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.     

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.     

The Role of Environmental Features in Social Engagement Among Residents Living in Assisted Living Facilities

The objective of this study was to describe how physical and social environmental features of assisted living facilities influence social engagement behaviors of older residents. A secondary objective was to identify the environmental features that were important to residents’ social engagement based on their perspectives. Using a qualitative approach, the authors depicted the environmental features and the social engagement patterns of older residents in two assisted living facilities in urban Saint Louis, Missouri. A stratified sample of 10 participants participated in in-depth interviews and 16 participant observations were conducted. Five physical and social features were identified as factors that influenced residents’ social engagement patterns. Environmental features that supported social engagement appeared to differ according to participant activity level. Findings from this study have the potential to inform design guidelines that will enhance social engagement in future assisted living facilities.     

Utility of the Maryland Assisted Living Functional Assessment Tool

Abstract

The purpose of this study was to consider the utility of the Maryland Assisted Living Functional Assessment (MALFA) in terms of predicting successful living in an assisted living facility. Consideration of utility of this tool was based on the predictive ability of the measure at baseline to explain length of stay and level of care needed for residents (nursing home versus assisted living) over a five year period. A total of 76 residents from a single ALF in the Baltimore area were tested annually over five years. Those who transitioned to a nursing home at some point during the 5-year period (47%) had higher mean scores on admission with regard to need for nursing interventions because of cognitive and psychiatric problems or to perform medical treatments. Medical illness influenced number of years in assisted living and accounted for 7% of the variance (F = 7.2, p < .05). The assessment tool provides a wealth of information about the resident and can be used to alert providers to consider individuals with high scores in subscales such as need for monitoring of cognitive and psychiatric problems or need for medical treatments in terms of being at risk for nursing home placement. Future work should consider how to optimally use the MALFA to implement interventions in assistive living that will prevent decline in areas that seem likely to result in a need for a higher level of care.     

The Mobility of Elderly Residents Living in Suburban Territories

Abstract

Many authors have observed die elders' unanimous aspirations to age in place. Such residential aspirations echo theoretical concepts such as “environmental-fit.” Aging residents adapt to their residential environment according to their autonomy level, their financial and social resources, as well as the meanings they invest in both residential situations and lifestyle (Lord, 2004; Wagnild, 2001). Therefore, the suburbs constitute a challenge for aging residents' intentions to remain in their home for as long as possible. These low-density environments encourage car dependency for almost every daily activity. In that regard, many studies have investigated the daily mobility patterns of elders living in such areas. However, most of them have focused on aspects linked to transportation and driving security (Rosenbloom, 2003). In this context, with a socio-anthropological (in-depth interviews) method, the elders' daily mobility is explored in a complex layering of issues. Two interdisciplinary qualitative researches on the daily and residential mobility of elderly suburbanites have been used: a group living in Quebec City's Post-War suburbs in Canada (n = 56) and another in Marseille's periurban suburbs in France (n = 36). The results show that we must investigate beyond the elders' “emotional attachment”to their “home” in order to explain the everyday tensions underlying accessibility and daily mobility. Aging in a single-family house is more than a deliberate choice. Moving away from one's neighborhood is considered a last resort alternative by the majority. Instead, the elderly from both milieus will adapt their lifestyles to the environment by redesigning their daily activities and their mobility practices in order to age in place. Therefore, adapting daily mobility practices to social interactions and social representations all become a sine qua nonecondition.     

Determinants of the Rigor of State Protection Policies for Persons With Dementia in Assisted Living

Continued growth in the number of individuals with dementia residing in assisted living (AL) facilities raises concerns about their safety and protection. However, unlike federally regulated nursing facilities, AL facilities are state-regulated and there is a high degree of variation among policies designed to protect persons with dementia. Despite the important role these protection policies have in shaping the quality of life of persons with dementia residing in AL facilities, little is known about their formation. In this research, we examined the adoption of AL protection policies pertaining to staffing, the physical environment, and the use of chemical restraints. For each protection policy type, we modeled policy rigor using an innovative point-in-time approach, incorporating variables associated with state contextual, institutional, political, and external factors. We found that the rate of state AL protection policy adoptions remained steady over the study period, with staffing policies becoming less rigorous over time. Variables reflecting institutional policy making, including legislative professionalism and bureaucratic oversight, were associated with the rigor of state AL dementia protection policies. As we continue to evaluate the mechanisms contributing to the rigor of AL protection policies, it seems that organized advocacy efforts might expand their role in educating state policy makers about the importance of protecting persons with dementia residing in AL facilities and moving to advance appropriate policies.     

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 Vernacular Landscape of Assisted Living

This article is an exploration into the vernacular landscape of Assisted Living (AL), a conceptual idea borrowed from cultural geographer J.B. Jackson, which distinguishes formalized, planned space from those spaces which are unintended and often created spontaneously--vernacular. Based upon three large-scale, multi-year ethnographic studies in Maryland, we consider some of the ways people who live in AL relate to and respond to the built environment, at times subverting the intended purpose of design to make it their own. The conflict that often ensues over both planned and vernacular public and private space, we propose is ultimately the product of living within an environment that is both someone's home as well as a place of business, whose job it is to keep people safe. Within this physical context of vernacular private and public spaces, this article enriches understandings about the way autonomy and privacy expresses itself.     

Geographic Migration Among Residents in Seniors Housing and Care Communities: Evidence From the Residents Financial Survey

ABSTRACT

Although the elderly as a while show relatively little geographic migration in the U.S., we were interested in the geographic migration patterns among a specific subset of elderly that we know have moved out of the traditional family home—those living in assisted living and independent living communities. We analyze data from the Residents Financial Survey, a survey of 2,617 residents in assisted living and independent living communities that asked about their previous living arrangement, where they lived before moving to their current community, and how their care needs were previously met. We find there is substantial migration among respondents. Using self-reported and community-reported location and zip code information, we calculated whether people moved across state lines and we computed the distance people moved between their previous location and their current community. While the median distance moved is less than 10 miles, 20% moved across state lines and 21% of the sample moved more than 100 miles, with the average distance moved among the sample being 165 to 190 miles. The evolution of living arrangements shows that there are strong correlations among respondents' current living arrangements, previous living arrangements, and their plan to move in the future.     

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.     

Childless Elders in Assisted Living: Findings from the Maryland Assisted Living Study

We compared data drawn from a random sample of 399 current assisted living residents and a subsample of 222 newly admitted residents for two groups: childless residents and residents with children. The percentage of childless residents (26%) in our study was slightly higher than U.S. population estimates of childless individuals aged 65 years and older (20%). In the overall sample, the two groups differed significantly by age, race, and women's years of education. The childless group was slightly younger, had a higher percentage of African American residents, and had more years of education than the group with children. In the subsample, we looked at demographic, functional, financial, and social characteristics and found that childless residents reported fewer diagnoses of dementia and fewer visits from a relative but more reported paying less money per month for assisted living and having private insurance than residents with children. As childlessness among older adults continues to increase, it will become increasingly important to understand how child status affects the need for and experience of long-term care.     

Interactions of Behavior and Environment as Contributing Factors in the Discharge of Residents with Dementia from Assisted Living Facilities

While retirement communities have existed for over fifty years, they have received relatively little analysis. A clear consensus on definition does not even exist. Based on a literature review, we offer a definition that includes several criteria related to the housing units, boundaries, services and/or leisure amenities, age restrictions, voluntary relocation, and shared space. We delineate the variety of types of retirement communities and address the current and future challenges facing retirement communities. Such a discussion is urgent, given the lack of current housing policy, when both the potential demand and pertinent financial challenges are greater than ever.     

Provider Dilemmas with Relocation in Assisted Living

Abstract

Support for increasing tenant frailty in assisted living (AL) is a complex and challenging issue. Philosophically, older persons, families, providers, and policymakers want to avoid unnecessary relocation. However, there is considerable opportunity for inconsistency in practice. We examined provider perspectives related to implementing aging-in-place, using information obtained from an evaluation of a three-year AL demonstration project in Illinois. We found differences in approaches to explicit move-out criteria, the actual application of move-out criteria, and provider willingness to develop flexible service plans. These findings raise questions for consideration in all states confronted with implementing the philosophy and intent of AL.     

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.     

Social Relationships of African American and Hispanic Older Assisted Living Residents: Exploring the Role of Race and Ethnicity

African American and Hispanic older adults are underrepresented in assisted living communities, so little is known about how they experience social relationships in these settings. The purpose of the study was to explore resident-to-resident and resident-to-staff relationships experienced and perceived by African American and Hispanic older residents in assisted living settings. In-depth interviews with 15 African American and 15 Hispanic older adults were conducted in seven assisted living communities in Central Florida. Three salient themes emerged using a grounded theory approach: formation of relationships: emotional vs. instrumental support; language as a facilitator or barrier; and avoidance of inter-racial relationships. Implications for providing culturally competent services in assisted living communities with diverse populations are discussed.     

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.     

Use and Usability of Assisted Living Facilities for the Elderly: An Observation Study in Gothenburg Sweden

To meet the demographic development, measures were initiated by the Swedish government entailing changed conditions for municipal eldercare, such as assisted living. Participant observation is used to study the daily use of common spaces in 14 assisted living units in Gothenburg. The results show examples where the current use diverges from the intended use and suggest diverging objectives and conflicts of use. The observations indicate that the degree of usability is determined by the physical environment itself in some cases, by the users and by changes in use in other cases, and by a combination of both in some cases.     

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.     

Living Arrangements and Informal Support for the Elderly

ABSTRACT

A network of informal care and support provided by family, friends and neighbors often forms the basis for elderly care. Changes in the structure of Chinese family alter this supportive function, and changes in traditional values affect the nature of the network and support provided. This is especially so in modernized Hong Kong where the traditional role of the family and especially children's duty of care for their aged parents (“filial piety”) may be weakening. This proposition was investigated by a qualitative study involving in-depth interviews with 50 older persons in a modern new town (Tuen Mun) in Hong Kong. Living arrangements, geographical proximity and the quality of relationships between potential caregivers and the elderly affected needs for and provision of informal support. Traditional Confucian filial piety is undergoing modification, perhaps erosion, implying ongoing changes in inter-generational relations in this modernized Asian society.     

Medicaid Funding for Assisted Living Care: A Five-State Examination

Medicaid waiver programs financing assisted living care are examined in five states to gain insights about program implementation, accomplishments, and challenges. Documents, augmented with stakeholder interviews, are used to describe income eligibility, options for supplementing payments to facilities, risk adjustment payment levels, and participation. Needs determination and waiver-based payments are in place. Eligibility and funding levels are complicated by room and board allocations that are linked to the federal benefit rate for Supplemental Security Income. Provider participation may be diminishing. Many recipients have to accept shared occupancy as program payments are insufficient for single units.