By David Dosa, MD

There are 900,000 people in the United States who reside in assisted living settings, at an average age of nearly 87. On average, these individuals pay privately between $3,000-$6,000 per month for services that often include room and board, medication delivery and pill box set-up, supervision, and assistance with activities of daily living. Assisted living facilities are an integral part of the health care delivery system for many of our nation’s frailest older adults.  Despite the high quality care that is often provided, the assisted living environment can often leave healthcare providers scratching their heads about what they can and cannot order for their patients.  My recent experience with such a facility involving a patient with possible influenza illustrates the complex middle ground these facilities occupy.

A phone call from an assisted living facility in town interrupted me from my afternoon schedule. The facility’s nurse introduced herself and began to give me a report about my 85-year-old patient with dementia.

“Mr. Smith has a fever to 102 and is coughing up some ugly looking sputum.  I’d like to order some labs and perhaps a chest X-ray. We might also want to consider an antibiotic.”

I asked the nurse a series of questions. Was my patient’s blood pressure unstable? Was he short of breath? Was he confused or disoriented?”

In each case, she told me, “no.”

“He is sitting quite comfortably watching a talk show on television. His only complaint is the occasional cough.”

I asked a few more questions and was reassured that he was otherwise fine. I told her that her initial request for blood work and a chest X-ray sounded like a good idea. We would wait on the antibiotic until the results came back.

“I’ll call you later today with the results,” she said.

I thanked the nurse and we said our goodbyes. Before she hung up, however, a last minute thought crossed my mind. With the current epidemic of influenza, I asked if we could add a rapid flu test to the litany of orders.  There was silence on the other end. Eventually the nurse answered,

“We can’t do that here. This is an assisted living.”

Why not, I countered. If he had the flu, we could start him on medications that might limit his symptoms or prevent hospitalization. We could isolate him from other residents and warn the staff who cares for his daily needs. We could even alert his family who visited regularly.

“If you want that test done, you’ll have to send him to the Emergency Room,” she said with an irritated tone.

Again, I asked why. Was it not true that my patient was otherwise stable – comfortably watching television in his room. If he went to the ER, couldn’t he potentially be at risk of infecting others, as well as risking unnecessary testing and medical procedures?

“I’m sorry but you can’t order the rapid flu swab here because we are not a medical facility.”

I paused as the statement resonated in my head.

“Don’t you have 100 patients at your facility, many of whom need more care than Mr. Smith?” I asked.

She corrected me:  “We have 105 residents, sir…they are not patients.”

I chuckled at the response and like an adept lawyer, redirected the line of questioning.

“Have any of the other residents begun to cough, sneeze, have nasal congestion in the last week?”

“Yes, but I can’t talk to you about them, because they are not your patients!”

“So these residents….you treat them with medications, you provide for all of their daily needs including bathing, dressing, and feeding…. You can even order a chest X-ray and blood work if need be, but you can’t test for the flu?”

“We are not a health care facility. If you want a flu test, you’ll have to send your patient out to the hospital.”

Now he was my patient.

“Look, our administrator doesn’t want us ordering flu swabs.”

I realized that our conversation was done. Whatever her reason for refusing to obtain the test, she wasn’t going to change her mind. I thanked her and reminded her to call me with the results. Frustrated, I placed the next call to the State’s Department of Health.

A few hours later, an official from the Health Department called me back. He apologized for the delay in the reply suggesting that things were crazy with the current influenza outbreak. I recounted my discussion with the assisted living nurse.  Surely, the Health Department didn’t want my otherwise stable patient to be sitting around an ER waiting area just so that we could obtain a rapid flu test?

“There is nothing we can do,” he said. “We don’t regulate assisted livings in the same manner that we regulate nursing homes or hospitals. Assisted livings are merely domiciliaries for those with disabilities. For the most part, these facilities can do as they like, even though I agree with you.”

“And the fact that they can offer chest X-rays, blood work, and physical therapy services?”

“It doesn’t make a difference, doctor. Technically, assisted livings don’t have to offer to do lab work or X-rays – but many do because they can profit by providing the service. Look, you and I both know that these [assisted livings] are now health care facilities, but they are not yet regulated like health care facilities. As such, there is nothing that I can do to make them order a test that they don’t want to do.”

I countered, “Doesn’t it make sense from a public health perspective to warn other residents and staff if my patient has the flu?”

“Absolutely, but I can’t make them order the test.”

I thanked him and hung up the phone.

Therein lies the problem. Though assisted living facilities are regulated by individual states, these regulations vary significantly and often prohibit certain types of care. Nevertheless, as the acuity of assisted living residents has increased over the years, many facilities toe the line between offering services (including health care services like physical therapy, and ordering tests such as chest X-rays) that they are technically not allowed to provide in the hopes of marketing these as amenities that will keep privately-paying residents from leaving their facilities to seek health care services elsewhere. This practice continues until it stops being financially lucrative for a facility, as seen with the flu swab test. While not all assisted livings are the same, these sorts of problems and contradictions will continue at the detriment of the 900,000 residents nationwide unless greater attention is paid to regulating assisted livings as the health care facilities that they are rapidly becoming.

A few hours later, the nurse called me back from the assisted living.

“I just wanted to let you know that Mr. Smith went to the Emergency Room.”

I asked if something had happened.

“No, Mr. Smith was fine when he left. My administrator just thought that he should go to the ER. He just felt if there was any chance that he has the flu, he shouldn’t be here.”

I shook my head, thanked her, and hung up the phone.

Dr. David Dosa is an Associate Professor of Medicine at the Warren Alpert Medical School at Brown University and a Course Director in Brown’s Executive Master of Healthcare Leadership. He is a New York Times bestselling author of Making Rounds with Oscar: The Extraordinary Gift of an Ordinary Cat, which has been published in over 20 countries worldwide.