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Expanding Long-term Care Choices for the Elderly

Linking Process & Outcomes


Sheryl Itkin Zimmerman, Ph.D., Co-Director and Senior Research Fellow, Program on Aging, Disablement and Long-term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC.

Connie Barrows, Senior Evaluator, Health Finance and Public Health Division, U.S. General Accounting Office, Washington, DC.

The Collaborative Studies of Long-term Care looked at the experiences of more than 2,800 randomly chosen individuals living in 233 long-term care (LTC) facilities in Florida, Maryland, New Jersey, and North Carolina in 1997-1998. They compared nursing facilities (NFs) with three types of residential care/assisted living facilities (RC/ALFs), including:

  • Small facilities (having fewer than 16 beds).
  • Traditional facilities with 16 or more beds.
  • New model facilities with 16 or more beds (built after January 1, 1987, with two or more private-pay monthly rates, at least 20 percent of residents requiring transfer assistance, at least 25 percent of residents incontinent daily, and/or a registered nurse [RN] or licensed practical nurse [LPN] on duty at all times).

The studies found a wide range of RC/ALFs, in terms of facility architecture, interiors, and administrative systems. Comparing across models, the studies found the following:

  • Residents: Small facilities tend to care for people needing assistance in a greater number of ADLs (2.5 on average); traditional 16+ facilities tend to care for people needing the least help (an average of 1.4 ADLs). Small facilities are also the most likely to care for people with dementia. Dr. Zimmerman noted that small facilities meet the needs of a needy population and that State policymakers should take this into account in developing regulations.
  • Physical environment (safety): Although NFs had the most safety features (extensive handrails, call buttons in bathrooms, and no slippery or uneven surfaces in the rooms), new-model 16+ RC/ALFs followed closely behind. Handrails and call buttons were least prevalent in small facilities.
  • Physical environment (orientation): Smaller facilities do better on such items as having the toilet visible from the bed and no or short hallways, important issues for people with dementia.
  • Admission policies: Small facilities and new-model facilities will admit people with more health issues (e.g., can't walk, can't feed self, can't communicate needs, confused/disoriented, needs daily bandage change) than traditional facilities.
  • Provision of health services: Larger facilities (both traditional and new model) are more likely to have a number of health services—including physician services on site, nursing services at least weekly, psychotherapy onsite, physical therapy onsite, and blood drawing onsite—than small facilities. Nearly all NFs have these services.
  • Use of "inappropriate" medications: Inappropriate prescribing is less common in RC/ALFs than in NFs or home care, although these trends may be changing in NFs and home care. Facilities with weekly physician visits have particularly low rates of inappropriate prescribing.
  • Family satisfaction with end-of-life care: In a sample of 51 families, preliminary results indicate that the areas of greatest satisfaction with RC/ALFs were:
    • Availability of a hospital bed.
    • Availability of nurses to the family.
    • Family conferences.
    • Family inclusion in care.
    • Information about prognosis.

    Areas of least satisfaction were:

    • Availability of physicians to the resident.
    • Availability of physicians to the family.
    • Test and treatment followup.
    • Information about tests.
    • Information about side effects.

    Areas of greatest satisfaction with NFs were:

    • Availability of a hospital bed.
    • Availability of nurses to the family.
    • Pain relief.
    • Family inclusion in care.
    • Coordination of care.

    Areas of least satisfaction were:

    • Speed with which symptoms were treated.
    • Thoroughness of physician assessment.
    • Information about tests.
    • Information about pain management.
    • Availability of physicians to the family.
  • Staff recommendations for best practices in end-of-life care: In a preliminary analysis of a sample of 80 ALF staff, the areas most commonly mentioned as needing improvement in both RC/ALFs and NFs were:
    • More nursing assistant time with the resident.
    • More staff education on care of the dying.
    • Bereavement counseling for staff.
    • More volunteers to work with the dying.

In conclusion, Dr. Zimmerman stated that the linkages between care structure, process, and outcome in the provision of LTC are complex. She noted that using data to determine quality is also a complex process that is affected by variations in individuals served, as well as aspects of structure and process. Choosing outcome measures on which to focus requires an understanding of the tradeoffs, e.g., fewer falls (seen as a good outcome), is usually related to less autonomy (seen as a bad outcome). Evaluators also need to realize that the same care can influence two outcomes differently or can influence the same outcome differently for different residents. For example, greater use of call bells can result in fewer hours of sleep for surrounding residents (a bad outcome) but fewer skin conditions for those using the bells (a good outcome).

The U.S. General Accounting Office's (GAO) Assisted Living Study was intended to describe residents' needs and services provided in ALFs, determine the adequacy of information provided to consumers, describe State approaches to oversight and determine the type and frequency of quality of care and consumer protection problems. It looked at four States: California, Florida, Ohio, and Oregon. Findings included:

  • Facility services and resident needs vary widely. Ms. Barrow noted, "If you've seen one facility, you've seen one facility."
  • Consumers may lack enough information to select the best facility. Information considered key by consumer and industry groups includes:
    • Cost of the basic service package.
    • Availability of additional services, who provides them, and their cost.
    • Circumstances under which costs may change.
    • How the facility monitors resident needs and coordinates with health providers.
    • Qualifications of facility staff.
    • Discharge criteria and procedures.
    • Grievance procedures.

Ms. Barrow stressed the importance of written information, especially contract documents, in comparing facilities.

Prospective residents and their family members rely on information provided by the facilities themselves, often in times of crisis. Word of mouth from family or friends is also used.

Key information is not routinely provided to consumers/family members in writing:

  • Only 25 percent routinely provide contracts.
  • Ten percent said they would not provide copies of the contract to a potential resident.
  • Most provide information on available services and their costs.
  • About 50 percent provide information on medication policies or when costs may change.
  • Less than 50 percent provide information on discharge criteria or staff qualifications.

Written marketing materials and contracts may be unclear or misleading. Key information is often missing, and discharge criteria are often unclear.

Ms. Barrow encouraged States to help consumers become more educated on how to choose a facility that will meet their needs with quality services. For example, Wisconsin and Oregon require disclosure of staffing patterns and training. New Jersey will develop a consumer guide by the end of the year.

States use a range of approaches to oversee ALFs. Each State regulates in its own way. Some States have requirements for licensure, some do inspections, some have LTC ombudsman programs (although Ms. Barrow noted that their role is often limited, because of a lack of resources). Most States use some combination of these methods.

States identify quality of care and consumer protection problems. In 1996-97, 38 percent of ALFs were not cited for any quality of care or consumer protection-related problems, 27 percent were cited for five or more, and 11 percent were cited for 10 or more. The most commonly identified and verified problems were related to quality of care, including:

  • Inadequate care.
  • Staffing and training-related issues.
  • Medication issues.
  • Resident care plans and assessments.
  • Admission/discharge/level-of-care issues.

Ms. Barrows noted that the GAO did not expect to find as many problems as it did nor problems as serious as they were. She urged States to act as "police" in this area, taking these problems seriously.


U.S. General Accounting Office. Report to congressional requesters: Quality-of-care and consumer protection issues in four States. Washington (DC): The Accounting Office; Health, Education, and Human Services; 1999 Apr.

U.S. General Accounting Office. Testimony of Katheryn G. Allen before the Special Committee on Aging: Quality-of-care and consumer protection issues. Washington (DC): The Accounting Office; Health, Education, and Human Services; 1999 Apr.

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