Assisted living continues to emerge as a major source of housing for the growing elderly population. Several factors will augment this trend, including the New Freedom Initiative Medicaid Demonstration Act of 2003, response to the 1999 Olmstead v. Supreme Court decision, the "rebalancing" demonstrations from institutions to home- and community-based sciences, and Medicaid cost containment strategies that are aimed at reducing nursing home use. Assisted living definitions vary, but fundamental to this long-term care setting is a philosophy of independence, with an emphasis on dignity, autonomy, choice, privacy, and maintaining a home-like environment.
When selecting an assisted living facility, a consumer's ability to make informed choices is compromised by the variability in philosophy, services, and accommodations among places called "assisted living" and by the lack of readily available, objective information about the characteristics and performance of facilities. While there are mechanisms to evaluate the quality of assisted living facilities, such as State licensing boards and private accrediting programs, the results of these evaluations are not readily accessible to consumers. To address this need, the Agency for Healthcare Research and Quality (AHRQ) sponsored an environmental scan of assisted living questionnaires and other long-term care instruments currently in use. The results of this scan, along with other initiatives, will inform the development of resources to help public and private organizations provide information to assisted living consumers.
Residents' experiences that affect their satisfaction and quality of life are key in developing consumer-oriented information tools. A number of factors are found to have strong influences on the resident's experience and life. For example, the facility's physical characteristics, such as private room and bath, and the safety and security the facility provides are important to consumers. The attitude of assisted living staff and the respect they show toward residents—along with services such as meals, activities, and access to health care, including medication assistance—also influence consumers' satisfaction and quality of life. Additional factors contributing to consumer satisfaction are social support and interactions among staff and residents that support a home-like atmosphere, as well as the residents' ability to maintain an independent lifestyle.
The instruments reviewed in this scan were used in an array of assisted living settings and other long-term care settings, such as nursing homes and residential settings, and include content that could be applied to assisted living. Consumer-reported instruments, expert observational instruments, and provider-reported tools featured content used to evaluate services offered, the physical and cultural environments, staff issues, activities, social support, and contractual issues.
Gaps in content exist between what is important to residents and what is addressed in most of the instruments, including medication management, patient safety issues, special diets, specialized care for cognitively impaired residents, assessment of potential resident abuse, physical accessibility to the facility, residents' involvement in planning their care, and families' involvement. A clearer understanding of how residents define safety and security is also needed. Areas related to staff—such as staffing levels and turnover, training, knowledge, and abilities—are not fully addressed in the instruments. Finally, content related to disclosing policies that relate to discharge and costs of care are rarely included.
We give special thanks to Catherine Hawes, PhD, Texas A&M Health Science Center, for her review and insightful comments on content of an early draft of this report. D.E.B. Potter, MS, of the Agency for Healthcare Research and Quality's Center for Financing, Access, and Cost Trends, and Rhona Limcangco, of the Social & Scientific Systems, made substantial contributions to this report, particularly to the content of Appendix A. We thank the following individuals who provided technical oversight and content review throughout the project: D.E.B. Potter, MS, of AHRQ's Center for Financing, Access, and Cost Trends; William Spector, PhD, of AHRQ's Center for Delivery, Organization, and Markets; and Charles Darby, PhD, and Judy Sangl, PhD, of AHRQ's Center for Quality Improvement and Patient Safety. We also thank Charles Darby for his expertise in contract management oversight. Mary L. Grady provided contract support through AHRQ's Office of Communication and Knowledge Transfer. She provided editorial review and prepared the final manuscript for the AHRQ Web site.