current, functioning and userfriendly?
______ Do your advertisements contain the Equal
Housing Opportunity logo?
______ Are the photographs in your printed
advertisements representative of your
community?
NCAL’s Guiding Principles
for Providing Information
to Consumers
• Main purpose: to articulate more fully
NCAL’s commitment to ethical marketing
practices and full disclosure of information
to prospective and current assisted living
resident sand their families or responsible
parties.
Consumer Disclosure Components
• Contracts
• Finances
• Transfer and/or Move-out
• Appeals Process
• Special Care Provisions
• Resources for Consumers
Contracts
• Primary tools to explain legal responsibilities
of both the provider and the resident
• Contract language should be consistent with
all marketing materials and information
conveyed verbally or through Web sites
• Modifications may be made only with the
agreement of all parties involved
Contracts
• Simple language is best
• Review of contract by third party
• Signature by responsible party or
third party
• Obtain rights, options, and limitations
concerning the resident’s ability to
obtain services outside of facility
Finances
• Fee increases
• Refundable or non-refundable fees
• Management of resident finances
• Public financing options
Transfer or Move Out
• 30 days notice (minimum)
• Effective date of transfer
• Reasons (facts and circumstances)
• Appeal process and time frame
• LTC Ombudsman contact information
• Right to representation
Special Care
• Special care provisions
(Alzheimer’s care, etc)
• Advance directives
• End-of-life care
Posting of State Contact Information
• State or local long term care
ombudsman program
• State regulatory agency
• Other advocacy bodies or government
agencies mandated to be posted.
Choosing an Assisted Living Residence
• This guide helps future residents and
their families learn about assisted
living, determine whether it is an
appropriate living option for their
needs and preferences, and helps
them make a wise selection.
“The goal is to
maintain maximum
independence in a
home-like setting.”
Moving Into an Assisted Living Residence:
Making A Successful Transition
• This guide helps residents about to transition into an
assisted living community. It covers:
• Privacy Concerns
• What to Bring to Your New Home
• Moving Day Helpers
• Making the Emotional Transition
• Advice for Residents and their Families
• Suggested Do’s and Don’ts
Preparing Residents for Moving Out of
Assisted Living Residences
• This guide helps assisted living professionals prepare and
support residents when they move-in or move-out to
reduce stress and anxiety.
“ALRs should find
ways to facilitate an
easy transition and one
that makes the resident
feel special and loved.”
NCAL’s New Web site – www.ncal.org

Assisted Living Research
and Studies


News
 Webinar and Event Info.

NCAL Publications
 Quality Resource

Labor, Workforce & OSHA
Resources
 Consumer Resources

Legislative Updates
Practice Guidelines and
Training Tools
 And more…
National Assisted Living Week
September 12 – 18, 2010
Contact Shane Osborne at
[email protected] for an
electronic version of this
year’s logo.
The Planning Guide and Product
Catalog will be available in June!
Visit www.nalw.org for more information.
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