March 24, 2025
An article in a recent issue of JAMDA, The Journal of the Post-Acute and Long-Term Care Medical Association by Tetyana P. Shippee, PhD, and colleagues from the University of Minnesota reports on major domains of quality relevant to assisted living.
The authors of this paper scanned databases for peer-reviewed literature published from 2009 to 2019 that assessed quality in assisted living communities in the United States. Feedback obtained from key informants in assisted living quality helped identify additional non-peered-reviewed papers, such as policy briefs, to better inform the results.
In total, 833 abstracts of peer-reviewed articles were screened, with 49 studies meeting inclusion criteria. Another 45 non-peer-reviewed sources were included in the analysis.
Ultimately, nine unique domains were assessed:
- Resident quality of life
- Resident/family satisfaction
- Staffing and staff-related outcomes
- Resident safety
- Resident health outcomes
- Care planning and integration
- Physical and social environment
- Service availability
- Core values and philosophy
Domains such as staffing, safety, resident health outcomes, care planning and integration were identified as “vitally important” for the increasing increasingly diverse and frail resident population. Expert panels emphasized the importance of the resident “voice” in the quality measurement process.
Although few could argue with the quality domains identified in this study, the authors admit that the current “lack of standardized measurement of quality impedes the provision of person-centered, value-based care in US-based AL settings.” A few states, such as Oregon, are taking a lead in promulgating quality measures that are standardized and publicly reported, but the majority of states are not being proactive.
The assisted living industry, understandably, is wary of developing a system that resembles the one seen in nursing homes, which is federally regulated and, at times, punitive. The cost of sustaining a workforce to promulgate such a system is yet another major disincentive.
A middle ground may exist, however — one that recognizes the differences between assisted living communities and nursing homes as well as the need for transparency that will allow consumers to make meaningful comparisons between communities anywhere in the United States. Whether the federal government will be needed to effect such change remains an open question.
Much will depend on the power of residents and their families to facilitate/demand change. Quality measures, after all, not only inform future and current residents but also provide the impetus for a continuous quality improvement process.
Undoubtedly, many assisted living communities already focus on quality and deliver excellent care and services. What is needed, however, is consistency and standardization for whatever measures are chosen. Such an approach also implies public accountability, a necessity in this era of increasing frailty and clinical complexity of residents living in assisted living settings.
The 1986 Institute of Medicine report on improving the quality in nursing homes brought to light the many care needs existing at that time in nursing homes and eventually led to the Nursing Home Reform Act contained within the Omnibus Budget Reconciliation Act of 1987. If the assisted living industry fails to be proactive, then it, too, may face similar scrutiny in the future — and a new regulatory framework in which to operate.
Paul Katz, MD, CMD, is a professor of medicine at McMaster University and Florida State University.
Barbara Resnick, PhD, CRNP, is a professor at the University of Maryland School of Nursing, where she also is the associate dean of research and the Sonya Ziporkin Gershowitz Chair in Gerontology. She is the co-editor of the JAMDA, The Journal of the Post-Acute and Long-Term Care Medical Association.
