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Who uses assisted living in British Columbia? : an initial exploration McGrail, Kimberlyn; Lilly, Meredith; McGregor, Margaret J.; Broemeling, Anne-Marie; Salomons, Kia; Peterson, Sandra; McKendry, Rachael; Barer, Morris Lionel, 1951- Apr 30, 2012

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Who Uses Assisted Living in British Columbia?An Initial ExplorationApril 2012Kimberlyn M. McGrail PhDMeredith Lilly PhDMargaret J. McGregor MDAnne-Marie Broemeling PhDKia Salomons MScSandra Peterson MScRachael McKendry MAMorris Barer PhDPrepared on behalf of Home & Community Care and Performance Accountability Branch, Health Authorities Division, BC Ministry of HealthW H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?Who Uses Assisted Living in British Columbia? An Initial Exploration was produced by:Centre for Health Services and Policy ResearchUniversity of British Columbia201–2206 East MallVancouver, BC V6T 1Z3Phone: 604-822-4969Email: enquire@chspr.ubc.caYou can download this publication from www.chspr.ubc.ca/research/patterns/assistedlivingLibrary and Archives Canada Cataloguing in Publication           Who uses assisted living in British Columbia? [electronicresource] : an initial exploration / Kimberlyn M. McGrail ... [et al.] ;prepared on  behalf of Home & Community Care and PerformanceAccountability Branch, Health Authorities Division, BC Ministryof Health.Includes bibliographical references.Electronic monograph issued in PDF format.ISBN 978-1-897085-21-9          1. Congregate housing--British Columbia.  2. Older people--Housing--British Columbia.  I. McGrail, Kimberlyn, 1966-II. University of British Columbia. Centre for Health Services andPolicy Research  III. British Columbia. Home and Community Care HD7287.92.C32B75 2012         363.5’94609711           C2012-902015-XUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH1About CHSPRAbout this Report The Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. CHSPR’s mission is to advance scientific enquiry into issues of health in population groups, and ways in which health services can best be organized, funded and delivered. Our researchers carry out a diverse program of applied health services and population health research under this agenda. The Centre’s work is:• Independent• Population-based• Policy relevant• Interdisciplinary• Privacy sensitiveCHSPR aims to contribute to the improvement of population health by ensuring our research is relevant to contemporary health policy concerns and by working closely with decision makers to actively trans-late research findings into policy options. Our researchers are active participants in many policy-making forums and provide advice and assistance to both government and non-government organizations in British Columbia (BC), Canada and abroad. For more information about CHSPR, please visit www.chspr.ubc.ca.This report reflects a close and ongoing working relationship among researchers based at the Centre for Health Services and Policy Research at UBC, the Home and Community Care and Performance Account-ability Branch at the BC Ministry of Health, and the Provincial Home and Community Care Council and its Standing Committee on Assisted Living. The scope of this project, research objectives and research questions were agreed on at the outset. Following this, the researchers took full responsibility for methods and database development and data analysis, with regular contact and sharing of work in progress with other stakeholders. What is presented here reflects these many interactions, but the responsibility for accuracy of data analy-sis and the resulting conclusions rests solely with the authors. Funding for this work was provided by the BC Ministry of Health.Contents1 About CHSPR1 About this Report 4 Main Messages4  Suggestions of success4  Findings of potential concern4  Future work5 Executive Summary5  What is Assisted Living? 6  Data and analysis6  Findings and conclusions7  Limitations and possible directions for future research8 Introduction10 Assisted Living in Canada11 Assisted Living in BC11  Context: Defining the need 11  Regulatory structure: Defining Assisted Living 13  Eligibility, entry criteria and public subsidies 13  Eligibility: Exit criteria14  Current size and growth of Assisted Living 15 Methods15  Source of the data16  Study population and variables16   Health status: The Adjusted Clinical Groups case-mix system18 Results18  Who resides in publicly-funded Assisted Living in British Columbia?19   Health status of Assisted Living residents23  Use of health care services prior to and after admission to Assisted Living25   Physician use25   Hospital use25   Pharmaceutical use25   Monthly trends in use27  How long do residents stay in Assisted Living?28   Early exiters from Assisted LivingW H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?231 Discussion31  Suggestions of success31  Findings of potential concern31   People with dementia 32   Other early exiters 32   Particular drugs32   End-of-life32   Private pay33  Limitations33  Possibilities for further investigation33   More gender-based analysis of Assisted Living residents33   Use of InterRAI data33   The continuum of care33   Dementia33   Pharmaceuticals33   Resource utilization bands33   Hospitalizations34 Appendix 134  Provincial legislation on Assisted Living across Canada34   British Columbia34   Alberta36   Saskatchewan36   Manitoba37   Ontario38   Quebec38   Nova Scotia39   New Brunswick40   Prince Edward Island40	 	  Newfoundland and Labrador41   The Territories42 Appendix 243 Appendix 343  Registered Assisted Living units by health authority46 ReferencesUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH3W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?4Main Messages• There is no consistent definition of Assisted Living, or consistent use of terminology, either in Canada or internationally, so readers should exercise caution when reading about this sector. • There are, however, a few principles that define Assisted Living (and whatever else it might be called), the most fundamental of which is providing supports for seniors (and in some jurisdic-tions, disabled adults) in a less formal institutional setting than long-term care.• In BC, there is a formal framework for Assisted Living—this is more structured and organized/ formalized than in other parts of Canada.• Half of Assisted Living residents are 85 or over, three-quarters are female, and about half subse-quently move on to residential care.Suggestions of success• Length of stay is often measured in years, and females tend to stay longer.• Use of other health care services appears to decline after moving to Assisted Living.• Polypharmacy appears to decrease somewhat.Findings of potential concern• Dementia diagnoses increase substantially in the first year after moving to Assisted Living, and a diagnosis of dementia is associated with a much shorter length of stay.• More generally, more than a quarter of people leave Assisted Living after less than one year.• Use of benzodiazepines and atypical antipsychotics in this population is high.• Only one-third of people who die do so in Assisted Living, suggesting a need for more attention to end of life care in this care setting.• Our understanding of this population is limited to the extent that we are missing information on  private payment for Assisted Living and other services.Future work• These analyses raise many additional potential research questions, such as: Would InterRAI data help with prediction of length of stay in Assisted Living? Are there other models of care that might be better suited for people with dementia? Is pharmaceutical use in this group appropriate? Can we understand more about reasons for hospitalization?UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH5The vast majority of older adults in Canada wish to remain independent and living in their own homes for as long as possible. Eventually, however, some people need more personal assistance than can be provided by home-based health services, and others (or their families/other caregivers) may feel that living at home is no longer viable because of safety or other concerns. Assisted Living is a relatively new form of care in Brit-ish Columbia which is a middle option between in-dependent living (with some limited support) in one’s own home, and living in a residential care facility. One objective for this report is briefly to define and describe the context for Assisted Living in BC and how it compares to other jurisdictions, both in Canada and internationally. A second objective is to describe the current publicly-funded Assisted Living resident population in British Columbia, including how long they stay, from what care settings they arrive in Assisted Living, and to what settings they go when they leave Assisted Living. This is not a formal evalua-tion of Assisted Living, but is instead a first descriptive report about how this new care model is working in BC. This work is timely given current policy focus on better integration of care provided in the community.What is Assisted Living? Assisted Living is a relatively new “housing with care” phenomenon in Canada; it first appeared in the Canadian landscape in the 1990s. The terminology that describes the combination of housing, support services and personal assistance available to seniors varies by province as does the purpose and organiza-tion of care. Arrangements in Assisted Living vary, but the standard is private suites, usually including private bathrooms and kitchenettes, within supervised Executive Summarybuildings. Assisted Living provides housing, hospital-ity services and personal assistance. Assisted Living residences also provide common dining rooms and space where residents can socialize. In 2002, the BC Ministry of Health and BC’s Health Authorities announced a three-year plan for Home and Community Care redesign. The objectives of this redesign included increasing the number of clients served at home relative to those in facilities, and reducing the use of acute care beds by seniors who could be served in the community. Access criteria for residential care were revised and characteristics of prototypical clients requiring 24-hour care were clear-ly laid out. The change in criteria for access to long-term residential care 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 residential care eligibility criteria. Assisted Living was conceived as a service option that would fill this gap. British Columbia was the first province in Canada to regulate Assisted Living residences. By law, Assisted Living operators must offer five hospitality services: one to three meals a day plus snacks; light housekeep-ing once a week; laundering of flat linens once a week; social and recreational opportunities; and a 24-hour emergency response system. They must also provide at least one, and not more than two, “prescribed services”, which are: regular assistance with activities of daily living; medication management; personal financial management; monitoring of food intake; structured behaviour management and intervention; and psychosocial rehabilitative therapy or intensive physical rehabilitative therapy. W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?6Data and analysisThe data for this study were provided by Population Data BC. The time period was 2003/04 to 2007/08 and the data included central demographics information, use of home and community are services, physician encounters, admissions to inpatient acute hospital beds, use of publicly funded prescription pharmaceu-ticals and deaths. This study included all British Columbians aged 65 and older who spent at least one night in a publicly-funded Assisted Living unit between 2004/05 and 2007/08. We ended analyses in 2007/08 both because these were the most recent data available when we started, but also because there are data quality issues after that as more health authorities were moving to the new reporting system. We produced descrip-tive analyses of the users of Assisted Living, where they were prior to admission to Assisted Living, what health care services they used before and after they moved to Assisted Living, how long they stayed, and for those who left, where they went after their stay in Assisted Living. Findings and conclusionsHalf of residents of Assisted Living are over age 85 and three-quarters are women. More than half of these individuals have two or more chronic conditions that are considered major. About half of people who move to Assisted Living subsequently move on to residential care—half directly, while the other half arrive in resi-dential care following an acute inpatient hospital stay. Typically, very few people move from Assisted Living back to the community. The functional impairment implied by assessment and eligibility for Assisted Liv-ing tends to be part of a natural decline, rather than something from which one might recover. Assisted Living length of stay is relatively long on average, as expected. There are differences in length of stay by sex, with females on average staying longer. The likelihood of a visit with a general practitioner remains stable (and nearly universal) after admission to Assisted Living but otherwise, use of physician and hospital services generally declines. There is, for example, a lower likelihood of admission to acute care and a smaller number of days of care for those admit-ted. There is also some indication that the extent of poly-pharmacy decreases somewhat after admission to Assisted Living, suggesting some rationalization of medication use. There are, at the same time, several areas that deserve further discussion and attention. One of the most important of these relates to our findings concern-ing people with dementia. Dementia is a relatively uncommon diagnosis when people move to Assisted Living, but almost one quarter (24%) of individuals have a diagnosis of dementia within the first year of their move to Assisted Living. Dementia is associated with much shorter lengths of stay and with exit from Assisted Living within the first year. In general, more than a quarter of people leave Assisted Living after less than one year. Almost 30% of Assisted Living resi-dents use benzodiazepines, with most individuals be-ing daily or nearly daily users. Similarly, use of atypical antipsychotics is also high, and increases in the year prior to admission to Assisted Living. UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH7Limitations and possible directions for future researchThe data used for these analyses have some important limitations. We do not have any information on ser-vices used that are paid for privately. We were missing data after 2004/05 for the Interior Health Authority. We had data only through 2007/08 for the rest of the population mostly because of concerns about data quality beyond March 2008. We do not have informa-tion on physician services paid for outside the fee-for-service system. We only have information on publicly-paid pharmaceutical use. Our measure of health status is one based on need for services and not functional ability. We also did not have access to assessment data, which might have provided additional contextual and functional information. Nevertheless, the analyses here are the first to look at Assisted Living in BC as a whole, and provide a broad picture of this important segment of the seniors’ population. There are many different directions future research might take. We have provided very limited analysis of differences in use of Assisted Living by sex. These could be expanded, for example to investigate whether diagnoses, reasons for leaving and destination after Assisted Living are the same for males and females. If InterRAI data are available for individuals prior to entry to Assisted Living, it may be of some use to investigate whether they alone, or in combination with administrative data, might predict length of stay in Assisted Living. Thus far, our work has focused on distinct users (e.g. home health services, Assisted Living), but of course, these are pieces of a broader continuum of care. Investigation of pathways through this continuum, and perhaps specifically at end of life, may add insights. There is clearly much more that could be done to understand care for people with dementia, and how those people move through the system now. Similarly, these analyses only scratch the surface of understand-ing the use of pharmaceuticals in this population. Future analyses would also benefit from using Phar-maNet instead of PharmaCare data. We understand the Ministry often uses ACG Resource Utilization Bands or RUBs for service analysis. That approach could be adopted for further understanding of service use in this sector as well. Hospital use is frequent among this population. It may be interesting to look at hospitalizations for specific conditions and/or for care-sensitive diagnoses, and compare user groups (e.g. home health, Assisted Living, Residential Care) as well as facility types....the analyses here are the first to look at Assisted Living in BC as a whole, and provide a broad picture of this important segment of the seniors’ population.W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?8The vast majority of older adults in Canada wish to remain independent and living in their own homes for as long as possible. When people become frail and need assistance with activities of daily living or with health conditions, providing this assistance through a visiting nurse or help from a care aide can allow them to remain at home. Eventually, however, some people need more personal assistance than can be provided by home-based health services, and others (or their families/other 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 available in residential care facilities (nursing homes). Congregate housing, supportive housing and Assisted Living can all be con-ceptualized as “middle options” between independent living (with some limited support) in one’s own home, and living in a residential care facility (1). In some cases Assisted Living can be a substitute for long-term care; in other words, Assisted Living can keep some people out of nursing homes (2). In Denmark and in BC, the development of Assisted Living has coincided with a decrease in residential care beds and a decrease in home support services for community dwell-ing seniors (3-5), suggesting that Assisted Living is conceived by policy-makers as an appropriate piece of a seniors’ care option menu, providing more support than home care, and less than residential care, and making possible the avoidance of or delay in a move to residential care for some individuals. The Canada Mortgage and Housing Corporation describes supportive housing as “the type of housing that helps people in their daily living through the pro-vision of a physical environment that is safe, secure, enabling and home-like and through the provision of support services such as meals, housekeeping, and social and recreational activities. It is also the type of housing that allows people to maximize their inde-pendence, privacy, decision-making, and involvement, dignity and choices and preferences.” The same report describes Assisted Living as one of the most service-enriched forms of supportive housing (6). The BC Office of the Assisted Living Registrar states that  “[t]he philosophy of assisted living is to provide hous-ing with supports that enable residents to maintain an optimal level of independence. Services are responsive to residents’ preferences, needs and values, and pro-mote maximum dignity, independence and individu-ality”(7). While definitions of Assisted Living vary greatly, there appears to be general agreement on four key elements:a. Meeting residents’ scheduled and unscheduled needs, having staff on site to provide services, and providing 24-hour access to emergency services; b. Facilitating (some degree of) aging in place by minimizing residents’ need to move as their needs for services increase and; c. Maximizing residents’ independence, autono-my, privacy, choice and dignity; d. Providing a home-like environment (8;9).The objectives for this report are as follows:a. Briefly define and describe the context for Assisted Living in BC and how it compares to other jurisdictions, both in Canada and inter-nationally; b. Describe the current publicly-funded Assisted Living resident population in British Columbia, including how long they stay, from what care settings they arrive, and to what settings they go when they leave Assisted Living. IntroductionUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH9Assisted Living is a relatively new form of care in British Columbia. This province has created a formal sector with clear regulatory and public funding struc-tures, without the benefit of a successful precedent model from elsewhere in Canada. Evaluation of the impact of that decision is now timely, especially given current policy interest in better integration of services provided in the community. This report is not a for-mal evaluation, but is instead a descriptive report in-tended to provide some of the critical data that would need to be taken into account in any such evaluation. It begins by defining Assisted Living in Canada, and BC more specifically. It proceeds to an empirical anal-ysis of residents in publicly-funded Assisted Living in BC, including where those residents come from, how long they stay in Assisted Living, what other health care services they use prior to and after moving to Assisted Living, and where they go upon leaving. The report concludes with a few preliminary observations about the experience of Assisted Living in BC thus far, and suggestions for future research. Evaluation of the impact of that decision is now timely, especially given current policy interest in better integration of services provided in the community. W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?1 0their home until well after they need the services. This model focuses on ensuring that individuals receive the care they need, rather than focusing on the particular style or provider of care. Supporters of this model would generally favour more regulations and inspec-tions and increased services for people with dementia, whose other care needs do not require residential care (Ibid., p. 88).Arrangements in Assisted Living vary, but the stan-dard is private suites, usually including private bath-rooms and kitchenettes, within supervised buildings. Sometimes, these independent apartments are part of multi-level facilities that are designed for aging in place (11). Assisted Living provides housing, hospi-tality services and personal assistance. The housing, support and personal assistance services may all be provided by the same organization (linked model), or one organization may provide housing, while others provide programs and support services (un-linked model). Assisted Living residences also provide com-mon dining rooms and space where residents can so-cialize. More details on Assisted Living legal and other structures across Canada can be found in Appendix 1 and Appendix 2.Assisted Living in CanadaAssisted Living is a relatively new “housing with care” phenomenon in Canada; it first appeared in the Canadian landscape in the 1990s. The terminology that describes the combination of housing, support services and personal assistance available to seniors varies by province, and includes supportive hous-ing (BC), Assisted Living (Nova Scotia, BC), Seniors’ Lodges (Alberta), Retirement Homes (various prov-inces), Retirement villages (Ontario), portions of a “campus of care” (various provinces), community care, or enriched community care facilities (PEI), enhanced independent living (Nova Scotia) and personal care homes (Newfoundland) (1;10). Moreover, these are not simply different terms used to reflect the same (or a similar) set of services, but “…mean utterly differ-ent things in different parts of Canada. […] They are funded differently. They are governed differently. They are regulated differently. They have different philo-sophical underpinnings”(1, p. 86).The Canadian Centre for Elder Law recently published a discussion paper entitled Assisted Living: Past, Pres-ent and Future Legal Trends in Canada (1). This report distinguishes three models of Assisted Living across Canada: the “autonomous” model, the “hospitality” model and the “pragmatist” model. The “autono-mous” model evolved from the disabilities movement of community living and promotes a private, non-governmental way of integrating supports into seniors’ lives. It favours independence and personal choice and is generally regulation- and inspection-averse. The “hospitality” model is more philosophically aligned with hotels, restaurants, cruise lines and valet services; it is a higher-end concept with more of a “private-pay” client base. The “pragmatist” model recognizes that many people in Assisted Living need a higher level of care than most home care programs provide and that the majority of seniors do not choose to move from UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH1 1Assisted Living in BCContext: Defining the need In 2002, the BC Ministry of Health and BC’s Health Authorities announced a three-year plan for Home and Community Care redesign. The redesign was intended to respond to views expressed by seniors in BC. The stated objectives included increasing the number of clients served at home relative to those in facilities, and reducing the use of acute care beds by seniors who could be served in the community. Access criteria for residential care were revised and char-acteristics of prototypical clients requiring 24-hour care were clearly laid out. Criteria defining “complex care” were set out in April 2002, and only those who met these criteria were eligible for publicly-funded residential care (12).The change in criteria for access to long-term residen-tial care 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 residential care eligibility criteria. Assisted Living was conceived as a service option that would fill this gap. Regulatory structure: Defining Assisted Living British Columbia was the first province in Canada to regulate Assisted Living residences. Assisted Living residences have to be registered (but not licensed) under the Community Care and Assisted Living Act. The Community Care and Assisted Living Act was proclaimed in 2002 and came fully into effect in 2004. Prior to proclaiming the Act, the government had committed to providing 5,000 new intermediate and long-term care beds by 2008, through partnership with the federal government, regional health authori-ties and the non-profit and private sectors (13). As part of this commitment, Independent Living BC (formerly Supportive Living BC) promised to create 3,500 new independent housing units with support-ive services and Assisted Living units throughout the province. Independent Living BC is the province-wide program for the development of publicly-subsidized Assisted Living units. BC Housing delivers the program in partnership with the federal government through the Canada Mortgage and Housing Corpora-tion, regional health authorities, and non-profit and private housing providers. Under Independent Living BC, each health authority receives funding for hous-ing units and in some cases, health authorities also directly subsidize units with additional funds. People who qualify receive housing subsidies through Inde-pendent Living BC, while the health authorities fund personal care services (14). In BC, Assisted Living is a service delivery model that combines housing, hospitality services, emergency response and personal assistance for frail seniors and people with disabilities who can no longer remain at home, yet do not require the 24-hour seven day per week nursing care provided in residential care facili-ties. The specific definition of Assisted Living is set out in the Community Care and Assisted Living Act as: “a premises or part of a premises in which hous-ing, hospitality, and at least one but not more than two prescribed services [see below for definition] are provided by or through the operator to three or more adults who are not related by blood or marriage to the operator”(15;16). The Office of the Assisted Liv-ing Registrar has jurisdiction over all Assisted Living residences in BC, regardless of the source of payment (public or private) for those facilities (16). By law, Assisted Living operators must offer five hos-pitality services: one to three meals a day plus snacks; light housekeeping once a week; laundering of flat linens once a week; social and recreational opportuni-W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?1 2ties (leisure pursuits, social interaction and commu-nity involvement); and a 24-hour emergency response system (15). These services can be and are offered by other types of housing operators as well, for example seniors’ retirement villages may offer such hospitality services as a way of attracting seniors to their locations being a good example. The distinction with Assisted Living is that all five services are a legal requirement.The other major aspect of Assisted Living that dif-ferentiates it from other senior housing options is the provision of at least one, and not more than two, “prescribed services” as defined in section two of the Community Care and Assisted Living Regulation (17-20). These prescribed services are: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 moni-toring 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 inter-vention;f. Psychosocial rehabilitative therapy or intensive physical rehabilitative therapy. (20)Assisted Living operators may offer all six of these service areas as “support”, but each facility may offer a maximum of two of these services to its residents at the “prescribed” level. The difference between the two is in degree; for example, operators may offer inter-mittent 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 implication is that if one individual requires assistance with activities of daily living and central storage of medication, and another individual requires monitoring of food intake and central storage of medications, these individuals will not live in the same Assisted Living facility. The vast majority of Assisted Living facilities have chosen to of-fer assistance with activities of daily living and central storage of medication ([a] and [b] above) as their two prescribed services (16;21). The cut-off of two prescribed services is set because offering three or more would designate a residence as a community care facility, and so it would be named and licensed under a different part of the Community Care and Assisted Living Act and would fall under the Residential Care Regulation (15;22). In theory, there should be no individuals who are too frail or other-wise impaired to qualify for Assisted Living while simultaneously not being frail or impaired enough to qualify for residential care. Residents of Assisted Living are expected to receive professional care in the same way they would if they were living independently in the community. Professional services can be obtained by accessing publicly-funded health authority programs (home care nursing, physiotherapy, dietitian) or purchasing these services from a private agency. Assisted Living residents may also supplement personal care/hospi-tality services provided by their facility with private payment for home support. UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH1 3Eligibility, entry criteria and  public subsidies Publicly-funded (and publicly-subsidized) Assisted Living is available to people who meet entry criteria as specified by the Ministry of Health. To be considered for public funding in Assisted Living, candidates must first be assessed by a Home and Community Care case manager; if eligible, the case manager refers people to residences that may be of interest. In order to qualify for Assisted Living, prospective residents must dem-onstrate need for support and personal assistance but must at the same time be able to make decisions on their own behalf. Persons may qualify if they are eli-gible to receive Home and Community Care services; require hospitality services and personal assistance (e.g., help with bathing or medications); are able to make decisions that allow them to function safely in an Assisted Living environment, or will live with a spouse who is willing and able to make decisions on their behalf; and are at significant risk in their current living environment (e.g. falls, isolation, poor nutri-tion) (23). One implication is that people with moder-ate to advanced dementia or other forms of cognitive impairment, who are unable to make decisions to function safely, are not considered suitable candidates for Assisted Living. We return to this issue. Residents pay 70 percent of their after-tax income for publicly-funded Assisted Living services up to a maximum amount. The maximum amount is based on the cost of comparable private rental and hospi-tality services and the real cost of personal support services in the geographic area of the facility (16). The fees are paid monthly to the Assisted Living operator, along with a monthly BC Hydro surcharge. Additional optional charges accrue for items such as television, telephone, extra meals, meal delivery, medication dispensing, and so on (16). Individuals who do not qualify for, or request assess-ment for, publicly subsidized units may live in private-pay Assisted Living units, where residents are respon-sible for all costs. While the Office of the Assisted Living Registrar has jurisdiction over both publicly- and privately-owned/funded residences, a case man-ager’s assessment is not needed to enter private-pay Assisted Living. In private-pay Assisted Living, the op-erator determines eligibility. The operator must ensure that residents are able to make decisions that allow them to function safely in Assisted Living, or live with a spouse who can make the decisions on their behalf (16;21;23). Operators may seek clinical input (e.g., from a prospective resident’s physician) about whether a person is able to live safely in an Assisted Living resi-dence. Private-pay residences may charge a fixed rate for a package of services, or on a fee-for-service basis, or a combination of the two. Eligibility: Exit criteriaWhen a resident requires 24-hour supervision and continuous professional care, the person must leave Assisted Living. Most often in this case, the person would move to a licensed long-term care facility. Exceptions are made for residents living with a spouse or who are involuntary patients on leave under section 37 of the Mental Health Act. However, some residents who are palliative, convalescent or transitional (await-ing placement in a licensed long-term care facility) may also be unable to make decisions on their own behalf. The Registrar’s policy enables registered As-sisted Living operators to provide professional care to such residents on a short-term basis. For all such residents, the operator must develop an exit plan that sets out the resident’s relocation plans, who is responsible for those arrangements and what additional services will be put in place in the interven-W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?1 4ing period to ensure the resident’s health and safety are not in jeopardy while awaiting transfer. Assisted Living operators are expected to assist residents to relocate as quickly as possible, subject to availability of alternate resources in the community (23).Current size and growth  of Assisted Living As of March 31, 2009, there were 6,436 Assisted Liv-ing units in 185 separate physical residences in BC. Of these, 4,351 units (69%) were publicly-subsidized, the rest were fully private pay (see Appendix 3 for a breakdown by health authority). These units are lo-cated in a mix of fully-private, fully-public and mixed buildings.* As Figure 1 shows, the number of Assisted Living units in BC doubled in just four years. Figure 1: Number of public-pay and private-pay  Assisted Living units in BC, 2005/06–2008/09Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest Oldest* http://www.health.gov.bc.ca/assisted/index.htmlSource: Assisted Living RegistrarUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH1 5MethodsSource of the dataThe data for this study were provided by Popula-tion Data BC (www.popdata.bc.ca). Data from this resource are available to researchers who meet access criteria set out in a Research Data Access Framework that complies with BC’s Freedom of Information and Protection of Privacy Act (24).* 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 indi-vidual across data files and over time without reveal-ing any identifying information. Ethics approval 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 2007/08: 1) Registry file, 2) Continuing Care (LTC Care Advice, Direct Care and Home Support Claims files), 3) Hospital Separations, 4) Medical Services Plan (MSP) and 5) Vital Statistics deaths information. The registry file is the central de-mographics file for Population Data BC and is a regis-try of all residents who meet eligibility criteria for BC health care insurance. This file provided information on year and month of birth, sex, region of residence and socioeconomic quintile of residence. The latter is derived using software and methods available from Statistics Canada. The Continuing Care files provide data on the use of publicly-funded home health services, residential care and Assisted Living throughout the province. Individ-uals who had some contact with Assisted Living were identified by the facility provider number and name in these files (this identification was done by staff of Population Data BC. The research team received only a coded number that indicated a facility was an Assisted Living provider.) Because the Interior Health Authority switched to a new reporting system in 2005/06, we lack complete data from Interior Health for the Continuing Care files which the remaining authorities continued to use and which were analyzed for this report. Thus, we captured Assisted Living data from Interior Health only for 2004/05.The Hospital Separations file contains data on all acute care admissions and day surgeries at hospitals in BC. Data contained in the file include dates of hospital ad-mission and discharge, the principal (ICD10) diagno-sis most responsible for admission, and other primary and secondary diagnoses identified as contributing to the length of hospital stay. The Hospital Separations file also includes information on deaths occurring in-hospital. The MSP file includes payment information for all fee-for-service care provided by physicians to BC resi-dents. This file includes the date of each visit, the phy-sician specialty code, and the diagnostic (ICD9) code most responsible for the visit. For purposes of analy-sis, we created four broad groupings of physicians: general practitioners, medical specialists (dermatolo-gists, neurologists, psychiatrists, neuro-psychiatrists, pediatricians, pediatric cardiologists, and specialists in internal medicine, physical medicine or emergency medicine), surgical specialists (obstetrician/gynecolo-gists, ophthalmologists, otolaryngologists, general surgeons, neurosurgeons, orthopedic surgeons, plastic surgeons, thoracic and cardiovascular surgeons, urolo-gists and anesthesiologists), and diagnostic specialists (radiologists, pathologists, medical microbiologists and nuclear medicine specialists). This categorization is consistent with previous analyses using these data (see, for example (25)). * http://www.popdata.bc.ca/dataaccess/rdafW H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?1 6It is worth noting that the MSP data do not include information on services for which physicians were paid by non-fee-for-service methods. Therefore, the MSP data analyzed here exclude services reimbursed through alternative payment arrangements (e.g., paid by salary).* These payments have traditionally repre-sented less than 10 percent of total payments to physi-cians, but their proportion has been rising in recent years (26). Furthermore, the relative importance of alternative payments varies by region (alternative pay-ments represent a greater proportion of all payments to physicians for clinical service provision in rural and remote areas of the province, which also tend to be poorer) and specialty of physician. This information gap means our analyses will under-represent use of services by (some) lower income individuals, as well some tertiary care services (such as cancer care) that cut across all income strata. Pharmaceutical use was assessed using PharmaCare data, which includes information for publicly-funded prescription drugs. These data are not complete (as PharmaNet would be) to the extent that individuals in this population pay privately for drugs. Study population and variablesThis study included all British Columbians aged 65 and older who spent at least one night in a publicly-funded Assisted Living unit between 2004/05 and 2007/08. We ended analyses in 2007/08 both because these were the most recent data available when we started, but also because there are data quality issues after that as more health authorities were moving to the new reporting system. As previously mentioned, our study population excludes individuals residing in Interior Health, except for 2004/05. The variables used for this study can be divided roughly into demographics and health care services use. All variables used in analyses are described in Table 1. The health status variables were derived using diagnostic coding in the hospital and physician pay-ment files as described below.Health status: The Adjusted Clinical  Groups case-mix systemThe Adjusted Clinical Groups (ACG) case-mix system is an individual-level measure of morbidity developed at Johns Hopkins University. This system accumulates the diagnoses associated with care received during en-counters with physicians and hospitals over a defined time period. In this case, and in most others, the time period is a year. Each diagnosis is assigned to one of 238 Expanded Diagnosis Clusters (EDCs), which are aggregations of diagnoses based on sections within the International Classification of Diseases. 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 need for health care services (28). The eight major ADGs on which we focus for our analyses are: 1. Time Limited – Major; 2. Time Limited – Major, Primary Infections; 3. Likely to Recur – Progressive; 4. Chronic Medical – Unstable; 5. Chronic Specialty – Unstable, Orthopedic; 6. Injuries/Adverse Effects – Major; 7. Psychosocial - Recurrent or Persistent, Unstable;8. Malignancy. * For a detailed description of non-fee-for-service reimbursement for physicians’ services in British Columbia, see     Appendix II of Developing	an	information	system	to	identify	and	describe	physicians	in	clinical	practice	in	British					Columbia	(1996/97–2004/05) by Watson DE, Peterson S, Young E, Bogdanovic B., 2006.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH1 7Table 1: Definitions of the variables used in this reportName DefinitionDemographic	variablesAge Six age groups, with age calculated at the start of the Assisted Living episode: 65-69, 70-74, 75-79, 80-84, 85-89 and 90+SexRegion of residence Each individual assigned to one of five geography-based health authoritiesSocioeconomic  quintile of residenceAssigned by Population Data BC prior to release of data to researchers. This variable uses postal code of residence to identify location in one of 7,000+ dissemination areas used by Statistics Canada. Each dis-semination area is assigned an average household income (adjusted for household size), areas are ranked by income within groups of similar population size, and quintiles are assigned so that they each represent approximately 20% of the total population. (27)Use	of	health	care	servicesPhysicians Analyzed in four physician groups as described above (general practitioners, medical specialists, surgical specialists and laboratory/diagnostic specialists). 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 combi-nation of individual, provider and date. Acute care  hospitalizationsIncluded separations from acute inpatient care. Measures of use included both likelihood and intensity, where intensity is the total number of days in hospital. Surgical day care  admissionsSame-day surgeries and other procedures that require specialized facilities such as an operating room but not an overnight stay. Measures of use included both likelihood and intensity, where intensity is the total number of surgical day care separations. Home health services This includes use of publicly-funded home support services (e.g. assistance with ADLs) and home health care services (e.g. home nursing care)Residential care Overnight stays, not including those for respite, in a publicly-funded residential care bed.Pharmaceuticals Based on PharmaCare data, so the data are not complete to the extent that some pharmaceuticals for this cohort are paid for privately. Prescriptions counted at the level of therapeutic code rather than at the indi-vidual drug identity number. In addition, two specific therapeutic classes were analyzed, benzodiazepines and atypical antipsychotics, as these drugs are often indicators of quality of care in frail senior populations. Health status Measured on a fiscal-year basis for all individuals in the study. Details are provided in the text. This case-mix system has been validated for use in BC using administrative data from Population Data BC (29). Because these case mix variables are based on an accumulation of diagnosis codes found in physi-cian payment and hospital separations data across an entire year, analyses that use these variables were limited to individuals registered for at least 275 days (nine full months) during the year, leaving in people who died during the year. Registration for less than a full year implies less opportunity (time) to use health care services in BC during the course of the year. This means there is less time to accumulate the diagnosis codes that determine classification into the Aggre-gated Diagnosis Groups used here. The restriction to 275 days is consistent with prior analyses of BC data (30;31), and affected fewer than 3% of individuals in the data set. It should be emphasized that this exclu-sion is limited to analyses of health status.W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?1 8ResultsNumber of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestNumber of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestWho resides in publicly-funded Assisted Living in British Columbia?Figure 2: Age at entry and sex of publicly-funded Assisted Living clients, 2004/05–2007/08Fi ure 3: Age at entry to Assist d Living compared to long-term home h alth services, 2004/05–2007/08Source: Long-term home health users data are from Home	Health	Services	in	British	Columbia:	A	portrait	of	users	and	trends	over	time (5), and for 2004/05 onlyUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH1 9Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestNumber of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 s ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestFigure 4: Assisted L ving clients by neighbourhood  income in the year prior to entering, 2004/05–2007/08Figure 5: Long-te m h me health care clients by  neighbourhood income, 2004/05One-half of publicly-subsidized Assisted Living clients are over the age of 85 and three-quarters are women (Figure 2). Assisted Living residents are older, on average, than long-term users of home health services; 75% of Assisted Living residents are 80 or older, com-pared to 58% of long-term home health users (Figure 3). Neighbourhood income quintiles represent the location of residence in the year prior to entering As-sisted Living. Figures 4 and 5 show that over one-third of publicly-subsidized Assisted Living residents are from neighbourhoods in the poorest income quintile, compared to about 30% of long-term home health users in this category.Health status of Assisted Living residentsFigure 6 shows that just over 15% of individuals who entered Assisted Living did not have any diagnoses considered “major” according to the ADG classifica-tion system.* Close to 30% of the population in each year was diagnosed with one major ADG, and more than half of individuals had two or more major condi-tions in the year prior to admission to Assisted Living. These percentages remained quite stable over time. Figure 7 compares Assisted Living clients and long-term home health service users and non-users of home and community care services. People residing in Assisted Living were more likely to have a greater number of major ADGs; 35% of Assisted Living cli-ents had 3 or more major ADGs, compared to 28% of long-term home health users and 5% in the non-user population. Looking in more detail at diagnoses (using the Expanded Diagnosis Clusters (EDCs)) (Table 2), we see that there are similar patterns in the year prior to admission to Assisted Living and the year of entry.    Note: Figures 4 and 5 represent publicy-subsidized clients only* The time period for measurement of ADGs is imperfect. These codes are assigned on a fiscal year basis, and     people enter Assisted Living throughout the year. If, for example, an individual entered Assisted Living in June     2007, we used the ADGs from the fiscal year April 2006 to March 2007 as his/her “year prior.”W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?2 0Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestNumber of AL units,,,,,,2005/062006/072007/082008/09li2005/062006/072007/082008/09i2005/062006/072007/082008/09lll Percent of AL clientsi  i i  li-   l   li Percent of AL or long-term home health services clientsPercent of AL clients, by yearPercent of AL clientsi  i  i il f j  t i t i iPercent of long-term home health services clientsi  i  i ilt i t i iPercent of clients, by service type f j   r ri  i i  li-   l  i  li-  f   i   f li   i  i  i i  i  i   l , Number of AL units,,,2005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09li i l f li   i  i  i i  i  i  i  l , Number of AL units,,,2005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09li i l f li   i  i  i i  i  i  l  l , Number of AL units,,,2005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09li i l f li   i  i  i i  i  i   l , Number of AL units,,,2005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09li i l f li   i  i  i i  i  i  l l , Number of AL units,,,2005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09li i li  i i  li   i  i  i     i   i ,  l  i , I ii ri  i tili ri  i tilMissingMissingMissingMissingMissingl I lPercent of AL clients, by health authorityii i it  s f lt  s r i s it   s f lt  s r i selar facilityFacility t at eca e L s italizatis i  ri r  ays s italizati s i  ri r  ays s .Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL starts .  ayst er s italizatii  ri r  ayst er s . i  ri r  ayst er s . l ili4 i , i   l  i i ,i  l  ixiti  cli ts /  t  /  ( , ) l ili25 i , i l  i i l i1  i ,i   l  iii i tit ; lts r i s  tit ;  lts r i s i( it i   s) tl -t rr  f ilit i     i  i i ,  l  i , I il I l80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityi  i i  li     l  i , Percent of AL clients, by health authorityI il I lllPercent of patients taking atypical antipsychotics, by age ilt l tFigure 6: Assisted Living clients by number of major ADGs in the year of entry, 2004/05–2007/08Figure 7: Assisted Living clients, long-term users of home health services, and non-users (age 65+), by number of major ADGsSource: Home	Health	Services	 in	British	Columbia:	A	portrait	of	users	and	trends	over	time (5) and current analyses. In both cases, the year is 2004/05, showing number of major ADGs for Assisted Living clients in the first year after admission.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH2 1Top 10 EDCs in year prior to Assisted Living entry Top 10 EDCs in year of Assisted Living entry1 CAR14 Hypertension, without major  complications50% 1 GSI01 Nonspecific signs and symptoms 50%2 GSI01 Nonspecific signs and symptoms 45% 2 CAR14 Hypertension, without major  complications49%3 NUR01 Neurologic signs and symptoms 32% 3 NUR01 Neurologic signs and symptoms 36%4 PSY01 Anxiety, neuroses 31% 4 PSY01 Anxiety, neuroses 32%5 CAR01 Cardiovascular signs and symptoms 29% 5 CAR01 Cardiovascular signs and symptoms 32%6 ADM05 Administrative concerns and nonspe-cific laboratory abnormalities22% 6 ADM05 Administrative concerns and  nonspecific laboratory abnormalities26%7 GAS01 Gastrointestinal signs and symptoms 20% 7 CAR05 Congestive heart failure 25%8 RES01 Respiratory signs and symptoms 20% 8 NUR11 Dementia and delirium 24%9 CAR05 Congestive heart failure 19% 9 GUR08 Urinary tract infections 24%10 RES02 Acute lower respiratory tract infection 19% 10 GAS01 Gastrointestinal signs and symptoms 23%14 GUR08 Urinary tract infections 18%17 NUR11 Dementia and delirium 15%Table 2: Common diagnoses in Assisted Living clientsLong-term home health users Non-users of home health care services1 GSI01 Nonspecific signs and symptoms 39% 1 CAR14 Hypertension, without major  complications38%2 AR14 Hypertension, w/o major complications 36% 2 GSI01 Nonspecific signs and symptoms 23%3 NUR01 Neurologic signs and symptoms 31% 3 NUR01 Neurologic signs and symptoms 16%4 CAR01 Cardiovascular signs and symptoms 27% 4 CAR01 Cardiovascular signs and symptoms 16%5 ADM05 Administrative concerns and nonspe-cific laboratory abnormalities24% 5 ADM05 Administrative concerns and nonspe-cific laboratory abnormalities15%6 PSY01 Anxiety, neuroses 23% 6 PSY01 Anxiety, neuroses 13%7 RES01 Respiratory signs and symptoms 21% 7 END06 Type 2 diabetes, w/o complication 11%8 RES02 Acute lower respiratory tract infection 20% 8 EAR11 Acute upper respiratory tract infection 11%9 CAR05 Congestive heart failure 20% 9 GAS01 Gastrointestinal signs and symptoms 11%10 GAS01 Gastrointestinal signs and symptoms 20% 10 MUS03 Degenerative joint disease 10%11 NUR11 Dementia and delirium 20% 11 RES01 Respiratory signs and symptoms 10%12 GUR08 Urinary tract infections 18%Table 3: Common diagnoses in long-term users and non-users of home health services (age 65+), 2004W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?2 2Figure 8: Where do new Assisted Living clients come from? For clients entering 2004/05–2007/08Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestThe one big difference between those two years (prior to, and first year of, Assisted Living) is for “Dementia/Delirium”. As might be expected, this is a lower prevalence diagnosis prior to admission to Assisted Living, but the diagnosis climbs 9% in the following year. Comparison with the long-term home health users and the elderly population not receiving home and community care services shows a similar pattern again (Table 3). The one striking difference is a higher prevalence of hypertension in the Assisted Living population (50% vs. 36% in long-term home health users). As depicted in Figure 8, most Assisted Living clients come from the community (65%) with some publicly-funded home health services in place, and most do not have a hospitalization in the three months prior to admission. Nearly one-third (31%) come from the community with no evidence of publicly-funded home-health services. Again, most of those do not have a hospitalization in the three months prior to admission. Finally, four percent come from residential care. This is mostly in the first year, when some people were transferred from residential care facilities to As-sisted Living when public funding for Assisted Living first started.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH2 3Use of health care services prior to and after admission to Assisted LivingTable 4: Use of health care services prior to and after entry to Assisted Living, for clients entering 2004/05–2006/07Year prior to Assisted Liv-ing entryDuring first year in Assisted LivingLong-term home health usersOverallFor people who stay in AL 1 year or moreFor people who stay in AL less than 1 yearN 2,919 2,919 1,887 1,032  GP% with 1+ physician contact 98.5% 96.6% 98.3% 93.6% 97.60%For	those	with	a	contact:	# of contacts per person 21.5 14.8 16.0 12.4 18.9# of contacts per person-year 21.5 17.9 16.0 24.9  Median # of contacts* 16 12 12 10  Medical	Specialist	% with 1+ physician contact 66.5% 54.0% 58.9% 45.0% 60.90%For	those	with	a	contact:	# of contacts per person 7.5 5.7 5.9 5.3 7.7# of contacts per person-year 7.5 6.7 5.9 10.0  Median # of contacts* 4 3 3 3  Surgical	Specialist	% with 1+ physician contact 64.3% 51.6% 58.8% 38.5% 54.50%For	those	with	a	contact:	# of contacts per person 4.4 3.6 3.9 2.9 4.6# of contacts per person-year 4.4 4.1 3.9 5.1  Median # of contacts* 3 3 3 2  Diagnostic	Specialist% with 1+ physician contact 93.4% 83.8% 88.8% 74.7% 87.40%For	those	with	a	contact: 	 	 	 	 	# of contacts per person 9.3 8.3 9.3 6.1 9.3# of contacts per person-year 9.3 9.7 9.3 11.3  Median # of contacts* 6 5 5 4  Acute	Hospitalizations% with 1+ hospitalization 50.1% 32.0% 31.0% 33.7% 47.20%% with Urgent only 40.6% 27.9% 25.9% 31.5%  % with Elective only 3.2% 1.9% 2.4% 0.9%  % with Both urgent & elective 6.3% 2.2% 2.7% 1.4%  W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?2 4Year prior to Assisted Liv-ing entryDuring first year in Assisted LivingLong-term home health usersOverallFor people who stay in AL 1 year or moreFor people who stay in AL less than 1 yearFor	those	with	1+	hospitalization:# of hospitalizations per person 1.8 1.7 1.7 1.6 1.6# of hospitalizations per person-year 1.8 2.0 1.7 1.6  Median # of hospitalizations* 1 1 1 1  Total days in hospital per person 31.5 17.6 16.6 19.2 28.8Total days in hospital per person-year 31.5 21.0 16.6 19.2  Median total days in hospital* 18 10 10 11  Day	Surgery% with 1+ hospitalization 16.6% 11.4% 13.7% 7.3% 14.10%For	those	with	1+	hospitalization:# of hospitalizations per person 1.3 1.4 1.4 1.2 1.4# of hospitalizations per person-year 1.3 1.5 1.4 2.0  Median # of hospitalizations* 1 1 1 1  Prescription	Dispensings% with 1+ Rx 92.3% 92.5% 93.9% 90.0%  % with 9+ unique drug categories 40.4% 33.0% 37.7% 31.2%  For	those	with	1+	Rx:# of unique drug categories per person 8.3 7.7 8.0 7.3  # of unique drug categories per person-year 8.3 9.4 8.0 15.0  Median # of unique drug categories* 8 8 8 8  Benzodiazepine	Dispensings% with 1+ Rx 33.7% 28.0% 29.0% 26.0%  For	those	with	1+	Rx:# of days dispensed per person 235 240 287 143  # of days dispensed per person-year 235 284 287 271  Median # of days dispensed* 232 287 335 193  Atypical	Antipsychotic	Dispensings	% with 1+ Rx 10.0% 12.3% 11.2% 14.4%  For	those	with	1+	Rx:	# of days dispensed per person 229 246 313 151  # of days dispensed per person-year 229 303 313 277  Median # of days dispensed* 188 276 352 152    * Calculation for median: For year prior and for analysis subset to those who stayed in for 1 full year after Assisted Living entry, calculation is    as per usual. For during first year while in Assisted Living or for analysis subset to those who stayed < 1 year in Assisted Living, median is     a per person year measure (each observation is weighted by the proportion of the year that person was in Assisted Living).    UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH2 5Physician useAs depicted in Table 4 above, virtually all Assisted Liv-ing residents have some contact with a GP both before and after they enter Assisted Living. However, the av-erage and median number of visits with GPs declines after admission to Assisted Living. The proportion of individuals referred to all specialist groups declines as well, and the median number of visits with specialists tends to go down as well. Hospital useUse of inpatient acute care decreases substantially, from about half the population in the year prior to admission to Assisted Living, to about one third in the year of entry to Assisted Living. This decrease is apparent for both urgent and elective admissions. The median number of days of care also declines by nearly one-half. The likelihood of use of surgical day care goes down as well, though more modestly, and there is no impact on median number of visits for users of these services. Among the subgroup that continued to get hospitalized, there was no significant change in frequency of hospital visits but a decrease in hospital length of stay.Pharmaceutical useNearly all Assisted Living residents receive at least one prescription drug both before and after entry to Assisted Living. If anything, this percentage seems to go up slightly after admission, while the proportion of people receiving medications from nine or more therapeutic classes declines somewhat. More than a third (33.7%) of this group use benzodiazepines in the year prior to moving to Assisted Living, and this falls only somewhat to 28.0% in the year after entry. The median days supplied of this drug class suggests that most are long-term (nearly daily) users of these drugs, with median days of use increasing from 232 to 287 after moving to Assisted Living. The use of atypical antipsychotics increases only modestly for people who stay in Assisted Living for at least one year (10.0% in year prior to 11.2% following Assisted Living admis-sion), but median days of use nearly doubles, from 188 to 352. There is a far more substantial increase in the proportion of atypical antipsychotics users (from 10.0% in year prior to 14.4% following Assisted Living admission) among those who do not stay in Assisted Living for a full year.Overall, the long-term home health users have a dif-ferent pattern of use from the other groups, though in all cases their service use is lower than the Assisted Living cohort in the year prior to entry.Monthly trends in useThe significant changes in health care services use after admission to Assisted Living identified above suggested that admission may have some sort of pro-tective effect. Average monthly use charts in Figure 9 show an interesting and consistent pattern for physi-cian and hospital services; use rises (on average) in the months prior to admission to Assisted Living, drops significantly around the time of admission, and then remains lower in the months immediately following admission. This trend suggests that admission may indeed be protective; that is, it helps prevent the use of both primary and acute care services. Another interpretation is the ‘null hypothesis’, that the observed trend is simply the natural health services utilization trend among most individuals when they become ill and then recover, regardless of their living circum-stances. Given that these charts present population averages, we suggest that this latter possibility cannot fully explain the observed trend. To use a practical example, in the twelfth month prior to admission, about 5% of the cohort of people who eventually W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?2 6Figure 9: Monthly patterns of health care services use before and after admission to Assisted Living, 2004/05–2006/07Monthly trends in health care services use before and after admission to Assisted LivingPercent of Assisted Living clients who visit a general practitionerbefore and a	er Assisted Living admission, by month0%30%20%10%40%50%60%70%80%Months prior to AL admission Months after AL admission1 2 3 4 5 7 8 9 10 11 2 3 4 5 7 8 9 10 116 12 1 6 12Percent of AL clientsAverage number of general practitioner visits per month by Assisted Living clients before and a	er Assisted Living admission0.00.51.01.52.02.5Months prior to AL admission Months after AL admission1 2 3 4 5 7 8 9 10 11 2 3 4 5 7 8 9 10 116 12 1 6 12Average number of visitsPercent of Assisted Living clients who were admitted to hospitalbefore and a	er Assisted Living admission, by month0%4%2%6%8%10%Months prior to AL admission Months after AL admission1 2 3 4 5 7 8 9 10 11 2 3 4 5 7 8 9 10 116 12 1 6 12Percent of AL clientsAverage number of hospital days per month by Assisted Living clients before and a	er Assisted Living admission0.00.51.01.52.03.02.5Months prior to AL admission Months after AL admission1 2 3 4 5 7 8 9 10 11 2 3 4 5 7 8 9 10 116 12 1 6 12Average number of daysPercent of Assisted Living clients who were prescribed antipsychotics before and a	er Assisted Living admission, by month0%2%4%6%8%12%10%Months prior to AL admission Months after AL admission1 2 3 4 5 7 8 9 10 11 2 3 4 5 7 8 9 10 116 12 1 6 12Percent of AL clientsPercent of Assisted Living clients who were prescribed benzodiazepinesbefore and a	er Assisted Living admission, by month0%5%10%15%25%20%Months prior to AL admission Months after AL admission1 2 3 4 5 7 8 9 10 11 2 3 4 5 7 8 9 10 116 12 1 6 12Percent of AL clientsUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH2 7enter Assisted Living are first admitted to acute care. This percentage of acute care admissions climbs to over 9% in the second month prior to Assisted Living entry, and then drops back to 5% by the 3rd month after entry into Assisted Living, where utilization then remains relatively consistent for subsequent months. In other words, although individuals may indeed be coursing in and out of illness, these charts indicate a population level drop in acute hospital admission after entry into Assisted Living that is unlikely explained by the null hypothesis interpretation. Pharmaceuticals follow a somewhat different pattern, at least for the two particular classes examined here. The monthly prevalence of benzodiazepines use is relatively constant at about 21%, with a very slight and temporary increase coinciding with the time of entry to Assisted Living. On the other hand, antipsychotic use climbs in the months prior to entry to Assisted Living: it then stabilizes and remains at this new high level for at least one year following entry to Assisted Living. We conclude that the shift in prevalence observable in Table 4 is accounted for by an increase in prescriptions in the year prior to admission to Assisted Living, rather than a change in utilization following admission. How long do residents stay  in Assisted Living?At its basic level Assisted Living is housing, and as such, the expectation is that people will have long “lengths of stay”. Public funding has been available for Assisted Living only since 2004, and people enter and leave throughout our study period. This creates an analytic challenge in trying to estimate how long people stay; many people who have entered have not yet left, creating a significant number of “censored” observations. That is, our time period of follow-up runs out before we know what happened to many residents of Assisted Living (and, indeed, a substantial number of those in our data set may still be in As-sisted Living today). The Kaplan-Meier estimator is a tool created to deal with just this situation. This estimator uses the cen-sored observations as long as they are available, but removes them from calculations of the probability of an event of interest. For example, if an individual is censored after 100 days of observation, that person will be in the population (the denominator) for 100 days, but on the 101st day will be subtracted from the denominator. This method allows us to use all of the information available, without letting censored data falsely inflate the number of people “at risk”, which would then result in an overall underestimation of length of stay. Using Kaplan-Meier estimates to adjust for the fact that we have many observations without full follow-up, Figure 10 shows that length of stay in Assisted Living is variable and can be quite long. The median length of stay is more than two years (Point A). At the same time, a quarter of people are expected (based on experience so far) to stay for less than a year (B), and a quarter are expected to stay four years or more (C).Censored observationCensored observationCensored observationCensored observationCensored observationCensored observationOverallResidential careDiedHospitalOtherTime (days)001.000.750.50.25250 500 750 1000 1250 1500Propotion aliveABCTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion alive<70 years70-79 years80-89 years90+ yearsFemaleMaleNo dementiaDementiaTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveInteriorFraserVancouver CoastalVancouver IslandNorthernFigure 10: Length of stay in Assisted Living, for clients entering 2004/05–2007/08W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?2 8There is also a significantly shorter length of stay for people who have a diagnosis (EDC) of dementia/delirium (Figure 13). The median length of stay for people with dementia is less than half that of those without that diagnosis, reflecting (we suspect) the fact that Assisted Living is not generally appropriate for individuals with dementia.Censored observationCensored observationCensored observationCensored observationCensored observationCensored observationOverallResidential careDiedHospitalOtherTime (days)001.000.750.50.25250 500 750 1000 1250 1500Propotion aliveABCTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion alive<70 years70-79 years80-89 years90+ yearsFemaleMaleNo dementiaDementiaTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveInteriorFraserVancouver CoastalVancouver IslandNorthernCensored observationCensored observationCensored observationCensored observationCensored observationCensored observationOverallResidential careDiedHospitalOtherTime (days)001.000.750.50.25250 500 750 1000 1250 1500Propotion aliveABCTime (days)01.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)01.000.750.50.25250 500 750 1000 1250 1500Proportion alive<70 years70-79 years80-89 years90+ yearsFemaleMaleNo dementiaDementiaTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveInteriorFraserVancouver CoastalVancouver IslandNorthernCensored observationCensored observationCensored observationCensored observationCensored observationCensored observationOverallResidential careDiedHospitalOtherTime (days)001.000.750.50.25250 500 750 1000 1250 1500Propotion aliveABCTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion alive<70 years70-79 years80-89 years90+ yearsFemaleMaleNo dementiaDementiaTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveInteriorFraserVancouver CoastalVancouver IslandNorthernFigure 11: Length of stay in Assisted Living, by age at entry, for clients entering 2004/05–2007/08Figure 12: Length of stay in Assisted Living, by sex,  for clients entering 2004/05–2007/08Figure 13: Length of stay in Assisted Living, by demen-tia status, for clients entering 2004/05–2007/08Length of stay decreases steadily with increasing with age (Figure 11), as expected. Length of stay is longer for females than for males (Figure 12).Early exiters from Assisted LivingWe defined “early exiters” as people who spent less than a full year in Assisted Living. There are nearly 1,100 early exiters in our cohort of just over 4,000 individuals. These people are more likely to be male, to be older (and particularly in the 90+ age group), to have more chronic conditions, and to have a demen-tia/delirium diagnosis (EDC). There is also some vari-ability by health authority. Early exiters are far more likely to have a hospital admission in the year prior to entry to Assisted Living and they are also more likely to be hospitalized during their first year of residence in Assisted Living. There is no clear pattern of reason for hospital admission (data not shown). Additional a alysis on the settings to which these early exiters are discharged is detailed in the next section.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH2 9Table 5: Demographics, health status and discharge settings of publicly-funded Assisted Living clients by duration in Assisted Living, 2004/05–2007/08Early exiters (exited AL in less than 1 year)Stayed in AL  1 year or moreAge	Group	at	entry	to	Assisted	Living 65 – 69 years 3.8% 4.8% 70 – 79 years 19.0% 21.4% 80 – 89 years 50.7% 52.0% 90+ years 26.5% 21.8%Mean (SD) 84.6 (7.1) 83.6 (7.3)Sex	at	entry	to	Assisted	Living% male 29.6% 22.1%HA* Fraser 44.8% 39.9% Vancouver Coastal 17.0% 25.0% Vancouver Island 29.4% 27.9% Northern 8.8% 7.2%Number	of	major	ADGs	in	start	year 0 7.8% 18.4% 1 19.3% 32.0% 2 25.2% 25.2% 3 22.0% 14.2% 4 16.1% 6.7% 5 7.5% 2.6% 6 1.9% 0.7% 7 0.2% 0.1%Mean (SD) 2.5 (1.5) 1.7 (1.3)Dementia/deliriumDementia/delirium 39.0% 23.1%Early exiters (exited AL in less than 1 year)Stayed in AL  1 year or moreHospitalizations	in	year	prior	to	Assisted	Living	entry** % with 1+ hospitalization 55.6% 47.4% % with Urgent only 46.3% 37.8% % with Elective only 2.2% 3.6% % with Both urgent & elective 7.1% 6.0% For those with 1+ hospitalization: # of hospitalizations per person 2.0 1.8 # of  italizations per person-yr. 2.0 1.8 Median # of hospitalizations* 1 1 Total days in hospital per person 35.2 32.7 Total days in hospital per person-yr. 35.2 32.7 Median total days in hospital* 21 19Hospitalizations	during	first	year	while	in	Assisted	Living** % with 1+ hospitalization 37.3% 31.0% % with Urgent only 34.9% 25.9% % with Elective only 0.8% 2.4% % with Both urgent & elective 1.7% 2.7% For those with 1+ hospitalization: # of hospitalizations per person 1.6 1.7 # of hospitalizations per person-yr. 3.0 1.7 Median # of hospitalizations* 1 1 Total days in hospital per person 19.4 16.6 Total days in hospital per person-yr. 35.7 16.6 Median total days in hospital* 14 10  * Interior Health is excluded because of lack of data due to a move to new reporting system.** Analyses are limited to clients who entered Assisted Living from 2004/05 to 2006/07, because a full       year of hospital data were not available for clients who entered Assisted Living in 2007/08.W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?3 0Figure 14: Where do Assisted Living clients go? 2004/05–2007/08Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestAs depicted in Figure 14, just over one-half (51%) of all Assisted Living residents eventually mo  to resi-dential care faciliti s. One-half of those move directly from Assisted Living to residential care, while the other half seem to be triggered to move to residential care following a hospital stay. Another 34% of Assisted Living clients die: 11% die in Assisted Living, 22% die after being admitted to hospital, and 1% die within 30 days of admission to residential care. A full 15% of Assisted Living residents appear to move back to the community: one-third of those with community-based home health services, and two-thirds without any publicly-funded services. It is important to note that people who move back to community may in fact be moving to private-pay Assisted Living or private-pay residential care, and those who appear not to be receiving any community-based services may actu-ally be purcha ing them privately. It is not possible to quantify these situations given the data available. Censored observationCensored observationCensored observationCensored observationCensored observationCensored observationOverallResidential careDiedHospitalOtherTime (days)001.000.750.50.25250 500 750 1000 1250 1500Propotion aliveABCTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion alive<70 years70-79 years80-89 years90+ yearsFemaleMaleNo dementiaDementiaTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveInteriorFraserVancouver CoastalVancouver IslandNorthernFigure 15: Length of stay in Assisted Living, by reason for leaving, for clients entering 2004/05–2007/08Length of stay in Assisted Living varies according to the reason for leaving (Figure 15). People who move to residential care tend to have longer lengths of stay than those who die or are transferred to hospital. The shortest lengths of stay are for the group who appear to move back to the community, with or without publicly-funded home health services. This includes the early exit group described previously, specifically those with a diagnosis of dementia/delirium.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH3 1DiscussionAssisted Living is a relatively new publicly-funded care model that combines housing and health care. In BC this is a formally structured service mode with regulations that make it distinct from other types of care, such as residential care of home-based services. There is no consistent definition of Assisted Living, or consistent use of terminology, either in Canada or internationally. This makes it difficult if not impossible to make direct comparisons between BC and other jurisdictions, and also demands caution when reading about this sector.There are, however, a few principles that define As-sisted Living (and whatever else it might be called) the most fundamental of which is providing supports for seniors (and in some jurisdictions, disabled adults) in a less formal institutional setting than long-term care.About half of people who move to Assisted Liv-ing subsequently move on to residential care—half directly, while the other half arrive in residential care following an acute inpatient hospital stay. Typically, very few people move from Assisted Living back to the community. The functional impairment implied by assessment and eligibility for Assisted Living tends to be part of a natural decline, rather than something from which one might recover. Suggestions of successAssisted Living length of stay is relatively long on average, as expected. There are differences in length of stay by sex, with females on average staying longer. This may simply reflect that women on average live longer than men, or that they are less likely to have someone at home to provide them with needed as-sistance, or both. The likelihood of a visit with a general practitioner remains stable (and nearly universal) after admission to Assisted Living but otherwise, use of physician and hospital services generally declines. There is, for example, a lower likelihood of admission to acute care and a smaller number of days of care for those admit-ted. The analyses presented here are simply descrip-tive, but they suggest some stabilization in health status upon moving to Assisted Living. This is perhaps anticipated, given that people who qualify for Assisted Living meet criteria indicating they can no longer live safely in their previous homes. The empirical evidence to support this expectation is nonetheless important, and may warrant further investigation. There is also some indication that the extent of poly-pharmacy decreases somewhat after admission to Assisted Living, suggesting some rationalization of medication use. Findings of potential concernThere are, at the same time, several areas that deserve further discussion and attention. People with dementia One of the most important of these relates to our find-ings concerning people with dementia. Dementia is a relatively uncommon diagnosis when people move to Assisted Living, but almost one quarter (24%) of individuals have a diagnosis of dementia within the first year of their move to Assisted Living. Dementia is associated with much shorter lengths of stay and with exit from Assisted Living within the first year. It is well recognized that this sort of move after such a short period is disruptive for many older adults, and particularly individuals with dementia. Such multiple moves may also trigger further declines in health. W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?3 2From the data we have analyzed, it is unclear why dementia clients have short lengths of stay relative to their counterparts without dementia. One possibility may relate to lack of suitability of the Assisted Living environment for such clients; individuals with moder-ate to advanced dementia were never intended to be eligible to reside in Assisted Living, given its require-ments for the ability to make decisions and self-direct care. If the Assisted Living environment is in fact unsuitable for individuals with dementia, it is impor-tant to note that there remain few publicly supported housing options for them, aside from residential care. Should fully one-quarter of residents have dementia within one year of entering Assisted Living, it suggests a need for greater attention to housing options for this population. Other early exiters In general, more than a quarter of people leave As-sisted Living after less than one year. This is of concern if there is a commitment to supporting seniors to age in place. Our results suggest that these early exiters may have arrived in Assisted Living in worse health than those who remained for more than a year. For instance, early exiters were more likely to be older, to have more chronic conditions, to have been hospital-ized in the year prior to entry to Assisted Living, and to have a diagnosis of dementia/delirium. Given this, it may be worthwhile to review the assessment criteria for suitability of entry into Assisted Living, and to consider the potential interplay of these factors on the likelihood of successfully remaining in Assisted Living for a significant period. Particular drugsRates of use of benzodiazepines decrease slightly after admission, but remain high at almost 30% of the population, with most individuals being daily or nearly daily users. This appears to be high use given that these drugs are considered potentially dangerous in an elderly population. Similarly, use of atypical antipsychotics is also high, and increases in the year prior to admission to As-sisted Living. This increase is even more pronounced among people who exit Assisted Living within the first year, going from 10.0% to 14.4% of the popula-tion. While there are certainly some residents for whom ayptical antipsychotic use is indicated, use in this population appears to be much higher than in the general age-matched seniors population.End-of-lifeOnly one third of Assisted Living residents who die do so in the facility—the other two-thirds either die in hospital or move to residential care before death. If an Assisted Living facility is conceived as a person’s home, this seems a low percentage. It suggests that there may be a need to address the availability and use of additional services such as community palliative support services within the Assisted Living environ-ment. It may also be useful to think about policy development surrounding advance directives and advance care planning, and general end of life care for this population. Private payOne final comment is that we still do not know much about private pay clients in Assisted Living facilities. This has an impact on interpretation of some of the findings here, e.g. that some people appear to leave Assisted Living and go back to the community.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH3 3LimitationsThere are several important limitations to our work, extending beyond the lack of data on private-pay services. We were missing data after 2004/05 for the Interior Health Authority. We had data only through 2007/08 for the rest of the population mostly because of concerns about data quality beyond March 2008. We do not have information on physician services paid for outside the fee-for-service system. We only have information on publicly-paid pharmaceutical use. Our measure of health status is one based on need for services and not functional ability. We also did not have access to assessment data, which might have provided additional contextual and functional information. Nevertheless, the analyses here are the first to look at Assisted Living in BC as a whole, and provide a broad picture of this important segment of the seniors’ population.Possibilities for further investigationThere are many different directions future research might take. We offer here a few possible suggestions, all of which would benefit from further discussion. More gender-based analysis of Assisted  Living residentsWe have provided very limited analysis of differ-ences in use of Assisted Living by sex. These could be expanded, for example to investigate whether diagno-ses, reasons for leaving and destination after Assisted Living are the same for males and females. Use of InterRAI dataInterRAI data offer a more comprehensive and con-textualized view of people. If these data are available for individuals prior to entry to Assisted Living, it may be of some use to investigate whether they alone, or in combination with administrative data, might predict length of stay in Assisted Living. The continuum of careThus far, our work has focused on distinct user (e.g. home health services, Assisted Living), but of course, these are pieces of a broader continuum of care. In-vestigation of pathways through this continuum, and perhaps specifically at end of life, may add insights. DementiaThere is clearly much more that could be done to understand care for people with dementia, and how those people move through the system now. PharmaceuticalsSimilarly, these analyses only scratch the surface of understanding the use of pharmaceuticals in this population. Future analyses would also benefit from using PharmaNet instead of PharmaCare data. Resource utilization bandsWe understand the Ministry often uses ACG Resource Utilization Bands or RUBs for service analysis. That approach could be adopted for further understanding of service use in this sector as well. HospitalizationsHospital use is frequent among this population. It may be interesting to look at hospitalizations for specific conditions and/or for care-sensitive diagnoses, and compare user groups (e.g. home health, Assisted Liv-ing, Residential Care) as well as facility types.W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?3 4Appendix 1Provincial legislation on Assisted Living across Canada*British ColumbiaIn BC, Assisted Living is considered as providing “housing, hospitality services and personal assis-tance services for adults who can live independently but need help with day-to-day activities” (http://www.hls.gov.bc.ca/assisted//about/services.html#). In BC Assisted Living is governed by the Community Care and Assisted Living Act (http://www.bclaws.ca/EPLibraries/bclaws_new/content?xsl=/templates/toc.xsl/group=C/lastsearch=/). Supportive Housing and Assisted Living are defined, and there are governance schemes that cover many aspects of the housing/health mix. The registration requirements for Assisted Living are clearly laid out (http://www.healthservices.gov.bc.ca/assisted/pdf/guide.pdf). In terms of resident protection however, the Assisted Living component covers only health and safety issues. The Residential Tenancy Act was amended in 2006 to include Sup-portive Housing and Assisted Living; however, these amendments are not yet in force. There is no registra-tion requirement for supportive housing. In BC, Supportive Housing/Assisted Living is funded primarily through regional health authorities, in a mix of public-private funding. Assisted Living is available through publicly subsidized and private-pay opera-tors. BC Housing oversees and funds low-income Supportive Housing/Assisted Living. In Assisted Living residents pay 70% of their net income (typically between $29.90 and $71.80/day (1)). In BC, typically, private operators build and manage the developments, BC Housing subsidizes the rent and regional health authorities fund personal care services and some of the hospitality costs to help seniors with daily activi-ties (“private sector makes Assisted Living accessible”). When entering Assisted Living, residents are required to sign an occupancy agreement that lays out rights and obligations. In BC, the Assisted Living model is “complaints-based” rather than one of inspection. The Assisted Living Registrar conducts investigations on complaints. The Registrar has the power to fine an operator, or to cancel an operator’s registration, but her powers do not extend to SH. The purpose of the complaints investigation is remedial. The Office of the Assisted Living Registrar has detailed information available on-line, outlining how complaints can be made. The Registrar’s jurisdiction covers health and safety (http://www.healthservices.gov.bc.ca/assisted/pdf/health%20and%20safety.pdf) and registration issues. The Registrar cannot investigate complaints on tenancy issues, on operating issues (staff or services), or case manager’s assessments.The protocols for entering Supportive Housing/Assist-ed Living depend on whether the facility is public-pay or private pay. For a subsidized residence the client must be assessed by a case manager; this is not the case in a private facility. When care needs exceed the capability of an Assisted Living residence, or when a resident loses the ability to make their own decisions, an exit plan must be created.AlbertaIn Alberta the middle option between “home living” and “facility living” is known as “supportive living”. Alberta Seniors and Community Supports (ASCS) has developed a “supportive living framework” and a framework of supportive living “accommodation standards” and Alberta Health and Wellness has *Summarized from Canadian Centre for Elder Law, Discussion Paper on Assisted Living:    Past, Present and Future Legal Trends in Canada (1).UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH3 5authority over publicly funded health care services (42;43). In 2008, Alberta had about 22,000 people living in approximately 600 supportive living spaces in lodges, enhanced lodges, designated assisted living, group homes, adult family living, and family care homes. In Alberta, “supportive living” is licensed under the Social Care Facilities Licensing Act (since 2007), which requires compliance with the Supportive Living Accommodation Standards. Lodges and Nurs-ing homes are not licensed under this act, but are still required to follow the accommodation standards. In Alberta, supportive living is conceptually divided on the basis of resident need and services offered (42). The supportive living framework provides definitions of supportive living, clarifies the roles and respon-sibilities of providers and residents and provides common terminology for supportive living in Alberta. Supported living combines accommodation and hos-pitality services with other supports and care. Opera-tors are responsible for coordinating and arranging hospitality services and may coordinate or provide personal care and other support services. In Alberta health and housing costs are “unbundled” and facili-ties are not necessarily limited to one level of resident need. Typically the resident pays the accommodation cost while the government pays the health costs. The services that fall under each category are determined by the government. Publicly funded personal care and health care services are provided to supportive living residents based on their assessed unmet needs (42). To qualify for Lodge accommodation, a resident must be functionally independent, meaning “physically and mentally self-sufficient” (lodge accommodation refers to level 2 of the 4 levels of supportive housing). Seniors Lodges are allowed to charge extra costs for services or facilities. Buildings are owned/operated by government supported organizations or by private for-profit or non-profit or voluntary housing operators. Supportive Living Standards require the operator to ensure that residents meet eligibility requirements and to have systems and policies for application, move-in and orientation, charge information, a list of optional personal services, notice of price increases, exit crite-ria, and a dispute resolution process. Operators must assess new residents for ability, safety, and suitability. The government has established a website with reports for inspection records (http://asalreporting.gov.ab.ca/astral/search_index.htm). There is no clear resolution for tenancy-type issues in Alberta. In Alberta, staff in supportive living must always have an employee trained in emergency first aid on site and criminal record checks are required.The framework provides four distinct levels of sup-portive living in Alberta and resident needs, building features, hospitality services and health and wellness services that correspond with each of the four levels are detailed. In most supportive living settings, resi-dents apply directly to the housing operator for ten-ancy. The exception is in “designated” spaces, where entry is based on an assessment of resident needs and is a collaborative process between the regional health authority and the housing operator. Desig-nated Assisted living was developed for people who require 24-hour on-site availability of personal care, but not continuous nursing care. Enhanced designated assisted living was introduced in 2004. Target popula-tions include those with cognitive impairments and challenging mental health needs (44).W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?3 6SaskatchewanIn Saskatchewan there are three options: Personal Care Homes (privately owned), Assisted Living (pub-lic, under the Saskatchewan Assisted Living Services Program (SALS), available in selected social housing projects for seniors in 70 communities throughout the province, and “Enriched” Assisted Living (Retirement Living) (45). Saskatchewan does not have specific Assisted Living legislation; only personal care homes are governed by the Personal Care Homes Act and the Personal Care Homes Regulations. SALS is run by local hous-ing authorities. In SALS all services are optional and SALS tenants pay the direct cost of those services. The Residential Tenancy Act applies to SALS and tenants pay rent geared to income. In Saskatchewan, “Assisted Living” means a lesser amount of care. “Personal Care Homes” provide assistance or supervi-sion with personal care (http://www.health.gov.sk.ca/personal-care-homes). PCHs are licensed and privately owned and operated and may be able to accommo-date residents with higher care needs. PCHs are not governed by the Residential Tenancy Act and may be inspected and investigated if there is a complaint. PCHs must provide sufficient care to meet the individ-ual needs of each resident (specified staffing require-ments). Specialized care must be provided by a health care professional or a person trained by a health care professional. In PCHs residents must be reassessed ev-ery 2 years and a care plan must be in place. Residents must be given a detailed admittance agreement. “Enriched” Assisted Living or “retirement living” is relatively recent, offered by private developers, people live in individual suites and tenancy may include three meals, laundry and housekeeping as part of the rent. There are usually also amenities for recreation and scheduled transportation.“Special Care Homes” are residential care facilities for people with high levels of care needs that can-not be met through home care or other community based options. In SCH residents pay an income-tested charge.ManitobaManitoba has a combination of five types of Support-ive Housing/Assisted Living, but little governance. The options are summarized in the Senior Access Resource manual (46) (http://www.gov.mb.ca/shas/publications/accessmanual_housing.pdf):1. Manitoba Housing Authority Senior 55 Plus Apartments (Elderly Persons Housing): support services vary; tenants must qualify based on in-come limit; subsidized, rent geared to income.2. Assisted Living Facilities: Housing with service package; privately owned and operated; not li-censed or regulated. Daily fees are not subsidized, but residents may qualify for Shelter Benefit Pro-gram and may access home care services.3. Supportive Housing (certain locations only): 24-hour personal support and supervision for people who can no longer live independently. Residents must be assessed and admitted through health authority long term care/home care case coordinator. Health authority monitors standards and covers cost of health care staff. Cost varies by facility; residents pay for rent and services, but residents may qualify for Shelter Benefit Program. Health authority monitors standards.4. Companion care (Winnipeg only): in private homes with services similar to supportive housing. Residents must be assessed and admit-ted through long term care/home care; cost is income-based.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH3 75. Personal care homes: professional nursing and personal care for people who can no longer live independently. Cost based on income, subsidized by Manitoba Health; rate depends on income. Private and semi-private rooms cost extra.The Regional Health Authority coordinates appli-cation, assessment and admission. Subsidized by Manitoba Health, the Social Services Administration Act governs “residential care”. The Residential Care Facilities Licensing Regulations provides the specific framework for residential care.The Residential Tenancy Act excludes residential care facilities and personal care homes, however, the RTA may intervene in cases of unlicensed residential care facilities. Ontario In Ontario, the bulk of the housing with care is located in “retirement homes’. These are nearly all for profit; care and support services are largely unregu-lated and based on a private pay system with no gov-ernment subsidies. Retirement homes vary widely in terms of care and services provided, amenities offered, types of accommodations, staffing patterns and physi-cal structures. Prices vary widely in accordance with the type of accommodation and range of services, but accommodation rates are subject to rent control through the Tenant Protection Act (47). (http://www.culture.gov.on.ca/seniors/english/programs/seniors-guide/housing.shtml.)Other aspects of retirement homes are regulated like other facilities that provide accommodation and food (Ontario Building Fire Code and Health Promotion and Protection Act (HPPA)); these standards and guidelines do not apply to care. Many retirement homes are member of a self-regulating association (ORCA) that has accreditation standards (staff train-ing issues, care services, safety control, etc.) (http://www.orca-homes.com). Tenants may also qualify for government-funded home care services (visiting nurses or therapists).ORCA has a government-funded complaints and information hotline that accepts complaints concern-ing all retirement residences in Ontario. ORCA can also inspect and report on conditions in residences. Unresolved complaints can be publicized via the ORCA website. All retirement homes must provide residents with an information package prior to signing the tenancy agreement; the package must outline the procedures for dealing with complaints, or a statement that there is no internal procedure. Residents must be provided with a “Bill of Rights”. ORCA requires a written orientation program for new staff, a staff development program and a continuing education program. Minimum staffing levels and staff qualifications must be included in the Care Home Information Package (CHIP) information package (http://www.orca-homes.com/intranet/orca_informa-tion/documents/AccreditationDocument_Public_March2007.pdf) (ORCA Accreditation Requirements).“Supportive Housing” in Ontario can provide onsite personal support services, essential homemaking ser-vices and staff available 24-hours to handle scheduled services and emergency needs. Supportive housing is available on a fee per use basis or can be provided by not-for-profit agencies, often partially funded by the Ministry of Health and Long Term Care. Supportive housing is primarily funded through the MOHLTC, but residents pay their own rent based on income. There may be no charge for the personal support and essential home making services, but residents W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?3 8are responsible for their own rent, food and clothing (2;11;48).“Assisted Living” exists in a limited way, is unregu-lated, operates pursuant to the Residential Tenancies Act, but is mostly directed at persons with disabilities.Long-term care homes offer 24-hour nursing care and supervision and are government funded and regulat-ed, but residents pay a share of the cost with addition-al fees for a private or semi-private room. If a person is low-income and not able to pay the fees, they pay their total minus $100.00 (1).There is an overlap between long-term care and lesser forms of care (for those who cannot afford lesser private-pay care, or where there is no availability for subsidized supportive housing. Home care approved by Community Care Access Centres is government funded, but seniors often need to pay for additional services privately. Community Care Access Centres conduct needs as-sessments and provide lists and information on home care, homes, services, and long-term care in Ontario. However, most of the “middle option” for health/housing is provided through retirement homes. The homes have their own entry requirements and the level of care that can be provided to residents varies. An operator may transfer a resident from a retirement home if a resident’s care needs are too high or too low.Retirement homes, supportive living and assisted liv-ing are all covered by the RTA and a tenancy agree-ment must be in place and these have several special provisions and requirements. However, the legislation deals with tenancy issues but not standards of care (1). QuebecIn Quebec housing and care for seniors consists of private supportive housing and a combination of private and public long-term care facilities. There are recent licensing requirements for supportive housing and there is a complaint mechanism in place with the ombudsman. The residential tenancy sections of the civil code apply to supportive housing.Residences for the elderly (RPPA) are regulated via a registration system (http://wpp01.msss.gouv.qc.ca/appl/K10/rubriques/K10LiensUtiles.asp); requirements for certification include health, safety and staffing. Services in RPPAs are provided based on needs, so they tend to house people with higher care needs than what they were designed for. RPPAs are privately funded and the operators are free to set their fees. Quebec has a voluntary accreditation program with specific standards for supportive housing. RPPAs must have at least one employee present at all times, and this person must have training in moving patients safely and in emergency first aid.Nova ScotiaThe housing with care system in Nova Scotia is fairly complex.“Community Based Options” are unlicensed, but if they are under the authority of the Ministry of Health they are inspected and approved by the Department of Health.Community based options (CBOs) provide accom-modation, minimal supervision and the development of self-care skills for three or fewer residents. CBOs are privately owned and operated by individuals or organizations.UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH3 9Assisted Living Facilities, sometimes called “Enriched Living” are a for profit option for people who seek housing with minimal supports. In Assisted Living in NS people are able to direct their own care and control access to the unit. The homes are not licensed to provide care. Accommodation and service fees vary. Some or all of the residents’ ADL needs are provided by the operator and are a mandatory part of the monthly accommodation costs. This includes Enriched Housing units under the jurisdiction of the Department of Community Services, Housing Services Branch. “Assisted” or “Enriched Living” is in essence a rental contract but it is not clear whether or not it is covered by the RTA. In Nova Scotia, funding is “unbundled”. The government pays for health care costs (nursing, personal care, social work, recreation therapy, occupational therapy). The resident pays for accommodation and maintenance, meals, housekeep-ing etc. Assisted Living is a private pay enterprise. Funding for Enriched housing is supported by the  Department of Community Services, Housing Ser-vices branch. In Nova Scotia, “residential care facilities” are gener-ally part of the “middle option”. They are subject to the Homes for Special Care Act and the Homes for Special Care Regulations (http://www.gov.ns.ca/legislature/legc/bills/57th_1st/1st_read/b079.htm, http://www.gov.ns.ca/just/regulations/regs/hsc7393.htm). Resi-dential Care Facilities are licensed homes for people who need supervision and limited help with personal care in a safe and supportive environment. RCFs are mostly owned by private individuals or organizations.In Nova Scotia, “Nursing Homes/Homes for the Aged” provide personal and/or skilled nursing care in a residential setting to people who need 24-hour access to nursing care.Complaints about licensed facilities (including abuse and neglect) are referred to the respective depart-ments. The operators of residential care facilities have the duty to permit an inspector to enter and inspect and if required to have any resident examined by a physician. Residential care facilities are to be inspected at least once a year. Residential Care facilities retain the services of a medical doctor. At entry, residents are assessed by a Care Coordinator, who does a functional assessment to determine unmet needs and makes a care recommendation. If a resident turns down a specific placement, due to a First Avail-able Bed policy, and if they are in hospital, they will either be discharged or forced to pay a daily fee for their hospital care. If resident needs change, an assess-ment is done and the resident will have to re-apply for another care facility.New BrunswickNew Brunswick has a single entry system, where all residents go through the same assessment and placement process. NB has a first available bed policy (within 100km).Special Care Homes and Community Residences are regulated. The facilities are also subject to Standards and Procedures for Adult Residential Care Facilities. Special Care Homes and Community Residences pro-vide 24-hour supervision and non-nursing support. Special Care Homes are usually privately owned and are for residents assessed at level 1 or 2: residents who are generally mobile but require the 24-hour avail-ability of supervision related to their personal care, and for residents who may need some assistance or supervision with mobility and require more individu-alized assistance or supervision on a 24-hour basis with personal care and ADLs. Community Residences W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?4 0are generally not-for-profit facilities and offer care at higher levels (3 and 4) similar to nursing home care. When a resident is unable to pay the full cost of any long-term care services, the government offers income-tested assistance. Low-income seniors must pay for supportive housing.Special Care homes are inspected yearly as part of the approval renewal process and in addition a district medical officer, fire marshal and ministry official must confirm compliance with various health and safety regulations. Operators must establish a regular written procedure for hearing concerns of residents; the procedure should be accessible to residents, their relatives and advocates, and all concerns, investiga-tions and outcomes should be recorded in a daybook. Staff at special care homes must have formal training and staffing ratios are prescribed (1:10 at all times in special care homes).Nursing homes in New Brunswick are governed by the Nursing Homes Act. The government of New Brunswick recently released a long-term care strategy (http://www.gnb.ca/0017/LTC/LongTermCareStrategy-e.pdf) that might signal a shift in the system. Prince Edward IslandLower level care is provided in Community Care Fa-cilities (CCF), which are licensed, but privately owned and operated and generally the cost must be borne entirely by the resident (http://www.gov.pe.ca/health/index.php3?number=1020395&lang=E). Seniors with low incomes may be eligible to receive financial assis-tance under the Social Assistance Act. These facilities do not provide 24-hour nursing care; however, some CCFs are located within a larger facility that provides higher-level nursing home care. CCFs are exempt from the residential tenancy legislation. In CCFs admission is determined by the parties, but there is a care needs assessment done to determine if the facility is appropriate to the care needs of the resident. The higher level nursing home care is both private and public. Nursing home care is subsidized, based on income. In Prince Edward Island, Community Care Facilities and nursing homes are regulated by the Community Care Facilities and Nursing Home Act, the Nursing Home Regulations, and the General Regulations.Other than the licensing system, there is no legislated process for complaint/dispute resolution.Newfoundland and LabradorNewfoundland and Labrador has a single entry system for all seniors’ residences and also has a first bed policy. The costs of care and accommodation are un-bundled. Only homes with more than four residences are covered by legislation.Personal care homes, also known as community care residences, are supportive care facilities; these are governed by the Health and Community Services Act (http://www.assembly.nl.ca/Legislation/sr/statutes/p37-1.htm) and the Personal Care Home Regulations (PCHR) (http://assembly.nl.ca/Legislation/sr/regula-tions/rc010015.htm). Personal care homes are for seniors who need minimal assistance with daily living activities and supervised care. Services may include meals and social activities. Personal care homes are privately owned and operated and residents must pay the costs themselves. Subsidies are available to some residents up to a maximum of $1500/month. Inspectors may inspect personal care homes to ensure compliance with the PCHR and its regulations. The complaints system is focused on in-facility resolution UBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH4 1of complaints. All long-term care facilities are re-quired to have a complaints procedure that is simple, clear and accessible to residents. Complainants must receive an initial response to complaints within two business days, followed by a post-investigation reply within one month. Residents are able to stay in a per-sonal care home as long as their needs do not exceed the available care.Higher level care is provided in nursing homes, special care homes and community health centres, which pro-vide accommodation, supervisory care, personal care, and nursing and medical services on a 24-hour basis.Special Care homes are regulated under the Homes for Special Care Act, while detailed standards for all long-term care facilities in Newfoundland are located in the Long Term Care Operational Standards. Resi-dential tenancy legislation does not apply to seniors’ facilities. Nursing home residents must also pay the full cost of their care, up to a maximum of $2800/month. In Prince Edward Island, Community Care Facilities (CCF) and nursing homes are regulated by the Community Care Facilities and Nursing Home Act, the Nursing Home Regulations, and the General Regulations.The TerritoriesAs the number of facilities in the region is much smaller than the provincial jurisdictions, govern-ments are more likely to create individual standards for homes rather than to legislate broadly. There is no specific legislation that regulates seniors’ housing in the Yukon Territory. In both the Northwest Territories and Nunavut, supportive housing is managed by local regional health authorities and there is no specific leg-islation governing these residences (http://www.hlthss.gov.nt.ca/english/our_system/authorities/default.htm). The Northwest Territories’ Department of Health and Social Services has published Service Standards and Guidelines for People in Supported Living Homes that outline how supportive housing should be adminis-tered in the province (http://www.hlthss.gov.nt.ca/pdf/manuals/2005/service_guidlines.pdf). In the Yukon, lower level care is provided in what is called Adult Group Homes and Approved Homes for Persons with Disabilities; these homes are approved by the govern-ment and their standards are set out contractually.In the NWT lower level care is administered in a variety of ways organized through regional health authorities. Arrangements vary from family style accommodations to apartments that support indepen-dent seniors. Fees for supportive housing vary across the territories. Care and accommodation costs are un-bundled and residents of the NWT living in assisted living must generally pay for their accommodations, in combination with a granting agency.W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?4 2Appendix 2This summary is based on presentations delivered by Gord White, CEO of the Ontario Retirement Communities Association and Marlene Williams, executive director of the BC Seniors Living Association at the Expo Aging and Design Conference on Senior Housing across Canada held in 2008 in Montreal.prov. Terms public sector accommodation and accommodation services funding Health/personal Care services fundingComments on  care deliveryRegulatory frameworkprovincial  descriptionsSize of sectorApplicable legislationAdmission  requirementsBC Assisted Living AL: Tenant pays 70% net income to a maximum (approx $3000) & province subsidizes accommodation and ac-commodation services.Supportive Housing: province subsi-dizes up to $630/month per resident.HA authorizes up to 1.5hrs/tenant/day & subsidizes service delivery with per diem approx $65 per day/tenant.Some HAs deliver personal care directly.yes; As-sisted Living Registrarprivate or subsidized homes offering a full range of serviceswith at least 1 but not more than 2 prescribed services4,050 (only AL)Community	Care	and	Assisted	Living	ActCare needs-based determined throughassessments by regional health authoritiesAB Supportive Living levelsApprox. 10,000 units Senior Citizens Lodge program- province pays $8.25/day/eligible low income resident plus $3.50/d for special services grant.- Municipalities pay operational deficits1. funding for health care aide delivering personal care.2. funding for designated AL at daily flat rate ($50 -$70/day/tenant)Some HAs deliver personal care directly. There are many funding arrangements based on health service requirements.yes; Ministry of Seniors and Commu-nity Supportspublic or private homes. full range of services offered within 4 distinct levels of care22,000 Social	Care	Facilities	ActCare needs-based determined throughassessments by regional health authoritiesSK personal Care Homes Approx. 10,200 units: Seniors Assisted Living Services- province pays to coordinate health and community based services.- Eligible residents pay 30% of income for rent and pay separately for additional support services (i.e. meals).- province also has a grant program for tenant associations.- All public sector housing is built, owned and maintained by the province.no – health services are provided through regional HAsIf services are pro-vided by the operator they must be paid for by the resident.yes; Sas-katchewan Healthprivate homes which offer a full range of services3,100 Personal	Care	Homes	ActDetermined by operatorMB Special Care HomesON Residential Assisted CareApprox. 9,100 units: Supportive Housing- province funds a rent supplement program within seniors affordable housing.- Eligibility (rent 30% of income) is income-based – must sell home as well.- Operated by municipalities and/or private not-for profit operations.- As of 2008, infrastructure funding is available for these groups only.No – health services are provided through regional health authorities except in small public sector.If services are pro-vided by the perator they must be paid for by the resident.private homes, mostly for-profit, range of services offered including meals, activities of daily living, nursing care, some dementia care40,202 Residential	Tenan-cies	Act,	Building	Code,	Fire	Code,	some	municipal	by-lawsDetermined by operatorpQ private Residences non-profit and for profityes – $82-$82 per day/client -2 hours/2 – ½ hours $95 per day, does not cover meds or prof. services.funding is blurred between accom-modation and health/personal care services. yes; Ministry of The Elderly and Social Servicesprivate homes which offer a full range of servicesAn	Act	Respect-ing	Health	Services	and	Social	ServicesDetermined by operatorNB Special Care HomesNS Assisted Living /Enriched Hous-ing/ Enhanced Independent Living/ Residential CarepE Community Care facilities/Assisted Living/Enhanced Community CareNL personal Care Homes - province funds $1,600/m/eligible “bed” – targeted to low income seniors – also asset tested. Includes accommodation and health services.- Access based on central health as-sessment, operated by all sectors.- o capital funding available.yes – $1,600 per “bed” includes health and accom-modation services.Access based on central health as-sessmentyes; Depart-ment of Health and Community Services – Re-gional Health Authoritiespublic or private homes with between 5 & 75 residents. No framework for 75+ residents. full range of services.2,676 Health	and	Community	ServicesAct,	Personal	Care	Homes	RegulationsIf subsidized, needs-based determinedthrough assess-ments by regional health authoritiesTerri-toriesSupportive Living/Supportive Living group homes/Elder Homes/ResidentialUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH4 3Appendix 3Registered Assisted Living units by health authority, 2005/06–2008/09Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestNumber of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestSource: Assisted Living RegistrarW H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?4 4Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestNumber of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior H alth, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services347%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestSource: Assisted Living RegistrarUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH4 5Number of public-pay and private-pay Assisted Living units in BC, 2005−2009Number of AL units02,0001,0003,0004,0005,0006,0002005/062006/072007/082008/09Public2005/062006/072007/082008/09Private2005/062006/072007/082008/09Total0 1 2 3 4 5 6 7FemaleMaleAge at entry and sex of publicly-funded Assisted Living clients, 2004/05−2007/080%5%10%15%20%25%Age group<65 65−69 70−74 75−79 80−84 85−89 90−94 95+Percent of AL clientsAssisted Living clientsLong-term home health care clientsAge at entry to Assisted Living compared to long-term home health services, 2004/05−2007/080%10%20%30%Age group65−69 70−74 75−79 80−84 85−89 90+Percent of AL or long-term home health services clientsAssisted Living clients by number of ADGs in the year prior to entry, 2004/05−2006/0710%5%20%25%15%30%Percent of AL clients, by yearAssisted Living clients by neighbourhood income in the year prior to entering, 2004/05−2007/08Percent of AL clients0%10%20%40%30%Neighbourhood income quintileNumber of major ADGsLowest Highest MissingLong-term home health care clients by neighbourhood income, 2004Percent of long-term home health services clients0%10%20%40%30%Neighbourhood income quintileLowest Highest Missing0%2004/05 2005/06 2006/07 2007/08Assisted Living clients, long-term users of home health services, and non-users by number of major ADGs60%Percent of clients, by service type20%0%50%40%10%30%Number of major ADGs0 1 2 3 4 5 or moreAssisted Living clientsLong-term home health services clientsNon-users of home and community careNumber of public-pay and private-pay Assisted Living units in Fraser Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Interior Health, 2005/06−2008/09Number of public-pay and private-pay Assisted Living units in Interior Health, 2004−2009Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Island Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Northern Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalNumber of public-pay and private-pay Assisted Living units in Coastal Health, 2005/06−2008/09Number of AL units05001,0001,5002,0002005/062006/072007/082008/092005/062006/072007/082008/092005/062006/072007/082008/09Public Private TotalAssisted Living clients by neighbourhood income in the year  prior to entering, by health authority, 2004/05−2007/080%10%20%30%40%InteriorNeighbourhoodincome quintileNeighbourhoodincome quintile1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5Missing 1 2 3 4 5MissingFraser VancouverCoastalVancouverIslandNorthernPercent of AL clients, by health authorityAssistedLiving61% with ≥30days of homehealth services4% with <30 days ofhome health services3%47%12%4%3%2%2%23%1%1%1%Regular facilityFacility that became ALNo hospitalizations in prior 90 daysNo hospitalizations in prior 90 daysNo hosp.Hospitalization≥10 days justprior to AL startHospitalization≥10 days justprior to AL startHosp. ≥10 daysOther hospitalizationin prior 90 daysOther hosp. in prior 90 daysOther hosp.4% fromlong-termcare facility25% fromcommunity, with nohome health services3171% fromcommunity,with homehealth services65Where Do Assisted Living Clients Go?Exiting clients 2004/05 to 2007/08 (N=1,775)25% tolong-termcare facility25% tocommunity, withhome health services5%25% tohospital5171% die14% to community,with no homehealth services8AssistedLiving1% tocommunity;home healthservices 1% tocommunity;no home healthservices1% die(within 30 days)28% tolong-termcare facility22% die Age at entry to Assisted Living, by health authority, 2004/05−2007/080%10%20%30%Interior Fraser VancouverCoastalVancouverIslandNorthern80−84<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+<6565−6970−7475−7985−8990−9495+Percent of AL clients, by health authorityAssisted Living clients by sex and health authority, 2004/05−2007/08Percent of AL clients, by health authority0%20%40%60%100%80%Interior Fraser VancouverCoastalVancouverIslandNorthernFemaleMalePercent of patients who receive atypical antipsychotics who also receive 1 or more paid fee-for-service claim for any mental disorder (ICD-9), by age and year100%Percent of patients taking atypical antipsychotics, by age0%75%50%25%Age decile1998/99 2003/04 2008/09Youngest OldestCensored observationCensored observationCensored observationCensored observationCensored observationCensored observationOverallResidential careDiedHospitalOtherTime (days)001.000.750.50.25250 500 750 1000 1250 1500Propotion aliveABCTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion alive<70 years70-79 years80-89 years90+ yearsFemaleMaleNo dementiaDementiaTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001. 00.750.50.25250 500 750 1000 1250 1500Proportion aliveTime (days)001.000.750.50.25250 500 750 1000 1250 1500Proportion aliveInteriorFraserVancouver CoastalVancouver IslandNorthernLength of stay in Assisted Living, by health authority,* for clients entering 2004/05–2007/08  * Only partial data is reported for Interior Health due to a move to new reporting system.W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?4 6References(1)  Canadian Centre for Elder Law. Discussion Paper on Assisted Living: Past, Present and Future Le-gal Trends in Canada; 2008. Available from: http://www.bcli.org/sites/default/files/2008-10-31_As-sisted_Living.pdf(2)  Kucharska D. Seniors’ Health and Housing Crossroads - Exploring Alternatives to Long-Term Care Facilities. Toronto: Ontario Coalition of Senior Citizens Organizations (OCSCO); 2004. (3)  Lewinter M. Developments in home help for elderly people in Denmark: the changing concept of home and institution. International Journal of Social Welfare 2004;13:89-96.(4)  Cohen M, Murphy J, Nutland K, Ostry A. Continuing Care Renewal or Retreat? BC Residential and Home Care Restructuring 2001-2004. Vancouver, BC: Canadian Centre for Policy Alterna-tives; 2005. (5)  McGrail KM, Broemeling AM, McGregor MJ, Salomons K, Ronald LA, McKendry R. Home health services in British Columbia: a portrait of users and trends over time. UBC Centre for Health Services and Policy Research; 2008. (6)  Canada Mortgage and Housing Corporation. Supportive Housing for Seniors. Ottawa; 2005. (7)  Ministry of Health Services BC. About Assisted Living in B.C. Province of British Columbia - Of-fice of the Assisted Living Registrar; 2009 [cited 2009 Dec 20]. Available from: http://www.hls.gov.bc.ca/assiste d//about/#(8)  Phillips CD, Munoz Y, Sherman M, Rose M, Spector W, Hawes C. Effects of Facility Characteris-tics on Departures From Assisted Living: Results From a National Study. Gerontologist 2003 Oct 1;43(5):690-6.(9)  Wright B. An overview of assisted living; 2004. [cited 2009 May 6]. Available from: http://assets.aarp.org/rgcenter/il/ib72_al.pdf(10)  McNiven J. More than Shelter: Housing Policy Kit for Seniors in Atlantic Canada. The Atlantic Seniors Health Promotion Network; 2004. (11)  Lum J, Ruff S, Williams P. When Home is Community - Community Support Services and the Well-Being of Seniors in Supportive and Social Housing. Toronto: Ryerson University, Neighbour-hood Link / Senior Link and the University of Toronto; 2005. (12)  Government of British Columbia, Ministry of Health Services. Home and Community Care Policy Manual; 2007. (13)  Ministry of Health Services. Government of British Columbia. Annual Service Plan Report 2002/03. Government of British Columbia; 2009 [cited 2009 Nov 20]. Available from: http://www.bcbudget.gov.bc.ca/Annual_Reports/2002_2003/hs/default.htmUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH4 7(14)  BC Housing. Independent Living BC; A Housing for Health Partnership. BC Housing 2009 [cited 2009 Dec 20];Available from: URL: http://www.bchousing.org/programs/independent(15)  Community Care and Assisted Living Act, [SBC 2002] CHAPTER 75, Government of British Columbia, (2002).(16)  Ministry of HealthServices.Government of British Columbia. Office of the Assisted Living Regis-trar. Goverment of British Columbia 2009 [cited 2009 Nov 20];Available from: URL: http://www.hls.gov.bc.ca/assisted//index.html#(17)  Community Support Continuing Care Division. Personal Assistance Guidelines. Government of British Columbia 1997 [cited 2009 Nov 20];Available from: URL: http://www.health.gov.bc.ca/as-sisted/pdf/guidelines.pdf(18)  Office of the Assisted Living Registrar. Personal Assistance Services Self-assessment Worksheet. Government of British Columbia Ministry of Health Services 2004 [cited 2009 Nov 20];Available from: URL: https://www.health.gov.bc.ca/exforms/assistedliving/1621.pdf(19)  Karmali S. Assisted Living in BC: Effects of Organizational Factors on Residents’ Satisfaction. Vancouver, BC: Department of Gerontology, Simon Fraser University; 2006.(20)  Community Care and Assisted Living Regulation [includes amendments up to B.C. Reg. 324/2008, November 7, 2008], Government of British Columbia. Ministry of Health Services; 2004.(21)  Telephone communication with the Office of the Assisted Living Registrar; 2009. (22)  Residential Care Regulation - Community Care and Assisted Living Act [includes amendments up to B.C. Reg. 96/2009, October 1, 2009], B.C. Reg. 96/2009, Government of British Columbia; 2009.(23)  Office of the Assisted Living Registrar. Registrant Handbook. Government of British Columbia website 2007 [cited 2009 Nov 23];Available from: URL: http://www.health.gov.bc.ca/library/publi-cations/year/2007/handbook_Entry_and_Exit.pdf(24)  British Columbia.Legislative Assembly. Freedom of Information and Protection of Privacy Act. [RSBC 1996] Chapter 165, 1-81. 1993. (25)  Barer M, Evans R, McGrail K, Green B, Hertzman C, Sheps S. Beneath the calm surface: the changing face of physician-service use in British Columbia, 1985/86 versus 1996/97. CMAJ March 2, 2004; 170(5):803-7.(26)  Canadian Institute for Health Information. The Status of Alternative Payment Programs for Physi-cians in Canada. Ottawa: Canadian Institute for Health Information; 2005. W H O  U S E S  A S S I S T E D  L I V I N G  I N  B R I T I S H  C O L U M B I A ?4 8(27)  Gonthier D, Hotton T, Cook C, Wilkins R. Merging area-level census data with survey data in Statistics Canada Research Data Centres. The Research Data Centres Information and Technical Bulletin 2006;3(1):21-9.(28)  Prosser B, QUILTS Team. The Utility of ACGs & ADGs in the Evaluation of the BC Nurseline. 2006. Presentation in British Columbia. (29)  Reid RJ, MacWilliam L, Verhulst L, Roos N, Atkinson M. Performance of the ACG case-mix sys-tem in two Canadian provinces. Medical Care 2001 Jan;39(1):86-99.(30)  Reid RJ, MacWilliam L, Verhulst L, Roos N, Atkinson M. Performance of the ACG case-mix sys-tem in two Canadian provinces. Medical Care 2001 Jan;39(1):86-99.(31)  Broemeling A, Watson D, Black C. Chronic conditions and co-morbidity among residents of Brit-ish Columbia. Vancouver: College of Health Disciplines; University of British Columbia; 2005. (32)  Frytak JR, Kane RA, Finch MD, Kane RL, Maude-Griffin R. Outcome trajectories for assisted liv-ing and nursing facility residents in Oregon. Health Serv Res 2001;36((1 Pt 1)):91-111.(33)  Sloane PD, Zimmerman S, Hanson L, Mitchell MC, Riedel-Lei C, Custis-Buie V. End-of-Life Care in Assisted Living and Related Residential Care Settings: Comparison with Nursing Homes. J Am Geriatr Soc 2003;51(11):1587-94.(34)  Zimmerman S, Gruber-Baldini AL, Sloane PD, Kevin Eckert J, Richard Hebel J, Morgan LA, et al. Assisted Living and Nursing Homes: Apples and Oranges? Gerontologist 2003 Apr 1;43(90002):107-17.(35)  Stearns SC, Park J, Zimmerman S, Gruber-Baldini AL, Konrad TR, Sloane PD. Determinants and Effects of Nurse Staffing Intensity and Skill Mix in Residential Care/Assisted Living Settings. Gerontologist 2007 Oct 1;47(5):662-71.(36)  Burdick DJ, Rosenblatt A, Samus QM, Steele C, Baker A, Harper M, et al. Predictors of Functional Impairment in Residents of Assisted-Living Facilities: The Maryland Assisted Living Study. J Gerontol A Biol Sci Med Sci 2005 Feb 1;60(2):258-64.(37)  Lyketsos CG, Samus QM, Baker A, McNabney M, Onyike CU, Mayer LS, et al. Effect of dementia and treatment of dementia on time to discharge from assisted living facilities: the Maryland As-sisted Living Study. J Am Geriatr Soc 2007 Jul;55(7):1031-7.(38)  Phillips CD, Hawes C, Spry K, Rose M. Residents Leaving Assisted Living: Descriptive and Ana-lytic Results From a National Survey. #HHS-100-94-0024 and HHS-100-98-0013; 2000. Available from: http://aspe.hhs.gov/daltcp/reports/2000/alresid.htmUBC  C E N T R E  f O R  H E A LT H  S E R V I C E S  A ND  p O L I C y  R E S E A R CH4 9(39)  Giuliani CA, Gruber-Baldini AL, Park NS, Schrodt LA, Rokoske F, Sloane PD, et al. Physical Performance Characteristics of Assisted Living Residents and Risk for Adverse Health Outcomes. Gerontologist 2008 Apr 1;48(2):203-12.(40)  Zimmerman S, Sloane PD, Eckert JK, Gruber-Baldini AL, Morgan LA, Hebel JR, et al. How Good Is Assisted Living? Findings and Implications From an Outcomes Study. J Gerontol B Psychol Sci Soc Sci 2005 Jul 1;60(4):S195-S204.(41)  Sloane PD, Zimmerman S, Gruber-Baldini AL, Hebel JR, Magaziner J, Konrad TR. Health and Functional Outcomes and Health Care Utilization of Persons With Dementia in Residential Care and Assisted Living Facilities: Comparison With Nursing Homes. Gerontologist 2005 Oct 1;45(suppl_1):124-34.(42)  Seniors Advisory Council for Alberta. Supportive Living Framework. 2007. Alberta, Alberta Seniors and Community Supports. (43)  Alberta Seniors and Community Supports. Supportive Living Accomodation Standards. 2007. Edmonton. (44)  Assisted Living in Alberta Health Services - Capital Health. Edmonton: Capital Health; 2008.(45)  Provincial Advisory Committee of Older Persons. Housing Options for Saskatchewan Seniors. 2008. Saskatchewan Ministry of Health. (46)  Manitoba Seniors and Healthy Aging Secretariat. Senior Access Resource Manual - Housing Module. 2007. Winnipeg, Manitoba, Province of Manitoba. (47)  Ontario Seniors’ Secretariat. A Guide to Programs and Services for Seniors in Ontario. 2007. (48)  Jones A. The Role of Supportive Housing for Low-Income Seniors in Ontario. Canadian Policy Research Networks and Social Housing Services Corporation; 2007. UBC Centre for Health Services and Policy ResearchThe University of British Columbia201-2206 East MallVancouver, B.C. Canada V6T 1Z3Tel:  604.822.4969fax:  604.822.5690Email: enquire@chspr.ubc.cawww.chspr.ubc.caAdvancing world-class health services and policy research, training and data resources on issues that matter to Canadians

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