A New Era for Regulation.

Everyone agrees that the ultimate measure of quality in any long-term care setting is customer satisfaction. But research from an Assisted Living Federation of America (ALFA) and Service TRAC study shows that when it comes to gauging customer satisfaction in assisted living communities, personal care services matter most to family members, while the residents themselves tend to focus on quality-of-life issues, such as meals and activities.

Regulators, however, historically have focused on prioritizing and codifying basic health and safety, while all but ignoring actual satisfaction and quality of life as equally important. Yet ask seniors what matters most to them as they age, and the answer is likely to be health and family, as well as the ability to live their lives as they wish.

Such is the conundrum that assisted living providers and regulators alike must address: How to strike the right balance between granting independence and ensuring quality care and safety for each resident.

Critics will forever complain that there are far fewer regulatory restrictions in assisted living than in nursing homes. But supporters of the assisted living model have learned from the nursing home industry's experience that having more regulations is not necessarily a guarantee of better care and, in fact, can damage customer satisfaction because no one really wants to live in a very restricted environment. To truly uphold a senior's wish for independence and choice in his/ her daily life, regulations must be flexible enough to let that happen, and a resident's right to make choices in his/her own home must be protected.

In many ways, 2001 will be a pivotal time for our industry. The increased popularity of community-based alternatives to institutional care such as assisted living, senior housing and home healthcare has drawn the attention of state regulators, the media, consumer advocates and elected officials, who are asking questions such as: Is there enough regulation for assisted living? What does the future hold for regulating this model? If regulations continue to be flexible, how can quality be ensured?

To adequately answer these questions, the first step is to acknowledge the paradigm shift in the long-term care system and the new premise that serves as the foundation on which the system rests today: The so-called "continuum" is out; consumer choice is here to stay. Consumers have made it clear that they do not want to be moved from setting to setting during their most vulnerable years. It's in the consumers' interest to put them in the driver's seat and bring care to them as needed, rather than requiring them to move around for the convenience of the system. Residents should have the same right to receive or coordinate services in their assisted living or retirement homes that they enjoyed in their private homes.

As the recent report on long-term care by the influential Institute of Medicine (IOM) emphasized, "Consumer-centered care that reflects the preferences and choices of the consumers of the service is desirable for almost all people across all health settings."

This basic paradigm shift is reinforced by the 1999 Olmstead v. LC U.S. Supreme Court decision, upholding the rights of the disabled to receive services in the least institutional setting possible, as well as the Fair Housing Act, which prohibits housing discrimination. Since then, the Health Care Financing Administration has emphasized home- and community based services over institutional care where appropriate. Most recently, a new Michigan law sponsored by State Sen. Dale Sugars champions the rights of assisted living residents to remain in that setting as their needs increase, as long as the resident, physician, family members and assisted living operator are in agreement that care can be adequately provided there. The new Michigan law favors a case-by-case team approach to making that decision.

The assisted living movement supports the role of state regulators in setting basic health and safety standards and rigorously enforcing them. At the same time, assisted living must also be accountable to its actual customers to whom it promises a flexible residential environment. How can a regulatory system be structured to accommodate both?

The state of Iowa is involved in a promising regulatory experiment to incorporate the importance of consumer preferences. The state is using a customer satisfaction survey developed by ServiceTRAC for ALFA as an essential component in an innovative pilot program that seeks to define quality in terms of an assisted living program's ability to meet or exceed customer expectations. This approach challenges the providers to excel in meeting the needs of their residents, rather than simply requiring them to meet basic state man dates that might or might not reflect the actual expectations of residents. As a result, the focus is on measurable outcomes and continuous quality improvement.

Notably, the IOM report said: "Although not all committee members agree on the specifics of how state regulatory systems should be modified, there was consensus in the committee that, at this time, these mechanisms need not mirror the extensive federal regulatory oversight that is in place for nursing homes."

A key component is successful self-monitoring within the industry itself. To that end, ALFA has supported a multipronged quality initiative that includes: supporting third-party voluntary accreditation through CARF; offering training and certification for caregivers and other key staff through ALFA University; developing risk management train ing; helping providers improve consumer education and disclosure; working with states as they revise their policies; and funding research on better ways to measure resident outcomes.

In the senior care system of the future, consumer choice will be "king" and assisted living and nursing home providers will work together to support each other on the many priori ties they share. We share common ground in wanting what's best for our customers, wanting to listen well to what our customers say they want and seeking ways to balance the basic health and safety goals we all share with these residents' priorities. That was the premise that the best nursing homes were founded on, before federal oversight made that goal all the more difficult for anyone to achieve.

Karen Wayne is president and CEO of ALFA.