Aging in Place and Negotiated Risk Agreements

ASSISTED LIVING COLUMN Ethel Mitty and Sandi Flores

Ethel Mitty

AGING

IN

Sandi Flores

PLACE AND NEGOTIATED RISK AGREEMENTS

Ethel Mitty, EdD, RN, Sandi Flores, RN, C

An assisted living community (i.e., residence [ALR]) that responds to a resident’s changing needs by adjusting services and level of care criteria means that the resident is less likely to be discharged to a higher level of care, such as a nursing home, and will “age in place.” A “managed” or negotiated risk agreement (NRA) can facilitate aging in place by accommodating a resident’s choices and potential risks of remaining in the residence. Although more than half the states speak to aging-in-place in their assisted living regulations, far fewer provide guidelines for negotiated risk discussion and its influence on service plans. Managing decline and the risks to a resident’s safety and well-being can perhaps be addressed by “upstream palliative care,” a concept and practice that respects a resident’s quality of life interests while meeting and supporting their physical, mental, and emotional needs. This article discusses these issues as well as the capacity of a cognitively impaired/demented resident to enter into an NRA and its continuance when resident understanding is questionable, and dying-in-place. (Geriatr Nurs 2008;29:94-101) Aing-in-place (AIP) is a major component of assisted living philosophy, services, and, in some states, regulations. Either specifically stated or alluded to in state or facility-specific

94

retention language and guidelines, AIP requires that an assisted living community (facility/residence [ALR]) respond to a resident’s changing needs and adjust its services and level of care criteria. In so doing, a resident is less likely to be discharged to a higher level of care—that is, to a nursing home or skilled nursing facility. A “managed” or negotiated risk agreement (NRA) facilitates remaining in the ALR; it is a record of recognition and accommodation of the risks of remaining in the residence. This article describes the policies and practices associated with AIP through regulation and statute (notably, NRAs) and the ambiguities and angst of making AIP happen as a practical operational matter.

AIP: Background Aging-in-place means not having to move from a current residence to one that can provide support services needed to maintain comfort and well-being. In fact, most older adults spend the remainder of their lives where they celebrated their sixty-fifth birthday.1 Inasmuch as approximately the same percent of older adults with 2 to 3 activities of daily living (ADL) dependencies are in assisted living as are in nursing homes, it has been suggested that the longer they can remain in AL, the greater the cost savings.2 The adverse consequences of relocation to secure the care and services needed, in the absence of an acute crisis, include stress,

Geriatric Nursing, Volume 29, Number 2

isolation, physiological changes (e.g., weight loss), depression, financial burden, and loss of personal possessions and personhood.3 Slightly more than half the states include an AIP philosophy in their statutes or regulations.3 Proponents of AIP hold that state subsidies (e.g., Medicaid) to meet the needs of less impaired older adults, currently in nursing homes, not only can reduce health care costs but can also provide a more dignified quality of life. The fork in the road— discharge to a nursing home or remain in an ALR—is determined by a state’s AL admission, retention, and discharge policies. An increasing number of states permit ALRs to offer additional (or skilled nursing) health services for an “intermittent” or “limited-time”; this facilitates AIP.4,5 Yet studies suggest that most ALR residents cannot and will not age in place in the residence until they die.6 Remaining or leaving (being discharged to another facility, such as a nursing home) is dependent on state regulations about specific resident characteristics and the services that may or may not be provided.3 Despite the latitude that some states may permit with regard to services and resident characteristics, individual ALRs have the right to be more restrictive.4 Most states do not permit retention of residents on continuous bed rest or who require 2-person transfer.4 The exception to all of this is that virtually all states permit hospice services/care in ALRs, in which case the additional services needed would be provided through hospice; the ALR is not liable for failure to provide care or neglect of obvious needs. Anecdotally, a service agreement that fails to indicate the possibility of death in the ALR can apparently expose the ALR operator and owner to liability. Opponents argue that AIP in AL poses financial, operational, and moral challenges.5 AIP might not have been a component of the ALRs business model or a market niche of interest. It may be difficult to attract and retain staff members who are unwilling to be caregivers to older adults with significant physical and or mental impairment. Morally, the ALR might be unable to meet the increasing needs likely associated with AIP and do not want to be in the position of false advertising or failure to disclose the limits of service. Yet despite these issues, many AL communities have increased their capacity for more complex care in response to consumer

demand to age in place. Consumers are requesting a higher level of care in the ALR. A study to understand AIP in assisted living and the factors influencing it found that AIP had negative and positive outcomes.6 Most residents preferred remaining in the ALR rather than relocating to a nursing home; they were satisfied with their care in the ALR. The residents felt they would avoid the stress associated with new surroundings, people, and routines and could retain the relationships and social roles they had in the ALR. Not surprisingly, the ALR benefited by avoiding discharge and admission costs (to fill empty beds) that would be associated with resident transfer. Although there were some increased financial costs associated with increased services, the social and emotional costs of AIP on other residents were noted. Some residents felt that the increased visibility of confused or frail residents altered the tone of the ALR. More wheelchair users added to a feeling of being in an institution and created physical obstacles. Some residents did not want to associate with those who were demented or cognitively impaired and, as a result, all felt socially isolated. An analysis of the admission and retention criteria, as well as the service models of care, of 5 states (NJ, OK, OR, VT, WA)—all of which allowed ALRs a considerable degree of flexibility in comparison to other states—identified 3 business models.5 ALRs that admit residents with high acuity/service needs are more concerned with serving their needs effectively than on the impact that these residents would have on their resident mix. The second model admits low-to-moderate acuity residents but retains them even as their needs increase. In this model, acuity levels rise but tend to be cyclical (over 3 years); some residents leave to go to a higher level of care, or die, and newer, low-acuity residents are admitted. The risk with this model is that prospective residents might be unenthused about joining a community where they see many residents using walkers and wheelchairs or are otherwise impaired. For the ALR owner/operator, there could be a drop in vacancies in the event that many high-acuity residents leave or expire within the same period of time. The third model admits low-to-moderate acuity residents has moved away from its policy of discharging residents when their needs increase and now

Geriatric Nursing, Volume 29, Number 2

95

permits residents to meet their increased need through privately arranged and paid for providers and caregivers. Other states (MI, TX) permit ALRs to retain residents who would otherwise have had to move out in keeping with the states’ AL regulations. The ALR, resident, family, and physician must agree, in writing, that the ALR can meet the resident’s needs.5 Staffing is tricky; a simple staff-to-resident ratio, even one that calculates acuity by some standard measure, fails to consider the nature and frequency of assistance needed. New Jersey AL regulations require that the admission agreement list the specific condition(s) or resident characteristic(s) that the ALR will serve, the intensity of the service, and any associated costs. Among the conditions that an ALR can choose not to serve are 24/7 nursing supervision, total dependency in 4 or more ADLs, bedridden status of more than 14 consecutive days, inability to respond to simple directions or cueing with personal care and eating, stage 3– 4 pressure ulcer, significant transfer assistance requirements, danger to self or others, medical instability, or a treatment regimen that cannot be properly provided in the ALR. Recently built ALRs must provide a nursing home level of care to at least 20% of residents within 3 years of licensure. Interestingly, NHs in this state have become more short-stay oriented, and their Medicare use for rehabilitation services has increased. Many residents go to and return from the NH to the ALR. In Oklahoma, ALR marketing does not include the phrase “aging in place” because of concern that it implies the obligation to provide care regardless of service needs or the ALR’s ability to do so. Among the required services offered are intermittent or unscheduled nursing care, care for individuals with a dementing illness, and medication administration. Similar to New Jersey’s constraints, residents cannot be admitted if they are a danger to self or others or if they have needs that cannot be met by the residence. In addition, a resident cannot be admitted who requires a physical or chemical restraint for situations other than an emergency. Oregon regulations originally permitted an ALR to admit any individual whose needs the residence felt it could meet; there were no limitations. Revised several years ago, the refer-

96

ence to AIP was eliminated, and regulations now address the circumstances in which a resident can be asked to move out; there are specific admission and retention guidelines. An ALR is not required to retain a resident if his or her needs exceed the ability to provide the support needed, whose cognitive impairment or dementing illness interferes with the resident’s or others’ well-being, or whose medical instability and treatment needs exceed the ALRs capacity (including 24/7 nursing supervision). Most discharges, however, are due to behavior. Vermont regulations, revised within the past 5 years, support AIP by virtue of language that guides admission and retention based on what the condition is and when the condition or the service need developed. The state can issue a variance that permits retention if a resident’s care needs can be met by appropriate staff and by licensed nurses in the ALR, if needed. Discharge is permitted for conditions similar to those of the previously described states. Boarding home regulations in Washington, revised in 2004, now provide considerable leeway for these residences to admit and retain residents who need, for example, suctioning, intravenous administration, or parenteral feeding, or who are bed bound for more than 14 days because of a medical condition, if the resident lives in a secure domicile with a private toilet and sink. Some ALRs chose not to change their admission and retention policies but, rather, encourage residents who need special services or are experiencing higher acuity to relocate to an ALR that has more intensive nursing services. Delegation of injections and insulin administration is a major issue in AIP. Oregon nurses can delegate injections; New Jersey medication aides must take a special course; Washington requires that a licensed nurse administers insulin. The Nurse Practice Acts vary across all states in this regard and should be closely read, if not revised, in response to the service needs of AIP—in assisted living as well as in home care.

Managing Decline Aging in place means managing the decline associated with chronic disease and assessing the frailty versus the reserve (i.e., capacity) of the older adult. The notion of resident-facility “fit” to manage decline resides in 2 strategies:

Geriatric Nursing, Volume 29, Number 2

1) preventing decline and 2) responding to decline.5 The first approach involves health promotion and maintaining therapeutic regimens. The second attempts to balance needs with resources and is met, in part or in combination, by increasing fees to hire additional staff, bringing in additional equipment (e.g., mechanical lifter), or increasing the family’s financial or physical support of increased care. Both strategies pose risk for the resident and the ALR. The resident might choose to refuse the additional care or services needed for a variety of reasons including increased costs or might not reveal a change in condition. The risk for the ALR is failure in its genuine attempt to provide the care needed and its liability to accusations of neglect. Managing risk to the resident’s safety and well-being and the ALR’s ability to remain in operation is a cornerstone of AIP.7

Dying in Place—Upstream Palliative Care An assumption of AIP is that death will take place in the ALR. Barriers to dying in place include state regulations that do not permit retention of a resident who needs skilled nursing, or who requires more care than was stipulated in the service contract; licensed nursing unavailability 24/7; risk of ALR liability if “risk of death” was not in the service contract; ALR legal liability if a dying resident is not transferred to a NH or hospital unless the resident was hospice covered; insufficient reimbursement for additional care or services; inadequate safe storage for pain management drugs; staff discomfort with a dying person or lack of education about care at the end of life; and physician aversion to one of their patients dying in an ALR. There is also the possibility that the resident or family will request hospitalization when death is immanent.8 A “good death”, if time is granted to be able to plan in advance, needs good advance planning. It has been suggested that advance planning of this kind is “upstream palliative care” (UPC).8 It is clearly applicable to AIP in assisted living. UPC needs advance planning, pain and symptom management (in advance of a significant need for this), a holistic approach made possible by an interdisciplinary team, a comprehensive plan of care, attending to quality-of-life preferences, and staff education. Few states re-

quire resident, family, or staff education about advance directives (ADs), yet some states require that all assisted living residents have a “life-sustaining treatment card” executed by their physician prior to admission. In some states, the resident must complete an AD or DNR (do not resuscitate order) as a condition of or shortly after admission. On the other hand, some states do not permit admission to an ALR if the individual has an activated durable power of attorney for health care (i.e., Health Care Proxy). Other barriers to UPC—and to AIP—are regulations (in some states) that prohibit the administration of controlled substances and asneeded medications by nonlicensed staff or that stipulate that the provision of nonpharmacological treatments is skilled nursing, which makes it a retention issue, absence of a team approach (except in those states in which Medicaid-covered ALR residents are assigned a case manager who participates in service plan development), and staff education about care at the end of life. A comparative study of care at the end of life in ALRs and nursing homes found that end-oflife care is as good as, and in some cases better than, end-of-life care in nursing homes.9 Physician services were in some cases better in the ALR than in the NH—a finding that researchers felt might be attributed to better case management in ALRs and physician involvement with hospice. Staff in both settings felt that the residents had a “good death.” In both settings, residents experienced overall comfort, but there was room for improvement. Staff and families of dying NH residents were more aware of the immanence of death than were ALR families and staff. Yet the deaths were lonely in both settings; there were no hospice staff present in either setting at the time of death. Almost half the states waive retention and discharge criteria if residents can secure the extra help needed to meet their needs, typically through a home health agency paid privately.10 Managed risk agreements or NRAs are a means to individualize care plans, acknowledge and accept resident risk, and recognize the ALR’s responsibility to notify the family in the event of change in condition or a need that requires more services or care than the ALR can provide. A waiver of liability “contract” avoids mandatory discharge associated with changed needs for care and allows the resident to obtain the addi-

Geriatric Nursing, Volume 29, Number 2

97

tional care from outside vendors. The legal standing of liability waivers is unclear in virtually all states. A provider association for the AL industry recommends that ALRs do not market themselves as a place to “age in place.” Nevertheless, the philosophy of assisted living—reducing the need to leave one’s residence— can be used in marketing.11 The average length of stay in an ALR is slightly over 1.75 years and only slightly over 10 months for residents residing in dementia special care ALRs.10 Residents with a psychiatric disorder, residing in a for-profit facility that is part of a continuing care retirement community or with a nursing home on the premises, are more likely to be discharged than residents who do not have mental illness.12

Negotiated Risk Agreements Provider approaches to retention and moveout criteria vary even within states, as does their willingness to create flexible and individualized service plans. To a degree, NRAs attempt to address this issue.13 NRAs are unique in AL; they do not exist in nursing homes or in-home care. Of the 41 states with regulations for residential care settings or assisted living, only 14 states and the District of Columbia have provisions or statutes about NRAs.14 Although the use of NRAs is not specifically prohibited in any state, some states restrict their use. Almost all states regard and support the NRA (concept or practice) as an expression of resident choice when that choice might be in conflict with medical advice or community norms. The NRA is considered a way to manage the risk associated with that choice. Following through, the service plan should reflect the situation, contingencies, and constraints denoted in the NRA, in greater or lesser detail. Wisconsin is currently the only state that requires individuals intending to reside in a residential care apartment complex (a specific type of ALR) to have an NRA.14 The interesting ethical argument for and against NRAs finds opponents saying that AL residents already have the right to act autonomously and that there is therefore no necessity to negotiate about it. NRA proponents counter that AL operators and owners are so worried about their legal liability when residents make poor or risky choices that the residents’ rights

98

are already being infringed on overtly or covertly. In those states with NRA regulations or reference, NRAs are viewed as a tool to identify, communicate, and discuss risk management as well as reduction. Whereas NRA proponents suggest that it is also a mechanism to attribute responsibility and limit provider liability, NRA opponents feel it is a mechanism to avoid liability for negligence. Argument about “good” and “bad” providers, standards of care, and the vulnerability of residents whose decision making or judgment might be compromised heat up the debate and, at times, cloud the issue. Interestingly, when the debate focuses on liability waivers, both sides agree that NRAs cannot effectively limit legal liability. The legal status of an NRA as a contract has not been established. The classic tension between autonomy/selfdetermination and safety needs, epitomized in the NRA debate, seems to hinge on assessment of a resident’s decision-making capacity. An NRA represents a “negotiated solution” to the concern (about risk) generated by a resident’s expressed preference or behavior. The document should contain a description of the resident’s understanding and acceptance of the possible risks and negative outcomes of his or her behaviors and activities. It should include a description of the provider’s accommodations to the resident’s choice or behavior and possible alternatives to the choice that could reduce the risk but still meet the resident’s wishes. A study of NRAs in AL found that some residents have no recall of creating an NRA or of its contents.14 Yet residents have strong feelings about the ethics of self-determination and lifestyle choices, even if such choices place them at risk. They feel that they should not be put into a position of having to sign a document as a precondition to making choices that express their preferences and that neither facility or family should be directing their choices if their decisions do not endanger others.14 An analysis of 15 states’ NRA requirements revealed that 5 states (AK, IA, OK, VT, WA) require a negotiation process when a resident’s behavior is placing oneself or others in harms way.14 Almost all the 15 states’ NRA rules speak to autonomy and choice, but only 7 have specific guidelines to address the resident’s capacity to understand the NRA; 3 states have general

Geriatric Nursing, Volume 29, Number 2

guidelines, and 4 are silent on the issue. Provider liability is specifically addressed in 5 states; that is, the state prohibits a facility from attempting to use the NRA to avoid liability. Seven states are completely silent on this issue. Specific rules regarding how the NRA relates to admission criteria are written in only 3 of the 15 states; 2 states have general rules; the remainder are silent on this issue. This finding is interesting inasmuch as an NRA is intended, in part, to address remaining in the ALR. Absent state guidance, it appears that this decision remains in the hands or control of the ALR owner or operator.

Dementia and Impaired Decision Making There are no reliable data about the prevalence of dementia in ALRs; it ranges from 12% to 66%.14 It is generally agreed, however, that at least half the residents have some degree of cognitive impairment. What is the resident’s degree of comprehension or understanding of the risk associated with a specific preference? This in itself lacks a gold standard of assessment. Typically, decisional capacity assessment in an ALR is performed informally and seems to rely on evidence of memory loss and poor judgment. Informal assessment could produce an overestimate or an underestimate of comprehension. Memory loss, although relatively easy to identify, is not an adequate measure of decisional capacity. Some ALRs use the Mini-Mental State Exam or Clock Drawing test of executive function, although neither of these instruments measures decision-making capacity. Staff are unaware that capacity determination is similar to determining capacity sufficient to make an informed consent.14 How important is the resident’s choice to the resident’s quality of life? What quality-of-life measure is to be used to make this determination? Should an NRA be created (or continue to be used) with—and for—a resident with cognitive impairment? It has been suggested that before creating an NRA, the resident should have a competency assessment. (Note: capacity assessment is a clinical determination of ability to make and be responsible for a health care decision. Competence is a legal determination of a person’s ability to enter into and be responsible

for a contract or financial obligation.) Another ethical question is whether an NRA should remain in effect if the resident has fluctuating comprehension of his or her behavior or its consequences. ALRs in Oregon cannot create or continue an NRA if the resident is incapable of understanding or recognizing his or her risky behavior and its consequences.14 In most states, there are no clear guidelines. In addition, most states do not address surrogate or guardian right to complete an NRA for a resident. Asked about acceptable (“appropriate”) and unacceptable (“inappropriate”) types of risk that could or should be addressed by an NRA, AL providers and NRA experts had varied opinions.14 Most felt that creation of an NRA depended on the resident’s physical and mental status, the nature of the risk, and gravity of possible outcomes. One third of the respondents felt that any risky behavior that might be occurring in a person’s private home would be appropriate for an NRA. Others felt that behavior that placed the resident or others at risk or behavior prohibited by regulation or facility policy was appropriate for an NRA. Opinions varied with regard to smoking, from it being a nonnegotiable issue to provision of a safe supervised location on the premises to an ironclad facility rule, in which case it should not be permitted even by NRA. Three specific hypothetical NRA situations were posed to the previously noted respondents: override the state or facility discharge criteria for self-evacuation, a resident’s refusal to take certain medication(s), and a resident’s refusal to use a walker. Among them, there was general agreement that refusal to use a walker in the face of high risk for falls was an appropriate reason to create an NRA. Inability to evacuate the premises could be overridden by a waiver, if, for example, it could be shown that there was always sufficient staff to assist the resident in such a situation. The experts were divided over whether an NRA should be created when a resident was consistently refusing medications; it depended on the type of medication (e.g., insulin), patient’s medical status, and so on. Several participants felt that more and better regulatory or statutory guidance was needed about NRAs, particularly with regard to residents with dementia.

Geriatric Nursing, Volume 29, Number 2

99

Parties to the debate about the value of NRAs disagree about the notion of “risk,” the weight that should be attached to self-determination and (or vs.) safety, and the advantages and disadvantages of NRAs. The circumstances that support creation of an NRA are variable. There are no studies on, or guidelines that indicate, specific resident characteristics or conditions that require discussion of risks or creation of an NRA. A review of extant NRAs did not reveal a consistent process of execution, form, or language.14 In addition, only 8 of 15 states with NRA regulations have specific time frames for review of the agreement.14 Florida regulations speak to “managed risk” as a discussion between the ALR and resident (and family) of the service plan, the resident’s preferences and decisions, any likely risks, and the ALRs ability to respond to changes in condition.14 The notion of “shared responsibility” is the method by which both parties explore options. Florida regulators apparently do not perceive these kinds of agreements as a way for ALRs to allow residents to refuse necessary services or engage in risky behaviors. In the regulators’ view, ALRs have to find creative ways to avoid risk and provide the necessary services. Should they fail to do so, the resident should be discharged. In Oregon, the managed risk plan must document a resident’s decision to modify his or her risky behavior or must document the resident’s recognition of the risk(s) and consequences. In both states, the plan has to be reviewed periodically. Interestingly, Oregon does not permit involuntary discharge from an ALR; this requires state approval. Rather, the ALR and resident have to try to work out something that is mutually acceptable; the managed risk process is to be used to facilitate this. States do not monitor creation or use of NRAs.14 Overall, use of NRAs appears to be low for reasons that include the possibility that few ALR residents are making choices that pose risk and dire consequences, the perception that an NRA is a final recourse to resolution of providerresident disagreement about lifestyle choices, and the questionable legal status of NRAs.14

Conclusion Aging-in-place and management of chronic disease and frailty (and UPC) depend on state

100

regulations and the type of AL licensure, levels of care, reimbursement, and, to some extent, on Nurse Practice Acts that regulate what, where, and by whom skilled nursing acts can be performed by nonlicensed persons. Given the growing concern about the “medicalization” of assisted living and the interest in avoiding nursing home placement at the end of life, the AL nurse must be knowledgeable about age-related changes, illness trajectories of common conditions afflicting the older adult (e.g., congestive heart failure, chronic obstructive pulmonary disorder, diabetes), common geriatric syndromes (e.g., sleep disorders and weight loss), and palliative care principles and practices. It is important to be familiar with the state’s retention and discharge regulations, the NPAs delegation rules and the state statutes that override them, and a resident’s right to assume the risk and responsibility for the outcome of risky behavior. The tension between a resident’s ethical right to self-determination and decision making regarding one’s person, and caregivers’ concerns about safety needs is clearly evident in the debate about aging-in-place and the creation of an NRA. Clearly, the NRA process can be used in service planning and as a formal mechanism to address substantive concerns about residents’ risky behaviors— even those that all parties would like to ignore.14 The notion of an ALR being “risk averse,” for example, not allowing a diabetic resident to eat some “real” chocolate cake, can be compared to an ALR where this would be permitted; staff will do a finger stick in a few hours to assess blood sugar and any need for fast-acting insulin. Anecdotally, this kind of scenario is occurring in nursing homes on their pathways of culture change and resident-directed/empowered lifestyle. Although virtually all ALR staff members feel that NRAs are appropriate for a resident whose behaviors place the staff or other residents at risk,14 they are torn by their ethical and philosophical obligation to support autonomy, their moral obligation to keep residents safe, and their concern that they are accountable should injury or harm occur pursuant to a resident’s risky behavior, even if it is in pursuit of interests or preferences that enhance the resident’s quality of life.

Geriatric Nursing, Volume 29, Number 2

References 1. Available at http://www.seniorresource.com/ageinpl. htm. Cited October 15, 2007. 2. Mollica R, Snow K. State assisted living policy 1996. Portland, ME: National Academy for State Health Policy. 3. Mollica R, Jenkins R. State assisted living practices and options: A guide for state policy makers. Portland ME: National Academy for State Health Policy; 2001. 4. Chapin R, Dobbs-Kepper D. Aging in place in assisted living: philosophy versus policy. Gerontologist 2001;41: 43-50. 5. Mollica R. Aging in place in assisted living: state regulations and practice. Washington DC: American Senior Housing Association; 2005. 6. Wagner L, Vickery K. Assisted living’s delicate balance. Operators face new challenges as they offer more nursing care. Provider 1997;23:34-43. 7. Ball MM, Perkins MM, Whittington FJ, et al. Managing decline in assisted living; the key to aging in place. J Gerontol 2004;59B:S202-12. 8. Mitty E. Assisted living: aging in place and palliative care. Geriatr Nurs 2004;25:149-64. 9. Sloane PD, Zimmerman S, Hanson L, et al. End-of-life care in assisted living and related residential care settings: comparison with nursing homes. J Am Geriatr Soc 2003;51:1585-94. 10. Kissam S, Gifford DR, Mor V, et al. Admission and continued-stay criteria for assisted living facilities. J Am Geriatr Soc 2003;51:1651-4.

11. NCAL. National Center for Assisted Living. Guiding principles for Assisted Living. Available at http://www. ncal.org/resource/index.cfm. Cited November 28, 2007. 12. Dobbs D, Hayes J, Oslund P. The relationship between psychiatric disorders and the ability to age in place in assisted living. Am J Geriatr Psychiatry 2006;14:613-20. 13. Munroe D, Guihan M. Provider dilemmas with relocation in assisted living: Philosophy vs. practice. J Aging Social Policy 2005;17:19-37. 14. Jenkens R, O’Keefe J, Carder P, et al. A study of negotiated risk agreements in assisted living: final report. Prepared for Office of Disability, Aging and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation (ASPE), DHHS 2006. Available at http://aspe.hhs.gov/_topic/topic. cfm?topic⫽Long-Term%20Care. Cited June 20, 2006. ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, and Consultant in Long Term Care at the Hartford Institute for Geriatric Nursing, College of Nursing, New York University. SANDI FLORES, RN, C, is executive director of the American Assisted Living Nurses Association and education director of Community Education LLC (www. communityed.com). 0197-4572/08/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2008.01.001

Geriatric Nursing, Volume 29, Number 2

101