This content origi­nally appeared in the Spring/​Summer 2020 issue (PDF) of The Washington Nurse magazine. See the full set of stories on long-term care.

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Pamela Pasquale, MN, RN

Long-term care covers many different care settings, including skilled nursing, assisted living facil­i­ties and adult family homes. It is a sector that continues to grow as people look for commu­nity-based options that meet their medical care and assisted living needs. And the need for long-term care is only expected to grow. The U.S. Congres­sional Budget Office estimates that by 2050, one-fifth of the total U.S. popula­tion will be 65 or older, up from 12% in 2000 and 8% in 1950.

As of January 2020, the Washington State Depart­ment of Social and Health Services’ roster of licensed commu­ni­ties included 209 skilled nursing facil­i­ties, 540 assisted living facil­i­ties and 3,135 adult family homes. Together, they serve more than 67,000 people.

Without skilled, profes­sional nurses, alter­na­tive care commu­nity options would not be successful.

In 2018, the Washington Center for Nursing and the Univer­sity of Washington Center for Health Workforce Studies conducted a survey with the goal of identi­fying practice areas and RN attitudes. The report focused on the approx­i­mately 63,122 RNs who were actively employed and practiced in Washington state. They found that nearly 12% worked in long-term care, which included assisted living facil­i­ties, home health, hospice and nursing home/​extended care.

Credit: Washington Center for Nursing, “Washington State’s Registered Nurse Workforce: Results of a 2018 Survey

Skilled nursing #

Most residents living in skilled nursing commu­ni­ties require direct nursing super­vi­sion because of complex health care related to multiple medical issues. In addition, according to the National Center for Health Statis­tics, 47.8% of nursing home residents were diagnosed with Alzheimer’s disease or other dementia. Skilled nursing care is highly regulated, and nurses must assure that licensing require­ments are met. The nurse’s role includes exten­sive multi-system assess­ments and documen­ta­tion of medical and social, memory loss and mental health behavior as well as skin health and falls. RNs oversee care staff and coordi­nate with health care providers, discharge planners/​case managers and commu­nity partners. Resident needs may include wound care, IVs, injec­tions, rehab, dialysis and hospice care. Nurses also oversee infec­tion control, care staff CE and immuniza­tions. Nurses must be present 24 hours a day.

Assisted living communities #

Today, most assisted living commu­ni­ties offer an exten­sive menu of personal care services as well as health manage­ment. Commu­ni­ties devoted to seniors with memory loss are common throughout the state. Regis­tered nurses and LPNs are now neces­sary to oversee services to assure the safety and appro­priate care of commu­nity residents, and assisted living regula­tions have become complex. As the primary medical staff, nurses need compre­hen­sive assess­ment skills and a current medical knowl­edge base in order coordi­nate complex resident medical needs. Nurses interact daily with commu­nity providers, health care providers, discharge planners/​case managers and commu­nity partners. They coordi­nate with hospital case managers and discharge planners; individual resident health care providers; and home health, hospice and pallia­tive care workers to allow residents to stay in their familiar surround­ings with support.

Adult family homes #

Adult family homes are licensed for up to six persons. The number of homes has grown substan­tially since 1995. A nurse may own one or several adult family homes and there­fore can coordi­nate care similar to assisted living nurses although the majority of these homes do not have a licensed person who owns them or is the manager of record. With up to six residents, adult family home care can be more individ­u­al­ized, especially for residents with memory loss. Residents have the same complex health care issues as with other commu­nity settings.

Regis­tered nurse delega­tors are an integral part of this system, and practice is regulated under Washington State law. The RN delegator visits the home frequently to assess residents for any medical changes and train caregivers to provide for those care needs within their licen­sure. The RN delegator constantly updates assess­ments and individual care plans as health care needs evolve.

Home care #

Home care agencies employ RNs for hourly care, either paid privately or by insur­ance. Skilled home health services include wound care, patient and caregiver educa­tion, intra­venous or nutri­tion therapy, admin­is­tra­tion of injec­tions and monitoring serious illness and unstable health status. One such agency provides hourly care to pediatric popula­tions who are on venti­la­tors or have multiple complex care needs requiring almost hourly super­vi­sion to prevent compli­ca­tions and ongoing family or caregiver training.

WSNA Community-Based and Long-term Care Nurse Practice Task Force #

This specialty task force was approved by the WSNA Board of Direc­tors in 2018 to shine a light on the work being done by our regis­tered nurse colleagues in this growing sector. Goals for the task force include the following:

Identify and address issues of impor­tance to nurses working in long-term care settings.

Increase aware­ness within WSNA and the broader nursing commu­nity about the oppor­tu­ni­ties of working in long-term care as a viable employ­ment opportunity.

Strengthen the transi­tional care processes between acute care settings and LTC commu­nity-based settings, consid­ering the respec­tive roles and respon­si­bil­i­ties of acute care and LTC nurses.

Work with the Washington State schools of nursing to better integrate LTC/​skilled nursing care practice into the curriculum.

Current task force members repre­sent educa­tion, manage­ment, LTC practice, ER nursing and policy. To draw in a broad spectrum of views and experi­ence, task force members are not required to be WSNA members.

Would you like to be a part of this work?

WSNA is seeking additional members of the Commu­nity-Based and Long-Term Care Task Force. To express your interest, email Sally Watkins at