Organizational Determinants of Resident Satisfaction With Assisted Living

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1 Copyright 99 by The Cerontological Society of America The Gerontologist Vol. 39, No. 4, This article examines the relationship of organizational factors to resident satisfaction with assisted living, while controlling for resident characteristics. Data were collected in interviews with 156 residents in 13 assisted living facilities. Results indicate that more satisfied residents are also happier, more functionally independent, more involved in their housing decision, and less educated. When controlling for resident characteristics, higher levels of resident satisfaction are associated with smaller facility size, a moderate level of physical amenities, greater availability of personal space, fewer sociorecreational activities, and nonprofit ownership. These findings might be helpful in structuring a resident-centered regulatory approach to assisted living. Key Words: Quality-of-life assessment, Frail elders, Residential care Organizational Determinants of Resident Satisfaction With Assisted Living Elzbieta Sikorska, PhD Assisted living is becoming an important housing alternative for the frail elderly population. It is estimated that there are between 30,000 and 65,000 assisted living facilities nationwide (Assisted Living Facilities Association of America [ALFAA], 96; Pallarito, 95). By 96, 15 states had created assisted living regulations and 9 states had begun to develop such regulations (Mollica & Snow, 96). The challenge for policy makers is to structure a regulatory approach for assisted living in such a way as to reflect a residentcentered "philosophy of care" (Lewin-VHI, 96). Resident demand and willingness to pay for assisted living are the major factors stimulating the rapid development of this care alternative (Mollica & Snow, 96). Despite the fact that assisted living is defined as a resident-centered model of care, little is known about the quality of assisted living from the resident's perspective (Lewin-VHI, 96). Although there are a growing number of studies on assisted living (Kane, Wilson, & Clemmer, 93; Lewin-VHI, 96; Mollica & Snow, 96; Newcomer, Preston, & Roderick, 95; Regnier, 94), no data exist on the relationship between organizational factors and resident-centered quality indicators. The purpose of this study was to examine the relationships between organizational factors and the quality of life of assisted living residents, using resident satisfaction as the quality indicator. Research stresses the importance of organizational factors such as facility size, physical environment, resident autonomy, availability of services, and staff resources to the quality of assisted living. Regnier (94) proposes that assisted living facilities should be small The research reported in this article was conducted at the University of Maryland Baltimore County. The author thanks Leslie Morgan for her expertise and guidance, and Kevin Eckert, Ann Gruber-Baldini, Cheryl Itkin-Zimmerman, and James Trela for insightful suggestions in the development of this research. Address correspondence to Dr. Elzbieta Sikorska, Center for Gerontology and Health Care Research, Brown University, GB-223C, Providence, Rl elzbieta sikorska@brown.edu in size in order to provide a "home-like" environment. Other experts note that assisted living can be provided most economically in larger facilities (Lewin-VHI, 96). The literature on nursing homes (Weihl, 81) and board and care homes (Morgan, Eckert, & Lyon, 95) suggests that more functionally limited residents may prefer smaller facilities. Physical features that add comfort and foster social interaction and residential privacy are considered necessary to enhance good service delivery in assisted living (Kane et al., 93). Comfortable physical environments in nursing homes have been found to be positively related to resident satisfaction (Kruzich, Clinton, & Kelber, 92). However, there are no data on the relationships between quality of resident life and physical environment characteristics in assisted living. Because resident autonomy is a core definitional characteristic of assisted living, some researchers argue that residents should be allowed to make decisions that others might view as posing safety concerns (Wilson, 96). Little, however, is Known about resident preferences concerning autonomy in assisted living. Research indicates that restrictive policies in nursing homes are associated with depression, helplessness, and physical decline among residents (Lieberman, 74), while policies oriented toward resident autonomy are associated with resident participation in selfinitiated activities, better integration into the community, and higher satisfaction (Moos & Lemke, 92b). The availability of services and adequate staff resources are important in assisted living facilities because many residents suffer from functional decline and cognitive impairment (Lewin-VHI, 96). Better staff resources (e.g., greater experience, diversity, and training) and greater availability of services in nursing homes are associated with better quality and higher resident satisfaction (Moos & Lemke 92c; Kruzich et al., 92). No data exist on the relationships between these organizational factors and resident satisfaction in assisted living. 450 The Gerontologist

2 The rapid growth of assisted living is currently stimulated by the for-profit sector, and private corporations develop the majority of facilities. Although Lemke and Moos (89) found that for-profit nursing facilities provide lower quality of care than nonprofit facilities, other researchers (Kosberg & Tobin, 72) found no relationship between quality and facility ownership. No data exist on the relationship between resident satisfaction and facility ownership in assisted living. Assisted living is also considered a less costly alternative to nursing home care. Although there are no data on the relationship between resident costs and quality in assisted living, research concerning patient satisfaction with primary health care indicates that personal expenditures are inversely related to satisfaction (Pascoe, 83). Studies that have examined the relationships between resident satisfaction and organizational factors in residential care setting (mostly in nursing homes) usually considered only a small number of organizational factors and rarely controlled for resident characteristics (Kruzich et al., 92; Weihl, 81). Both sociological research and consumer research agree that satisfaction involves an evaluation that is based on a comparison process (Pascoe, 83). Resident characteristics may influence this process by shaping evaluation standards (e.g., expectations and norms). Research suggests that residents who are happier, more functionally independent, and who actively participate in their housing decisions tend to be more satisfied with residential care (Kruzich et al., 92; Pascoe, 83; Weihl, 81). In summary, there are no recent data examining relationships between resident satisfaction and organizational factors in assisted living. The few studies that have examined such relationships in nursing homes are methodologically limited, due to the small number of organizational factors considered and the lack of controffor relevant resident characteristics. Accordingly, this study examined the relationships between resident satisfaction and a broad set of organizational factors, while controlling for resident characteristics. It was hypothesized that higher resident satisfaction would be related to smaller facility size, more comfortable physical environment, greater service availability, greater staff resources, lower costs to residents, and nonprofit ownership. These relationships were examined while controlling for potentially confounding variables represented by resident characteristics. Information concerning relationships between resident satisfaction and organizational factors could guide policy makers and professionals interested in improving the quality of life for frail elders in assisted living settings. Such data could also be helpful in structuring a regulatory approach for assisted living that reflects a residentcentered model of care, an avowed goal of the assisted living movement. Methods The study sampling involved two stages. First, a stratified random sample of facilities was selected. The stratification was conducted according to facility size in order to reflect the greatest variability in organizational characteristics. Second, approximately equal numbers of residents were randomly selected from each facility to allow comparisons within the stratification system. A resident represented the unit of analysis, but the role of organizational factors in relation to resident satisfaction was the primary interest of the study. Sample of Facilities As proposed by Kane and colleagues (93), assisted living has been defined in this study as a freestanding facility for elderly adults that is not licensed as a nursing home, provides assistance with the activities of daily living (ADLs), and offers continuity of care. Facilities in the sample were selected from 34 freestanding domiciliary care homes in Maryland and stratified into four groups based on their size: (a) to 29 residents (n = ); (b) 30 to 59 residents (n = 5); (c) 60 to 89 residents (n = ); and (d) 90 to 211 residents (n = 9; Maryland Department of Health and Mental Hygiene, 96). Initially, three homes in each group were selected randomly. Due to the smaller number of residents in the first group of facilities, one additional facility was selected, resulting in a total of 13 facilities. Of the facilities that were selected randomly and asked to participate, 6 (32%) refused. The reason given was a lack of interest in the study. There was no significant relationship between facility characteristics (e.g., size and ownership) and facility refusal rates. Sample of Residents The resident census in each facility served as a sampling frame. All residents were considered potentially able to participate in the study. In each facility 12 to 13 residents were selected randomly. To be interviewed, residents had to: (a) have resided in the facility no less than 3 months, (b) be physically and mentally able to participate in the survey, and (c) have no private duty nursing assistance. The interviews were conducted in residents' apartments by the investigator and lasted, on average, 45 minutes. Residents' mental abilities were assessed using items in the Short Portable Mental Status Questionnaire (SPMSQ). Scores were adjusted for race and education (Pfeiffer, 75). An interview was terminated if the resident gave fewer than four correct answers. From among 375 residents randomly selected to participate in the study, 156 (41%) were willing and able to participate, 173 (46%) were unable to participate due to cognitive and/or physical limitations, 29 (8%) refused to participate, 3 (1%) had private duty nursing assistance, and 14 (4%) had not lived in a facility long enough to qualify. Although residents with moderate levels of cognitive impairment were included in the study, the sample was biased in favor of cognitively intact residents. Approximately half of the participating residents (52%) had 0-2 errors on the SPMSQ, indicating that they were intellectually intact; 34% had 3-4 errors, indicating mild impairment; and 14% had 5-6 errors, suggesting moderate impairment. Vol. 39, No. 4,

3 Measures The measures used in the study are described in Table 1. Resident satisfaction with assisted living served as a dependent variable and was measured by the Resident Satisfaction Index (RSI) developed for the study. The RSI scores were normally distributed (Lilliefors =.06, p >.20). Based on the literature, the independent variables chosen for examination included facility size, physical environment, service package, policy autonomy, staff resources, costs to residents, and facility ownership. Multiple indicators were used to assess physical environment (i.e., physical amenities, sociorecreational aids, communal space, and personal space), service package (i.e., health services and sociorecreational services), and policy autonomy (i.e. policy choice, resident control, and provision of privacy; see Table 1). Nine scales from the Multiphasic Environmental Assessment Procedure (MEAP) were adopted to assess organizational factors: Physical Amenities, Sociorecreational Aids, Space Availability, Health Services, Sociorecreational Activities, Policy Choice, Resident Control, Provision of Privacy, and Staff Richness (Moos & Lemke, 92a, 92b, 92c). The first three scales (Physical Amenities, Sociorecreational Aids, and Space Availability) were slightly modified for use in this study (e.g., several items were dropped due to a lack of sensitivity). Additionally, a scale of Personal Space was created using three items concerning resident private areas; these items were correlated negatively with the overall scale of Space Availability (Moos & Lemke, 92b). Also, the Functional Abilities Scale was adopted from the MEAP and modified to measure functional ability at an individual resident level as opposed to facility level (Moos & Lemke, 92c). Data concerning organizational factors were collected in interviews with administrators and through direct observation at facilities. The control variables assumed to influence resident evaluation standards included psychological wellbeing, functional ability, participation in the decision concerning relocation, and education (see Table 1). Data concerning these characteristics were collected during interviews with residents. Except for the Affect Balance Scale (ABS), the reliability estimates for the measures used in the study (see Table 1) were relatively high. The ABS alpha of.62 was similar to the alpha of.60 reported by other researchers (Namazi, Eckert, Kahana, & Lyon, 89). The low internal consistency estimate might be due to the fact that the ABS subscales represent two conceptually independent dimensions of psychological well-being (Bradburn, 69). In the present study the independence of these subscales was supported by their low correlation (r = -.22). A similar correlation (r = -.23) was reported by Moriwaki (74). Data Analysis The strength and direction of relationships between resident satisfaction and organizational factors were examined using zero-order correlations and partial correlations controlling for resident characteristics. In order to determine how much variance resident characteristics and organizational factors explained, both control and independent variables (which were related to satisfaction at an individual level) were included in the multiple regression equation using the backward elimination method. An alpha of.05 (onetailed test) was selected as the significance level. Statistical analysis of the data was completed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago; Norusis, 90). Results Characteristics of Residents The majority of residents were women (76%), widowed (74%), and White (97%). On average, they were 85 years old (Mean = 85, SD = 7.7). More than half (55%) of the residents had more than 12 years of education (see Table 2). The sample of residents was demographically comparable to larger samples from other studies that have been conducted over wider geographic areas (ALFAA, 96; Kane et al., 93). For example, the study conducted by Kane and colleagues (93) in Oregon indicated tnat assisted living residents (n = 947) were predominately women (75%) with a mean age of 85 years, 97% of whom were unmarried. In the present study, the median length of resident stay in a facility was 21 months with a maximum of 13 years. Almost all residents were completely independent in eating meals (97%), taking care of their own appearance (97%), getting in and out of bed (94%), and using a telephone (91%). Approximately half the residents needed assistance with walking (48%) and bathing (54%). The most difficult tasks for residents to perform were those related to the instrumental activities of daily living, such as paying bills (20%) and shopping (24%). The relationships between resident satisfaction and resident characteristics, such as psychological wellbeing, functional ability, participation in the housing decision, and education, were examined using the bivariate correlations presented in Table 3. Residents who were happier, more functionally independent, and had participated in the decision concerning relocation were significantly more satisfied with assisted living. Education was inversely related to satisfaction, indicating that the more educated residents were less satisfied. This relationship may be due to the fact that more educated persons tend to be more critical in their assessments of quality. When considered together in the first regression model (see Table 4), psychological well-being, functional ability, participation in the housing decision, and education explained 40% of the variation in resident satisfaction. Stepwise selection of variables resulted in the same equation being produced by both forward selection and backward elimination. 452 The Gerontologist

4 Table 1. Description of the Measures Used in This Study Variables Description of Measures Mean SD No. Range Items a Dependent Resident Satisfaction Index (RSI) Independent Facility Size Physical Amenities Scale 3 Sociorecreational Aids Scale a Communal Space Personal Space Heath Services Scale b Sociorecreational Services Scale" Policy Choice Scale b Resident Control Scale b Resident Privacy Staff Resources Costs to Residents Facility Ownership Control Psychological Weil-Being Functional Abilities Scale Participation in Decision Level of Education Assesses residents' perceptions of health care, housekeeping, physical environment, relationships with staff, and social life/activities. Items are scored on a 4-point scale (always = 3, usually = 2, rarely = 1, never = 0). For example, a resident response of "always" to the question "Is the staff kind and caring?" is indicative of satisfaction. A higher cumulative score reflects greater satisfaction. One item assessing number of licensed beds in a facility. Measures provision of amenities that add comfort to the environment. The scale provides a percentage score of the available amenities from the total number of amenities assessed. Assesses presence of amenities that foster social life and recreation and provides a percentage score of the available amenities from the total number of amenities assessed. The Space Availability Scale 3 measures availability of communal areas in relation to the number of residents and provides a percentage score of the available areas out of the total number of areas assessed. The Personal Space Scale measures availability of private areas and provides a percentage score of the available areas out of the total number of areas assessed. Assesses provision of health services and provides a percentage score of the available services out of the total number of services assessed. Assesses availability of social and recreational services and provides a percentage score of the available services out of the total number of services assessed. Assesses degree of choice residents have in establishing their own daily routines and provides a percentage score of the available policies fostering choice out of the total number of policies assessed. Assesses policies that facilitate residents' participation in the facility governance and provides a percentage score of the available policies out of the total number of policies assessed. The Provision of Privacy Scale b assesses features and policies that foster residential privacy and provides a percentage score of the available features out of the total number of features assessed. The Staff Richness Scale c measures staff resources in terms of education and professional experience. The scale provides a percentage score of the available resources out of the total number of resources assessed. One item reporting a mean of the highest and the lowest resident out-of-pocket monthly expenditure for assisted living in a facility. One item identifying two types of ownership: nonprofit facility and for-profit facility. The Affect Balance Scale d measures subjective well-being in terms of a balance between positive affect (PAS) and negative affect (NAS). One point is assigned to each "yes" response. A total score is calculated by subtracting the NAS score from the PAS score. Measures resident independence in performing tasks of daily living (e.g., dressing, walking, shopping) on a 3-point scale (No help needed = 2, Some help needed = 1, Cannot do at all = 0). A higher cumulative score reflects greater independence. 3-item index: How much say did you have in the decision that you needed to come here? How much choice did you have in selecting this facility? How much choice did you have in picking this apartment or room? The items are scored on a 5-point scale (None = 0, A little bit = 1, Moderate = 3, Quite a bit = 4, Complete = 5) and summed to provide the total score. One item assessing six educational levels: 1 = 8th grade or less, 2 = th grade or less, 3 = Vocational education, 4 = Some college, 5 = College graduate, and 6 = Graduate or professional degree. a Scales adopted from the MEAP Physical and Architectural Features Checklist (Moos & Lemke,92a). b Scales adopted from the MEAP Policy and Program Information Form (Moos & Lemke,92b) c Scale adopted from the MEAP Resident and Staff Information Form Manual (Moos & Lemke,92c). d The Affect Balance Scale as presented by Bradburn (69) N/A N/A N/A N/A N/A 1 N/A N/A Vol. 39, No. 4,

5 Table 2. Characteristics of the Sample of Residents (n = 156) Characteristics n % Sex Female Male Marital Status Married Widowed Separated/divorced Single Age Race White Black Education 8th grade or less 9th-12th grade Post high school Some college College graduate Graduate/professional school ?n z u JO 1 A I ^ i *> Q y Table 4. Zero-Order and Partial Correlations Between Resident Satisfaction and Organizational Factors Organ/zationa/ Factor Facility size 3 Moderate physical amenities 6 Sociorecreational aids Communal space Personal space Health services Sociorecreational services Policy choice Resident control Resident privacy Staff resources Costs to residents Facility ownership 0 Zero-Order Correlation.27**.44***.05**.09.21** ** *** Partial Correlation.27**.30*** * * * a Dummy variable: X = 1 if < 30 residents, and X = 0 if > 30 residents. b Dummy variables: X1 = 1 if < 32% else X1 = 0; X2 = 1 if >32% and <53% else X2 = (reference group). 0. X3 =1 if >53% else X3 = 0 c Dummy variable: 1 = nonprofit, 0 = for-profit. *p <.05; **p <.01; ***p <.001. The Role of Organizational Factors The relationships between resident satisfaction and organizational factors were examined while controlling for resident characteristics using partial correlation. These relationships are presented in Table 4. After controlling for resident characteristics, residents in smaller facilities were significantly more satisfied with assisted living than were residents in larger facilities. Due to a significant curvilinear relationship with satisfaction, facility size was recoded as a dichotomous variable with smaller facilities (housing fewer than 30 residents) and larger facilities (housing 30 or more residents; Regnier, 94). From among the indicators of physical environment, only availability of personal space and physical amenities were significantly related to resident satisfaction. Residents in facilities that provided more personal space tended to be more satisfied with assisted living. Additionally, residents in facilities that provided moderate levels of physical amenities (between 32% and 53% of the amenities assessed) were more satisfied than residents in facilities that provided lower or higher levels Table 3. Zero-Order Correlations Between Resident Characteristics and Resident Satisfaction Resident Characteristics Psychological Well-Being Functional Ability Participation in Decision Education *p <.01; ***p <.001. Correlation With Satisfaction.53***.29***.23** -.21** of these amenities. Due to a curvilinear relationship between physical amenities and resident satisfaction, physical amenities were recoded into two dummy variables based on the distribution for subsequent analyses (see Table 4). Contrary to what was hypothesized, residents in facilities that offered more organized group activities tended to be less satisfied with assisted living. Residents in nonprofit facilities were more satisfied with assisted living than residents in for-profit facilities, regardless of their characteristics. When considered together in the second regression model, organizational factors accounted for 25% of the variation in resident satisfaction (see Table 4). The dummy code for the moderate level of physical amenities was the strongest organizational predictor of satisfaction, followed by personal space and facility ownership. To determine how much additional variance in resident satisfaction was explained by organizational factors when considered with resident characteristics, a multiple regression equation was calculated. Resident satisfaction was used as a dependent variable, with resident characteristics (i.e., psychological well-being, functional ability, participation in the housing decision, and education) as control variables, and organizational factors (i.e., physical amenities, personal space, and ownership) as independent variables. The backward elimination method was used in selecting the independent variables (see Table 5). Organizational factors and resident characteristics together explained 47% of the variation in resident satisfaction. From among organizational factors, only the moderate level of physical amenities and availability of personal space remained significant predictors of satisfaction, contributing 7% of the explained variation in satisfaction. 454 The Gerontologist

6 Table 5. Regression Results for Resident Characteristics and Organizational Factors as Predictors of Resident Satisfaction Partial Variables Beta R or R 2 Correlation Resident Characteristics (Model 1) Psychological Weil-Being.49***.52*** Education -.26*** -.31*** Functional Ability.*.23* Participation in Decision.15* R =.63.* R 2 =.40 F = 23*** Organizational Factors (Model 2) Moderate Physical Amenities.28**.26** Personal Space.27*.15* Facility Ownership.21* R =.50.20* R 2 =.25 F = 12*** Combined Model (Model 3) Psychological Weil-Being 44*** 49*** Moderate Physical Amenities.23**.27** Personal Space.23*.16* Education -.21** -.26** Functional Ability.12* R =.69.16* Participation in Decision.12* R 2 =.47.15* F = 17*** *p <.05; **p <.01; ***p <.001. Discussion The purpose of this study was to examine the quality of resident life in assisted living facilities using resident satisfaction as a quality indicator. The assessment of quality was based on the relationships between organizational factors and resident satisfaction while controlling for resident characteristics. Higher levels of resident satisfaction were associated with smaller facility size, a moderate level of physical amenities, greater availability of personal space, fewer sociorecreational services, and nonprofit ownership. Residents in smaller facilities (fewer than 30 residents) were more satisfied with assisted living than residents in larger facilities. Timko and Moos (91) suggest that smaller facilities may provide more cohesive social environments, and therefore residents in these facilities may be more satisfied. In addition, residents in facilities that provided better quality of personal space and moderate levels of physical amenities were more satisfied with assisted living. Physical amenities were the most important predictor of satisfaction from among organizational characteristics. Facilities that offered a moderate level of physical amenities were small in size, primarily nonprofit, and had long histories of serving elderly persons in their communities. The higher resident satisfaction in these facilities might be due to correlation of physical amenities with other, unmeasured factors rather than the level of physical amenities itself. Surprisingly, resident satisfaction diminished as more sociorecreational activities were offered. This relationship might be due to a lack of congruence between resident preferences and types of activities offered. The negative correlation (r = -.53, p <.05) between resident participation rates and the levels of sociorecreational activities offered in a facility seems to indicate that those facilities that provided more sociorecreational services tended to care for more functionally impaired residents. Subsequently, if activities offered in these facilities are designed for the cognitively impaired persons, the more independent residents participating in the study may simply not like them. Research in congregate housing indicates that relatively independent residents are unlikely to prefer services that are designed for the functionally limited elders (Timko & Moos, 91). The more impaired persons might be more satisfied with the available activities, but they were unable to voice their opinions. Consistent with previous studies, residents in nonprofit facilities were more satisfied with assisted living than residents in for-profit facilities (Lemke & Moos, 89; Timko & Moos, 91). The differences in resident satisfaction by ownership type might be due to a varying facility ethos of service to the consumer rather than profit for the owners. It may also be due to a greater likelihood that residents of nonprofit facilities had preexisting ties to the sponsoring agency, and/or to other residents. Resident self-selection to these facilities may facilitate greater congruence between residents' expectations and facility characteristics. The effect sizes of organizational variables were relatively small and had limited practical significance. Together, organizational factors accounted for 25% of the variation in resident satisfaction, but added only 7% of the explained variance when considered with resident characteristics. Although modest, this amount of variation in the dependent variable, explained by organizational factors, was more than twice as large as the amount of variation reported in the literature. Kruzich and colleagues (92) found that organizational factors explained only 11% of the variation in resident satisfaction with nursing homes. This study's correlational design does not allow the generation of reliable inferences concerning causation. Therefore, the identified relationships can be interpreted only in terms of associations. The moderate explanatory power of organizational factors may be due to a small sample of facilities and a limited variation among them. There were only 13 facilities participating in the study, and all of them operated under the same set of state regulations. Future research should include a larger sample of facilities representing the variety of assisted living programs nationwide to allow for greater generalizability of the findings. Because the study population included relatively functionally independent residents, the extent to which the findings apply to a more impaired assisted-living population is unknown. Moreover, the instruments used to measure organizational factors (MEAP scales) were designed to assess different types of residential care settings (Moos & Lemke, 92a, 92b, 92c) and may not detect differences among assisted living facilities. The index to measure resident satisfaction was more refined than the MEAP scales, but it may be that some Vol. 39, No. 4,

7 of its dimensions require a different amount of weight in the overall scale. Further reliability and validity analysis of the RSI needs to be conducted. Also, the relatively low reliability of the ABS (alpha =.62) posed an additional limitation to the study. In light of the study findings, policy makers should focus on the aspects of assisted living that are most likely to affect resident satisfaction, such as physical and social environment characteristics. Efforts might concentrate on providing residents with more opportunities to develop friendships and by encouraging more personal contacts with staff, particularly in larger facilities that tend to provide more institutional environments. There is also a need for an individualized approach to structuring sociorecreational activities in assisted living because there is a great variation in residents' levels of cognitive functioning. Monitoring and responding to individual resident preferences concerning social life and activities might lead to a better quality of assisted living. Furthermore, factors that influence residents' selection of a facility should be considered to enable greater congruence between resident expectations and services offered. The implications of this study, in light of the current debate concerning assisted living policies nationwide, indicate that extensive regulation of assisted living can increase costs and have an ambiguous effect on quality. The study cautions us about assuming that higher levels of resources are simple answers for improving the quality of resident life in assisted living facilities. Residents' and policy makers' perceptions may differ considerably, and the factors that are assumed by policy makers to ensure resident well-being may have little or no impact on residents' perceptions of quality. More research needs to be done to identify the aspects of assisted living that are critical to residents. Only when resident preferences are taken into account in the design, delivery, and evaluation of services, can assisted living truly be considered a resident-centered model of care. References Assisted Living Facilities Association of America. (96). An overview of the assisted living industry. Washington, DC: Coopers and Lybrand. Bradburn, N. M. (69). The structure of psychological well-being. Chicago: Aldine. Kane, R. A., Wilson, K., & Clemmer, E. (93). Assisted living in the United States: A new paradigm for residential care for frail older persons? Washington, DC: AARP Public Policy Institute. Kosberg, J., & Tooin, S. (72). Variability among nursing homes: Policy and practice issues. The Gerontologist, 12, Kruzich, J. M., Clinton, J. F., & Kelber, S. T. (92). Personal and environmental influences on nursing home satisfaction. The Gerontologist, 32, Lemke, S., & Moos, R. H. (89). Ownership and quality of care in residential facilities for the elderly. The Gerontologist, 29, Lewin-VHI. (96). National Study of Assisted Living for the Frail Elderly. Literature review update. (DHHS Publication No ). Research Triangle Park, NC: Author. Lieberman, M. A. (74). Relocation research and social policy. The Gerontologist, 14, Maryland Department of Health and Mental Hygiene. (96). Freestanding domiciliary homes. Baltimore: Author. Mollica, R. L, & Snow, K. I. (96). State assisted living policy. Portland, Ml: National Academy for State Health Policy. Moos, R., & Lemke, S. (92a). Physical and Architectural Features Checklist manual. Palo Alto, CA: Department of Veterans Affairs and Stanford University Medical Centers. Moos, R., & Lemke, S. (92b). Policy and Program Information Form manual. Palo Alto, CA: Department of Veterans Affairs and Stanford University Medical Centers. Moos, R., & Lemke, S. (92c). Resident and Staff Information Form manual. Palo Alto, CA: Department of Veterans Affairs and Stanford University Medical Centers. Morgan, L. A., Eckert, K. J., & Lyon, S. M. (95). Small board-and-care homes: Residential care in transition. Baltimore: The Johns Hopkins University Press. Moriwaki, S. Y. (74). The Affect Balance Scale: A validity study with aged samples. Journal of Gerontology, 29, 73-7'4. Namazi, K. H., Eckert, J. K., Kahana, E., & Lyon, S. M. (89). Psychological well-being of elderly board and care home residents. The Gerontologist, 29, Newcomer, R., Preston, S., & Roderick, S. 95. Assisted living and nursing units among continuing care retirement community residents. Research on Aging, 17, Norusis, M. J. (90). SPSS-PC+ Statistics 4.0. Chicago, IL: SPSS Inc. Pallarito, K. (95). Assisted living captures profitable market niche. Modern Healthcare, 25, Pascoe, G. C. (83). Patient satisfaction in primary health care: A literature review and analysis. Evaluation and Program Planning, 6, Pfeiffer, E. (75). A Short Portable Mental Status Questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23, Regnier, V. (94). Assisted living housing for the elderly: Design innovation from the United States and Europe. New York: Van Nostrand Reinhold. Timko, C, & Moos, R. H. (91). A typology of social climates in group residential facilities for older people. Journal of Gerontology: Social Sciences, 46, S160-S169. Weihl, H. (81). On the relationship between the size of residential institutions and the well-being of residents. The Gerontologist, 21, Wilson, K. (96). Assisted living: Reconceptualizing regulation to meet consumers' needs and preferences. Washington, DC: AARP Public Policy Institute. Received November 17, 98 Accepted March 12, The Gerontologist