CoreQ: AL Family Satisfaction Measure

Collecting satisfaction information from Assisted Living (AL) residents and family members is more important now than ever. We have seen a philosophical change in healthcare that now includes the patient and their preferences as an integral part of the system of care.  The Institute of Medicine (IOM) endorses this change by putting the patient as central to the care system (IOM, 2001). For this philosophical change to person-centered care to succeed, we have to be able to measure patient satisfaction for these three reasons: 

(1) Measuring satisfaction is necessary to understand patient preferences. 

(2) Measuring and reporting satisfaction with care helps patients and their families choose and trust a health care facility. 

(3) Satisfaction information can help facilities improve the quality of care they provide. 

The implementation of person-centered care in long-term care has already begun, but there is still room for improvement. The Centers for Medicare and Medicaid Services (CMS) demonstrated interest in consumers’ perspective on quality of care by supporting the development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for patients in nursing facilities (Sangl et al., 2007). We have developed three SNF based CoreQ measures, and these are NQF endorsed.  We have also developed two CoreQ measures for AL, and these are also NQF endorsed.

Further supporting person-centered care and resident satisfaction are ongoing organizational change initiatives. These include: the Center for Excellence in Assisted Living (CEAL) which has developed a measure of person-centeredness of assisted living with UNC,  the Advancing Excellence in America’s Nursing Homes campaign (2006), which lists person-centered care as one of its goals; Action Pact, Inc., which provides workshops and consultations with long-term care facilities on how to be more person-centered through their physical environment and organizational structure; and Eden Alternative, which uses education, consultation, and outreach to further person-centered care in long-term care facilities. All of these initiatives have identified the measurement of resident satisfaction as an essential part in making, evaluating, and sustaining effective clinical and organizational changes that ultimately result in a person-centered philosophy of care. 

The importance of measuring resident satisfaction as part of quality improvement cannot be stressed enough. Quality improvement initiatives, such as total quality management (TQM) and continuous quality improvement (CQI), emphasize meeting or exceeding “customer” expectations. William Deming, one of the first proponents of quality improvement, noted that “one of the five hallmarks of a quality organization is knowing your customer’s needs and expectations and working to meet or exceed them” (Deming, 1986). Measuring resident satisfaction can help organizations identify deficiencies that other quality metrics may struggle to identify, such as communication between a patient and the provider.

As part of the US Department of Commerce renowned Baldrige Criteria for organizational excellence, applicants are assessed on their ability to describe the links between their mission, key customers, and strategic position. Applicants are also required to show evidence of successful improvements resulting from their performance improvement system.  An essential component of this process is the measurement of customer, or resident, satisfaction (Shook & Chenoweth, 2012). 

The CoreQ: AL Family Satisfaction questionnaire and measure can strategically help AL facilities achieve organizational excellence and provide high quality care by being a tool that targets a unique and growing patient population. Moreover, improving the care for AL patients is tenable. A review of the literature on satisfaction surveys in long-term care facilities (Castle, 2007) concluded that substantial improvements in resident satisfaction could be made in many facilities by improving care (i.e., changing either structural or process aspects of care).  This was based on satisfaction scores ranging from 60 to 80% on average (with 100% as a maximum score). 

It is worth noting, few other generalizations could be made because existing instruments used to collect satisfaction information are not standardized. Thus, benchmarking scores and comparison scores (i.e., best in class) were difficult to establish. The CoreQ: AL Family Satisfaction Measure has considerable relevance in establishing benchmarking scores and comparison scores. AHCA/NCAL developed three skilled nursing facility (SNF) based CoreQ measures: CoreQ: Long-Stay Family Satisfaction Measure, CoreQ: Long-Stay Resident Satisfaction Measure, and CoreQ: Short-Stay Discharge Measure. All three of these measures received NQF endorsement in 2016. In addition to the CoreQ Family Satisfaction Measure received NQF endorsement in 2019. With these five satisfaction measures, it enables providers to measure satisfaction across the long term care continuum with valid and reliable measures. 

This measure’s relevance is furthered by recent federal legislative actions.  The Affordable Care Act of 2010 requires the Secretary of Health and Human Services (HHS) to implement a Quality Assurance & Performance Improvement Program (QAPI) within nursing facilities. This means all nursing facilities have increased accountability for continuous quality improvement efforts. In CMS’s “QAPI at a Glance” document there are references to customer-satisfaction surveys and organizations utilizing them to identify opportunities for improvement. Some assisted living communities have implemented QAPI in their organizations. 

Lastly, in CMS’s National Quality Strategy (2024), one of the four key areas is advancing equity and engagement for all individuals. Specifically, CMS calls out expanding the use of person-reported outcomes and experience measures as a key action. Similarly, in the most recent SNF payment rule (CMS, August 2024), CMS acknowledges an opportunity to add patient experience or satisfaction measures to the Quality Reporting Program (QRP) that spans across post-acute and long-term care providers and created by the IMPACT Act of 2014. While CMS does not provide direct oversight of assisted living, more states are covering assisted living as part of home and community-based Medicaid waivers. As of 2020, 44% of assisted living communities were Medicaid certified (CDC, 2020).  Thus, the principles of CMS’s Quality Strategy apply and the CoreQ: AL family measure can further CMS’s quality efforts.    

Castle, N.G. (2007). A literature review of satisfaction instruments used in long-term care settings. Journal of Aging and Social Policy, 19(2), 9-42.

CDC (2020). National Post-Acute and Long-Term Care Study. https://www.cdc.gov/nchs/npals/webtables/overview.htm

CMS (2009). Skilled Nursing Facilities Non Swing Bed - Medicare National Summary. http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/NationalSum2007.pdf

CMS, University of Minnesota, and Stratis Health. QAPI at a Glance: A step by step guide to implementing quality assurance and performance improvement (QAPI) in your nursing home. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIAtaGlance.pdf.

CMS (April 2024). Quality in Motion: Acting on CMS National Quality Strategy. https://www.cms.gov/files/document/quality-motion-cms-national-quality-strategy.pdf

CMS (August 6, 2024). Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2025. https://www.federalregister.gov/d/2024-16907/p-588

Deming, W.E. (1986).  Out of the crisis.  Cambridge, MA. Massachusetts Institute of Technology, Center for Advanced Engineering Study.

Institute of Medicine (2001). Improving the Quality of Long Term Care. National Academy Press, Washington, D.C., 2001.

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities; Department of Health and Human Services. 80 Fed. Reg. 136 (July 16, 2015) (to be codified at 42 CFR Parts 405, 431, 447, et al.). 

MedPAC. (2015). Report to the Congress: Medicare Payment Policy. http://www.medpac.gov/documents/reports/mar2015_entirereport_revised.pdf?sfvrsn=0.

Sangl, J., Bernard, S., Buchanan, J., Keller, S., Mitchell, N., Castle, N.G., Cosenza, C., Brown, J., Sekscenski, E., and Larwood, D. (2007). The development of a CAHPS instrument for nursing home residents. Journal of Aging and Social Policy, 19(2), 63-82.

Shook, J., & Chenoweth, J. (2012, October). 100 Top Hospitals CEO Insights: Adoption Rates of Select Baldrige Award Practices and Processes. Truven Health Analytics. http://www.nist.gov/baldrige/upload/100-Top-Hosp-CEO-Insights-RB-final.pdf.