End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

J Am Med Dir Assoc. 2023 Jun;24(6):827-832.e3. doi: 10.1016/j.jamda.2023.02.002. Epub 2023 Mar 10.


Objective: We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations.

Design: Cohort study.

Setting and participants: Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662).

Methods: We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics.

Results: End-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death.

Conclusions and implications: There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.

Keywords: Assisted living; end-of-life; staffing; state regulations; transition.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Assisted Living Facilities*
  • Cohort Studies
  • Hospice Care*
  • Humans
  • Medicare
  • Terminal Care*
  • United States
  • Workforce