Chapter 5. Factors Important to Consumers When Choosing Residential Care

This chapter outlines findings from the research on the factors that most influence assisted living residents' and families' satisfaction and potential quality of life. While quality of life and satisfaction are different constructs, many areas overlap. For example, Kane and Wilson (2001) consider quality of life as a three-legged stool: home-like residential environment, a facility's capabilities for providing services, and consumer choice and control. All of these areas affect satisfaction. In addition to factors that affect satisfaction, this chapter also provides information on features that consumers consider to be important in choosing facilities.

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Facility Characteristics

Many articles indicate that characteristics of the facility have been found to influence satisfaction. For example, among continuing care retirement community residents, Ejaz et al. (2003) showed that cleanliness of the facility was important to residents. Sikorska (1999) noted that a smaller facility size, greater amount of personal space, and a moderate level of physical amenities were associated with higher levels of satisfaction among assisted living residents. In focus groups conducted to determine the information needs of potential residential care consumers, consumers considered the availability of a private room, the type of facility, and level of care provided as most important (Edwards, Courtney, and Spencer, 2003). In fact, in rating what was important in choosing an assisted living facility, top facility characteristics for respondents included a private room and bath and a safe place (Reinardy and Kane, 2003). Safety and security are also key contributors to overall satisfaction in assisted living communities (ALFA, 1999; Ejaz, et al., 2003; Vital Research, 2005).

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Staff

Another important area is staff communication, which accounts for a significant component of overall resident satisfaction (Vital Research, 2005). Chou, Boldy, and Lee (2002) found that satisfaction with the staff's attitude, respect, and timely response had a positive effect on other aspects of resident satisfaction. A higher level of support between assisted living staff and residents led to lower depression levels and higher facility satisfaction on the part of residents; whereas, higher levels of anger and conflict between staff and residents resulted in lower levels of resident satisfaction (Mitchell and Kemp, 2000). In Soberman and Murray's (2000) research, the two domains that correlated most highly with global satisfaction were staff interactions and relationships with residents and dignity of residents as a result of staff interactions. Staff-related issues were strongly associated with satisfaction, including staff working together to care for the resident, confidence in staff, staff assistance, and the care that staff provides (Gesell, 2001). Indeed, management responsiveness and emotional support by aides are among top priorities for assisted living residents (Gesell, 2004).

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Services and Activities

Meals and activities are the daily focus of residents. Food services, food/meals, and the mealtime/dining experience consistently influence resident satisfaction with facilities and quality of life (Reinardy and Kane, 2003; Guse and Masesar, 1999; ALFA, 1999). Meaningful activities also increase quality of life and satisfaction for assisted living residents (Ball, Whittington, Perkins, et al., 2000; Gesell, 2004; Cummings, 2003; Vital Research, 2005; ALFA, 1999; Reinardy and Kane, 2003). Access to emergency services and medical care are also important to assisted living residents (Ejaz, Schur, and Fox, 2003; Reinardy and Kane, 2003).

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Independence and Choice

Some assisted living residents may experience a decrease in perceived control, similar to that of nursing home residents, despite the philosophy of independence that defines assisted living facilities (Slivinske and Fitch, 1987). As assisted living residents' perceived control increased, researchers reported an improvement in physical health and quality of socialization (Slivinske and Fitch, 1987). Significant positive correlations were found between the choice residents perceive they have in their self-care and leisure activities and their quality of life (Duncan-Myers and Huebner, 2000). Similarly, resident choice and autonomy also have a positive impact on satisfaction (Duncan-Myers and Huebner, 2000; Ball, Whittington, Perkins, et al., 2000). Respondents who exercised independent choices and had influence over facility policies had more positive ratings of satisfaction (Mitchell and Kemp, 2000). Also, long-term care residents who are involved in their care planning and day-to-day activities report that they are healthier and happier (Blair, 1994). Having the ability to exercise personal control in having one's own furniture and personal visitors is an important influence on satisfaction and quality of life in assisted living (Reinardy and Kane, 2003; Salmon, 2001). Ejaz, Schur, and Fox (2003) noted that "freedom to live one's own lifestyle" was important to residents.

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Social Factors

Family and staff involvement also influences resident satisfaction in assisted living. For example, monthly family contact has a positive impact on life satisfaction (Mitchell and Kemp, 2000), and social support and interaction within the facility also relate to quality of life satisfaction and reduced isolation and depressive symptoms (Ball, Whittington, Perkins, et al., 2000; Cummings, 2003; Guse and Masesar, 1999). Social interactions are especially important for independent residents (Chou, Boldy, and Lee, 2002). Residents who are "personally invested" in the facility are more satisfied (Wylde, 2002).

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Resident Characteristics

Although the focus of this report is on helping consumers evaluate facilities and services, it is important to note in developing any instrument that the residents' unique characteristics influence satisfaction and quality of life. Therefore, when measures are evaluated they often are adjusted to account for these biases. Also, evaluating service quality based on consumer satisfaction alone is incomplete since resident well-being affects overall satisfaction with services (Duffy and Ketchand, 1998). Researchers found that residents with higher functional competence were more satisfied (Sikorska, 1999; Cummings, 2002), as were those residents who could perform IADLs (Mitchell and Kemp, 2000). Hedrick, Guilhan, Chakpro, et al., (2005) found that assisted living residents were more satisfied than residents in other adult living situations, in part because assisted living residents require less help. Resident age (older) is positively correlated with residents' satisfaction with the care they receive from staff and overall satisfaction (Mitchell and Kemp, 2000; Chou, Boldy, and Lee, 2002). Residents with chronic health problems have lower quality of life satisfaction (Mitchell and Kemp, 2000). In addition, residents who are less educated have higher levels of satisfaction (Sikorska, 1999; Curtis, Sales, Sullivan, et al., 2005). Being female, increased functional impairment, and lower levels of self-reported health relate to poorer psychological well-being (Cummings, 2002).

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Resident's Family Satisfaction

Factors that influence the satisfaction of family members may differ from the factors that influence resident satisfaction. This difference suggests that a family questionnaire and a resident questionnaire may need to be constructed differently to reflect the different points of view. In addition, the differences in perception suggest that family members are not true proxies for residents. Gesell (2001) found that the family members of assisted living residents rated facilities higher than did residents. Further, residents who had a family member help them complete the survey gave higher ratings overall than those than those residents who were assisted by a volunteer, which has implications in survey administration. While what is important to families and residents is sometimes similar, e.g., food services, families often vary in what influences satisfaction. In free standing assisted living facilities, family satisfaction differed from that of the residents—personal care services and staff (including their attitude, knowledge and communication) most influenced the family's satisfaction, in contrast to residents, whose priorities included the friendliness and caring attitude of the administrator and security services (ALFA, 1999). Priority factors for families of assisted living residents include an aide's ability to anticipate residents' needs, managerial responsiveness, value for the money, and well organized activities (Gesell, 2004).

In focus groups with families of assisted living residents with dementia, researchers found that staffing was the most important quality domain (Hawes, Green, Wood, and Woodsong, 1997). The families considered seven staff subcategories as core to quality: staffing level and qualifications; training; attitude of kindness, respect, and affection; communication with the family; low turnover rate; continuity of care; and a shared sense of responsibility among staff members. These family members also viewed specific services as critical areas of quality including activities that helped maintain functioning, physical assistance, Alzheimer's disease specific care, medication supervision, meals/food, transportation, assessment, and individualized care plans. In addition, the families were concerned with safety and security for residents who wander, visual cues to help with memory loss, good lighting, and a homelike setting that avoided potential isolation of residents (Hawes, Green, Wood, and Woodsong, 1997).

In developing instruments that help consumers evaluate assisted living facilities, these studies suggest the importance of including measures to evaluate:

• Facility characteristics, such as cleanliness and an evaluation of personal space and privacy.
• The philosophy of the facility, including attitudes about choice, independence, autonomy, and involvement in decisionmaking in developing facility policies, operations, and care planning.
• Interactions with staff and other residents.
• The services provided by the facility, specifically food services, health-related services, and security.
• The activities provided by the facility.
• Demographics and health status to allow bias adjustments to satisfaction measures.
• Separate surveys for family and residents.

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