Mary M. Ball

Pathways to Assisted Living: The Influence of Race and Class

This article examines how race and class influence decisions to move to assisted living facilities. Qualitative methods were used to study moving decisions of residents in 10 assisted living facilities varying in size and location, as well as race and socioeconomic status of residents. Data were derived from in-depth interviews with 60 residents, 43 family members and friends, and 12 administrators. Grounded theory analysis identified three types of residents based on their decision-making control: proactive, compliant, and passive/resistant. Only proactive residents (less than a quarter of residents) had primary control. Findings show that control of decision making for elders who are moving to assisted living is influenced by class, though not directly by race. The impact of class primarily related to assisted-living placement options and strategies available to forestall moves. Factors influencing the decision-making process were similar for Black and White elders of comparable socioeconomic status.

Managing the Care Needs of Low-Income Board-and-Care Home Residents: A Process of Negotiating Risks:

Small, low-income board-and-care homes play a critical role in the long-term care system, serving a variety of at-risk groups, including chronically mentally ill individuals, frail elders, and developmentally disabled adults. Unfortunately, the supply of homes available to serve these populations is decreasing. The purpose of this study, based on an in-depth ethnographic case study of one small (13-bed) African American-owned and -operated home in metropolitan Atlanta, was to understand how and why some homes continue to operate despite significant challenges. Grounded theory analysis showed that the survival of this home and residents’ ability to remain in it involved a basic social process conceptualized as Negotiating Risks. This survival process often put participants at risk of losing their means of subsistence. Community support emerged as an important protective factor. Findings have implications for community interventions to increase these homes’ survival and improve resident care.

This is our last stop: Negotiating end-of-life transitions in assisted living.

Where people die has important implications for end-of-life (EOL) care. Assisted living (AL) increasingly is becoming a site of EOL care and a place where people die. AL residents are moving in older and sicker and with more complex care needs, yet AL remains largely a non-medical care setting that subscribes to a social rather than medical model of care. The aims of this paper are to add to the limited knowledge of how EOL is perceived, experienced, and managed in AL and to learn how individual, facility, and community factors influence these perceptions and experiences. Using qualitative methods and a grounded theory approach to study eight diverse AL settings, we present a preliminary model for how EOL care transitions are negotiated in AL that depicts the range of multilevel intersecting factors that shape EOL processes and events in AL. Facilities developed what we refer to as an EOL presence, which varied across and within settings depending on multiple influences, including, notably, the dying trajectories and care arrangements of residents at EOL, the prevalence of death and dying in a facility, and the attitudes and responses of individuals and facilities toward EOL processes and events, including how deaths were communicated and formally acknowledged and the impact of death and dying on the residents and staff. Our findings indicate that in the majority of cases, EOL care must be supported by collaborative arrangements of care partners and that hospice care is a critical component.

“Meds are a Real Tricky Area” Examining Medication Management and Regulation in Assisted Living

Medication management is among the most commonly cited reasons for moving to assisted living and is closely associated with resident quality of care and life. Yet the issue has received little research attention. Using data from the statewide study, “Job Satisfaction and Retention of Direct Care Staff in Assisted Living,” this article examines medication management policies and practices across 45 facilities in Georgia. Guided by principles of Grounded Theory Method, we analyzed qualitative data from surveys with 370 direct care workers (DCWs) and in-depth interviews with 41 DCWs and 44 administrators. Our analysis showed that medication managers vary widely in their backgrounds, positions, and training, largely based on home size and resources. Despite identifying common dimensions of the medication management process, we found variation in procedures and regulatory compliance based on facility, staff, and resident factors. Our findings relate to and extend existing work and have practice and research implications.

A Comparison of Functional Outcomes Following a Physical Activity Intervention for Frail Older Adults in Personal Care Homes

Purpose: The purpose of this study was to determine the effectiveness of 2 consecutive 10‐week exercise interventions for increasing functional ability of residents living in personal care homes (PCHs). Methods: Residents in 2 intervention homes (n = 15) participated in a series of exercise classes followed by a walking program. Residents living in 2 PCHs matched for demographic and environmental variables served as controls (n = 15). Pre‐ and post‐test measures (0 weeks and 21 weeks) included the Modified Barthel Index (MBI), the Tinetti Performance‐Oriented Mobility Assessment (POMA), and the Functional Reach Test (FRT). A General Linear Model was used to analyze group (control vs. intervention) by time (0 vs. 21 weeks) interactions as well as changes over time within the intervention group (0 vs. 10 vs. 21 weeks). Results: In comparing the 2 groups at the beginning and end of the intervention, the POMA Balance Subscale showed significant improvement (p = .04) for the intervention group. Within the intervention group, scores of the MBI and POMA increased after the 10‐week exercise class series, then declined exhibiting a significant quadratic relationship (p = .03). Conclusions: It is likely that without the intervention, the gradual decline noted in the control group would have occurred in the intervention group as well. Given that older adults who live in PCHs often experience declines in their activities of daily living (ADL) and independent activities of daily living (IADL) performance, it is critical that physical activity programs be available to residents to mitigate and/or reverse these declines.

Exposing the Backstage: Critical Reflections on a Longitudinal Qualitative Study of Residents’ Care Networks in Assisted Living:

In this article, we analyze the research experiences associated with a longitudinal qualitative study of residents’ care networks in assisted living. Using data from researcher meetings, field notes, and memos, we critically examine our design and decision making and accompanying methodological implications. We focus on one complete wave of data collection involving 28 residents and 114 care network members in four diverse settings followed for 2 years. We identify study features that make our research innovative, but that also represent significant challenges. They include the focus and topic; settings and participants; scope and design complexity; nature, modes, frequency, and duration of data collection; and analytic approach. Each feature has methodological implications, including benefits and challenges pertaining to recruitment, retention, data collection, quality, and management, research team work, researcher roles, ethics, and dissemination. Our analysis demonstrates the value of our approach and of reflecting on and sharing methodological processes for cumulative knowledge building.