Finding the Right Home -- and Contentment, Too
When your elderly relative needs to enter some sort of long-term care facility -- a moment few parents or children approach without dread -- what you'd like to have is clarity.

Does assisted living really mark a great improvement over a nursing home, or has the industry simply hired better interior designers? Are nursing homes as bad as people fear, or is that an outmoded stereotype? Can doing one's homework really steer families to the best places? It's genuinely hard to know.

I'm about to muddy the waters further by suggesting that what variety of facility an older person lives in may matter less than we've assumed. And that the characteristics adult children look for when they begin the search aren't necessarily what makes a difference to the people who move in.

I'm not talking about quality of care, let me hastily add. Nobody flourishes in a dismal environment with negligent staff and a lousy safety record. But an accumulating body of research indicates that some distinctions between one type of elder care and another have little real bearing on how well residents do.

The most recent of these studies, published in The Journal of Applied Gerontology, surveyed 150 Connecticut residents of assisted living, nursing homes and smaller residential care homes (known in some states as board and care homes or adult care homes). Researchers from the University of Connecticut Health Center asked the residents a raft of questions about their quality of life, emotional well-being and social interaction, as well as about the facility's quality.

“We thought we'd see differences based on housing types,” said the study's lead author, Julie Robison, an assistant professor of medicine at the university. A reasonable assumption -- don't families struggle to avoid nursing homes and suffer real guilt if they can't?

In the initial results, assisted living residents did paint the most positive picture. They were less likely to report symptoms of depression than those in the other facilities, for instance, and less likely to be bored or lonely. They scored higher on social interaction.

But when the researchers plugged in a number of other variables, such differences evaporated. It's not housing type, they found, that creates disparities in residents' responses.

“It's the characteristics of the specific environment they're in, combined with their own personal characteristics -- how healthy they feel they are, their age and marital status,” Dr. Robison explained. Whether residents felt involved in the decision to move and how long they'd lived there also proved significant.

An elderly person who describes herself as in poor health, therefore, might be no less depressed in assisted living (even if her children preferred it) than in a nursing home. A person who had input into where he would move and has had time to adapt to it might do as well in a nursing home as in a small residential care home, other factors being equal. It's an interaction between the person and the place, not the sort of place in itself, that leads to better or worse experiences.

“You can't just say, ‘Let's put this person in a residential care home instead of a nursing home -- she'll be much better off,' ” Dr. Robison said. What matters, she added, “is a combination of what people bring in with them, and what they find there.”

Such counterintuitive findings have surfaced before. In a multistate study of assisted living, for instance, University of North Carolina researchers found that a host of variables -- the facility's type, size or age; whether a chain owned it; how attractive the neighborhood was -- had no significant relationship to how residents fared in terms of illness, cognitive decline, hospitalizations or mortality.

What mattered most was residents' physical health and cognitive status. What people were like when they came in had greater consequence than what happened once they were there.

As I was considering all this, a press release from a respected research firm crossed my desk announcing that the five-star rating system that Medicare developed in 2008 to help families compare nursing home quality also has little relationship to how satisfied its residents or their family members are. In fact, consumers expressed higher satisfaction with the one-star facilities, the lowest rated, than with the five-star ones. (More on this study and the star ratings in a subsequent post.)

Before we collectively tear our hair out -- how are we supposed to navigate a landscape this confusing? -- here's a thought from Dr. Philip Sloane, a geriatrician at the University of North Carolina: “In a way, that could be liberating for families.”

Of course, sons and daughters want to visit facilities, talk to administrators and residents and other families, do due diligence. But perhaps they don't have to turn themselves into private investigators or Congressional subcommittees. “Families can look a bit more for where residents are going to be happy,” Dr. Sloane said. And involving the future resident in the process can be very important.

We all have our own ideas about what would bring our parents happiness. They have their ideas, too.
A friend recently took her mother to visit an expensive assisted living/nursing home near my town. I've seen this place -- it's elegant, inside and out. But nobody greeted the daughter and mother when they arrived, though the visit had been planned; nobody introduced them to other residents. When they had lunch in the dining room, they sat alone at a table.

The daughter feared her mother would be invisible there, and she decided to move her into a more welcoming facility. Based on what's emerging from some of this research, that might have been as rational a way as any to reach a decision.

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August 6, 2010, 9:00 am
By PAULA SPAN