Assisted Living's Rise: Navigating Independence, Care, and Costs

Daniel David PhD, RN

Assistant Professor, NYU Meyers

Assistant Director of Community Linkages and Housing, HIGN

The growth of Assisted Living (AL) in the US is unmistakable. Over the past 2 decades, the number of facilities has grown 20%, beds 40%, and cost 100%. In fact, it is quite possible that AL beds will outnumber nursing home (NH) beds in the U.S. in the future, given several ongoing trends. These include the rising demand for independence, chronic disease management and wellness, cost considerations, policy shifts for expansion of services, and changing care needs.

AL facilities are home to nearly 1 million older adults in the U.S., compared to 1.4 million residents in NH. Each generation is living 6-8 years longer than the previous one, with life expectancy rising from 58 to 78 years in the past century. However, living longer doesn’t guarantee independence in later life. With age, vulnerabilities accumulate, making it harder to maintain autonomy. This has driven demand for less restrictive care environments like AL, which offer more independence than the highly regulated NH setting. By leveraging functional support for medication administration, hygiene, meal preparation, paying bills, making medical appointments, and occasional supervision of medical conditions by support staff, older adults seek to age in place with a sense of dignity and community.

In AL, residents must manage their health conditions to maintain independence. When self-care falters, unfavorable outcomes are predictable - avoidable hospitalizations, premature placement in NHs, and a lower quality of life due to unaddressed pain, fatigue, depression, anxiety, and stress. As AL residents’ care needs become more complex, society faces new challenges. How can care services help residents stay out of the hospital and NH? How much autonomy can frail older adults retain while managing complex illnesses? And who will cover the costs—insurance or residents themselves?

For the industry, addressing these questions means rethinking how care is delivered in AL. As residents' needs grow, AL facilities must evolve to offer comprehensive, flexible and affordable care while promoting independence. This could include more access to on-site providers, partnerships with community services, and tailored wellness programs. Mental health services are also vital, as psychological well-being plays a key role in residents’ quality of life. The financial burden of care is another challenge. The median cost of basic AL housing, food, and services is $5,000 per month, usually paid out of pocket, while NH care costs double that but is often covered by Medicare. Additional a-la-cart services cost more. As AL options expand, the issue of affordability remains, limiting access for those without sufficient income.

Balancing autonomy and necessary care is critical in AL. Facilities must provide enough support to ensure residents’ health and safety while respecting their independence. This includes services like medication management, chronic disease monitoring, and personalized care plans, but also honoring residents' decisions while accommodating family preferences even when those tensions carry risks. A lapse in communication, service, or health can knock down this house of cards. The future of AL care depends on finding balance—supporting independence while meeting the growing complexity of care needs. To do so the AL industry must continue to grow from a social model that historically only provided support for daily activities of living to that of more extensive support systems with resources that circumvent premature loss of autonomy.

Association of Nurses in AIDS Care Webinar

Prof. Tara Cortes was invited by the Association of Nurses in AIDS Care (ANAC) to speak at the second webinar in a three-part series focused on long-term care issues impacting persons living and aging with HIV. This webinar will explore the challenges facing the older adult population as they and their families explore options for long-term and community-based services. 

The Crisis in Long-Term Care: October 16th, 2pm ET.