Facility Ownership and Resident Satisfaction with Assisted Living

Abstract

Although the majority of assisted living facilities operate as for-profit organizations and serve increasingly frail elderly populations, little is known about the impact of ownership on the quality of care in assisted living. This study examines the relationship between facility ownership and the quality of care in assisted living, using resident satisfaction as a quality indicator. The assessed aspects of satisfaction include health care, housekeeping, physical environment, relationships with staff, and social life/activities. The relationship of facility ownership to resident satisfaction is examined controlling for resident psychological well-being, functional ability, facility size, and staff resources. Data were collected in personal interviews with 156 residents, including 96 residents in eight for-profit facilities and 60 residents in five nonprofit facilities in Maryland. Residents in the sampled nonprofit facilities were more satisfied with assisted living than were residents in the for-profit facilities. In particular, residents in nonprofit facilities were more satisfied with health care, physical environment, and social life/activities in the facility. Better understanding of the relationship between facility ownership and resident satisfaction can help administrators create environments that maximize resident satisfaction in both nonprofit and for-profit facilities.     

Influence of Satisfaction with Services on Assisted Living Resident Satisfaction

The purpose of our investigation was to provide insight into the service domains that most heavily influenced self-reported resident satisfaction among residents in assisted living facilities. Data was gathered from the 2008 Press Ganey Assisted Living Survey. Satisfaction with service domains was measured using 7 subscales addressing the areas of activities, staff attentiveness, meals, apartment space, facility attractiveness, personal issues, and management. Generalized linear mixed models were specified to assess the influence of demographics, functional status, self-rated health, and satisfaction with service domains on resident satisfaction. In the final multivariate model self-rated health, independence with laundry and finances, and satisfaction with aides, meals and management demonstrated a significant positive effect on resident satisfaction. As the number of assisted living facilities continues to increase, senior management would be wise to consider which domains of service are particularly salient in assisted living environments.     

Relationships Among Active Engagement in Life Activities and Quality of Life for Assisted-Living Residents

This cross-sectional research explored the relationships between active engagement in life activities (leisure, social, and instrumental activities of daily living) and quality of life for seniors aged 65 and older residing in assisted living facilities. It is increasingly recognized that active participation in diverse physical, cognitive, and social activities can promote older adults’ quality of life, including physical and mental health, but there is limited information about this in the population of residents in assisted living facilities. It is estimated that there are one million older adults residing in assisted living facilities, making assisted living facilities a rapidly growing segment of senior housing. Older adults who relocate to assisted living facilities commonly experience lifestyle changes, often related to their altered physical and social environment, reduced demands regarding household chores and meal preparation, and new opportunities for recreation and socialization. In this study, interviews were conducted with 131 ambulatory residents from assisted living facilities in the New York City metropolitan area using the 55-Item Activity Checklist, SF-36v2, Life Satisfaction Index-Z, and demographic questions. Results found significant low to moderate correlations between retained engagement in life activities (leisure, social, and instrumental activities of daily living) and life satisfaction, and several quality of life domains, including physical functioning, mental health, general health, and vitality. Older adults continued to engage in a greater percentage of everyday life activities they identified as important. This data supports exploration of client-centered activity programs to promote participation of residents in assisted living facilities in diverse activities to both maintain resident functional abilities and manage functional decline.     

Workplace support, role overload, and job satisfaction of direct care workers in assisted living

This study aims to enhance our understanding of job satisfaction of direct care workers in assisted living facilities. Low job satisfaction is related to high turnover rates and lower quality of care in assisted living. We integrate two theories of job satisfaction to investigate relationships among workplace support, role overload, and job satisfaction. Data are from a survey of 984 direct care workers in 108 assisted living facilities. Results from multilevel hierarchical linear models (HLM) indicate that job satisfaction varies both within and among facilities. Job satisfaction is negatively associated with role overload, and it is positively associated with institutional support, supervisor instrumental and emotional support, and coworker emotional support. These workplace support measures and role overload are separately and independently associated with job satisfaction. Enhancing job satisfaction of assisted living direct care workers will likely require a multipronged approach that includes improving institutional, supervisor, and coworker support while simultaneously directly addressing role overload.     

Resident and family perspectives on assisted living

This research describes and compares the relative importance residents and family members place on attributes of the environment, the programs, and the policies of assisted living; describes their satisfaction with these features; and identifies factors associated with congruence between residents' and family members' ratings of importance and satisfaction. Both residents and their family members had high importance and satisfaction ratings. Family members gave the assisted living setting lower satisfaction ratings on all features than did residents. Congruence ranged from 34% to 71% for importance items and from 29% to 63% for satisfaction. Female residents, affectionate family relationships, and residing in an AL owned by a chain were positively associated with congruence on importance items, while resident and family education, resident income, and family involvement were negatively associated with congruence on importance items. For congruence on satisfaction items, having an affectionate relationship was positively associated and higher ADL dependency, more family involvement at the facility, and family members who viewed the facility as a safe place were negatively associated with congruence. This study makes a major stride forward because cognitively intact residents' perspectives are compared and contrasted with their own family members' perspectives, thus showing that residents and family members are two distinct groups, each with a unique set of preferences.     

Resident and Family Perspectives on Assisted Living

Abstract

This research describes and compares the relative importance residents and family members place on attributes of the environment, the programs, and the policies of assisted living; describes their satisfaction with these features; and identifies factors associated with congruence between residents' and family members' ratings of importance and satisfaction. Both residents and their family members had high importance and satisfaction ratings. Family members gave the assisted living setting lower satisfaction ratings on all features than did residents. Congruence ranged from 34% to 71% for importance items and from 29% to 63% for satisfaction. Female residents, affectionate family relationships, and residing in an AL owned by a chain were positively associated with congruence on importance items, while resident and family education, resident income, and family involvement were negatively associated with congruence on importance items. For congruence on satisfaction items, having an affectionate relationship was positively associated and higher ADL dependency, more family involvement at the facility, and family members who viewed the facility as a safe place were negatively associated with congruence. This study makes a major stride forward because cognitively intact residents' perspectives are compared and contrasted with their own family members' perspectives, thus showing that residents and family members are two distinct groups, each with a unique set of preferences.     

From the streets to assisted living: perceptions of a vulnerable population

The rapid growth of assisted-living facilities is paralleled by the necessity to understand the needs of the people living in them. A hallmark challenge for individuals who are poor and disabled, and often marginalized from mainstream society, is maintaining integrity and being a whole person, rather than a sum of broken parts. A key to maintaining this integrity is the ability to find stable housing and support systems. The inner-city assisted-living facility in this study is unique in that all of its residents are funded by Medicaid. The residents have complex needs related to histories of homelessness, mental illness, drug and/or alcohol addiction, and chronic illness. The purpose of this study was to explore the needs of this vulnerable population as they adapt to a new home and a new concept of assisted, yet independent, living. Structured interviews with key informants and oral survey questionnaires with residents provided quantitative and qualitative data about physical and mental health status, social support, perception of control, psychological wellbeing, and life satisfaction. This study provided valuable insights into the challenges inherent in providing a high quality of life in assisted living for a vulnerable population with diverse needs.     

What do Potential Residents Need to Know about Assisted Living Facility Type? The Trade-off between Autonomy and Help with More Complex Needs

The current study surveyed 74 assisted living facilities to examine the effect of facility type on resident autonomy and the willingness of providers to admit residents requiring complex services. Facility types included adult family homes, residential care facilities, and traditional assisted living facilities. Adult family homes were more willing to admit residents with higher care needs. By contrast, assisted living facilities’ policies did not support the provision of intensive services, but their policies promoted higher resident autonomy, suggesting that consumers may have to choose between autonomy and help with complex needs when exploring assisted living for long-term care.     

Chapter 2 Residents in Assisted Living Facilities and Visitation Patterns

Abstract

Resident visitation patterns within an assisted living facility provide insight into a resident's life satisfaction. This study investigated residents' perceptions of family and friend visitation. Thirty assisted living residents from Oklahoma participated in a comprehensive interview that included demographics, life satisfaction, visitation frequency, and perceptions of visitation patterns. A majority of the respondents (90%) perceived family and friend visitation as “important” to “very important” in their life. Visitation allows residents to reminisce with family members and friends, to fulfill the need to have outside contact, and to be reassured that they have not been forgotten. Results indicate residents do desire continued relationships with family and friends through visitation. Facilities should encourage activities involving outside members of a resident's support network and be aware of residents less visited, developing programs creating social contact and involvement.     

Two lives in transition: Agency and context for assisted living residents

This research uses data on two “focal case” individuals residing in one residential care/assisted living (RC/AL) facility, collected as part of a larger ethnographic study exploring later-life transitions, including those leading to the moves into housing and care settings. In-depth examination of the 10-year transition histories of these two women highlights the major erosion of autonomy with advancing frailty, illness, and relocation into supportive housing. A second major theme is that an understanding of the contemporary events and challenges for these two individuals is substantially enhanced by nesting them within the temporal context of earlier life events, including personal relationships, social events, and preferences. Individual history, elicited from resident, family, staff and professional views, serves to contextualize current choices and reactions to key events. As researchers, adding this temporal context moves our understanding of their identities well beyond a simplistic snapshot view as “resident” in AL.     

Functional Ability,Neighborhood Resources and Housing Satisfaction among Older Adults in the U.S.

The purpose of this study was to explore neighborhood resources that influence the housing satisfaction of older adults. The study included 10,146 participants from the 2009 panel of the American Housing Survey who were 65 years and older. Hierarchical regression modeling was performed to examine older adults’ perceptions of neighborhood resources and consequently the role these resources play in predicting housing satisfaction among community dwelling and residents of assisted living, controlling for age, sex, ethnicity, education, and housing maintenance. In addition, three levels of physical functioning among residents of assisted living were examined. Results showed that there were differences in housing satisfaction by residences and levels of physical functioning. Subjective evaluations of neighborhoods and the near surrounds were significant predictors of housing satisfaction. Results of the study suggest that policy makers and housing professionals need to continue to consider the role of supportive neighborhoods and social environments in promoting successful aging particularly for frail older adults.     

Negotiating Boundaries of Refugee Resettlement: A Study of Settlement Patterns and Social Support*

This article analyses aspects of the bureaucratie process of negotiating placement and social support by and for resettled refugees in Canada. Theoretical issues addressed include refugee resilience and effects of power structures on migrant networks. The article describes a qualitative study of underlying reasons for government‐assisted refugee secondary migration to Ontario. The study demonstrates that refugees seek social support by moving from initial settlement sites to join extended family and analyses how the resettlement bureaucracy, driven by political as well as humanitarian interests, attempts to control the process, in contradiction to refugees' preferences. The negotiation of placement and definitions of relevant social supports by bureaucrats and refugees are discussed. In conclusion, greater attention to refugee self‐determination is suggested to improve settlement outcomes.     

Birthday celebrations as a family homelessness intervention: a mixed-methods analysis

Families report that the experience of homelessness presents a significant barrier to family functioning and interrupts regular family routines. This study uses data from 22 homeless shelters in Massachusetts to examine the relationship between birthday parties for homeless children, family functioning, and parent well-being in homeless families. The study includes a sample of 255 residents across 20 homeless shelters in both urban and rural communities that received regular monthly birthday parties from a nonprofit agency. A small comparison sample of 25 residents came from two shelters that were not receiving birthday parties from the nonprofit agency. Data from 78 staff members working at all 22 shelters was collected on shelter environment and resident cohesion. Results indicated that residents in those shelters that received monthly birthday party celebrations for children had higher levels of happiness. Residents’ satisfaction with the birthday parties showed correlations between levels of hope, happiness, and parental empowerment. Shelter staff who reported higher levels of satisfaction with birthday parties also reported higher levels of resident cohesion. Results point toward the value of continuing regular family routines, such as annual birthday celebrations, to help mitigate the stressors and disruptions of homelessness on families.     

Linking structure, process, and outcome to improve group home services for foster youth in California

The California Youth Connection obtained funding from two foundations to evaluate the performance of group homes serving foster youth in Alameda County, California, in order to inform state policy-making. The evaluation team initially included 14 foster youth that personally experienced group home living. Three inter-related aspects of service were studied: structure, process, and client outcomes, specifically residents' increase in developmental assets leading to the ability to transition successfully to independent living by the age of 18 years. Data were collected at 32 group homes from 127 residents and 72 staff members using three questionnaires. Both structural and process aspects of services influenced residents' satisfaction with services. However, only the process of care predicted changes in residents' developmental assets. State-level regulatory agencies learned from these results that auditing only structural aspects of services was not sufficient to promote effective services. Further, one structure item and two process items were identified as less consistently occurring in the group homes: timely distribution of clothing allowances, healthy communication between staff and youth, and staff support of regular exercise for the residents. Focusing on these aspects of service first should promote more change in outcomes and satisfaction for foster youth residing in group homes.     

Autonomy in Assisted Living: Employees’ Perspectives

This focused ethnography explores how employees in assisted living facilities give meaning to the term autonomy, a core value in the mission of assisted living facilities. In-depth interviews were conducted with managerial and front line staff in two assisted living facilities to understand their interpretation of the concept of autonomy and how they felt they enhance the autonomy of the residents. Four interrelated themes capturing the meaning of autonomy emerged from analysis of the interview data: (1) autonomy is synonymous with functional independence, (2) expectations of residents of assisted living are different from residents of nursing homes, (3) rehabilitation is a goal of assisted living, and (4) a tendency to intervene in the best interests of the residents. The implications of the findings are discussed in terms of their potential effect on residents.     

You Can't Get There From Here: Reaching the Outdoors in Senior Housing

By providing access to outdoor environments, exterior doors can enhance the sense of freedom in residential environments for aging. However, doorways may also present barriers to outdoor access. Using environmental audits, this study examined doorway problems at 68 assisted living facilities in three geographic regions. Results were compared with resident surveys (n = 1,128), staff surveys (n = 432), and resident focus groups (n = 76). Specific doorway issues were found to be associated with residents’ weekly minutes of walking, outdoor usage, and perceived ease of reaching outdoor areas. The main problems were door opening/closing, thresholds and landings, and self-locking doors. The findings indicate that exterior doorways often present barriers to assisted living residents, resulting in lower levels of walking and outdoor use. By discouraging these health-related behaviors, doorway problems may negatively affect residents’ health and well-being. Practice implications suggest that many existing doorway problems, such as high thresholds or excessive opening force, are easily remedied.     

Building aid workers’ resilience: why a gendered approach is needed

The concept of resilience is increasingly earning attention in development and humanitarian literature. Agencies and organisations are interested to learn about resilient communities, and keen to support the goal of ‘building resilience’ in developing countries. However, there is comparatively little interest in the resilience of aid workers themselves. This article will discuss the need to support aid workers to build resilience, for their own well-being and also for the effectiveness and sustainability of the essential humanitarian and development work they do. It will advocate for the need of embracing a gender-focused approach in the study of aid workers’ resilience, and more generally, in the study and promotion of aid workers’ well-being. The article draws on a qualitative study which found international women aid workers face specific stressors within the organisations they work for, in working relationships with national staff, and in their personal life. Humanitarian and development organisations need to adopt a gender-focused approach to resilience in the provision of psychosocial support for staff working in development, and emergency relief/humanitarian aid.     

Coming together and pulling apart: Exploring the influence of functional status on co-resident relationships in assisted living

Social relationships can have considerable influence on physical and mental well-being in later life, particularly for those in long-term care settings such as assisted living (AL). Research set in AL suggests that other residents are among the most available social contacts and that co-resident relationships can affect life satisfaction, quality of life, and well-being. Functional status is a major factor influencing relationships, yet AL research has not studied in-depth or systematically considered the role it plays in residents' relationships. This study examines the influences of physical and mental function on co-resident relationships in AL and identifies the factors shaping the influence of functional status. We present an analysis of qualitative data collected over a one-year period in two distinct AL settings. Data collection included: participant observation, informal interviews, and formal in-depth interviews with staff, residents, administrators and visitors, as well as surveys with residents. Grounded theory methods guided our data collection and analysis. Our analysis identified the core category, “coming together and pulling apart”, which signifies that functional status is multi-directional, fluid, and operates in different ways in various situations and across time. Key facility- (e.g., admission and retention practices, staff intervention) and resident-level (e.g., personal and situational characteristics) factors shape the influence of functional status on co-resident relationships. Based on our findings, we suggest strategies for promoting positive relationships among residents in AL, including the need to educate staff, families, and residents.