Volume 71, Issue 5 p. 1358-1361
Free Access

One accurate measurement is worth 1000 expert opinions—Assessing quality care in assisted living

Daniel David PhD, MS, BSN

Corresponding Author

Daniel David PhD, MS, BSN

Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, New York, USA


Daniel David, NYU Rory Meyers College of Nursing, New York, NY, USA.

Email: [email protected]

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Abraham A. Brody PhD, RN, FAAN

Abraham A. Brody PhD, RN, FAAN

Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, New York, USA

Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA

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First published: 21 February 2023

This editorial comments on the article by Mao et al.


This editorial comments on the article by Mao et al.

There is no shortage of expert opinions when it comes to evaluating the quality of assisted living (AL). For the hundreds of thousands of AL residents in the United States, there are countless family members, care providers, administrators, and other anonymous “experts” willing to share their thoughts on internet websites as to the quality of care at individual AL facilities. What is lacking on Google, Yelp, and in the scientific literature is a reliable, transparent, and comprehensive measurement to compare facilities, guide placement, and improve care.

AL is a care model that delivers supportive services in a residential setting to older adults as they contend with functional decline, complex medical conditions, and often cognitive challenges. On the spectrum between independent living without any supportive services and high-cost nursing home care requiring extensive support, AL offers an alternative with varying levels of support and quality. But what is quality care in AL and how might one measure it? Does it refer to a pleasant social environment with amenities directed at improving quality of life and the capacity to deliver a rare emergency response in the event of acute illness? Or does it refer to more substantial organizational involvement in the health of residents living with chronic, complex diseases that require services more similar to the type of support services provided in skilled nursing facilities? To amplify what has been boldly stated by others, there is a need to not only reimagine the delivery of care in AL, but also its measurement.1

For decades, the profile of those residing in AL has been shifting.2 Leaders in AL have called for the need to address not only social and functional, but also health needs, cognitive, emotional, and financial challenges, which are prevalent in the AL community.3 Indicators of frailty, need, and personal cost have risen and reflect the intensity of some AL care that approaches care in nursing homes. So much so that government, academic, and industry leaders have called for the need to re-imagine AL.1, 4, 5 However, compared to nursing homes, AL is a free-wheeling, regulatory-lite entityoften owned by mixed senior housing and service corporations.6 Methodologically, uniform measures in representative samples are hard to come by and make comparisons between high- and low-quality care challenging. Even more, within a competitive housing and care marketplace, decisions driving care may reflect the realities of profit margins rather than measures of quality.

With the increasing methodological advancement and availability of AL data that is linked to claims data, new questions have emerged. To this end, the authors of “Are online reviews of assisted living communities associated with patient-centered outcomes?” approach the thorny problem of measuring quality in AL with great pragmatism (JAGS REFERENCE TBA). Mao et al.7 use the measure “home-time,” the percentage of time a resident spends within their home as opposed to a clinical environment, such as a hospital, rehab facility, or long-term nursing home. The measure is not without controversy, as it does not integrate concepts of symptom or caregiver burden.8 Nevertheless, all things considered, it is an excellent aggregate measure of person-centered quality that reflects what is important to older adults in AL, the freedom to live in their home in relatively stable health. Increased home-time has also shown a modest association with improvement or maintenance of patient symptom burden in seriously ill populations.9 Furthermore, the authors use Medicare data linked to the expansive Google review platform to skillfully marry the concepts of quality data collection with a measure of consumer evaluation (Google's 5-star system). Much like your favorite restaurant, ALs can be rated using Google's 5-star rating system. A strength of this measure is its accessibility to the layperson, whether that be resident, family member, staff, or curious observer. The limitations of using this measure must be weighed against its strengths. Google ratings have questionable psychometric validity and selective sampling with a high potential for both positive and negative scoring bias. Alternatively, the breadth of the sampling cannot be ignored—nearly 60,000 respondents in over 12,000 ALs. This provides valuable insight to describe care in the vast, unconnected, and unregulated AL ecosystem.


To be sure, this study sheds much needed light on an industry characterized by nebulous measures that make comparisons of quality challenging. However, perhaps the most salient feature of this work is the need to further explore the void of overall quality measures in the opaque and often industry-focused system of AL care. Traditionally, quality care is defined using six domains put forth by the Institute of Medicine (now known as the National Academy of Medicine), which has been integrated into multiple health organizations (the World Health Organization, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid, and others). The six domains reflect the provision of care that is: person-centered, effective, safe, efficient, timely, and equitable. The oft-neglected quality measure of person-centeredness takes centerstage in the showcased research article with the “home-time” measurement. Conceptually represented in a radar chart, the difference between low and high overall quality may be visualized as total area (Figure 1A).

Details are in the caption following the image
Quality radar chart of the conceptual domains of quality in assisted living (AL). A scale for each domain of quality is scored from 0 (low-quality) to 10 (high-quality) and represented by points on 6 number lines radiating from the center to the perimeter. Established quality measures would be transformed to standardized scores ranging from 0 to 10. By connecting the individual points on each scale, a polygon is created. The area of the polygon is representative of overall quality. Figure 1A compares a low-quality versus high-quality AL. Figure 1B compares a low-quality AL versus an AL with enhanced patient centeredness (e.g., greater home-time) resulting in higher efficiency (greater cost-savings secondary to lower healthcare expenditures). Figure 1C compares a low-quality AL versus an AL with higher equity and patient-centeredness. A low resource AL was used as a contrasting comparator to demonstrate how improving quality within individual and interconnected domains (patient centeredness and efficiency, equity and patient centeredness) expands the area of the polygon representing improved overall quality.

On a single dimension, improving person centeredness marginally increases the overall quality as measured in the diagram. But what about overlapping and interconnected measures of quality? We present additional concepts for consideration: 1. The quality of low- and high-resourced AL can be visualized with a radar chart. 2. Person-centered care is a multiplier that enhances other dimensions of quality. 3. Addressing equity as a quality indicator improves person-centeredness and may have implications for other dimensions of quality.


There are hidden AL costs revealed through the person-centered quality measure of home-time. Person-centered quality impacts the quality domain of efficiency (cost/health expenditure). Home-time is an established measure that has been used to evaluate cost efficiency in patients recovering from stroke and performance in accountable care organizations.10, 11 The primary finding of this work is that high quality AL facilities provide 1.1–2.2 more days of home-time a year when compared to low quality using the Google star rating system. On the surface, the authors dutifully recognize the small effect size on the person-centered outcome of home-time. Residents who do not have to pay for an unoccupied residence experience an improved care experience with financial implications. Using simple math to investigate the relationship between home-time and cost savings, the fiscal context becomes clear for residents in this sample and the 1 million residents living in AL in the United States. Approximately one third of the sample (n = 20,433) lives in high quality facilities. Within the marketplace, residents, and family caregivers shoulder a median out-of-pocket burden of $54,000 per year in 2022.12 Extrapolating the authors findings, 1.1–2.2 days/year of home-time across 20,433 residents in the sample sums to a cost savings of $3.325–6.651 million a year. If this relationship can be extended to the 1 million AL beds in the US, we are hypothetically witnessing a savings of $54 million a year for the third of residents living in high quality AL. It raises other questions. Such as, how many facilities in the US are of high quality? What is the trade-off for consumers and taxpayers for lower quality care resulting in less home-time and more expensive acute health care utilization? Are higher cost facilities of higher quality? Do those costs increase home-time and quality of life? There is as of yet no comprehensive way to measure these trade-offs or overall value for consumers and taxpayers, as pricing is not transparent and one cannot assume that cost and quality are synonymous. And this speaks nothing of the equity and who can or cannot afford the costs of AL. We visually depict this in Figure 1B, where the combined effect of person-centeredness and efficacy improves overall quality. Additional relationships between person-centeredness and other dimensions of quality are needed.


Beyond the general challenges noted above, there is a hidden AL population even more affected by these considerations; approximately one in six (16.5%) of residents in AL rely on Medicaid to support care services.13 State-level practices and policies vary considerably for AL facilities that receive Medicaid support.14 Furthermore, substantial disparities exist between Black and White AL residents with respect to Medicaid-Medicare dual eligibility, the acuity of residents, acute care hospitalizations, and transitions to skilled nursing facilities.15 But what about the quality indicator of equity? On the surface, AL rarely conjures images of equitable care. Those that have the resources to pay for these services represent a small sliver of older adults with complex chronic illness with functional and cognitive care needs addressed in AL. There is a need for a broader view of geriatric communities that recognizes different financial resources and equitable distribution of services, which greatly impact differential access to care that exists within AL.16 Each state regulates the provision of home-based and community services through local Medicaid priorities. Increasingly, states are offering full and/or partially subsidized AL through this mechanism to extend housing and care options to residents who lack the financial means for more expensive residential care.17 Equitable care demands quality measures that identify where disparity exists and how to close the gap between low- and high-resourced residentials. We argue that addressing equity is a vital, underexplored, and interconnected component of person-centeredness (Figure 1C). Further development of AL models that promote equitable care is needed to improve person-centeredness and overall quality.

In summary, this study highlights the need to not only develop accessible and valid measures of person-centered quality care in AL for consumers but also the need to consider how person-centered care is associated with other quality measures, particularly efficiency and equity. In the quest to re-imagine AL, we propose the need to visualize quality care with easy-to-understand graphics and establish national measures of quality that holistically address all six domains of quality care: person-centeredness, effectiveness, safety, efficiency, timeliness, and equitable care. In doing so, we hope to provide residents, caregivers, AL staff, administrators, and policy leaders with accessible, valid, and transparent information to drive high quality AL care.


Both authors have full responsibility for the development and content of this manuscript.


No specific funding was received for this work.


None declared.


There was no sponsor role for this manuscript.