Opportunities to Improve End-of-Life Care in Assisted Living: Results From a National Survey of Administrators

Assisted living is a common place of care for dying residents, with extensive variation in residents' outcomes such as hospice enrollment. This research aimed to gather national evidence about end-of-life care processes in assisted living.

A national survey of administrators was conducted in 2021-2023, using a random sample proportional to the number of large assisted living communities (≥25 beds) across licenses and states.

Administrators at eligible assisted living communities across the United States as listed in public state registries.

Standard measures from existing surveys of residential care were used or adapted from other long-term care settings after cognitive testing, including staffing and admission/retention policies, end-of-life care processes such as protocols for dying and deceased residents, and quality of hospice collaboration. Nonresponse adjusted sampling weights provide nationally representative estimates.

Among 4796 eligible assisted living communities invited, 2084 administrators completed the survey from all 48 targeted states, a response rate of 43.4%. One in 5 (20.4%) administrators reported no residents dying in the past 12 months, and 15.3% of very large communities (≥100 beds) did not report decedents. Yet, among those caring for dying residents, less than one-third of administrators rated the quality of dying in their community as excellent. Among 1882 communities whose administrators reported collaborating with hospice, 32.0% also responded that hospice always assessed a resident within 24 hours of referral.

This national study of administrators highlights important opportunities to improve end-of-life care both as part of assisted living care processes for dying residents and through collaboration with hospice. These novel survey measures will help determine how end-of-life care processes vary along state regulations and shape residents' outcomes.