Chapter 7. Measures Framework, Gaps, and Overall Summary

Investigators derived the measures framework shown in Table 1 for analyzing content from the assisted living instruments reviewed. It is based on information synthesized for the environmental scan, including core principles of assisted living; operational definitions from experts in the field, such as the Assisted Living Workgroup; public policy concerns; issues important to assisted living consumers; articles from the literature; industry checklists; private accreditation sources; and the existing instruments. The categorization of the specific measures cited in this chapter reflects the opinion of the investigators of this report and may not reflect the original survey developer's domain assignments, which are available in Appendix A (PDF File, 700 KB; PDF Help).

Table 1. Assisted Living Measures Framework Services, including: Health-related services such as access to medical care, providing safe care, medication management/assistance, emergency care, skilled nursing and other therapeutic services, care monitoring. Personal services such as food services, laundry, housekeeping, transportation, and assistance with personal care based on resident need—hygiene, dressing, and bathing. Recreational activities offered within and outside the facility that support socialization and wellness, such as special events, educational offerings, and games. Amenity services such as shopping and beautician services. Facility environment and operations including the: Descriptive characteristics such as ownership, bed size, and characteristics of residents. Physical plant such as private room/bath, availability of public spaces – inside and outside, cleanliness, safety and security, and maintenance. Social, cultural atmosphere of the environment, which includes elements of choice of lifestyle, privacy, autonomy, independence, individuality, involvement and respect of rights, home likeness, and fostering a sense of community. Staff issues, including their attention, caring interactions, availability, training and knowledge, turnover, job responsibilities, and levels of various types of staff in assisted living, e.g., aides, professional nursing staff, administrators, and food service employees. Contractual matters, including providing information on costs for services, admission processes, aging-in-place-related issues such as transfer criteria and discharge policies and negotiated risk agreements.

Using this framework, investigators describe the types of questions and items found in the assisted living instruments that were reviewed including consumer-reported, expert observation, and provider-reported instruments that are relevant to the areas listed above. Based on an evaluation of content gaps, investigators explore items in other instruments used in nursing home and other long-term care settings for potential application.

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Services

Health-Related Services, Including Medication Management

As noted earlier, nearly all assisted living residents need assistance with medications and often have medical comorbidities. Further, the level of acuity is rising. A 1999 GAO report described assisted living residents' complaints related to problems in receiving adequate access to medical care and treatment, and problems with medication (GAO, 1999). Easy access to medical care ranked third in importance to assisted living residents in Oregon (Reinardy and Kane, 2003).

Resident-reported assisted living instruments that were reviewed did not address health-related services comprehensively. Some focused on emergency medical care. Ejaz's (Ejaz, Schur, and Fox, 2003) instrument for the continuing care retirement setting measures the residents' "confidence in the facility's response to a medical emergency" and "promptness of emergency response calls." The Chong and Chi (2001) instrument includes "Can you see a doctor quickly when you are sick."

Non-emergency medical care was addressed by instruments from Hawes, Phillips, and Rose (2000b). In a resident survey they asked about the need for additional temporary nursing care, assistance with medication, and purchase of new or different assistive devices.

Health maintenance activities were found in the ALFA/ServiceTRAC (1999) resident instrument featuring an item "monitoring changes in your health." Simmons' (2001) assisted living instrument includes "receiving the medical attention that you need" and staff "make efforts to keep you healthy." Hawes and colleagues' surveys of providers, staff, residents, and families address basic health status monitoring and specialized health services offerings (Hawes, Phillips, and Rose, 2000b).

Nursing home instruments (Robinson, Lucas, Castle, et al., 2004; Norton, van Maris, Soberman, and Murray, 1996; Kane, Kling, Bershadsky, et al., 2003; Moxey, O'Connor, White, et al., 2002) hold promise for consumers' evaluation of health-related services. For example, items in these surveys included evaluating the "availability of nursing care if needed," "arrangements for medical appointments, if needed," "getting the medical help that you need," and "getting a doctor or nurse quickly." Also, the Medical Expenditure Panel Survey (Agency for Healthcare Research and Quality, 1996) and the Medicare Current Beneficiary Survey (Centers for Medicare & Medicaid Services, 2004) feature a comprehensive series of questions about the availability and variety of health professionals within and outside the facility.

Importantly, assisted living instruments rarely included items related to medication management, which represents a significant measurement gap, given the need for the service, how often it is provided in assisted living, and the level of consumer concern about the service. One exception is the resident interview of Hawes, Phillips, and Rose (2000b), which asked whether the resident takes any prescription or over-the-counter medications and whether they received help. Again, nursing home instruments hold promise for expanding coverage in this area. Robinson, Lucas, Castle, et al., (2004) assess a resident's perception of "the amount of help you get with your medications." Other areas of evaluation for medication, more appropriate for expert observation than resident evaluation, include the effectiveness of medication storage or assisting residents in self administration (e.g., timely reminders), services that are commonly provided by assisted living facilities (Hawes, Rose, and Phillips, 1999). Although medication issues were not provided in the assisted living observational instruments that were reviewed, provider instruments asked about the availability of medication reminders and assistance with and central storage of medications. Residents were asked about whether they took medications, received help with their medications, and about their opinion of the help they received (Hawes, Phillips, and Rose, 2000b). Other long-term care instruments and consumer experience surveys may evaluate the effectiveness of providing medication, e.g., pain relief and ability to enjoy life (Casarett, Hirschman, Miller, and Farrar, 2002) or whether residents need special help to take medications (for example, set up their pills, put pills in their hand) or go without medications because no one can help them (Galantowicz and Jackson, 2005; Minnesota Department of Human Services, 2005). Also, in this high risk population, instruments that assess vaccination status, e.g., influenza and pneumococcal vaccine, could be of value (National Center for Health Statistics, 2004).

Safety and error prevention in assisted living (JCAHO, 2005b) are important. Lau, Kasper, Potter, et al., (2005) found that, at a minimum, 50 percent of all residents 65 or older with a nursing home stay of at least 3 months experienced at least one prescription in error in 1996. The fact that relatively few instruments assessed avoidable care problems points to an opportunity for further measurement development. Among the instruments that did address the issue, Yee and colleague's resident instrument features patient safety items: "have you had any falls, skin sores or infections in the last 3 months," or "been stuck in the tub or shower" (Yee, Capitman, Leutz, and Sceigaj, 1999) and Hawes' surveys asked about falls sustained in the last year (Hawes, Wildfire, Iannacchione, et al., 1996; Hawes, Phillips, and Rose, 2000b).

Personal Services

Meal and dining services are essential components of assisted living services and influence residents' overall satisfaction and quality of life (ALFA, 1999; Lengyel, Smith, Whiting, and Zello, 2004). The fundamental importance of this service is reflected in the instruments reviewed, since virtually all of them have resident-reported measures that relate to food/meals/dining services. Residents evaluated meals and food services in the study by Hawes and colleagues in the following ways: 54 percent consistently had a choice of entrée, and 40 percent thought the food was tasty and well-seasoned (Hawes, Phillips, and Rose, 2000b). Menu quality is among the most frequent consumer complaints according to ombudsman reports (Administration on Aging, 2004). Gesell (2001) found that three of five issues receiving the lowest satisfaction scores were food related: special diet needs, wait time before being served, and quality of food.

The instruments comprehensively evaluated food services using such items as menu selection and variety/choice, quality, taste, appearance, enjoyment, freshness, amount and temperature of the food, availability of snacks, dining room schedule, dining room cleanliness, and waiting times. Items also evaluated the friendliness of food service staff and responsiveness to complaints. However, review of the assisted living instruments did not show consistent coverage of special diets, which this population may require. Hawes' provider survey features special diet content (Hawes, Phillips, and Rose, 2000b), and Gesell's (2001) resident survey includes this criterion: "the extent to which your food meets special diet needs." One nursing home survey asks whether the nursing home satisfies the residents' special dietary needs (Davis, Sebastian, and Tschetter, 1997). The provider survey used by Hawes and colleagues uniquely asks about escort services and room service (Hawes, Phillips, and Rose, 2000b). Depending on the acuity of the residents, the nursing home instruments that assess tube feeding may provide additional content for assisted living assessments (Norton, van Maris, Soberman, and Murray, 1996), as would in-depth instruments designed exclusively to evaluate food services in long-term care (Crogan, Evans, and Velasquez, 2004; Lengyel, Smith, Whiting, and Zello, 2004).

Laundry

In evaluating qualitative data from residents in developing a long-term care survey, Soberman and Murray (2000) found that the only area of resident concern related to laundry was the loss of personal belongings. Further, following pilot implementation of this survey, the data analyses showed that laundry did not correlate to satisfaction (Soberman and Murray, 2000) and was deleted from the instrument. From the instruments that were reviewed for this report, few featured laundry related measures (the surveys only asked if the service was provided and if clothing had been lost or damaged) reflecting the findings of Soberman and Murray's research (2000). The provider survey used by Hawes and colleagues asks whether the service includes linens alone or whether it also includes personal clothing and whether additional costs are involved; the resident interview asked whether he or she had purchased more frequent changing of bedding or personal laundry services during the last month (Hawes, Phillips, and Rose, 2000b).

Transportation

As noted earlier, transportation is a service that is commonly provided in assisted living facilities. Instruments that were reviewed provide measures that relate to transportation, with the content addressing if the service "meets residents' expectations/needs, was available" (Ejaz, Schur, and Fox, 2003), if there were "problems encountered," and how much of the time transportation was "offered" (Hedrick, Guilhan, Chakpro, et al., 2005; Hawes, Phillips, and Rose, 2000b). The provider survey used by Hawes, Phillips, and Rose (2000b) differentiates transportation availability for health-related appointments from that provided for social outings. The resident interview asks about whether there is enough transportation on weekends and whether there is transportation to "things you enjoy." Based on the evaluation of research reported earlier, transportation was not a major factor in overall assisted living satisfaction. Similarly, transportation received relatively little attention in the nursing home instruments; however, other long-term care tools, such as the Minnesota Department of Human Services Aging and Adult Services Consumer Experience Survey (2005), ask if clients could get to the places that they need to go such as shopping, church, and other places and asks about van use and the helpfulness of transportation staff (MEDSTAT, 2003).

Assistance with Personal Care

Providing assistance with basic activities of daily living—such as hygiene, dressing, and bathing—is fundamental to assisted living. Some resident-reported instruments have content related to personal care needs, assistance with personal hygiene needs (ALFA, 1999), and needing more help with personal care (Yee, Capitman, Leutz, and Sceigaj, 1999). The Hawes resident interview (Hawes, Phillips, and Rose, 2000b) asks about assistance with ADLs, as well as medications, and asks about unmet needs for each one. Also the provider survey by Hawes Phillips, and Rose (2000a) asks about the provision of personal services (bathing, toileting, toilet assistance). However, many instruments evaluate whether needs are being met in the context of staffing (are staff available to meet "needs"). Rather than specific reference to hygiene, dressing, or bathing, the observational tool used by Aud and colleagues assesses personal care outcomes, that is, whether residents are well-groomed and clean (Aud, Rantz, Zwygart-Stauffacher, and Manion, 2004). The Health and Retirement Survey (Institute for Social Research, 2004) includes a wide variety of items about services available in retirement communities.

Assisted living facilities provide 24-hour services; however, few measures were found that addressed providing 24-hour services or care other than a few examples of staff availability (e.g., weekends), which is further discussed in the staffing section featured below. Hawes and colleagues, in a survey of administrators, ask whether the facility provides "24-hour direct care staff who can respond to residents' needs for assistance or monitoring" (Hawes, Phillips, and Rose, 2000b)

Assisted living provides services for residents who often require a higher level of care or who have specialized needs, such as residents with dementia who require more orientation cueing. Phillips and Hawes (2005) found that at high levels of cognitive impairment, staff cueing activities decreased, suggesting that it took longer than merely helping the resident perform the task. The provider survey used by Hawes and colleagues asks whether dementia care was offered (Hawes, Phillips, and Rose, 2000b). Hawes' family telephone survey asks about dementia care, e.g., safety for residents who wander, rating of the environment for people with cognitive impairment, and how often staff members deal appropriately with residents who have behavioral or cognitive impairment (Hawes, Phillips, and Rose, 2000b). The observational nursing home instrument for dementia by Sloane, Mitchell, Weisman, et al., (2002) is designed to evaluate a setting that includes residents who need specialized care, and it could help inform this gap, since cognitive impairment is prevalent in the assisted living population.

Recreational Activities

Meaningful activities enhance satisfaction and quality of life for assisted living residents (Ball, Whittington, Perkins, et al., 2000; Vital Research, 2005; Jenkins, Pienta, and Horgas, 2002). Many of the instruments that were reviewed included activity-related items and domains. Survey questions from the resident and observational tools included overall quality of specific activities, if the number and variety of activities that were offered met the residents' needs, an evaluation of the time spent in activities, and if there was enough information posted about the schedule of activities. The observational tool used by Aud and colleagues uniquely features activities involving children (Aud, Rantz, Zwygart-Stauffacher, and Manion, 2004). As noted earlier, residents often do not participate in activities because of lack of interest; thus several of the instruments reviewed have questions about the relevance of activities to residents, e.g., are they of a variety to reflect residents' interests (Ejaz, Schur, and Fox, 2003), are they interesting (Simmons, 2001), do they meet residents' needs (Gesell, 2001), and are they stimulating and enjoyable, that is, things residents like to do (ALFA, 1999; Hawes, Phillips, and Rose, 2000b). Also, included are questions concerning whether staff makes an effort to find out activity preferences (Hawes, Phillips, and Rose, 2000b). Spiritual and religious activities are cited in several of the resident instruments; health promotion and exercise in fewer (Chong and Chi, 2001; Hawes, Phillips, and Rose, 2000b; Yee, Capitman, Leutz, and Sceigaj, 1999). The nursing home instrument used by Moxey and colleagues provides specificity in activities not seen in the assisted living tools (Moxey, O'Connor, White, et al., 2002). Importantly, assisted living instruments that were reviewed did not address activities for special needs residents, such as those with dementia or those who are cognitively impaired, which represents a gap.

Other Services and Amenities

Items that evaluated other services and amenities—such as hair salons, pet services, and libraries—were found in few instruments and were not universally defined. However, amenities have not been reported as a major factor in overall satisfaction.

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Facility Environment

Descriptive Characteristics

The basic descriptive characteristics of an organization are important for potential consumers, that is, ownership and financial viability of the organization, the levels of care provided, and the level of frailty of residents. Provider-reported instruments alone offer an assessment of this information; Hawes, Phillips, and Rose (2000b) and the American Seniors Housing Survey (2004) instruments solicit information from administrators about the corporate structure of the assisted living facility. The instruments address such topics as State or private accreditation status, operational and capital financial status, size of the facility, and how accommodations are described—semiprivate rooms, private bath, etc., average length of stay/turnover, the age range of residents, and the number and kinds of frailties of the facility's resident population. The Medical Expenditure Panel Survey, Nursing Home Component, (AHRQ, 1996) contains many items that categorize and describe facilities that could be adapted to an assisted living situation. These instruments could provide a format for developing tools to help consumers evaluate assisted living facilities at this fundamental level. Also, such tools as the National Nursing Home Survey (NCHS, 2004) could help inform specialty units; for example, does the facility have special, physically distinct or designed clusters of beds or segregated wings or units used exclusively for Alzheimer care or care for cognitively impaired residents?

Physical Plant

Equipment and building problems are a frequent complaint of consumers (Administration on Aging, 2004). Survey content from the instruments that relates to the physical environment was generally well represented and addressed the overall appearance of the grounds and buildings, the facility cleanliness and timely upkeep (items also found in housekeeping/maintenance domains), lighting, odor, noise, decoration, and a sufficient amount of living and storage space. The Hawes, Phillips, and Rose (2000b) facility observation instrument uniquely provides a comprehensive evaluation of the facility, including specific evaluation of community rooms and the neighborhood. Few surveys, however, addressed the design of the facility and accessibility/ease of getting around or the adequacy of storage space (Chou, Boldy, and Lee, 2002; Hawes, Phillips, and Rose, 2000b). Other long-term care questionnaires that may inform this gap would include items such as handicapped access, elevators, and special railings.

An important factor in assessing the assisted living environment is a feeling of safety and security. As noted previously, safety and security are extremely important to residents' overall satisfaction (Ejaz, Schur, and Fox, 2003; Vital Research, 2005; Reinardy and Kane, 2003). Having a safe place to live was the second most important issue described in Reinardy and Kane's (2003) research on assisted living residents. Safety and security are measured in several contexts in the instruments reviewed: safety and security of the building, grounds, and living area (Ejaz, Schur, and Fox, 2003); feeling safe in the place (Moran, White, Eales, et al., 2002; ALFA, 1999); the existence and reliability of emergency procedures and security/alarm systems (ALFA, 1999; Aud, Rantz, Zwygart-Stauffacher, and Manion, 2004; Robinson, Lucas, Castle, et al., 2004); the ability to lock rooms (Hawes, Phillips, and Rose, 2000b); and the safety of personal belongings (Gesell, 2001; Chong and Chi, 2001; ALFA, 1999). Hawes, Wildfire, Iannacchione, et al., (1996) asked how safe residents felt their possessions were and how safe they felt in their neighborhood. Walk-through instruments asked researchers to observe and rate facility amenities and the safety of the neighborhood (Hawes, Wildfire, Iannacchione, et al., 1996; Hawes, Phillips, and Rose, 2000b).

Another important element in residents' perception of safety and security is the absence of physical or psychological abuse by the staff. Hawes, Wildfire, Iannacchione, et al., (1996) asked residents about whether they were reluctant to report complaints or had observed a series of actions by staff, some of which constituted physical, verbal, or psychological abuse. A nursing home instrument (Kane, Kling, Bershadsky, et al., 2003) adds another safety dimension related to potential abuse in "afraid because of how you or others are treated," which is further described in a subsequent section. While the issue of security and safety is not a specific content gap, how assisted living residents actually characterize safety and security needs additional clarification.

Social/Cultural Environment

The social and cultural environment/atmosphere is the crux of assisted living philosophy and, as defined earlier, includes concepts of privacy, choice, autonomy, independence, involvement, and home likeness. The surveys that were reviewed feature many measures that relate to these vital concepts.

In these instruments, privacy is considered from both a facility feature context, for example, "you have privacy in your apartment" (Gesell, 2001) and a behavioral context, "staff knock before entering" (Utz, 2003). Measures regarding choice are reflected in having personal furniture (Ejaz, Schur, and Fox, 2003; Hawes, Phillips, and Rose, 2000b), food choice (Chong and Chi, 2001; Hawes, Phillips, and Rose, 2000a), and temperature control of their unit (Hawes, Phillips, and Rose, 2000b). Examples of autonomy measures include having your own schedule, (Ejaz, Schur, and Fox, 2003), deciding if you need assistance, and exercising your own religious beliefs (Chong and Chi, 2001). The Utz (2003) survey features 13 items on autonomy, ranging from assigned seats in the dining room to policies about smoking and alcohol use. The nursing home literature also features measures such as going to bed when you want and choosing what clothing you wear (Kane, Kling, Bershadsky, et al., 2003). Hawes, Phillips, and Rose (2000a) asked about facility policies on pets, furniture, and visiting hours.

Measures of involvement generally reflect residents' involvement in the facility operations, e.g., how willing the manager is to listen to residents' concerns (Curtis, Sales, Sullivan, et al., 2005) and responsive management is to residents' ideas (Gesell, 2001). Chong and Chi (2001) feature items related to keeping residents informed about their health and about orientation programs; Kane, Bershadsky, Kane, et al. (2004) extend the concept of involvement to the external community. Chou, Boldy, and Lee (2002) address resident involvement, including keeping residents informed and maintaining their freedom to express views and concerns. As noted earlier, long-term care residents who are involved in their care planning and day-to-day activities are healthier and happier (Blair, 1994). Only one observational instrument (Utz, 2003) features an item assessing residents' involvement in care planning, representing a gap.

Social interaction and support affect life satisfaction and the quality of life in assisted living. Items that evaluate social interaction are frequently presented in the context of activities as well as independent domains. The social support subscale of Ejaz and colleagues (2003) has seven items including "having someone to listen to," "shows love and affection," and "have a good time with." Some social support-related questions specifically address roles, e.g., "do you have friends among staff members" (Simmons, 2001; Chong and Chi, 2001) or "what is your relationship with roommate, other residents." Yee, Capitman, Leutz, and Sceigaj, (1999) ask whether the resident has confidantes, friends, or gives/receives help from neighbors. Kane, Bershadsky, Kane, et al., (2004) and Chou, Boldy, and Lee (2002) extend their social assessment focus to the external community. As noted earlier, monthly family contact showed a positive impact on life satisfaction. While several featured family items—e.g., did they visit, have an area to meet with family, are there family activities, good communication (Moran, White, Eales, et al., 2002; Chong and Chi, 2001; Kane, Bershadsky, Kane, et al., 2004; Aud, Rantz, Zwygart-Stauffacher, and Manion, 2004; Hawes, Phillips, and Rose, 2000a)—the instruments reviewed did not have standardized items to systematically assess family involvement, which represents a gap. The nursing home instruments may provide content to bridge this gap; for example, Tornatore and Grant (2004) ask about family involvement in care planning, and Moxey, O'Connor, White, et al., (2002) address the existence of family councils.

Home-likeness items are also included in Simmons (2001) and Moran, White, Eales, et al., (2002) and are often worded as "do you feel at home." The Utz (2003) instrument has 15 items that relate to home likeness, such as visitation policies, mail receipt, and having pets; and the Aud, Rantz, Zwygart-Stauffacher, and Manion (2004) observational survey features nine items that range from having pets to having access to computer-based communication. Home likeness also relates to the physical environment; for example in Chong and Chi (2001), an item asks whether the facility "resemble(s) that of a domestic home." Several different instruments from Hawes, Phillips, and Rose (2000a) have items referring to home likeness (e.g., "can residents control thermostats? Can they rearrange their furniture?").

Independence measures in Gesell (2001) consider "the extent to which living here maintains your independence." Yee, Capitman, Leutz, and Sceigaj's (1999) assisted living survey and the nursing home instrument of Robinson, Lucas, Castle, et al., (2004) have subscales related to independence and maintaining an independent lifestyle. The provider survey of Kane, Bershadsky, Kane, et al., (2004) assesses the administrator's strategies for resident connection to the outside community.

Staff

As previously stated, staff has a major influence on satisfaction and represents a key measurement area in nearly all of the instruments reviewed. Staff roles are differentiated for evaluation in many of the instruments, e.g., nurse aide, nurse, administrator, housekeeper, activities director, and dining room staff. Instruments feature staff items that evaluate interpersonal reactions, such as whether staff members are caring, courteous, concerned, respectful, helpful, and genuine; take time to listen; show affection; or are trustworthy, friendly, and warm. Aud, Rantz, Zwygart-Stauffacher, and Manion's (2004) observational instrument asks about staff visibility, cleanliness, and grooming. Also, some items evaluate staff interactions, for example, staff "working together." Hawes, Phillips, and Rose, (2000a) in their resident and family interview instruments asked several questions about residents' views of the staff including (among others) treating residents with dignity and respect and with affection.

Lack of dignity or respect on the part of the staff is a frequent complaint to State ombudsmen (Administration on Aging, 2004). Residents of assisted living facilities are not informed about how to deal with an abusive situation (Wood and Stephens, 2003). Instruments reviewed included the concept of dignity in evaluating staff. Instruments also include items evaluating staff behavior, such as do they "treat residents in a personal manner," promptly, and responsively? However, assisted living surveys rarely feature items about potential abuse, representing a gap. Vital Research (2005) has an item, "staff gets angry with me." As noted earlier, potential abuse represents a safety and security element for the resident. Sources from other long-term care instruments that have specific content about potential abuse could inform items for assisted living. These include being yelled at or hurt by the staff (Minnesota Department of Human Services, 2005), injured by the staff (MEDSTAT, 2003), or being hit, slapped, yelled at, cursed at, threatened, or punished by the staff (Hawes, Wildfire, Iannacchione, et al., 1996).

A key role for the staff is to promote the independence of assisted living residents—that is, not doing things for residents that residents could do for themselves. Several instruments feature content that evaluates staff roles in promoting independence: ALFA (1999) has an item "staff encourages and supports independence"; Ejaz, Schur, and Fox (2003) consider "does the resident have the opportunity to do as much as he/she would like to do for himself/herself"; Vital Research (2005) asks whether the resident is "encouraged to be independent." Hawes, Phillips, and Rose (2000b) asked family members, "How often do staff encourage or help your relative to function as independently as possible?" The nursing home survey by Ryden, Gross, Savik, et al., (2000) explicitly asks "do staff encourage you to maintain your personal independence?"

According to the Hawes, Phillips, and Rose (2000a) study, assisted living residents' greatest points of concern about staff relate to inadequate staffing levels and high staff turnover. The resident survey by Curtis, Sales, Sullivan, et al., (2005) has an item related to evaluating staff turnover: "how much of a problem is staff turnover?" Hawes, Phillips, and Rose (2000a) also feature "how successful is the facility at keeping good staff"? Regarding staffing levels, Ejaz, Schur, and Fox (2003) include content on staff availability and the Hawes, Phillips, and Rose (2000a) and Hedrick, Sales, Sullivan, et al., (2003) surveys ask "how much time including weekends, are there enough staff on to adequately care for all the residents?" Given the importance of staffing to consumers, evaluating staffing levels and turnover presents a gap; however, a consumer survey may not be the most effective way to gather this information. Rather, using data from provider reported instruments (Hawes, Phillips, and Rose, 2000a that could supply actual hours by staff category and turnover rates may offer a quantitative evaluation of staffing, an understanding of the staff expertise available (e.g., social worker, dietician, activity director), and whether these resources are staff members or subcontractors.

The National Nursing Assistant Survey (NCHS, 2004) provides a comprehensive survey of nursing assistants who in the nursing home setting are often in the closest contact with the residents. Topics covered include their training, support given to them by the facility to carry out their duties, continuing education, time and ability to carry out their assistance tasks (help with ADLs, etc.), number of assigned residents, job satisfaction, and their workplace environment.

In a survey of assisted living facilities, Hawes, Phillips, and Rose (2000b) found that the majority of staff members were almost completely unaware of what constitutes normal aging, which is troubling in a setting of care exclusively devoted to the elderly. In the ALFA (1999) study, 19 percent of assisted living residents expressed concern about the general knowledge of assisted living of staff. Staff training was cited frequently as a quality of care concern in a GAO (1999) report. Hedrick, Guilhan, Chakpro, et al., (2005) features an item "how well trained and supervised do you think staff are at this facility." The ALFA (1999) survey assesses the "assisted living knowledge of the staff." Simmons' (2001) tool addresses residents' satisfaction with "the skills of nursing assistants," and Norton, van Maris, Soberman, and Murray (1996) include an item "are the staff skilled and knowledgeable." The Hawes, Phillips, and Rose (2000b) survey asks "how well trained and supervised are staff?" Assessment of staff's knowledge, training, skills, and abilities represents a gap; however, as with staffing levels and turnover, this information may be more appropriately obtained from sources other than residents, e.g., provider surveys that detail the number of hours and the content of training provided to staff (Hawes, Phillips, and Rose, 2000b). In developing CAHPS® instruments, cognitive testing "showed that most consumer respondents find it easier to report on their experiences than to make judgments that go beyond their experience" (McGee, Kanouse, Sofaer, and Hargraves, 1999, p. MS34).

Contractual Matters

Content that relates to important contractual issues, such as aging in place in assisted living, was not consistently found among the instruments that were reviewed. Discharge eviction planning and notice are among the most frequent complaints against assisted living facilities (Administration on Aging, 2004). Issues related to aging in place—such as transfer criteria, discharge, move out policies, and negotiated risk agreements—were addressed in the Curtis, Sales, Sullivan, et al., (2005) instrument: "If your health deteriorates, how confident are you that the facility will be able to meet your future needs?" The Hawes, Phillips, and Rose (2000a) instruments ask "Do you expect to be able to reside here as long as you want to?" and "Will the facility be able to meet your needs for assistance and health care?" Ejaz, Schur, and Fox (2003) ask in general about the "quality of the information in the resident handbook," but not about specific policies. Kane (2004) has an item on negotiated risk: "negotiated risk process so residents can take informed risk in apartments and other locations to pursue their own interests." Provider-reported surveys that specify conditions for admission and discharge (behavior problems, incontinence, transferring assistance), such as Hawes, Phillips, and Rose (2000a), could give consumers a clearer understanding of both short- and long-term needs. Also, other long-term instruments address aging in place in the following ways: "Would the facility allow the resident to continue living in the facility or their unit if they needed substantial care?" (Institute for Social Research, 2004); "What is your usual practice if a resident becomes ill or disabled for a longer period of time (longer than 14 days)?" (Hawes, Wildfire, Iannacchione, et al. 1996).

Evaluation of cost and charge issues also was not consistently found in resident-reported instruments. In an evaluation of the admissions process, Ejaz, Schur, and Fox (2003) ask "How do you rate information about monthly charges?" Gesell (2001) asks if the "bill is easy to understand." The Hawes, Phillips, and Rose (2000a) instruments feature "Are you aware of the monthly bill on charges from the facility?" "How do charges compare with expectations?" and "Have you been provided written information about the charges for the type of care received?" The nursing home instruments offer content that may apply to assisted living: Robinson, Lucas, Castle, et al., (2004), Castle (2004b), Castle, Lowe, Lucas, et al., (2004), and Ejaz, Schur, and Fox (2003) nursing home resident instruments have items related to costs such as "Are you getting good value for the money?" "Rate the information you were given about payments," and "Did you get clear information on the daily rate, additional charges, and how to pay for care?" Again, uniform facility-reported data about monthly charges and what constitutes the rates may provide better data for consumers, such as the Hawes, Phillips, and Rose (2000a) provider survey.

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Summary

As assisted living continues to emerge as a major source of elderly housing, the need for a better understanding of what consumers need to know and how they evaluate services will grow. Investigators in the nascent field of research on assisted living and its potential impact on consumers have begun to develop methods and tools to document and examine facility characteristics that the residents consider "homelike" and that influence quality of life and satisfaction.

Based on this environmental scan of assisted living instruments, investigators found that most assisted living instruments are resident-reported and few are observational or provider-reported, although all potentially can inform the development of an instrument for consumer choice. Instruments are not standardized, and there is no standardized set of domains, which reflects the ambiguous definition of assisted living. The tools are largely research oriented; however, proprietary tools exist in the industry.

Content-related gaps from the assisted living instruments reviewed include:

• Medication management.
• Patient safety concerns, avoidable problems in care.
• Special diets.
• Meeting needs for specialized care and activities, e.g., dementia patients.
• Ease of resident physical accessibility in the facility.
• Clearer definition of safety and security from a resident's perspective.
• Assessment of residents' understanding of how to address potential elderly abuse.
• Residents' involvement in their care planning.
• Family involvement.
• Staff issues, including:
  • The promotion of resident independence in cognitively impaired residents.
  • Staffing levels and turnover.
  • Staff's knowledge, training, skills and abilities.

In preparing this report, we explored the burgeoning literature in the field to examine what features are considered important by researchers, facilities, and most importantly, consumers. Further, the report presents the measures that have been created to capture and evaluate information on these features. Literature and measures from nursing home instruments, which are more developed, also help inform how to examine what is important to residents. The research shows that, although there are a number of tools examining various aspects of assisted living and nursing home care using different methodologies, there is still much room for growth. A number of gaps exist in both the content that is collected and the methods used to collect the data. Research to fill these gaps will contribute to the ability to inform consumers.

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