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This report was prepared under contracts #HHS-100-94-0024 and HHS-100-98-0013 between the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging, and Long-Term Care Policy (ASPE) and Research Triangle Institute. In addition to ASPE, other support for the study, A National Study of Assisted Living for the Frail Elderly, has been provided by the American Association of Retired Persons, the Alzheimer's Association and the National Institute on Aging. For additional information about the study, you may visit the DALTCP home page at http://aspe.os.dhhs.gov or contact the ASPE Project Officer, Pamela Doty, at HHS/ASPE/DALTCP, H.H. Humphrey Building, Room 424E, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: pdoty@osaspe.dhhs.gov.The views expressed in this report do not necessarily reflect the view of any of the sponsoring organizations.
The most rapidly growing form of senior housing in recent years has been a form of supportive housing or residential long-term care known as assisted living. This growth has been a response to several factors, including the aging of the population, the preferences of the elderly for settings other than nursing homes, the availability of private financing for development and construction of assisted living facilities (ALFs), and public policies aimed at containing use of nursing homes.
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This report presents data on 41% of the ALFs nationwide and on the residents and staff in those facilities. These are the facilities among all ALFs that offer the highest levels of services and privacy. |
The Office of the Assistant Secretary for Planning and Evaluation (ASPE), in the U.S. Department of Health and Human Services, has a long-standing interest in the ability of residential and community-based service providers to meet the needs of the elderly and people with disabilities. As a result, ASPE has funded several studies of residential long-term care, including this first national study of ALFs for the frail elderly. ASPE's interest in assisted living and its ability to meet the needs of the frail elderly has been heightened during the study by a series of reports and a Congressional hearing that raised concerns about quality and consumer protection in assisted living (U.S. General Accounting Office, 1997 & 1999).
Despite growing interest and a rapidly expanding industry, the knowledge base available to those interested in assisted living is quite limited. Most prior and on-going research has been confined to a relatively small number of facilities and states. However, this study, A National Study of Assisted Living for the Frail Elderly, is based on data collected in a nationally representative sample of ALFs. Several reports based on the data collected about these facilities are available, and each provides data on a sample that is representative of a nationwide universe of ALFs, residents and staff. Those reports include:
This report is the second of those mentioned above. It reports data on a nationally representative sample of residents and staff in ALFs classified as providing relatively high services or offering a high privacy environment. These facilities, which comprise about two-fifths (41%) of the places calling themselves assisted living, were selected for more extensive and in-depth data collection because they seemed to most effectively exhibit key elements of the philosophy of assisted living.
The national population of ALFs sampled for this study included only certain types of residential care settings. The population included all residential care facilities with 11 or more beds that primarily served the frail elderly and that publicly represented themselves as providing assisted living. It also included facilities that did not specifically identify themselves as assisted living but that appeared on some listing of residential care providers and met study criteria for size, mission, privacy and service.1 A telephone survey of a national probability sample of such facilities, representing nearly 11,500 facilities across the nation, formed the basis for our first study report (Hawes, Rose, & Phillips, 1999a and 1999b).
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Distribution of ALFs Nationwide and Those Included in This Report |
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High Services |
Low Services |
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High Privacy |
11% of all ALFs IN |
18% of all ALFs IN |
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Low Privacy |
12% of all ALFs IN |
59% of all ALFs EXCLUDED |
As noted, this report focuses on a subset of two-fifths (41%) of the original sample. The facilities in the original sample were divided into groups, based on the level of privacy (i.e., high and low/minimal) and the level of service (i.e., high and low/ minimal) that they provided. An explanation of the way in which these groups were defined is discussed in detail in Section II of the report. Facilities in three of these groups (i.e., high service & high privacy, high service & low privacy, low service & high privacy) were chosen for further study through site visits that included more detailed data collection. The site visits included interviews with facility administrators, staff, residents, and family members, as well as a "walk-through" evaluation of the facility environment. The 300 facilities involved in the site visits represented a population of 4,383 ALFs across the nation -- or all those that met the definition of a facility that offered either high services or high privacy.
ALF Residents. The residents in the high privacy or high service ALFs were largely white, widowed females, who were quite elderly. More than one-half of the residents were 85 years of age or older. ALF residents were relatively well-educated; 45 percent had completed at least some college. They were also relatively affluent. Most entered assisted living from their own home or apartment (70%) and made the decision with help from someone else (90%), almost always their adult children. However, one-quarter of residents indicated that they had little or no control over the decision to enter a facility.
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ALF RESIDENTS
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Over one-quarter (27%) of the residents suffered from moderate or severe cognitive impairment, one-half of residents (51%) received assistance with bathing, and one-fifth of residents received assistance in some other activity of daily living. The overwhelming majority (77%), however, received help with their medications, and many residents used assistive devices, especially to help with ambulation or locomotion. Almost one-third (32%) experienced urinary incontinence. Two-fifths of the residents considered themselves in only fair or poor health, and, in the year prior to their interview, they used inpatient services at rates much higher than the general population.
Residents were relatively satisfied with the attitudes of staff and how staff treated them (e.g., with respect and affection). Their greatest points of concern about staff were related to inadequate staffing levels and high staff turnover. Residents were split almost evenly in their perceptions of the availability of activities they enjoyed and on the availability of transportation to events they might enjoy. One of the more unsettling findings concerning activities was that almost three-fifths of the residents (59%) indicated that ALF staff never or only sometimes asked them about their activity preferences.
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RESIDENTS' PERCEPTIONS
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Assisted living residents in ALFs classified as providing high services or high privacy were almost equally likely to be found in accommodations consisting of a full apartment or only a bedroom. The majority (81%) had a private living space or shared it with a related individual; however, nearly one-third of the residents did not have a private full bathroom. Most residents (i.e., more than three-quarters) also had other types of autonomy over their environment, such as ability to lock their doors, furnish their apartments and arrange the furniture as they wished, and control the temperature in their room or apartment. Only about half, however, had a refrigerator and only about one-third had space for cooking. Most had access to key supportive devices, such as call buttons and safety railings in the bathroom.
When they needed temporary nursing care, they were most likely to receive it from the facility staff; however, one-third of the residents who needed such care were either discharged to a hospital or nursing home or, with family members, arranged for home health themselves. Finally, fewer than one-third of the residents reported being informed by the facility about the discharge and retention policies. Despite this, the vast majority of residents expected to be able to stay in the facility for as long as they wished.
ALF Staff. The project investigated facility staff's knowledge of the appropriate response in a variety of situations involving relatively common health problems among frail older persons. In many instances, the vast majority of staff was aware of the proper response to specific situations, including most medication management issues. On the other hand, a significant number of staff members were poorly informed about antipsychotic drugs and some issues related to the care of individuals with dementia. More troubling, the majority of staff members were almost completely unaware of what constitutes normal aging. Given the goal of enabling residents to age in place and the advanced age of current residents, these results are particularly disquieting. Poor training and knowledge in these areas may in the future become more and more troublesome and risky, both for providers and residents, since many of the conditions staff identified as a "normal part of aging" were potentially treatable and reversible.
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STAFF
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Most staff in the high privacy or high service ALFs reported relatively high levels of satisfaction or positive affect toward their working conditions. Two areas, however, were a concern or area of low satisfaction for most staff. The first was their pay level, which usually ranged from between five and nine dollars per hour for personal care attendants. They also expressed dissatisfaction with what they viewed as limited possibilities for advancement.
Personal care staff did not report their workload as overly heavy, and the median number of residents for whom they cared was fourteen.2 In a nursing home this level of staffing would cause concern for some experts. However, as discussed above, the ALF residents were not as impaired as nursing home residents. At the same time, the survey demonstrated that most direct care staff in ALFs also had responsibility for a variety of tasks in addition to direct resident care, including housekeeping, laundry, and meal service. This complicates any attempt to evaluate the adequacy of staffing levels or compare them to those in other settings.
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The median ratio of direct care
staff to residents was 1:14; however, these staff,
particularly the PCAs typically were responsible for tasks
such as laundry, housekeeping, and meal service, in addition
to direct resident care. |
Walk-Through Observations. The observers' judgments about the physical plant in assisted living facilities indicated that these settings were largely well-maintained, clean, relatively homelike settings for the frail elderly with a wide range of social and recreational resources. Most were in suburban areas, and nearly half (46%) were single story buildings.
Facilties, Administrators, and Staffing. Assisted living facilities were almost equally likely to be operated by for-profit as by not-for-profit entities. However, the vast majority (79%) of organizations that owned or operated the high service or high privacy ALFs were involved in the operation of other types of supportive housing for the elderly, such as nursing homes and congregate apartments. Almost two-thirds (64%) of the not-for-profit ALFs, for example, were located on a multilevel campus that housed various types of supportive housing for the elderly, including a nursing home. Indeed, nearly half (49%) the owners of all of the high service or high privacy ALFs owned or operated nursing homes, and nearly half (46%) of these ALFs were part of a multi-facility system or "chain" of assisted living facilities.
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Facilities showed some variation in the level of functional limitations and cognitive status among their residents. In most ALFs, relatively few residents had significant functional limitations and care needs. In most ALFs, assistance with medications was the only area in which they reported most residents needing and receiving help. However, approximately 15 percent of ALFs seemed to have a substantial proportion of residents with somewhat heavier physical care needs, such as need for help with transfers and other middle-range and late loss ADLs. Administrators also reported fairly high "turnover" rates among residents, with an average annual rate of 41 percent of the residents each year.
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Administrators reported an annual turnover rate for residents of 41%. |
Staffing varied considerably across facilities. According to administrators, on first shift, one-quarter of the ALFs had direct care staff to resident ratios of 8-to-1 or lower, and another quarter had ratios of 16-to-1 or greater. (In evaluating these reports, it is important to remember that the personal care attendants (PCAs) reported very different staffing ratios, with a median of 1-to-14 and one-quarter of the PCAs reporting that they cared for 23 or more residents). While staffing ratios varied considerably, there was some consistency across ALFs in the types of staff used. For example, the sampled ALFs that were site visited almost universally utilized some licensed nursing services. Staff turnover was lowest among licensed nursing staff, but administrators estimated that roughly one-quarter of all direct care staff turned over during the course of a year.
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FACILITIES
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The most common basic monthly charge in the high privacy or high service ALFs was between $1,735 per month and $19,990 -- or an average of about $1,800. However, because of the diversity among ALFs in the number and types of services included in that base rate, one is not quite sure what that sum purchased. For example, relatively few facilities (36%) provided temporary nursing care as part of their base monthly rate, while a substantial majority (80%) provided planned recreational activities. For those residents who exhausted their funds paying at this level, many facilities were willing to accept payments from alternative sources if they were available (e.g., charity, SSI, Medicaid). However, policy in a substantial proportion of facilities (45%) required the discharge of those who exhausted their private financial resources.
There are a number of policy issues surrounding the emergence and growth of assisted living and its ability to help meet the long-term care needs of the elderly and disabled. This report begins to address some of these by focusing on only those facilities that seem to most closely embody the philosophical tenets of "assisted living." Thus, the report describes the facilities that offer either high privacy or high services -- or both -- and their policies and practices, particularly with respect to services, policies on autonomy and resident control, and staffing. Further, this report describes the characteristics of the residents and their perceptions about the care they receive and the environment of the facilities in which they live. In providing this descriptive data, we begin to address questions about the role and performance of assisted living facilities and their place in the constellation of long-term care services. We also attempt to relate the descriptive data to the central study questions about whether ALFs embody the principles of assisted living and whether the needs of residents are being met. These issues are discussed at length in Section VII on conclusions. Finally, it is important to note that even in this special subgroup of ALFs, there was tremendous variability in ownership, size, staffing, policies, and performance along key dimensions.
In conclusion, assisted living appears to offer an important type of residential long-term care setting for persons with mild or moderate disabilities who cannot safely or securely live alone but do not need the level of care provided in a nursing home. Further, the high privacy or high service ALFs provide this care in a setting that has many components valued by consumers, particularly in terms of privacy and environmental autonomy. In addition, most high service or high privacy ALFs offered a wide array of services. The issue of whether such services can meet residents' unscheduled needs is more complex. Moreover, the degree to which such facilities enable residents to age in place is clearly mixed unless one limits the concept to one of "aging in place without significant decline in physical or cognitive functioning." Finally, assisted living is still a largely private-pay sector and, among the high service or high privacy ALFs, one that is largely unaffordable for most moderate and low income older persons unless they spend down their assets or receive help from relatives.
The last decade has seen the emergence and growth of a new industry known as assisted living. Consumer demand, concerns about nursing home quality, pressure from providers, and the availability of capital for construction and conversion have combined with states’ interest in containing long-term care costs to produce dramatic growth in this industry. Initially, this development was largely an unregulated market response to both demographic trends and consumer preferences. More recently, however, state involvement in setting standards and developing Medicaid payment policies for assisted living has expanded exponentially (Mollica, 1998). Despite this, there is tremendous variability among facilities known as assisted living (ALFA, 1998; Gulyas, 1997; Hawes, Rose & Phillips, 1999; Hodlewsky, 1998). Further, relatively little is known about the assisted living industry and its residents. This dearth of information is problematic, given the rapid growth of the assisted living industry, its increasingly prominent role in providing long-term care for the frail elderly, and the largely uncritical enthusiasm for assisted living that has dominated the policy process.
Because of the promise of assisted living, its rapid growth, and the lack of broadly generalizable information about the industry and its performance, the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) has funded a number of studies to examine the role of residential care and its newer incarnation, assisted living. The current ASPE study is known as A National Study of Assisted Living for the Frail Elderly.
The “graying” of the American population represents a major public policy challenge, particularly given estimates that the number of elderly needing long-term care will double to 14 million over the next two decades (US-GAO, 1999). Some commentators liken the effects of this trend on public expenditures for social and health services to the development of a “fiscal black hole” (Callahan, 1987). As a result, there have been a number of private and public sector responses to meeting this growing need for long-term care (Harrington, Dunah and Carillo, 1994; Williams & Temkin- Greener, 1996). The most dramatic response in the long-term care sector has been the emergence and growth of facilities known as assisted living (American Seniors Housing Association [ASHA], 1998; Citro & Hermanson, 1999; Mollica, 1998). For the last several years, assisted living residences have dominated new construction of housing for seniors3 (ASHA, 1998). Indeed, one-third of facilities that call themselves “assisted living” have been in business for five or fewer years, and 60% have been in operation for ten or fewer years (Hawes, Rose & Phillips, 1999).
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Assisted living dominates new construction in the area of senior housing with supportive services. |
The key elements or philosophical tenets of assisted living are based on the premise that assisted living’s goal is to meet customers’ “scheduled and unscheduled” needs, promote independence, autonomy and dignity among consumers, and enable residents to age in place in a home-like environment (Assisted Living Quality Coalition4, 1998; ALFA, 1998; Gulyas, 1997; Hodlewsky, 1998; Kane & Wilson, 1993). This philosophy is typically translated into an operational definition of an assisted living facility (ALF) as one that provides or arranges at least the following: 24-hour staff, housekeeping, at least two meals a day; and help with at least two activities of daily living (ADLs).5 There is less agreement among members of the industry on the environmental characteristics of assisted living; however, privacy is typically considered a key element of assisted living (Assisted Living Quality Coalition, 1998; Citro & Hermanson, 1999; Gulyas, 1997; Hodlewsky, 1998).
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Most definitions of assisted living include 24-hour supervision, housekeeping, meal preparation, and some level of personal care. |
It has been difficult to arrive at a precise estimate of the number of ALFs in the U.S. for three reasons. First, there is no federal regulation and thus no national listing of facilities. Second, definitions vary across states and because of this, it is often difficult to distinguish assisted living from other types of housing with supportive services, such as board and care homes, personal care homes, and other types of residential care facilities. Third, some states do not license ALFs that consist of apartments. As a result, many estimates include a multitude of different types of facilities, some of which do not meet the common conception or definition of assisted living. For example, the Assisted Living Federation of America (ALFA) estimated that there were more than 40,000 ALFs nationwide in 1998 (ALFA, 1998; Citro & Hermanson, 1999). However, this estimate appears to have included small board and care homes, as well as other facilities.
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Using the study definition, there were an estimated 11,500 ALFs with more than 611,000 beds at the beginning of 1998. |
As part of this study, A National Study of Assisted Living for the Frail Elderly, project staff developed a more explicit definition of assisted living and created a sampling frame from which a national probability sample of ALFs was selected. This operational definition limited ALFs to those facilities that served the elderly, had more than ten beds, had no rooms shared by three or more residents, and either advertised themselves as assisted living or provided key services, including assistance with two or more activities of daily living.6 By this definition, as of the start of 1998, there were an estimated 11,500 ALFs nationwide with more than 611,000 beds7 (Hawes, Rose & Phillips, 1999). As a point of comparison, there were an estimated 17,000 nursing homes with 1.6 million beds in 1996 (Krauss et al., 1997).
While assisted living initially developed in the U.S. largely in the absence of regulation or public financing, states have more recently moved fairly rapidly to develop and implement assisted living regulations.8 The first licensure regulation specifically directed at assisted living was passed in Oregon in 1989. By 1992, fewer than 10 states had such regulations in place (Mollica & Snow, 1996). By 1998, however, 30 states had passed legislation or issued regulations. Other states were considering draft regulations or revising their regulations, and 35 states reimbursed or planned to reimburse services in assisted living or board and care facilities as Medicaid-covered services (Mollica, 1998). This includes both Medicaid waiver programs and more aggressive use of payments for Medicaid personal care services (Harrington et al., 1994; Mollica, 1998).
In addition to creating new licensure categories and expanding Medicaid waiver programs, many states began allowing higher levels of care to be provided outside nursing homes. For example, by the mid-1990s, the majority of state licensing agencies allowed ALFs to house residents who were chair-fast because of health problems or who used wheelchairs to get around inside the facility. One-third of the licensing agencies allowed such facilities to retain residents who were bedfast (Hawes, Wildfire & Lux, 1993). Some states also embarked on more aggressive strategies for expanding the potential role of ALFs. These strategies included:
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Public payors see assisted living as a potential substitute for more expensive nursing home care. |
Despite this growth in state policy activity, no consensus has emerged on the appropriate regulatory model for assisted living. Some state policies sought to create assisted living as a unique arrangement, with distinctive environmental features (e.g., requiring that ALFs provide apartments with kitchens). Other states differed on whether regulation should even address the housing component or should be limited to only the service component, in effect treating assisted living as a kind of “home health” service. Some states allowed ALFs to provide daily nursing care, while others explicitly prohibited such services -- requiring facilities to arrange for the provision of these services through home health agencies. Still other states subsumed assisted living under their traditional board and care home regulations (Mollica, 1998; Mollica & Snow, 1996).
Despite variations in regulations, it is clear that most states intend to encourage the growth of assisted living and other forms of residential care. Indeed, it appears that some states have substituted residential care beds for nursing home beds in their long- term care system (Hawes et al., 1995b). In part, public payors have grown interested because some research has found that housing with supportive services might be a cost-effective alternative to nursing homes (Lawton, 1976; Mor, Sherwood & Gutkin, 1986). For example, one recent study suggested that use of assisted living for patients with Alzheimer’s disease and other dementias could reduce nursing home utilization and reduce Medicaid costs by an estimated $2,000 per person per month (Leon, Cheng, & Neumann, 1998).
In the view of many observers, assisted living represents a promising new model of long-term care that blurs the sharp and invidious distinction between nursing homes and community-based long-term care and reduces the chasm between receiving long-term care in one’s own home and in an “institution.” In addition, ALFs are thought to provide (or be capable of providing) a range of long-term care services that makes them a viable but less institutional alternative to nursing homes (Kane & Wilson, 1993; Mollica & Snow, 1996; Wilson, 1993).
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The current study provides the only data drawn from a nationally representative sample of ALFs. |
Despite the promise of assisted living, its rapid growth, and expansion of state policy in the area, there is relatively little empirical information about this new sector of the health care system. First, there have been few studies of residential care and practically none of assisted living. Second, previous assisted living studies have been limited to facilities in a single state or a few states. These studies include work in California (Newcomer, Preston & Broderick, 1995; Newcomer, Lee & Wilson, 1997); Oregon (Rosalie Kane, personal communication, 9/1/99); Washington (Susan Hedrick, personal communication, 9/1/99 ) or in a few states, such as Maryland, North Carolina, Georgia, and New Jersey (Philip Sloane & Sheryl Itkin Zimmerman, personal communication, 9/1/99). This is a serious limitation of the previous research. As noted above, there is tremendous variation across states in the way assisted living is defined, in the services ALFs are allowed to provide, and in the residents ALFs may serve. Thus, there is variation across states and communities in the relationship between assisted living and other parts of the health and long-term care systems.
This report is the third in a series of planned reports based on data collected from a survey of a national probability sample of ALFs. These data were collected as part of a study, "A National Study of Assisted Living for the Frail Elderly." This study was initiated and funded by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). Additional support for the project has been provided by AARP, the Administration on Aging (AoA), the National Institute on Aging (NIA), and the Alzheimer’s Association. Other reports produced during this study include surveys of state licensing agencies (Mollica, 1998; Mollica & Snow, 1996), interviews with developers (Manard & Cameron, 1997); a report on a telephone survey of a national probability sample of ALFs (Hawes, Rose & Phillips, 1999a and 1999b); and a report on a sample of discharged residents (Phillips, Hawes, Spry & Rose, 2000). One more report is forthcoming: a report on the effects of different privacy and service arrangements on such issues as resident satisfaction, aging in place, and affordability.
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This study is part of an ASPE research agenda that has evaluated the effect of growth and changes in residential care in the U.S. for almost two decades. |
ASPE has a long-standing interest in the potential for housing with supportive services, including board and care homes and ALFs, to meet the needs of aged and disabled persons for residential long-term care services. As noted earlier, since the early 1980s, ASPE has commissioned a number of studies aimed at increasing both the depth and breadth of the knowledge base for policy-making in this area.
This report presents information gathered in site visits to a nationally representative sample of 300 ALFs. These are ALFs that provided either a high level of privacy in accommodations or a high level of services or both high services and high privacy. This sample of facilities is a sub-sample of the original sample of all ALFs developed for The National Study of Assisted Living for the Frail Elderly (Iannacchione, Byron, Lux, Wrage & Hawes, 1999). Analysis of information on the entire sample of facilities was presented in an earlier project report (Hawes, Rose & Phillips, 1999). The sample of facilities included in this report is a sub-sample of those ALFs in the original sample that provided a level of privacy or services that the research team considered consistent with the basic philosophy of assisted living.9 Thus, the report provides generalizations only to the 41% of the full sample of ALFs nationwide that met the study criteria for providing high privacy or high service (or both).10
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This report provides information on a small sub-sample (41%) of all ALFs -- those that provide either a relatively high level of services or a high level of privacy or both high services and high privacy. |
The report provides information on this special group of ALFs in the following structure:
This section of the report presents the eligibility criteria used for ALFs included in the overall study, as well as the criteria used to select a subset of ALFs for site visits. This section also describes the criteria and process used to determine whether an ALF provided high services or high privacy or both. Finally, this section describes the process of data collection in interviews with administrators, other staff, residents and, for some, their family members, and through a structured observation of conditions in the facility by project staff. A more detailed description of the study methods in terms of sampling design and data collection may be found in other project reports (Ahlen & Major 1999; Iannacchione et al., 1999).
The National Study of Assisted Living for the Frail Elderly considered residential care facilities eligible for inclusion in the study only if they met certain criteria. In order to be eligible, a facility had to be operating in the United States at the time of the initial sample frame construction in late 1997 and the telephone eligibility screening and data collection (late 1997 and early 1998). To be identified as eligible, an ALF also had to:
1. Serve the elderly2. Have 11 or more beds; AND
3a. Be a “self-proclaimed” ALF, that is, a facility that referrred to itself as an ALF or advertised itself as providing “assisted living;”
OR
3b. Be a residential care facility that, at a minimum, offered (provided or arranged) certain key services, defined as: at least two meals, 24-hour staff, housekeeping, and assistance with at least two of the following: medications, bathing, or dressing.
The study excluded facilities with fewer than 11 beds for three reasons. First, we expected the majority of these very small facilities to be board and care homes that did not serve the elderly or did not provide the level of care and services commonly associated with assisted living. Previous studies of the board and care industry (Hawes et al., 1995a; Hawes et al., 1995b) indicated that very small facilities were more likely than larger homes to serve a younger population with developmental disabilities or chronic mental illness. They were also much less likely to make a wide array of services available to residents and much less likely to have a nurse on staff. Thus, including small facilities in the sampling frame would have contributed to a large number of ineligible facilities being found during the screening calls. Second, in practice, there were not many places with fewer than 11 beds that referred to themselves as assisted living. For example, in Oregon, which had a specific licensure category called assisted living and which allowed licensure of places with fewer than 10 beds, there were no facilities constructed that were that small. Thus, it seemed unlikely that otherwise “eligible” facilities would be eliminated simply because of the study’s size criterion. Third, including the small homes would have meant basically re-examining many issues that were addressed in an earlier study of the board and care industry (Hawes et al., 1995a) and would, in many ways, have duplicated that effort.
The study also excluded places that did not serve the elderly, places licensed for only special populations (e.g., persons with developmental disabilities), and places licensed only as nursing homes. (Long-term care campuses that housed eligible ALFs and a nursing home or other residential setting was eligible).
In order to determine whether a place met our study eligibility criteria, project staff created a list of places believed to be assisted living or similar residential care facilities in 60 geographic areas known as First Stage Sampling Units (FSUs). As noted above, greater detail about this process can be found in the project’s sampling report (Iannacchione et al., 1999). A sample of these facilities was selected, and project staff conducted telephone interviews with the administrators. The report on these interviews describes the general nature of the assisted living industry (Hawes, et al., 1999). Some of the information from these telephone interviews was used to identify facilities that were eligible for additional data collection.
After interviewing facility administrators in the sample of eligible ALFs, project staff selected a sub-sample of facilities for additional data collection. One group of facilities that met general eligibility criteria did not appear at all consistent with the philosophy of assisted living or with the generally accepted concept of what ALFs offer. These were facilities that, despite what they called themselves, in fact offered minimal services or minimal privacy, as defined below. This group of facilities was excluded from additional data collection. A second group was identified that provided a combination of low services and low privacy, as defined below. A sub-sample of these facilities was targeted for a second telephone interview intended to collect additional information from the administrator about policies, services, and price. A third group of ALFs was targeted for additional data collection that involved on-site, in-person interviews with administrators, staff, and residents, and telephone interviews with family members of very impaired residents. This third group of facilities consisted of a sample of the ALFs that offered high services or high privacy or both high services and high privacy. The criteria that define these groupings are described below.
ASPE and the project team decided early in the process of designing the study to conduct site visits to only those facilities that conformed closely to the philosophy of assisted living or, more correctly, to the general consensus about what were key elements of assisted living. To examine the characteristics of these facilities and to make comparisons between different types of facilities, the project team recognized the importance of identifying characteristics of ALFs that were expected to affect their performance. As noted earlier, two major dimensions intended to capture key features of the facilities were the availability of needed services (i.e., to meet scheduled and unscheduled needs and to enable residents to age in place) and resident control over his or her environment. The project team considered privacy of accommodations an important aspect of the environment, and indeed prior research found that residents had strong preferences for privacy (Jenkens, 1997; Kane, Baker, Veazie & Solomon, 1998). Thus, we used the service and privacy dimensions to sort all the facilities that had been surveyed during the first telephone data collection.
The facilities interviewed during the initial telephone survey were divided into the three sub-populations or tiers shown in Exhibit II.1. The level of services and privacy offered by a facility determined its tier membership. During the design phase of the study, we developed working definitions for each of the levels of service and privacy. (The criteria for inclusion in each Tier are described below.) The working definitions were then refined based on the results of the initial facility telephone screening survey and appear below (Hawes et al., 1999; Iannacchione et al., 1999). Only those facilities that met criteria for inclusion in Tier #3 were eligible for site visits that included interviews with residents, administrators and other staff. For any resident who was too impaired to respond to the interview, project staff interviewed a direct staff caregiver and, by telephone, a family member. Thus, only data from Tier #3 facilities were included in this report
This report concentrates on describing the facilities, staff and residents in this group of ALFs. Relatively little attention is devoted to differences across the three types of facilities in Tier #3 (e.g., high service with low privacy, low service with high privacy, or high service with high privacy). More detailed discussions of the effects of these different privacy and service levels on such factors as resident satisfaction, length of stay, and so on, will appear in subsequent project reports.
In the initial telephone screening survey, project staff collected sufficient information about each responding facility to place it in one of three categories or Tiers. The Tier #1 facilities offered minimal privacy or minimal services or both. To be rated as providing minimal privacy, a facility had to have one or more rooms or apartment bedrooms shared by at least three residents. Such an arrangement, referred to as a “ward-type bedroom,” is considered incompatible with the concept of assisted living -- regardless of the characteristics of a facility’s other units. To be rated as providing minimal services, a facility did not provide what were considered basic services. Those basic services included the following:
Thus, if a facility did not offer all of these basic services it was classified as providing minimal services. As noted above, ALFs classified as offering either minimal privacy or minimal services (i.e., Tier #1 facilities) were deemed ineligible for any further data collection, since they did not meet the study’s definition of “assisted living.” As shown in Exhibit II.2, 32% of the ALFs nationwide fell into this category, even among “self-described” ALFs.
For ALFs that offered both low services and low privacy, that is, the Tier #2 ALFs, the only additional data collection was a more extensive telephone survey of the administrator. Those data will be reported elsewhere. An ALF was defined as low privacy if it had no bedrooms shared by three or more persons but was a facility in which fewer than 80% of the bedrooms were private. An ALF was classified as low services if it did not have an RN on staff and did not provide nursing care with its own staff but did provide the following:
As shown in Exhibit II.2, an estimated 27% of ALF sites nationwide offered both low privacy and services.
ALFs that reported providing either high services or high privacy or both were included in the Tier #3 sampling strata. These ALFs constituted an estimated 41% of the total supply of ALFs nationwide. A subset of these ALFs was then selected for the on-site, in-person interviews. A high privacy facility was one in which 80-100% of the units were private. A high service ALF provided at least the following:
There was some disagreement about whether the last two criteria were essential. For example, one could argue that a facility that will arrange nursing care might also be classified as high service. However, having an RN on staff should improve the ability of the facility to appropriately supervise assistance with medications, monitor the health status of residents, assess changes over time, and supervise and monitor the quality of the services provided or arranged. Certainly, it seems likely that such a facility would be more able to allow residents to age in place and to serve as a viable alternative to nursing home care.11
Tier #3 facilities offered one of the following combinations of services and privacy: (1) High Service and Low Privacy; (2) Low Service and High Privacy; or (3) High Service and High Privacy. Tier #3 facility administrators were surveyed using the Administrator In-Person Interview and the Administrator Self-Administered Supplemental Questionnaire. Also, project staff conducted a structured observation of the Tier #3 facilities, using the Walk-Through Observation instrument.12 Thus, for these facilities, there is very detailed information about resident case mix, services, prices, admission and discharge policies, visiting hours, other policies related to resident autonomy, administrator background, staff training, facility ownership, and affiliations with multi-facility systems.
In addition, a probability sample of staff and residents of Tier #3 facilities were interviewed on-site, using the Staff Member Interview and the Resident Interview. For members of the resident sample who were moderately or severely cognitively impaired or who were physically unable to participate at the time of the interview, proxy respondents were identified. For each resident requiring a proxy, we used the Resident Proxy Respondent Interview to interview a staff member who provided direct care to the resident. Using the Family Member Telephone Interview, we also interviewed a family member of each resident who required a proxy respondent.13
This section briefly describes the study sampling approach.
The sampling design for the study was a stratified, three-stage, national probability sample with the following sampling units defined at each stage:
One of the study objectives was to determine the extent to which ALFs conformed to the philosophy of assisted living. Thus, criteria were used to identify those facilities that most closely approximated the philosophy -- that is, those offering high services or high privacy or both. In order to describe these facilities and to identify any differences in performance associated with variations in facility characteristics, subsequent data collection was conducted among the participating Tier #3 facilities. On-site interviews were conducted with Tier #3 facility administrators, staff members, and residents.14 A total of 705 Tier #3 facilities were identified in the 60 FSUs originally selected for the facility eligibility screening and initial telephone survey. However, limited project resources required that a sub-sample of 40 FSUs be selected from these 60 FSUs for subsequent on-site data collection. The sub-sample of 40 FSUs was selected with equal probabilities using systematic sampling (Kish, 1965). To preserve the geographic spread of the sub-sample, the 60 FSUs were ordered by state prior to selection. A total of 482 Tier #3 facilities were associated with the sub-sample of 40 FSUs and were the ALFs targeted for recruitment to participate in the on-site data collection.
The administrators of the Tier #3 facilities were recruited by telephone in order to secure permission for a Field Representative (FR) to visit the facility to conduct the various in- person interviews. During this telephone recruitment, the facility administrator was asked how many residents and staff members were currently at the facility. These staff member and resident counts were used to generate sample selection worksheets that the FR used to select which residents and staff members would be interviewed. For the resident samples, six random numbers were selected in each facility. If the number of residents at the facility was less than eight, all residents were selected. Similarly, for the staff members, two random numbers were selected for each facility, but if there were less than four staff members at the facility, all of the staff members were selected.
The staff and resident response rates within Tier #3 facilities were quite high. Ninety-three percent of the selected staff members responded. Information was gathered for 88% of the residents selected for interviews (from in-person interviews with residents or their proxy respondent). However, only 62% (i.e., 300) of the 482 eligible facilities participated in the full on-site data collection. This rate is lower than the 74% rate achieved in the earlier Board and Care study (Hawes et al., 1996). However, the assisted living industry is in a greater state of flux than the board and care industry, and a lower rate of participation might be expected because of that turmoil. In addition, to be counted, a facility had to participate in all aspects of the data collection (i.e., have completed interviews with administrators, staff and residents and the walk-through observation). Further, most surveys of ALFs have had difficulty obtaining good response rates, and most have had participation rates that were lower (e.g., ALFA, 1998; Gulyas, 1997; Hodlewsky, 1998). Finally, with statistical adjustments for non- response, we can develop meaningful national estimates with these data. The 300 ALFs included in this analysis represented the estimated 4,693 ALFs across the nation that offered high services or a high privacy environment or both high services and high privacy.
This report focuses on providing descriptive information about residents in assisted living, ALF staff and administrators, and the policies and environments within these facilities. The reported statistics will, in the main, be comprised of means and proportions and their standard errors. All results reported were produced using SUDAAN, a statistical software package expressly designed to provide appropriate estimates of variance and standard errors for data derived from multi-stage samples (Shah, Barnwell & Bieler, 1997). A number of tables including a relatively large number of variables are presented in this report. In many instances, different numbers of individuals responded to the various items reflected in the tables. For these tables, the reported N is the largest number of respondents for a single item in the table. The numbers in parentheses beside the reported means or proportions within the tables and in the text are the standard errors associated with these population estimates.
Throughout the presentation of these data it is important to remember that the estimates apply to only about two-fifths (41%) of the places that identified themselves as an ALF or provided a comparable level of services in a residential long-term care setting. These were the ALFs that provided the higher levels of service or privacy that the research team deemed most consistent with the general philosophy underlying the “assisted living movement.”
This section of the report describes the characteristics of residents in the 41% of ALFs that offer high services or high privacy or both high privacy and high services. Thus, this group of residents does not represent all the residents in all ALFs nationwide but only those in this special group of ALFs. This sample of residents represents nearly 200,000 elderly residents in high service or high privacy ALFs.
|
The data reported here apply only to those residents who lived in ALFs that offered high privacy or high services or both. |
As Exhibit III.1 indicates, individuals residing in high service or high privacy ALFs were, like most elderly persons in long-term care, overwhelmingly white, widowed females. Only 12% were still married. They were also quite elderly. The average resident in the high service/high privacy ALFs was 84.5 years old. More than 96% (0.90) were over 65 years of age, and 54% (1.79) were aged 85 or older. By comparison, 49% of U.S. nursing home residents were 85 and over (Krauss & Altman, 1998). About three-quarters (76%) of ALF residents in the high service/high privacy facilities had one or more living children, and most (86%) had a relative within a one-hour drive of the facility. The vast majority (91%) reported being visited by friends or relatives within the last month, and more than one-third (36%) reported receiving visitors either daily or more than once a week. They were, on the whole, a relatively well- educated group. More than 40% had at least some college education, and more than 20% were college graduates. Of those residents who provided information on their annual income (i.e., only 47% of the residents interviewed), 70% reported incomes between $9,000 and $50,000; more than half of the residents reported incomes greater than $14,000 per year.
|
Characteristic |
Prevalence |
|---|---|
|
Female |
78.6 (1.11) |
|
Marital Status |
|
|
Married |
12.1 (1.00) |
|
Widowed |
70.8 (1.64) |
|
Divorced/separated |
7.2 (0.70) |
|
Never married |
9.9 (1.23) |
|
White |
98.7 (0.55) |
|
Living Children |
75.8 (1.51) |
|
Relatives Within Hour Drive |
85.9 (1.90) |
|
Age |
|
|
Under 75 |
10.9 (1.21) |
|
75-84 |
34.8 (1.12) |
|
85+ |
54.3 (1.79) |
|
Friends/Relatives Visit--Last 30 Days |
|
|
None |
9.3 (1.28) |
|
Once or twice |
26.7 (1.44) |
|
Once a week |
27.6 (2.04) |
|
More than once a week, not daily |
30.1 (2.29) |
|
Daily |
6.3 (0.91) |
|
Education |
|
|
Not a high school graduate |
26.8 (2.23) |
|
High school graduate |
28.4 (1.69) |
|
Some college |
24.6 (1.96) |
|
College graduate |
20.3 (1.80) |
|
Income (47.3% reporting) |
|
|
Less than $5,000 |
11.6 (1.84) |
|
$5,000 to $8,999 |
12.7 (2.19) |
|
$9,000 to $13,999 |
23.7 (2.04) |
|
$14,000 to $24,999 |
23.0 (1.63) |
|
$25,000 to $50,000 |
23.1 (2.66) |
|
Over $50,000 |
5.9 (1.10) |
Seventy percent of current ALF residents resided in their own home or apartment prior to moving to the ALF in which they were interviewed. As one might expect, most residents (73%) received help in making the decision to move from their previous residence into an ALF, as Exhibit III.2 indicates. In the vast majority of cases (91%), the other participants in the decision were family members. Only 18% of the time was a physician involved in the decision. What was more surprising, only about half (52%) of the residents who received help in making the decision indicated that they had complete or almost complete control over the decision. One-quarter (25%) indicated that they had little or no control over the decision or choice of ALF. As discussed in the section on conclusions, this fact has significant implications for facilities’ perceptions of who the “consumer” is and potentially for how their services are marketed.
|
Characteristic |
Prevalence |
|---|---|
|
Residence Prior to ALF |
|
|
Own home/apartment |
70.2 (1.95) |
|
Relative's home |
8.8 (1.00) |
|
Nursing home |
4.2 (0.73) |
|
Subacute care |
2.2 (0.42) |
|
Supportive housing |
12.5 (1.47) |
|
Other |
2.1 (0.55) |
|
Received Help with Decision |
72.9 (1.65) |
|
Who Helped (multiple response) |
|
|
Family |
90.5 (1.31) |
|
Physician |
17.7 (2.62) |
|
Other |
16.1 (2.92) |
|
Amount of Control Over Decision |
|
|
Complete/almost complete |
52.2 (4.67) |
|
Some control |
23.0 (2.54) |
|
Little or no control |
24.9 (3.33) |
|
Length of Stay |
|
|
Less than one year |
37.5 (2.19) |
|
One to three years |
43.1 (1.78) |
|
Over three years |
19.4 (1.44) |
At the time of the survey, the average resident had lived in the study facility for just over two and one-half years. Thirty-eight percent of residents had been in the facility for less than one year; 43% had been in the facility for between one and three years; and 19% had been in the facility for more than three years. When reviewing these figures, it is important to remember that these data come from a cross-sectional survey, not a prospective study that followed people from entry to departure. This means that longer-stay residents were somewhat “over-represented” in the study, and the estimated average length of stay was somewhat higher than one would find in a prospective study of an admission cohort.
Prior Living Situation. For a significant proportion of assisted living residents, their current ALF residence was not their first experience with supportive housing. Within the five years prior to the survey, 6% of the residents had been in a nursing home (4%) or subacute care facility (2%), while 13% had been in some other type of residential facility or other housing setting with supportive services. These current ALF residents left their previous setting for a variety of reasons. Many needed more care than was available (40%); some preferred a location closer to family and friends (22%); others became acutely ill and required hospitalization and did not return to their previous setting after the hospitalization (11%). Slightly more than one in four of these residents (27%) reported dissatisfaction with quality of care or some other aspect of facility operations as part of the reason for their departure.
One of the major determinants of an individual’s need for assistance or supervision is his or her cognitive status. In the ALFs classified as providing high service or high privacy, almost three-quarters (73%) of the residents were cognitively intact or had only mild symptoms of cognitive impairment, as displayed in Exhibit III.3. Thirteen percent of the residents exhibited moderate cognitive impairment, while 14% had severe cognitive impairment. Thus, more than one-quarter of assisted living residents (27%) exhibited symptoms of moderate to severe cognitive impairment.15
The analyses also revealed some differences in the distribution of resident characteristics and care needs across the three types of ALFs. The high privacy facilities, with both high and low services, served residents for whom the distribution of cognitive impairment was similar to the distribution of the population as a whole. However, the ALFs classified as low privacy and high service served a resident population with significantly higher levels of cognitive impairment than one would expect, given the distribution in the resident population as a whole. As Exhibit III.4 indicates, almost 36% of the residents in the high service/low privacy facilities had moderate or severe cognitive impairment, in comparison to 23-25% in other types of ALFs.
These results indicate that residents in assisted living, even in facilities with high levels of service or privacy, were much less likely to be cognitively impaired than were residents in nursing homes, where one sees moderate to severe impairment in 60-70% of residents (Krauss & Altman, 1998). The results also suggest that residents in assisted living were less likely to be cognitively impaired than residents in more traditional board and care facilities. Prior research on residents in board and care facilities in ten states found over 40% of residents had moderate to severe cognitive impairment (Hawes et al., 1995a, 1995b & 1995c).
|
ALFs offering high privacy environments were less likely to have residents with moderate to severe cognitive impairment than ALFs with low privacy, regardless of the level of services offered. |
Both cognitive impairment and physical ailments affect an individual’s physical functioning. Exhibit III.5 provides information on the functional problems experienced by residents in ALFs offering high privacy or high services. The analysis focused on five activities of daily living (ADLs): dressing, locomotion, transfer, toilet use, and eating.16 As one would expect, it was in dressing, an “early-loss” ADL, that one found the highest levels of functional limitations, with nearly one-fifth of the residents (19%) receiving some type of assistance or supervision from another person. For “mid-loss” ADLs (locomotion, transfer, toilet use), between 8% and 9% of residents received supervision or physical assistance. For the ADL in which function is usually lost latest in the process of decline (eating), only 3% of residents received supervision or assistance. When one looks at ADL function in the aggregate, 79% of residents were independent. Thirteen percent received help with one or two ADLs, while just over 8% received help with three to five ADLs.
While residents in assisted living make relatively light use of staff assistance, they made considerable use of assistive devices to compensate for functional limitations. In the week prior to the interview, at least one-fifth of the residents used a cane (27%) or wheelchair (21%) to assist them with locomotion, while slightly more than two-fifths (44%) used a walker. One-third (32%) of residents had some urinary incontinence during that same seven-day period. Residents and proxy respondents reported even higher levels of assistance in instrumental activities of daily living (IADLs). For example, about three-quarters (77%) of residents received assistance in managing medications.17
|
Type of Activity |
Prevalence |
|---|---|
|
Supervision or "Hands-on" Help Provided In |
|
|
Dressing |
19.3 (2.08) |
|
Locomotion |
7.5 (1.22) |
|
Transfer |
8.9 (1.57) |
|
Toilet use |
9.0 (1.52) |
|
Eating |
3.4 (0.92) |
|
Supervision of Physical Assistance in ADLs |
|
|
None |
79.2 (2.17) |
|
One or two |
12.7 (1.32) |
|
Three to five |
8.1 (1.53) |
|
Use of Assistive Devices |
|
|
Hearing aid |
21.8 (1.53) |
|
Wheelchair |
20.6 (1.71) |
|
Walker |
43.7 (2.03) |
|
Cane |
27.0 (1.68) |
|
Incontinent of Urine |
31.7 (1.65) |
|
Received Help with Medications |
76.7 (2.12) |
|
Needed More Help with |
|
|
Dressing |
12.0 (2.89) |
|
Locomotion |
11.5 (3.29) |
|
Toileting |
26.1 (2.07) |
|
Eating |
0.0 (0.0) |
These levels of impairment in physical functioning are much lower than those found among nursing home residents, where nearly three-quarters of the residents received help with three or more ADLs (Krauss & Altman, 1998). They were roughly similar to the levels observed in board and care homes, where about 12% of the residents received “hands-on” assistance with three of more ADLs (Hawes et al., 1995b and 1995c). Further, the levels directly reported by residents and their proxy respondents were lower than the estimates provided by the administrators about their overall resident case mix. In those interviews, administrators estimated that nearly one-quarter (24%) of their residents had received hands-on assistance with three or more ADLs during the preceding seven days.18
|
Characteristic |
Prevalence |
|---|---|
|
Self-Reported Health |
|
|
Excellent |
7.1 (1.02) |
|
Very good |
19.1 (2.28) |
|
Good |
34.6 (1.41) |
|
Fair |
29.3 (1.85) |
|
Poor |
9.9 (.098) |
|
Health Service Use (last 12 months) |
|
|
Hospital |
32.3 (2.30) |
|
Emergency room |
24.2 (1.87) |
|
Health Events |
|
|
Stroke |
5.6 (0.69) |
|
Heart attack |
2.6 (0.53) |
|
Hip fracture |
3.2 (0.53) |
|
Fall |
37.0 (1.77) |
|
Pain Interferes with Activities |
|
|
All of the time |
6.1 (0.67) |
|
Some of the time |
18.5 (1.52) |
|
Little of the time |
16.9 (1.35) |
|
None of the time |
58.5 (2.27) |
Additional bivariate analyses indicated that there were no significant differences across the three facility types in the proportion of residents needing ADL assistance. The low privacy/high service facilities did serve a population with a somewhat higher proportion of individuals who needed help with two or more ADLs; however the difference was not statistically significant.
The residents were also asked about unmet care needs. The questions about assistance with ADLs asked about help provided, not help needed. Thus, the data on ADL assistance received could have under-represented residents’ actual needs. To address this, at least partially, residents who received some assistance were asked whether they needed more assistance than they received (e.g., needed or wanted more assistance, had to wait inordinately long for needed help). None had unmet needs for assistance in eating, but some residents reported needing more help with dressing (12%) and locomotion (walking or using a wheelchair) (12%). Further, slightly more than one-quarter (26%) of residents who were receiving some assistance with toilet use reported they had unmet needs for assistance in toileting. It is important to note that these “unmet need” questions were asked only of the residents who were able to respond for themselves.
For residents who were too physically or cognitively impaired to respond, a family member specified by the resident or one identified by the facility as the primary health care decision-maker was interviewed. When asked how much of the time their relative received the help he or she needed with bathing and dressing, the vast majority (75%) of family members interviewed responded that they received such help “always.” Fourteen percent reported the resident “usually” received the help needed, while nearly 12% of the family members reported that their relative received needed help only sometimes or never. The responses were similar for a question about whether family members received needed help with eating.
While the residents in ALFs with high services or high privacy received relatively little assistance in their ADLs, many did indicate some type of health problems or condition, as shown in Exhibit III.6. Most residents (60%) reported having good to excellent health; however slightly less than two-fifths of residents reported their health as only fair (29%) or poor (10%). These self-reported health rates were relatively similar to those of residents in board and care homes (Hawes et al., 1995c).
Residents also reported health conditions with the potential to limit physical functioning. For example, more than one-third of the residents (37%) also reported a fall in the last year, and one quarter (25%) of the residents reported that pain interfered with their normal activities some or all of the time during the preceding month.
Hospitalization was also relatively common. Residents reported a relatively high rate of use of hospital care. One-quarter (24%) of residents indicated that they had visited an emergency room in the 12 months prior to the interview, and almost one-third (32%) had an overnight stay in a hospital distinct from any emergency room visit. Again, these results are similar to the utilization rates observed among board and care home residents (Hawes et al., 1995b and 1995c). However, ALF residents had higher rates of hospital use than the general elderly population (i.e., only 18% had an inpatient hospital stay) and than nursing home residents (i.e., at 26%) (Krauss, Machlin & Kass, 1999; Krauss & Altman, 1998; Phillips, Hawes, Green & Norton, 1998).
Bivariate analyses indicated that the distribution of residents who had been hospitalized in the previous year in the three different types of high service or high privacy ALFs did not differ significantly from the distribution in the population as a whole. However, residents in ALFs offering the combination of high privacy and low service did have somewhat higher hospitalization rates than the whole population (i.e., 37% v. 32%), although the difference was not statistically significant.19
This section of the report addresses ALF residents’ attitudes and perceptions of the environment in which they lived. Literature in the area of patient and client satisfaction with health care suggests the importance of securing information from patients or residents about their experience (Cleary & McNeil, 1988). At the same time, studies have frequently noted an “aquiescent response bias” or a tendency of persons receiving services to provide positive responses when asked about their satisfaction with the services (Meister & Boyle, 1996; Pascoe, 1983). In an attempt to address this, both residents and family members were asked about their experiences as well as their ratings of various aspects of facility performance in key areas. Again, the data reported here are from interviews with residents and relatives of residents in ALFs that were classified as providing either high services or high privacy (or both high services and high privacy).
In focus group interviews, ALF residents and family members of ALF residents with dementia consistently identified staffing issues as a major component of quality (Hawes, Greene, Wood & Woodsong, 1996; Greene, Hawes, Wood & Woodsong, 1998; Hawes and Greene, 1998). Thus, residents in high privacy or high service ALFs were asked for their views on the level of staffing, staff retention, and the manner in which staff interacted with them. Exhibit III.7 displays the proportion of resident responses that were in the most positive category (e.g., staff “always” treat me with respect) for the various queries about staffing in the facility in which they lived. As shown, nearly all (79%) of the residents indicated that staff always treated them with dignity and respect. Almost two-thirds of residents (61%) indicated that staff was always affectionate and caring in their interactions with them.
In other areas, resident responses were more mixed. Just over half of the residents (52%) indicated that staff always took the time to stop and listen to them, and the same proportion (52%) reported feeling that staff training and supervision were very good. The most significant areas in which resident ratings were low were in the areas of staffing levels and staff turnover. Only 42% of the residents responded that adequate numbers of staff were always available, and just over one-quarter (28%) indicated that the facility was very successful in retaining good staff. Families had similar reactions. Only 48% of family members interviewed felt there were always enough staff on duty to adequately care for all the residents.
An important aspect of the assisted living environment is the type and quantity of activities offered to residents. As Exhibit III.8 shows, 45% of residents indicated that they were involved in activities all of the time or most of the time. However, 49% reported being involved in activities only some of the time. Most of this activity, however, was confined to the premises of the ALF in which the resident lived. Slightly more than one-third (35%) of the residents indicated that they had not been involved in an activity outside the facility in the two weeks preceding the interview. Slightly more than another third of the residents (36%) indicated that they had been involved in an activity outside the facility only once or twice during the preceding 14 days.
One reason residents may have reported relatively few activities outside the facility was that most residents reported that the ALFs in which they lived offered limited transportation to activities they enjoyed. More than half of the residents (55%) reported that transportation to activities that they enjoyed was either never available or only sometimes available. Forty-six percent of family members reported that the ALF never or only sometimes offered transportation to activities their relative enjoyed.
In addition, about half (49%) of the residents indicated that the facility never or only sometimes offered activities that they enjoyed. Family members were also skeptical about the activities program, with 36% reporting that the facility never or only sometimes offered activities the resident enjoyed and in which he/she could participate.
These results are not too surprising when one notes that only 41% of residents and 56% of family members indicated that staff usually or always asked about the residents’ activity preferences.
|
Resident Attitudes |
Prevalence |
|---|---|
|
Involvement in Activities |
|
|
None of the time |
6.1 (1.00) |
|
Some of the time |
48.7 (2.15) |
|
Most of the time |
35.1 (1.62) |
|
All of the time |
10.0 (1.46) |
|
Activity Outside Facility (14 days) |
|
|
Never |
35.4 (1.63) |
|
Once or twice |
36.1 (1.79) |
|
Three to five times |
20.6 (1.25) |
|
Every day or every other day |
7.9 (0.77) |
|
Offer Activities You Enjoy |
|
|
Never |
8.5 (1.14) |
|
Sometimes |
40.5 (3.27) |
|
Usually |
31.4 (2.17) |
|
Always |
19.6 (2.35) |
|
Transportation for Things You Enjoy |
|
|
Never |
19.3 (2.73) |
|
Sometimes |
34.7 (3.34) |
|
Usually |
26.1 (2.41) |
|
Always |
19.9 (2.83) |
|
Staff Ask About Activity Preferences |
|
|
Never |
22.9 (3.19) |
|
Sometimes |
36.1 (3.71) |
|
Usually |
26.1 (2.19) |
|
Always |
14.9 (2.35) |
Living arrangements are also considered a key aspect of assisted living, with their emphasis on creating a non-institutional environment. In particular, prior studies found that residents have strong opinions about and preferences for private accommodations, both for their sleeping place and bathroom (Jenkens, 1997; Kane et al., 1998).
Accommodation Type. In the ALFs offering high privacy or high services (or both), the accommodations of the residents were almost evenly split between apartment and bedroom units, as shown in Exhibit III.9. For residents living in apartments, the most common arrangement (58%) was a one-bedroom apartment, with only 6% of the residents having a two-bedroom apartment. However, about one-third (34%) of the residents living in an apartment had a studio apartment.
Privacy. Private accommodations were common in the ALFs that offered either high privacy or high service or both. Eighty-one percent of the residents lived alone. Some residents shared their space with a relative, but among the one-fifth (19%) of residents who lived with someone, almost 70% shared their living space with a person unrelated to them by marriage or blood.
As noted, private bathrooms were considered a key aspect of privacy, according to most residents. Three-quarters (77%) of the residents in these high privacy or high service ALFs had a full bath attached to their unit (apartment or bedroom). Fewer than one-fifth (17%) of these residents shared the bathroom attached to their unit, and nearly all those residents (95%) shared that attached bath with only one other person. For the 23% of residents who did not have a full bathroom attached to their apartment or bedroom, some did have a private half-bath attached to their unit; however, all of these residents shared at least bathing rooms for taking a shower or bath. Taken together with the residents who shared a full bathroom, this means that slightly more than one- third (35%) of all the residents in high privacy or high service ALFs shared all or part of a bathroom.
|
Characteristic |
Prevalence |
|---|---|
|
Living Situation |
|
|
Apartment |
50.8 (4.67) |
|
Bedroom only |
49.2 (4.67) |
|
Type of Apartment |
|
|
Studio |
34.4 (4.78) |
|
One bedroom |
57.6 (4.77) |
|
Two bedroom |
6.1 (1.27) |
|
Other |
1.9 (0.87) |
|
Share Living Space with Another |
18.5 (2.40) |
|
Full Bath Attached to Room/Apt. |
76.9 (2.93) |
|
Attached bathroom is shared |
17.0 (2.63) |
|
Other Shared Bathroom |
23.0 (2.67) |
|
Able to Arrange Furniture as Wishes |
94.5 (2.11) |
|
Individual Temperature Control |
83.9 (2.63) |
|
Able to Lock Door for Room/Apt. |
83.2 (3.12) |
|
Available in Room /Apartment |
|
|
Separate kitchen space |
35.6 (5.13) |
|
Refrigerator |
53.7 (3.94) |
|
Something to heat food |
36.4 (4.53) |
|
Call button in bedroom |
81.5 (2.71) |
|
Seat in shower or tub |
65.1 (3.46) |
|
Railing in shower or tub |
77.5 (3.08) |
|
Railing beside toilet |
80.5 (2.70) |
|
Call button in bathroom |
77.7 (2.50) |
|
Choice Among Entrees |
|
|
Never |
19.5 (4.29) |
|
Sometimes |
12.8 (2.52) |
|
Usually |
13.6 (2.29) |
|
Always |
54.1 (5.49) |
|
Food is Tasty & Well-Seasoned |
|
|
Never |
5.2 (1.01) |
|
Sometimes |
28.8 (2.03) |
|
Usually |
40.3 (2.62) |
|
Always |
25.7 (1.83) |
Amenities. The residents reported that their rooms or apartments were equipped with various amenities and safety devices. Safety devices, such as call buttons in bedrooms (82%) and bathrooms (77%) and railing in the shower/tub (78%) or beside the toilet (81%), were fairly common. However, even in the ALFs that offered high privacy or high services, kitchens were rare. Only about one-third (36%) of the residents reported having a kitchen or place to heat food. Moreover, only slightly more than half the residents (54%) had a refrigerator in their room or apartment.
Meals. Residents were also asked a number of questions about the meals and food service at the facility. Slightly more than half (54%) of the residents reported that they always had a choice among entrees, but 20% indicated that they never had such a choice. Only 26% of residents found the food was “always&#
