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Addressing long-term care’s “dark matter”


Toronto, ON, August 8, 2023 — Two new ICES studies shed light on the rapidly expanding population in assisted living and finds that residents have the highest rates of emergency department (ED) visits and hospitalizations compared to community-dwelling older adults.

There was a 34% increase in the resident population size of assisted living facilities in Ontario from 2013 to 2019, according to a recently published study in the Journal of the American Medical Directors Association (JAMDA). Women accounted for nearly two-thirds of the population across all years.

Assisted living communities range from stand-alone residences to lower levels of care offered within larger residence or retirement villages. Assisted living is designed to meet the needs of older adults who desire aging-in-place services, as opposed to twenty-four-hour care provided by long-term care facilities.

“Canadians are living longer and prefer to age-in-place, but they’re also facing significant health challenges and barriers to adequate healthcare,” says lead and corresponding author Derek Manis, Assistant Professor at Arizona State University and post-doctoral fellow at ICES. “There is an urgent need for improved access to primary care for these older adults to reduce strain on emergency and hospital-based services.”

“We often call this the “dark matter” of long-term care, because this is the population of older adults that is growing the fastest but is the least visible” says senior author Andrew Costa, adjunct scientist at ICES, and Schlegel Research Chair in Clinical Epidemiology & Aging and associate professor of the Department of Health Research Methods, Evidence, and Impact at McMaster University. “Residents in assisted living communities are dealing with complex clinical health needs that are not being met with adequate services.”

Previous evidence shows that residents of assisted living have fewer visits with a primary care physician and less continuity of care, which can increase the reliance on emergency services. In a second JAMDA paper, the research team calculated rates of ED visits, hospital admissions, and alternate levels of care (ALC) days (defined as the number of days that an older adult remained in hospital when they could not be safely discharged). They included community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada from January, 2013 to December, 2019.

There were 136,655 older adults living in assisted living facilities and nursing homes in 2013, and 152,900 in 2019. Residents of assisted living facilities were older (average age of 86), and they also had the highest number of people with heart failure, cardiac arrhythmias, and osteoporosis.

The researchers also found that residents of assisted living facilities have the highest rates of ED visits, hospital admissions, and ALC days, and these rates consistently increased over the study period.

One limitation of the study is that researchers could not account for the scope of privately-secured health services for any older adult population, which may have led to an underestimation of the intensity of health service utilization in assisted living facilities.

Taken together, the findings from both studies underscore the healthcare needs of a growing population, which requires significant expansion of infrastructure and services to meet the needs and preferences of older adults. This is especially important for those with lower financial security and limited ability to access aging-in-place services.

The study “Rates of hospital-based care among older adults in the community and residential care facilities: a repeated cross-sectional study,” was published in the Journal of the American Medical Directors Association (JAMDA).

Author block: Manis DR, Katz P, Lane NE, Rochon PA, Sinha SK, Andel R, Heckman G, Kirkwood D, Costa AP.

ICES is an independent, non-profit research institute that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. For the latest ICES news, follow us on Twitter: @ICESOntario


Misty Pratt
Senior Communications Associate
[email protected]

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