Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

OBJECTIVES

To identify different approaches (unique domains) and indicators to evaluate quality in assisted living communities in the United States.

DESIGN

Scoping review supplemented with key informant and technical panel guidance.

SETTING AND PARTICIPANTS

Assisted living settings and residents.

METHODS

We obtained feedback on our review protocol and search strategy from key informants with expertise in AL quality, including feedback on a supplementary gray literature search for relevant non-peer-reviewed literature (such as nonempirical policy briefs). We scanned MEDLINE and CINAHL databases for peer-reviewed literature published from 2009 through 2019 assessing quality in assisted living in the United States. We synthesized evidence using the Donabedian framework and presented our analyses in 2 expert panel discussions for additional insights.

RESULTS

We screened 833 abstracts, of which 49 studies met our selection criteria. Gray literature search yielded an additional 45 non-peer-reviewed sources. Nine unique domains were assessed: (1) resident quality of life, (2) resident and family satisfaction, (3) staffing and staff-related outcomes, (4) resident safety, (5) resident health outcomes, (6) care planning and integration, (7) physical and social environment, (8) service availability, and (9) core values and philosophy. Resident quality of life and satisfaction were the most prioritized domains in published literature, key informant interviews, and expert panel discussions. Domains such as staffing, safety, resident health outcomes, care planning, and integration were identified as vitally important for the increasing clinical and sociodemographic heterogeneity in the resident population. Expert panels emphasized the importance of including residents' voice in the quality measures development process.

CONCLUSIONS AND IMPLICATIONS

Lack of standardized measurement of quality impedes provision of person-centered, value-based care in US-based assisted living settings. Our comprehensive list of domains and indicators should inform future concerted efforts to develop and incorporate standardized quality measurement as part of routine practice in assisted living communities in the United States.

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

OBJECTIVES

Online reviews provided by users of assisted living communities may offer a unique source of heretofore unexamined data. We explored online reviews as a possible source of information about these communities and examined the association between the reviews and aspects of state regulations, while controlling for assisted living, county, and state market-level factors.

DESIGN

Cross-sectional, observational study.

SETTING AND PARTICIPANTS

Sample included 149,265 reviews for 8828 communities.

METHODS

Primary (eg, state regulations) and secondary (eg, Medicare Beneficiary Summary Files) data were used. County-level factors were derived from the Area Health Resource Files, and state-level factors from the integrated Public Use Microdata series. Information on state regulations was obtained from a previously compiled regulatory dataset. Average assisted living rating score, calculated as the mean of posted online reviews, was the outcome of interest, with a higher score indicating a more positive review. We used word cloud to visualize how often words appeared in 1-star and 5-star reviews. Logistic regression models were used to determine the association between online rating and a set of community, county, and state variables. Models were weighted by the number of reviews per assisted living bed.

RESULTS

Overall, 76% of communities had online reviews. We found lower odds of positive reviews in communities with greater proportions of Medicare/Medicaid residents [odds ratio (OR) = 0.986; P < .001], whereas communities located in micropolitan areas (compared with urban), and those in states with more direct care worker hours (per week per bed) had greater odds of high rating (OR = 1.722; P < .001 and OR = 1.018, P < .05, respectively).

CONCLUSIONS AND IMPLICATIONS

Online reviews are increasingly common, including in long-term care. These reviews are a promising source of information about important aspects of satisfaction, particularly in care settings that lack a public reporting infrastructure. We found several significant associations between online ratings and community-level factors, suggesting these reviews may be a valuable source of information to consumers and policy makers.

Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place

Importance

Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place.

Objective

To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place.

Design, Setting, and Participants

This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022.

Exposures

Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US.

Main Outcomes and Measures

Presence in assisted living residences on the date of death.

Results

The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71).

Conclusions and Relevance

The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living

OBJECTIVES

Develop and evaluate the implementation of a proposed model for large-scale data-driven quality improvement in assisted living.

DESIGN

We conducted a mixed-methods evaluation of the implementation of a large-scale data-driven quality improvement collaborative of Wisconsin assisted living communities (ALCs).

SETTING AND PARTICIPANTS

The model has been voluntarily implemented by 810 Wisconsin-licensed ALCs serving >20,000 residents.

METHODS

The model was codesigned iteratively 2009-2012 by a public-private multistakeholder advisory group. Using system usage statistics and project records, we evaluated implementation outcomes: appropriateness, acceptability, adoption, feasibility, fidelity, penetration, and sustainability.

RESULTS

Implementation for ≥1 quarter was feasible for 92% of the 810 ALCs that enrolled. The model has been deemed appropriate and acceptable by public-private stakeholders representing residents, providers, regulators, and payers, and appropriateness for ALCs serving different populations has been iteratively improved through targeted workgroups. The model is currently adopted in Wisconsin by 31% of the 1573 ALCs in provider associations. Among adopters, 88% on average implemented the model with fidelity to key membership rules per quarter. The model achieved demographic and institutional penetration by currently reaching 24% of Wisconsin ALC residents and by leveraging initial grant funding to become integrated in Wisconsin's annual Medicaid budget and being central to Wisconsin's incentive program to managed care organizations. Model implementation for 8 years has been sustained by member enrollment for nearly 4 years on average, with 71% of members enrolled >2 years and sustained early adopters representing 37% that have been enrolled >5 years.

CONCLUSIONS AND IMPLICATIONS

This is the first implementation study of large-scale data-driven quality improvement in assisted living, despite its demonstrated value in other health care sectors. The article proposes a model with core components and implementation strategies drawing on a decade-long public-private collaboration. The implementation study findings establish a promising path and future directions for wider implementation.