Residents of private retirement (or assisted-living) homes have significantly higher rates of hospital-based healthcare service utilization, compared with patients receiving home care or living in long-term care (or nursing) homes, new data indicate.

In a population-based Ontario study, rates per 1000 person-months of emergency department visits, hospital admissions, days of alternate level of care (that is, less than full intensity of hospital care), and specialist physician visits were increased for residents of retirement homes in comparison with residents of long-term care homes. On the other hand, retirement home residents had approximately 92 fewer primary care visits per 1000 person-months, compared with residents of long-term care homes.

“Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes,” the authors write.

The study was published online May 30 in the Canadian Medical Association Journal.

Continuum of Care

Ontario’s continuum of settings for older adults includes publicly funded home care for independently living adults at one end and shared-cost, 24-hour long-term nursing home care at the other. Retirement homes, which offer congregate living with meals, social activities, and some supportive services, lie in between. Such retirement homes are predominantly privately funded and are operated on a for-profit basis.

Dr Derek Manis

Residents of these private facilities constitute an untapped population for research, study author Derek R. Manis, PhD, a health policy researcher at McMaster University in Hamilton, Ontario, told Medscape Medical News.

He and his colleagues examined Ontario health administrative data from 2018 to analyze the health of residents in retirement homes, a senior population that Manis considers underresearched. For outcomes, they focused on rates of emergency department visits, hospital admissions, alternate levels of care days, primary care visits, and specialist physician visits.

The retrospective cohort study identified 54,733 residents of 757 Ontario retirement homes (mean age, 86.7 years; 69.0% women) by matching the postal codes of individuals in the healthcare database to those of licensed retirement homes. The investigators also identified 2,354,385 residents in other settings.

Provincial healthcare data revealed that, compared with residents of long-term care homes, those identified as living in retirement homes had higher utilization rates per 1000 person-months of the following items:

• Emergency department visits: 10.62 vs 4.48 (adjusted relative rate [aRR], 2.61; 95% CI, 2.55 – 2.67)

• Hospital admissions: 5.42 vs 2.08 (aRR, 2.77; 95% CI, 2.71 – 2.82)

• Alternate level of care days: 6.01 vs 2.96 (aRR, 1.51; 95% CI, 1.48 – 1.54)

• Specialist physician visits: 6.27 vs 3.21 (aRR, 1.64; 95% CI, 1.61 – 1.68).

In contrast, the rate of primary care visits was significantly lower among participants living in retirement homes (16.71 vs 108.47; aRR, 0.13; 95% CI, 0.13 – 0.14).

Healthcare usage rates were also significiantly higher for residents of retirement homes in comparison with recipients of home care, but the relative differences were generally not as great as between residents of retirement homes and residents of long-term care homes.

An “Important Population”

Lack of regular access to primary care physicians may be the driving factor behind these results, according to the researchers.

The findings of his analysis were interesting, said Manis. “The real take-away message when we look at the characteristics of this population is that they are older, and there is descriptive evidence that they have a similar clinical profile to those in long-term care homes,” he told Medscape. In contrast, however, the latter have high rates of primary care utilization. “Policymakers need to be more invested in ensuring that older adults in these private facilities are receiving the primary care they need to keep them out of hospital.”

What would better planning look like? Manis said that in a model such as that for long-term care, these private facilities might have several physicians under contract to provide a set number of on-site visits per month. “Increasing access within the home itself would be an important first step,” he said.

“Assisted living in most US states and in Canada is outpacing the growth of nursing homes,” he added. “This is a very important population, and policy makers and scientists need to pay attention to it.” Policies should ensure appropriate primary and preventive care to avoid high rates of emergent care and hospitalization, he added.

“Timely and Excellent Paper”

Commenting on the study for Medscape Medical News, Paula Carder, PhD, a professor in the School of Public Health at Oregon Health and Science University and Portland State University in Portland, called it “a timely and excellent paper that fills a significant gap in our knowledge about the population of older adults who live in retirement homes.” She was not involved in the study.

Dr Paula Carder

According to Carder, the finding regarding hospital use indicates the lack of a formal support system, resulting in increased hospitalization among retirement home residents, compared with residents in licensed care settings. “This information can now be acted upon by health systems, housing operators, and policymakers.”

Dr Emmanuelle Belanger

Emmanuelle Belanger, PhD, an assistant professor at Brown University School of Public Health in Providence, Rhode Island, who also was not involved in the Canadian study, agreed that the analysis makes an important contribution toward understanding this senior population. But in terms of comparison with the US setting, she said, “It is difficult to draw a clear parallel beyond the fact that these represent private, long-term care settings that deserve more research to ensure that residents’ care needs are being met.”

The authors called for research to examine in more detail the reasons why this distinct population visits emergency departments or are admitted to hospital.

The study was supported by the Schlegel Chair in Clinical Epidemiology in Aging at McMaster University (the Schlegel family owns Schlegel Villages, a chain of long-term care and retirement homes), the Juravinski Research Institute, and the Ontario Ministry of Health System Research Fund. Manis, Carder, and Belanger have disclosed no relevant financial relationships.

CMAJ. Published online May 30, 2022. Full text

Diana Swift is a medical journalist based in Toronto. She can be reached at [email protected].

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