Chapter 5 Impacts of Profit Status of Assisted Living Facilities

Abstract

Florida is a bellwether state in terms of the need for assisted living among elderly persons and has more than 2,000 of the nation's estimated 11,459 assisted living facilities (ALFs). The authors of this article surveyed 140 ALFs in Florida in order to examine the relationship of profit status to ownership of other facilities, willingness to serve low income groups, formal policies, and persons involved in decisions about resident retention. Significant differences were found between for-profit and non-profit facilities in terms of ownership of nursing homes and resident involvement in retention decisions. A discussion of how the profit motive and formal policies can impact residents concludes the article.     

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.     

The Effects of Organizational Policies on Resident Perceptions of Autonomy in Assisted Living

Abstract

This study examines the effects of organizational policies on resident perceptions of autonomy in assisted living. The sample included 412 residents in 59 facilities. Organizational policies were measured in terms of policies that foster resident choice and control in the facility. Resident autonomy was assessed according to resident perceptions of influence and independence. Hierarchical linear modeling was used to examine the effects of organizational policies on resident autonomy, controlling for facility size, ownership, and level of care. Higher levels of choice-enhancing policies were related to more favorable resident perceptions of autonomy. These findings suggest that allowing residents more choice in their daily routines may contribute to a greater resident autonomy.     

The Mediating Effect of Resilience Between Social Support for Exercise and Resident Satisfaction in Assisted Living

This study examined whether residents' level of resilience mediated the relationship between social support for exercise from staff and resident satisfaction in assisted living. This was a secondary data analysis using baseline data from a function-focused care intervention study including 171 residents from four assisted living facilities. Using structural equation modeling, we found that mood and social support for exercise from staff were the only variables associated with resilience. Mood, gender, cognition, and social support for exercise from staff directly influenced resident satisfaction and explained 31% of the variance in the model. Implications for future research and practice are discussed.     

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.     

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.     

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.     

Mental Illness in Assisted Living: Challenges for Quality of Life and Care

ABSTRACT

An unknown number of mentally ill elders in the United States receive care in assisted living, along with persons facing physical or cognitive challenges. While dementia is familiar in assisted living, our data indicate that neither staff nor residents are prepared to work or live with the mentally ill. Challenges are created for professionals, since these residents bring diverse needs. Daily interresident interactions are also disrupted or stressful. Qualitative data describe the impacts on quality of resident life as well as care and management dilemmas identified within five assisted-living settings having varying presence of mental illness among residents.     

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.     

Choosing Privacy over Interaction: Restructuring Expectations and Interpretations of Community Integration in Canadian Small-House Long-Term Care Settings

In Nova Scotia, Canada, the small-house model of care has been introduced as an alternative to institutional care settings, and the province has funded and built 11 new long-term care (LTC) communities in the small-house model. Each of the new facilities was built with multiple cottages housing 12 to 15 residents; each cottage features private bedrooms and a residentially scaled kitchen and dining area. Through smaller numbers of residents living in home areas, the goal of the Provincial Department of Health was to encourage relationship building, as well as to provide opportunities for autonomy and choice in resident daily living. A qualitative case study was conducted in one of these small-house communities, focusing on the model's impact on resident interaction and community integration. Thematic analysis revealed that while resident social patterns were directly impacted by the physical environment and culture of care in the new model, interpretations of these patterns by staff and family members were influenced by preexisting expectations of community integration rooted in institutional care models of the past.     

Abuse,neglect and exploitation in assisted living: an examination of long-term care ombudsman complaint data

Long-term care ombudsmen are advocates who empower and assist residents with complaints relating to quality of care and violations of resident rights in assisted living (AL) and skilled nursing facilities (SNF). Given that long-term care residents are vulnerable to elder abuse, neglect and exploitation (ANE), and existing gaps in the literature addressing ANE in AL, more research is needed to understand the prevalence of ANE in these communities. Ombudsman complaint data (n = 140,497 complaints) in 3,171 Texas long-term care facilities were analyzed using proportion Z tests. Findings showed that SNF had higher rates of ANE per resident. For both AL and SNF, verbal/psychological abuse was the most reported type of ANE and sexual abuse was the least reported. AL residents had disproportionately high rates of financial exploitation. We explored factors that may contribute to these findings and recommend strategies for preventing ANE.     

“They are the reason I come to work”: The meaning of resident–staff relationships in assisted living

This article aims to provide understanding of how direct care workers (DCWs) in assisted living facilities (ALFs) interpret their relationships with residents and to identify factors that influence the development, maintenance, quality, and meaning of these relationships. Qualitative methods were used to study two ALFs (35 and 75 beds) sequentially over seven months. Researchers conducted in-depth interviews with 5 administrative staff and 38 DCWs and conducted 243 h of participant observation during a total of 99 visits. Data were analyzed using a grounded theory approach. Results showed that the emotional aspect of caregiving provides meaning to DCWs through both the satisfaction inherent in relationships and through the effect of relationships on care outcomes. Within the context of the wider community and society, multiple individual- and facility-level factors influence DCW strategies to create and manage relationships and carry out care tasks and ultimately find meaning in their work. These meanings affect their job satisfaction and retention.     

Nonprofit and for-profit home care in Israel: clients' assessments

Clients' assessments of differences between nonprofit and for-profit organizations delivering home care services to Israel's frail elderly were studied. No significant differences were found between nonprofit and for-profit providers with respect to organizational efficiency; speed of placement and replacement of home care workers; responsiveness to clients' complaints; and supervision of care plans, schedules, and service delivery. Systematic differences were found, however, in clients' perceptions of workers employed by nonprofit versus for-profit service providers. The differences related to the home care workers' adaptation to clients' needs and wants; how well workers delivered services; and how satisfied clients were with the services received. Indications are that the relatively high efficiency of nonprofit organizations can largely be attributed to the performance of their home care workers.     

Staff-resident interaction in the nursing home: An ethnographic study of socio-economic disparities and community contexts

In recent years, nursing home (NH) researchers have paid increasing attention to socio-economic and racial/ethnic disparities in quality of care. Although there is growing evidence of disparities in resident health outcomes, less is known about the ways in which these differences manifest in care processes from a qualitative perspective. This paper addresses this gap by comparing staff-resident interactions in two urban, non-profit NHs, including roughly 50 staff participants in each facility. The researcher conducted ethnographic observation in one facility serving a white, middle class community and another serving low-income Black and Hispanic clients from an underserved neighborhood. Grounded theory methods generated three categories of interaction—activating, relating, and attending—which were performed differently in the two NHs. In the more affluent facility, staff interacted with residents in a dynamic fashion, adapting to residents’ responses, and they were relatively well equipped with resident-specific information when responding to individual concerns. In the safety-net facility, staff interacted with residents in a one-directional, “didactic” fashion, providing instruction without a mechanism for adapting to residents’ responses, and they were not as well equipped with resident-specific information. These differences reflected disparities between the two facilities in staff communication skills, underscoring the importance of workforce development to enhance the quality of staff-resident interaction and promote resident-centered care. This study raises further questions about the role of neighborhood contexts in shaping organizational processes that influence quality of life for NH residents. Moreover, the study offers a unique contribution to the NH literature by generating a typology of styles of interaction that can be used to develop a conceptual framework for understanding staff-resident interaction in the nursing home. Such a framework can inform efforts to improve residents’ quality of life.     

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.     

Nonprofit and For-Profit Home Care in Israel

Clients' assessments of differences between nonprofit and for-profit organizations delivering home care services to Israel's frail elderly were studied. No significant differences were found between nonprofit and for-profit providers with respect to organizational efficiency; speed of placement and replacement of home care workers; responsiveness to clients' complaints; and supervision of care plans, schedules, and service delivery. Systematic differences were found, however, in clients' perceptions of workers employed by nonprofit versus for-profit service providers. The differences related to the home care workers' adaptation to clients' needs and wants; how well workers delivered services; and how satisfied clients were with the services received. Indications are that the relatively high efficiency of nonprofit organizations can largely be attributed to the performance of their home care workers.     

DO NONPROFIT AND GOVERNMENT NURSING HOMES ENTER UNPROFITABLE MARKETS?

Using data from markets in the rural United States, this study addresses whether nonprofit and government nursing facilities locate in markets that for-profit firms cannot profitably enter, thereby expanding access to nursing care to populations that would not otherwise be served. The results indicate that while nonprofit and for-profit nursing homes typically enter similar markets, government nursing homes are more likely to enter markets that have small populations generally and too few elderly residents to be profitable for for-profits. The results have implications for the efficient provision of access to long-term care for isolated populations and other underserved groups. (JEL L10, L20, I11)     

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.