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J Am Med Dir Assoc. 2020 Feb 26. pii: S1525-8610(20)30031-1. doi: 10.1016/j.jamda.2020.01.006. [Epub ahead of print]

Changes in Long-Term Care Markets: Assisted Living Supply and the Prevalence of Low-Care Residents in Nursing Homes.

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Providence VA Medical Center, Providence, RI; Brown University School of Public Health, Providence, RI. Electronic address:
Providence VA Medical Center, Providence, RI.
Providence VA Medical Center, Providence, RI; Brown University School of Public Health, Providence, RI.



To assess the effect of changes in assisted living (AL) capacity within a market on prevalence of residents with low care needs in nursing homes.


Retrospective, longitudinal analysis of nursing home markets.


Twelve thousand two hundred fifity-one nursing homes in operation during 2007 and 2014.


We analyzed the percentage of residents in a nursing home who qualified as low-care. For each nursing home, we constructed a market consisting of AL communities, Medicare beneficiaries, and competing nursing homes within a 15-mile radius. We estimated the effect of change in AL beds on prevalence of low-care residents using multivariate linear models with year and nursing home fixed effects.


The supply of AL beds increased by an average 258 beds per nursing home market (standard deviation = 591) during the study period. The prevalence of low-care residents decreased from an average of 13.0% (median 10.5%) to 12.2% (median 9.5%). In adjusted models, a 100-bed increase in AL supply was associated with a decrease in low-care residents of 0.041 percentage points (P = .026), controlling for changes in market and nursing home characteristics, county demographics, and year and nursing home fixed effects. In markets with a high percentage of its Medicare beneficiaries (≥14%) dual eligible for Medicaid, the effect of AL is stronger, with a 0.066-percentage point decrease per 100 AL beds (P = .026) vs a 0.016-percentage point decrease in low-duals markets (P = .48).


Our analysis suggests that some of the growth in AL capacity serves as a substitute for nursing homes for patients with low care needs. Furthermore, the effects are concentrated in markets with an above-average proportion of beneficiaries with dual Medicaid eligibility.


Assisted living; long-term care; nursing home residents

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