Creating a Typology of Health Service Regulation in Assisted Living

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Health Services Research

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Research Objective

State agencies regulate Assisted living (AL), with a high level of within-state variation in licensing and certification approaches. Differences between licenses within and across states can reflect differential access to health services and differences between resident populations by licensed setting type. We set out to develop an empirically driven typology of regulatory provisions for health service provision in AL residences and to use the typology to describe the prevalence of types of health service regulations within and across states. Furthermore, we designed this typology to facilitate future analyses of AL resident characteristics and outcomes across the regulatory approaches.

Study Design

In our earlier work, we analyzed and summarized regulatory requirements by AL license. We used this data to develop a typology using a mixed-methods approach. We took an explanatory typology approach, as described by Elman, to identify thematic dimensions and regulatory domains describing the scope of health services regulated in AL settings. Then, we used our existing data to create a specificity score for each of the five dimensions and each of the 350 license types. Finally, we conducted a k-means cluster analysis to identify groups of license types with a similar combination of dimension values.

Population Studied

Our analysis included the regulations licensing AL for the 50 states and Washington DC.

Principal Findings

We identified five dimensions of health service regulation in AL which vary across states and license types. These dimensions describe whether each license: requires medication review, requires licensed nurse staffing, allows third party end-of-life care, allows skilled nursing, and allows medication administration. Using these dimensions and our existing dataset, we found six clusters of regulatory approaches to licensing health services in AL. We can describe each cluster with a distinct combination of high, mid, or low specificity in regulating each of the dimensions.


To understand variation, our team developed a typology of health services regulated by states across licensed AL environments. Between 11 and 15 states utilize each of the six clusters as an approach to licensing assisted living. We can now use these clusters of regulatory approaches in future research to both investigate the differences between these approaches and use these clusters as analytic groupings that may be more meaningful than grouping by state or geography.

Implications for Policy or Practice

These approaches to regulating health service provision in AL reflect how state policymakers and rule-makers conceive of these different settings, and also how operators have chosen from the available licensing options. By grouping these licenses according to how prescriptive their regulations are for each of the identified dimensions, we have constructed types of AL licensing that can be used analytically. This typology of health services may better differentiate between types of regulated AL, allowing for more nuanced analyses that take into account within-state variation.


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