Alzheimer’s Association calls for federal involvement to increase dementia care workforce, training in assisted living

by Lois A. Bowers

Joanne Pike, DrPH, is president and CEO of the Alzheimer’s Association and CEO of its advocacy affiliate, the Alzheimer’s Impact Movement.

“Congress should consider the steps it can take at the federal level, including expanding the necessary workforce and improving dementia training standards and access,” as part of efforts to “help ensure a quality direct care workforce that can meet the unique needs of our nation’s growing number of Americans living with Alzheimer’s and other dementia” in assisted living communities and elsewhere, the Alzheimer’s Association and its advocacy affiliate, the Alzheimer’s Impact Movement, said in comments submitted to the US Senate Special Committee on Aging for the record of the hearing it held Thursday, titled “Assisted Living Facilities: Understanding Long-Term Care Options for Older Adults.”

The entities also urged the committee to take steps to support states in implementing and improving dementia training for direct care and other workers in assisted living communities.

Thursday’s Aging Committee hearing was its first one focused strictly on assisted living in more than 20 years and was held in response to recent articles in The Washington Post and the New York Times and KFF Health News. The Post articles, published in December, reported on the deaths of several senior living residents with dementia who had eloped from communities. The Times / KFF articles, published in November, reported on an assisted living industry pricing structure that adds fees on top of basic charges to cover additional services, as well as rate increases and the for-profit status of most providers.

The committee now awaits responses from three large senior living operators about their efforts related to safety, staffing and pricing; has asked the US Government Accountability Office to study federal assisted living-related spending as well as industry pricing and transparency; has announced a website and email address where consumers can share their bills and their experiences interacting with providers; and is pondering increased federal involvement in the industry.

The Alzheimer’s Association and Alzheimer’s Impact Movement focused on dementia and workforce issues in their eight-page letter.

“Assisted living is one of the fastest-growing options for residential housing for older Americans,” the groups said in their letter, noting that there are approximately 30,600 assisted living communities with almost 1.2 million licensed beds in the United States today. Thirty-four percent of assisted living have Alzheimer’s disease or another type of dementia, they said (the federal government estimate is higher, at 42%).

By 2050, the organizations said, it is projected that the Medicare and Medicaid programs will be paying $1.1 trillion toward the healthcare and long-term care of people living with dementia as the number of people in that group increases.

“While the prevalence of Alzheimer’s disease increases, so does the need for well-trained members of the paid dementia care workforce,” the groups said, noting that the industry already is experiencing workforce challenges.

Fifty-eight percent of assisted living communities care for residents who are living with dementia, and 19% have a dementia care unit, the Alzheimer’s Association and Alzheimer’s Impact Movement said. They added, however, that “most states do not specify minimum staffing levels or ratios in dementia care.”

Although noting that “there is limited research identifying an optimal ratio of staffing,” the groups said that literature “verifies that there is a clear association between higher levels of licensed staff and higher quality of care” and that “there is an association between higher turnover rates and lower quality of care.”

Beyond potential mandatory staffing requirements, however, “there is a growing awareness of the need to deploy staff in a matter that aligns with resident routines and needs,” the organizations said, noting that recommendations made in a 2020 research article about staffing levels in nursing homes could “inform facilities and policymakers.”

Support of state efforts encouraged

Regulation of staff training in long-term care primarily occurs at the state level, the groups said, but they encouraged the Aging Committee “to consider proposals that support state health departments in implementing and improving dementia training for direct care workers and their oversight of these activities.”

Training-related policies, the Alzheimer’s Association and Alzheimer’s Impact Movement said, should be based on competency and should target providers in a broad range of settings. Additionally, the groups said, such policies should enable staff members to provide person-centered dementia care “based on a thorough knowledge of the care recipient and their needs, advance optimal functioning and high quality of life and incorporate problem-solving approaches into care practices.”

The organizations also urged the Aging Committee to support state dementia-related efforts by calling for any training curriculum to be delivered by knowledgeable staff members who have hands-on experience and demonstrated competency in providing dementia care, for continuing education to be offered and encouraged, and for training be portable, meaning that workers have the opportunity to transfer their skills or education from one setting to another.

Efforts to improve the quality of dementia care in three states are “instructive,” the Alzheimer’s Association and Alzheimer’s Impact Movement said, adding that they could provide the committee with additional examples on request.

• In Georgia, House Bill 987, signed into law in 2020, established memory care licensure and dementia training requirements for all direct care workers and all other staff members in memory care centers. Among other things, the law requires all assisted living communities and personal care homes that offer memory care to obtain a certificate to operate and to have at least one dementia-trained direct care staff member for every 12 residents during the daytime and one such staff member per 15 residents overnight, based on a monthly average. All staff members must undergo four hours of dementia training within the first 30 days of employment, and all direct care staff members must obtain at least 16 hours of specialized dementia training within their first 30 days of employment and eight hours of dementia training each year thereafter. The law specifies the topic areas to be covered in the training.
• In Indiana, Senate Bill 169, introduced in 2021, requires assisted living communities that provide memory care services to disclose their dementia-specific care, staffing levels and transfer/discharge policies. And Senate Bill 353, introduced in 2022, establishes dementia training standards for home health aides caring for people who are living with dementia, requiring three hours of annual continuing education about dementia and six hours of initial dementia training for newly hired individuals.
• In Pennsylvania, regulations updated in 2022 require skilled nursing facilities to provide dementia training as part of all staff members’ orientation.

Dementia Care Practice Recommendations detailed

The letter also detailed the Alzheimer’s Association’s Dementia Care Practice Recommendations for professional caregivers, released in 2018, which contain goals related to person-centered care; detection and diagnosis; assessment and care planning; medical management; information, education and support; ongoing care for behavioral and psychological symptoms of dementia, and support for activities of daily living; staffing; supportive and therapeutic environments; and transitions and coordination of services — and the letter relayed what assisted living communities “should” do based on the recommendations.

Regarding staffing, “[a]n adequate and well-trained workforce is fundamental to providing quality dementia care,” the organizations said, adding that, based on the workforce-related recommendations, assisted living communities should:

• provide a thorough orientation program for new staff members, as well as ongoing training;
• develop systems for collecting and disseminating person-centered information;
• encourage communication, teamwork and interdepartmental/interdisciplinary collaboration;
• establish an involved, car[ing] and supportive leadership team;
• promote and encourage resident, staff and family relationships; and
• evaluate systems and progress routinely for continuous improvement.

To maintain a strong dementia care workforce, the groups said, assisted living communities should:

• have staffing levels adequate to allow for proper care at all times, day and night;
• ensure that all staff members are sufficiently trained in all aspects of care, including dementia care;
• adequately compensate staff members for their work;
• provide a supportive atmosphere for staff members that appreciates their contributions to overall quality care, because improved working environments will result in reduced turnover in all care settings; and
• ensure that staff members have the opportunity for career growth.

“Additionally, we know that consistent assignment is an important component of quality care for staff working with residents with dementia,” the Alzheimer’s Association and Alzheimer’s Impact Movement said.

“We look forward to working with the Committee and other members of Congress in a bipartisan way to advance policies that will ensure individuals living with Alzheimer’s and other dementia have adequate access to high-quality assisted living and all long-term and community-based care services, especially as the population of Americans living with dementia continues to grow,” the letter concluded.

Read the letter here.

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Alzheimer’s Association calls for federal involvement to increase dementia care workforce, training in assisted living