My father moved into an
assisted-living residence last fall. When I visited him several weeks later, I was surprised and intrigued to learn that he had an assigned table and ate with the same three people at all of his meals. The facility’s director told me the staff had put careful consideration into choosing my dad’s table companions.
My dad is content to be a loner, so I thought assigned seating at meals was a good fit. This way, my dad would at least have acquaintances, someone to exchange niceties with when he was out in the common areas. It seemed to me this would give him a sense of belonging.
Assigned seating might be great for my dad, but there are downsides to the practice, says Tetyana Shippee, an expert in social gerontology at the University of Minnesota School of Public Health. For instance, she says, a quick-witted person grouped with cognitively impaired residents would probably find the arrangement depressing.
Shippee spent two years living in a long-term-care facility as part of her graduate work, including eating meals with residents. Food and dining are keys to resident satisfaction in assisted-living facilities and nursing homes, she says, both the enjoyment of food itself and the people one eats with. “Mealtime is the primary time for social interaction,” Shippee says, but it also can be a scene of cliquishness — “like high school.” Without assigned seating, a person might be told that a seemingly empty seat is taken. “Assigned seating does avoid social rejections.”
I wondered what other practices of my dad’s place supported residents’ sense of feeling at home. I wondered how intentional the practices were and whether there was research to support them.
If you’ve ever visited a long-term-care facility, you’ve probably seen the activity calendar. My dad’s place regularly holds trivia games and hosts musical acts. Skye Leedahl, an assistant professor of aging and health at the University of Rhode Island, says activity directors can have a huge effect on residents’ social engagement. A great director gets to know the individual preferences of residents and uses that information to design activities. A great facility supports small-group activities — perhaps a bridge club or a knitting group — in addition to larger events.
A 2014 study backs up the importance of activities. For this study, Shippee and colleagues analyzed data from interviews with residents of Medicaid-certified nursing homes in Minnesota. The most salient predictors of good quality of life were size of the facility (smaller is better) and staffing levels (especially activities staff).
Medical care at nursing homes is the usual focus of research because it is regulated and because payers, such as Medicare and Medicaid, are interested in cost/benefit analysis. There is far less research on the nonmedical aspects of senior living, such as relationships and food, and on assisted-living facilities, which vary widely — from a couple of beds in a house to apartment-style buildings with several dozen rooms.
More recently, however, researchers such as Shippee and Leedahl have focused on “quality of life versus quality of care,” she says. Nonmedical aspects of daily living determine overall satisfaction with life, which can translate into healthier elder years as evidenced by lower rates of depression and reduced risk of falls, Shippee says.
Leedahl worked as a certified nursing aide in a nursing home before getting her PhD in social work. “I always wanted to know: Is there a better way?” she says. “I felt we could be doing better at care by paying attention to quality of life.” In her research, she has visited many facilities. “Some are so beautiful. Others are less elaborate, but they felt cozy and people were happy.”
Nan Sook Park, an associate professor of social work at the University of South Florida in Tampa, studies assisted-living facilities using in-depth interviews of residents. In a 2012 paper, 29 residents at four assisted-living facilities in Alabama were questioned about friendships, routines, mealtimes and activities.
“What was striking was the difference in what administrators said and what residents said,” Park says. For instance, administrators say assigned seating at meals makes it easier to track dietary restrictions and gives consistency to people with memory impairment. But residents reported that sitting with the same people at every meal meant there was nothing to talk about.
There were exceptions, Park says. Some people love their tables, citing fun people and exchange of ideas.
So how can families assess assisted-living facilities? My siblings and I initially focused on location and cost in putting together a list of places, but we also asked about demographics. We didn’t want my 90-year-old father surrounded by people a generation younger or by a supermajority of women. My dad approved the first place he visited.
Here are some other things to keep in mind:
Atmosphere. Visit places that are under consideration, and pay attention. “The feeling of a place is important,” Park says. “Beyond a clean look and a good smell, do the people look happy and relaxed? Observe the staff and the residents and feel the chemistry of the atmosphere.”
Activities. Look for a diversity of social events, Park says — both large-group and small-group. Ask if some activities are tailored to residents’ interests.
Staff. “Talk to them,” Shippee says. “Do they know residents’ names? Do they know the residents personally — their stories?”
Food. Shippee emphasizes the importance of food as a daily enjoyment. Institutional food can get tiresome. “How frequently does the menu change? Can you order off-menu?”
Personalization and privacy. Leedahl says residents should have the freedom to arrange their room and to lock their door. “How can people individualize their lives here?”
Rules. Some facilities have a lot of rules and strict schedules. Leedahl suggests asking: How do people spend their time? “The ideal answer,” she says, is “ ‘However they want.’ ”
Indeed, my dad feels that his desire for solitude is being honored. Nobody’s pressing him to join a bridge group, for instance, and it’s a good thing, because he doesn’t want to join.