Assisted living is recognized as one of the fastest-growing components of the long-term care industry, with an increasing proportion of residents having diagnoses of Alzheimer’s disease and related dementias, according to presenters at the Gerontological Society of America 2020 Annual Scientific Meeting Online. 

Little is known, however, about assisted living quality, due to a lack of measures, they said last week. Poor staffing, inadequate teamwork and poor management are among the concerns that have been raised about assisted living communities, especially during the COVID-19 pandemic. The presenters reviewed efforts from two states — Oregon and Minnesota — to address quality in assisted living, new legislation and new metrics.

Minnesota Assisted Living Report Card

In 2019, concerns about assisted living prompted funding from the Minnesota Legislature for an Assisted Living Report Card. The goal of the project is for the Minnesota Board on Aging and the Minnesota Department of Human Services Aging and Adult Services Division to create a licensure for assisted living communities. Minnesota is one of the last states in the country to create such licensure.

Tetyana Shippee, Ph.D., an assistant professor from the University of Minnesota and first author on the paper “Identifying Domains of Assisted Living Quality for Minnesota’s Assisted Living Report Card,” discussed the results of the first two phases of the report card project.

The first phase of the project involved a national literature review of quality measures and technical advisory panels to identify nine quality domains and indicators for assisted living quality — resident quality of life, resident and family satisfaction, safety, resident health outcomes, staff, physical and social environment, service availability, core values and philosophy, care services and integration. 

The second phase focused on statewide stakeholder engagement to determine priority rankings for those domains and indicators relevant to Minnesota. There were 822 respondents to an online survey, 13 public presentations, 266 attendees during a statewide livestream event, and a focus group of four assisted living residents and one advocacy organization.

Shippee said quality of life, staff quality and resident safety were the top three domains identified across all stakeholder groups as important measures of assisted living. The lowest-rated domains of importance were physical environment and social environment, she said.

“The domains of quality were highly consistent across stakeholder roles,” Sippee said, adding that assisted living residents and advocacy focus group participants rated social and physical environment higher than those who participated in the survey and other outreach efforts. “Of note, residents placed more importance on the social environment than the physical environment alone.”

An advisory group was formed to provide input on different aspects of the report card development and implementation process. Through the end of the year, project work will include a pilot test of draft resident and family surveys, development of measures of quality based on the surveys and other data, and development of a report card website. Resident and family surveys are expected to be implemented in 2021. 

Minnesota resident quality surveys

Cathy Coddington, Ph.D., a senior researcher at Los Angeles-based consulting firm Vital Research, shared lessons learned with implementing the new tools and different aspects of the Minnesota Assisted Living Report Card development and implementation process, as well as survey findings. 

The Minnesot Department of Human Services and Vital Research, as well as the University of Minnesota, developed survey items and conducted analyses.

Survey items were developed from published literature and existing tools on assisted living quality and underwent testing with Minnesota stakeholders and cognitive testing with assisted living residents. Pilot-testing further identified changes to the satisfaction surveys. 

The main points of feedback, Coddington said, addressed the length of the survey, diversity of respondents and their levels of independence, survey administration and survey results. The pandemic suspended the project through June, she said, but resident and family phone calls resumed in July.

Key takeaways from those phone calls identified the challenge of phone interviews with the older adult population. Coddington said the original intent was to conduct in-person interviews, but the pandemic changed the mode of survey administration. 

The project now is in full-scale pilot-testing, with a goal of 400 completed surveys each from residents and families. Based on the phone interviews, researchers decided to mail surveys to residents with a postage-paid return envelope and included the option of completing the survey over the phone. Families will receive mailed surveys and have the option of using a URL and unique access code to complete the survey online. Pilot-testing results are not yet available.

Oregon Resident VIEW Project

Quality is defined in multiple ways by different stakeholders, including residents, regulators and informed observers. Diana White, Ph.D., a senior research associate at Portland State University, discussed a paper on “Quality in Assisted Living: Does It Lie in the Eyes of the Beholder?”

Resident VIEW (Voicing Importance and Experience for Well-Being) is a measure developed and validated by the Institute on Aging. The tool, funded by the Oregon Department of Human Services Quality Care Fund, aims to assess person-directed care from the point of view of residents.

At the center of the measure’s conceptual framework is personhood, or the recognition that each person is unique and worthy of respect. Five areas that affect the quality of daily life of residents include staff knowing the person, engaging in meaningful activity, relationships with staff, individualized care, and autonomy and choice. 

Researchers collected data from 241 residents living in 31 assisted living and residential care communities in Oregon regarding their overall satisfaction and satisfaction with their facility as a place to live and receive care. Deficiency citations from regular inspections by the licensing agency were used to provide a regulatory perspective.

White said the paper focused on the voices of residents from the VIEW tool, identifying what’s important to them and what they experience in person-centered practices, as well as measures of satisfaction and quality of life. There also were open-ended questions about the setting feeling like home, most important decisions made and how a community could be run better.

“The qualitative comments were helpful,” White said. “The comments demonstrate a sensitivity and awareness they need for residents struggling with loss of independence. The comments illustrate resident perceptions of their own needs relative to others in the community.”

Results showed that perceived quality varied by stakeholder. This variation suggests that efforts to make quality indicators publicly available should include multiple measures and perspectives, especially residents.

Immediate next steps include continued data analysis to explore other voices related to quality. Future research will focus on the state’s Quality Measurement Council, quality improvement intervention studies, longitudinal research and multistate research.