March 2020, Volume XXXIII, No 12

  Long-Term Care

Developing an Assisted Living Report Card

A mandate of the 2019 ElderCare Act

he number of assisted living (AL) settings is steadily increasing nationally and in Minnesota there are currently about 1,300 AL communities. AL is commonly defined as the senior living option that combines housing, support services (e.g. meals), and health care, as needed. AL is meant to provide more assistance than an independent retirement community but less medical and nursing care than a nursing facility. As per the new licensing framework passed by the Minnesota Legislature, AL is defined as “a licensed facility that provides sleeping accommodations and assisted living services to one or more adults.” AL includes dementia care. AL is distinguished from other residential long-term care options, and especially skilled nursing facilities, by its philosophy of service delivery that aims to maximize independence, individual choice, dignity, autonomy, and quality of life. However, as residents’ care needs become more complex, there has been more focus on the importance of appropriate and quality clinical care supports for AL residents as well as other measures of quality.

Lack of data on AL quality. Although there is a growing trend of people choosing to live in AL settings compared to nursing homes (NH) when they can, little is known about the quality of AL care. For reference, Minnesota has built a nationally acclaimed Nursing Home Report Card (http://nhreportcard.dhs.mn.gov/) that includes various measures of NH quality, including clinical care. Yet, no such tool exists for ALs. Concerns over issues like poor staff quality, resident acuity, and safety escalated to the state level and resulted in a legislative bill for a new licensing framework for AL settings. The Elder Care and Vulnerable Adult Protection Act, passed in May 2019, provided funding for the development of a report card that will include annual resident quality of life and family satisfaction surveys, as part of a multi-pronged effort to encourage and reward quality.

Physicians can play a role in this process.

AL report card goals. The report card is slated for 2021 and the goal is to provide consumers and their families enough information to make informed decisions about which AL communities best fit their needs. Its secondary aim is to help AL providers improve quality of care services and supports they provide. The AL report card can provide important information about various aspects of consumers’ well-being to aid physicians and other care providers in navigating client care if their patients are also AL residents. The report card may be useful for physicians by including information about what clinical care services and supports are offered/available, the experiences of care for consumers, how the quality of care may impact well-being, and the potential remaining gaps in clinical care services.

Data collection and dissemination. The development of the AL report card began in the spring of 2019 and is a multi-phase effort towards a quality measurement system. The first phase included efforts to identify domains, subdomains, and existing AL quality indicators based on a national review of peer-reviewed literature; review of various reports; and interviews with national experts. Nine AL quality domains were identified: 1) resident quality of life; 2) resident and family satisfaction; 3) safety; 4) resident health outcomes; 5) staff; 6) physical and social environment; 7) service availability; 8) core values and philosophy; and 9) care services and integration. Each domain has a set of elements of subdomains and potential indicators that can be used to measure those elements (e.g., safety and policies around resident safety/accountability practices).

Phase 2 (Summer–Fall 2019) sought to gather feedback from pertinent stakeholders in Minnesota on the domains and subdomains of AL quality that were identified from national work. During this phase, we aimed to address three questions: 1) Which domains of AL quality are also highly supported by Minnesota stakeholders?; 2) What sub-domains and associated measures were most important to stakeholders when measuring resident quality of life and family satisfaction?; and 3) What are areas of consensus across all stakeholder groups and which areas are more stakeholder-dependent (e.g. providers as compared to family members of AL residents)? Various outreach initiatives to elicit stakeholder feedback were conducted in the fall of 2019, including a state-wide online survey with 822 respondents; 13 public presentations, which included a variety of provider groups; a statewide livestream event with 266 attendees and five focus groups (four with AL residents and one with consumer advocacy organizations). The overarching goal of this feedback was to inform the development of a quality framework for the AL report card.

Findings

Our findings indicate a high level of support among Minnesota stakeholders of the domains of quality that were identified in the national work.

The domains of AL quality endorsed as most important were: 1) quality of life; 2) staff quality; and 3) resident safety. The lowest-rated domains were physical and social environments of AL (vs other domains). As far as sub-domains of quality of life, stakeholders viewed dignity/respect, staff-related items, and security as very important when measuring quality of life and found staff competency, respect from staff, and care experience as very important for resident and family satisfaction. Lastly, we found that domains of quality were highly consistent across stakeholder roles. Differences between stakeholders mainly included higher importance placed on the social and physical environment of the AL by residents and other focus group participants than those who participated in the survey and other outreach efforts.

There is a growing trend of people choosing to live in AL settings.

Planning for the report card

There are currently five phases planned for this project:

  1. Phase I. In January–June 2019, the University of Minnesota conducted a literature review on AL quality which produced nine AL quality domains.
  2. Phase II (July–December 2019) focused on gathering stakeholder input on research findings.
  3. Phase III (January–June 2020) includes the development and testing of resident and family surveys, measurement development, and the start of planning for the report card website.
  4. Phase IV (July 2020–February 2021) will finalize surveys and resident and family surveys will start to be conducted, along with the development of the AL report card website
  5. Phase V (March–June 2021) will include the analysis and release of the first round of survey results.

Phases I and II have been completed and are described in more detail in this article. Phase III work is underway with resident and family surveys being developed. Refinement of these surveys will come from input from provider and advocate focus groups, in addition to testing with AL residents. Work in the early phases will pave the way for a website that tracks AL quality measures of most importance to consumers.

We believe this work is salient for physicians, who might make their patients and caregivers aware of this initiative. During patient consultations, physicians may discuss the assisted living choices with patients and their families and how best to meet patient needs. Some strategies to that regard are included below:

  • Share with patients and caregivers where they can sign up online for updates on the assisted living report card development.
  • Encourage patients and caregivers to get involved at different stages of project development and get engaged when the results are posted.

Overall, this work of developing an AL report card aims to address some of the significant trends in AL care and how this impacts quality of care for AL residents, especially for the areas of increasing resident acuity and the growing proportion of residents with diagnoses of Alzheimer’s disease and other dementias and cognitive impairment in those who use AL. In addition, the growing investment through home and community-based waivers (publically supported programs to meet the needs of people with disabilities and older adults) nationally and in Minnesota, has resulted in AL providers needing to address the variability in quality of AL services provided for those on waivers, which better helps these consumers choose settings that work best for their needs and will also report these investments to payers. Physicians can play a role in this process as older adults increasingly turn to AL, as not only the place to provide them with services, but also a place they can call home.

Learn more

The report card—and the planning leading up to it—may help physicians assist their patients, families, loved ones, and caregivers in navigating assisted living care services and supports. We encourage all health care providers to learn more about the project.

Visit https://tinyurl.com/mp-AL-report-card2 for additional details, including project milestones, links, and contact information for those who wish to participate, submit questions, or sign up for email updates.

Tetyana P. Shippee, PhD, is an Associate Professor at the University of Minnesota School of Public Health, Division of Health Policy and Management, whose research focuses on quality of long-term services and supports and health equity.

Tricia Skarphol, MA, has worked in public health research at the University of Minnesota for over 17 years.

Odichinma Akosionu, MPH, is a PhD student and a Research Assistant at the University of Minnesota, School of Public Health, Division of Health Policy and Management, doing research at the intersection of long-term care and racial and ethnic health inequities

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Odichinma Akosionu, MPH, is a PhD student and a Research Assistant at the University of Minnesota, School of Public Health, Division of Health Policy and Management, doing research at the intersection of long-term care and racial and ethnic health inequities