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Assisted living. Oregon and California: Two models compared

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Assisted living. Oregon and California: Two models compared

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Content J i INFORM ATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter free, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. 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ASSISTED LIVING Oregon and California: Two Models Compared by Jodi Lyn Chamberlain A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA Requirement for the Degree MASTERS OF SCIENCE IN GERONTOLOGY August 1997 © 1997 Jodi Lyn Chamberlain Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. UMI N um ber: 1 3 8 7 8 1 5 C o p y r ig h t 1 9 9 7 b y C h a m b e r la in , J o d i L yn All rights reserved. UMI Microform 1387815 Copyright 1998, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. UNIVERSITY OF SOUTHERN CALIFORNIA LEONARD DAVIS SCHOOL OF GERONTOLOGY University Park Los Angeles, CA 90089 This thesis, written by , ^ e > e\'\ vj \ r\______________________ ^ \ ______________________ under the director of h ev- Thesis Committee and approved by ail its members, has been presented to and accepted by the Dean of the Leonard Davis School of Gerontology in partial fulfillment of the requirements for the , degree of: e-C S } r',-rtr\c e A f L i'S </, ■ * ' 1 Dean \ - r { f , y __ Date 'ja t.b / / w ? I / THESIS COMMITTEE -----------------------------------a — U. Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. TABLE OF CONTENTS Abstract...........................................................................................................1 I. Chapter I/Introduction to Assisted Living.................................................4 Defining Assisted Living.................................................................... 6 Similarities...........................................................................................12 Initial Concerns................................................................................... 14 II. Chapter I I/Literature Review..................................................................16 Regulations and Licensure.................................................................. 17 The States.................................................................................17 The Oregon Assisted Living Program.................................... 18 California’s Residential Care Facilities................................... 20 Long-term Care and the Continuum of Care...................................... 22 Movement Through Long-term Care..................................... 24 Where Assisted Living Fits..................................................... 25 Funding Alternatives........................................................................... 26 Medicaid and Supplemental Security Income........................ 27 Medicaid Waivers.................................................................... 28 Long-term Care Insurance.......................................................32 The Oregon Model.............................................................................. 34 Specific Oregon Regulations................................................... 35 Oregon’s Medicaid Waiver..................................................... 39 Aging-in-Place..........................................................................41 Financing in Oregon................................................................42 The California System......................................................................... 44 Common California Concerns.................................................45 Three Assisted Living Models................................................. 45 III Chapter IE/Methodology..........................................................................48 Procedures........................................................................................... 49 Participant Selection........................................................................... 50 Interviewing Protocol.........................................................................51 Limitations........................................................................................... 52 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. IV. Chapter IV/Findings................................................................................. 53 Question # 1 ..........................................................................................54 Question # 2 ..........................................................................................56 Question # 3 ..........................................................................................58 Question # 4 ..........................................................................................59 Question # 5 ..........................................................................................60 V. Chapter V/Applications and Discussions.................................................. 63 Differences in RCFEs and Assisted Living Facilities..........................66 A Combination Approach.....................................................................71 Assisted Living Philosophy.................................................................. 73 Assisted Living Licensure.....................................................................73 Bibliography......................................................................................................75 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. TABLES Table 1/Comparison of State Assisted Living Regulations and Medicaid Reimbursement.............................30 Table 2/Service Priority Categories................................................... 42 Table 3/Service Priority and Payment Rates...................................... 43 Table 4/Awareness of State Assisted Living Development...............56 Table 5/Assisted Living and RCFEs, Oregon and California.............68 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. ABSTRACT Assisted Living is currently receiving much attention in the United States due to the aging of the population and the desire of frail older persons’ to preserve their independence, dignity, freedom of choice, and individuality. Assisted Living is the most common term used to describe the somewhat recent development in retirement housing that focuses on meeting these desires. With increased age, individuals are more likely to require extra assistance with personal care activities which they used to perform independently. Such activities are referred to as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Activities of daily living include eating, toileting, bathing, dressing, and ambulating. Instrumental activities of daily living include activities such as shopping, money management, taking medications, meal preparations, and housekeeping. If individuals need extra assistance, they usually find themselves having to make important life decisions regarding where they can obtain that assistance. This may determine the move to an assisted living setting that allows the individual to receive the extra care he/she may need while preserving independence, choice, dignity, privacy, and individuality. The favorable environment of assisted living enables the individual to enjoy the many comforts of a home-like environment while obtaining needed assistance. In many cases assisted living substitutes for nursing home placement, as will be discussed in terms of the Oregon model. Regulating quality of care and funding assisted living projects to make them more affordable are common concerns for investors and state regulatory units. There is 1 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. much debate regarding the regulatory process which governing bodies should assume. Some prefer a less stringent umbrella which allows control based on outcomes rather than by specific tasks. Oregon’s Medicaid waiver has been the pioneer for many states looking for a way to fund and regulate assisted living. The waiver has enabled Oregon to develop an outcome oriented, consumer driven model which is less restrictive than traditional approaches to regulation. Operating costs in Oregon are well below 80 percent of nursing home costs. Many other states, such as California, are interested in exploring Oregon’s budget neutral and cost effective program. California is currently assessing whether assisted living reduces the numbers of individuals placed in skilled care. The premise is that many skilled care residents may not need this level of care. The likely result would be a reduction in state long-term care expenditures. California also recognizes the growing elderly population and understands the need for a system of long-term care which will successfully support their needs. The following study is based on a series of interviews of key informants in the assisted living field as well as a current literature review and two in-depth case studies of Oregon and California. The representatives of the assisted living field used in this study show varying and diverse understanding of the assisted living market. Highlighted in “Methodology” and “Findings” the reader will be introduced to the questions asked of these key informants, their responses and the implications that these responses may suggest for the future of assisted living in Oregon and California. 2 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Conclusions at the completion of this study (June, 1997) suggest that California is looking to develop a state specific system for assisted living. Diversity in state population size; funding alternatives; regulatory restrictions; and overall ability of innovation create state differences between Oregon and California. These differences are thought to be (by those participants in this study) the premise behind Oregon having a valuable model to study, but not likely a model which could be completely adopted by the state of California. Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. CHAPTER I Introduction to Assisted Living R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. The development of assisted living is a rather new and experimental phenomenon. Because of the innovative and potentially costly approach generally required for a state to adopt assisted living licensure, some states are hesitant to embark on a new approach to caring for these elderly residents. Those states that are most successful in implementing such a system of licensure are paving the way for many other states where decision makers may fear the transition, regulatory environment, and/or minimal financial alternatives for funding (e.g., Medicaid waivers). This study will explore two state programs. The regulations, philosophy, financing, and innovation of the Oregon system of assisted living will be examined and California’s system of long-term care will be compared to Oregon’s assisted living licensure. The purpose of this thesis is to propose a system of assisted living licensure for California by introducing the possibility of assisted living as a specific licensure or as a new philosophy into which current residential care facilities for the elderly (RCFEs) could transition. Chapter I explains current assisted living definitions and offers an overview of the organization of this study. In Chapter II a literature review of the assisted living field based on regulations, funding alternatives, the Oregon model and the California system is discussed. Data gathered through key informant interviews are examined in Chapter III along with an explanation of the characteristics of the participants, the research questions asked and the procedures used in the interviewing process. Individuals ranging from state policy makers to private developers were interviewed in both Oregon and California. This comparative case study of the two states provides a contrast of two ends of a spectrum of Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. development for assisted living. Chapter IV investigates the findings related to the key informant interviews and research questions asked of these representatives. Finally, Chapters V and V T summarize and discuss implications of California adopting a new system of long-term care with an assisted living focus and/or philosophy. Defining Assisted Living Assisted Living has evolved into a distinct industry in the past decade as a result of the aging of the population and the increasing demands of the elderly requiring assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are basic activities that support survival, including eating, bathing, toileting, and hygiene/grooming. IADLs are higher order activities which support independence , including housekeeping, shopping, budgeting, and money management (Bonder, 1994). Many older persons desire an environment which supports their need to make personal decisions about their care while living in a private home-like setting which respects their individuality. Because of the lack of a clear definition of assisted living (due to varying state regulations, funding and consumer needs) many states, professional organizations, media, and researchers studying this field of retirement housing have developed their own definitions. A literature review prepared for The Office of the Assistant Secretary for Planning and Evaluation and the Administration on Aging/U.S. Department of Health and Human Services (1996) recently gathered information regarding the various definitions. Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. The following definitions are from many different areas of the aging market but some similarities may provide a future common ground for a universal definition of assisted living. FORMAL ASSOCIATIONS DEFINITIONS American Association of Homes and Services for the Aging (AAHSA) Assisted Living Facilities Association of America (ALFAA) Assisted living is a program that provides and/or arranges for the provision of daily meals, personal and other supportive services, health care, and 24 hour oversight to persons residing in a group resi dential facility who need assistance with activities of daily living and instrumental activities of daily living. It is characterized by a philosophy of ser vice provision that is consumer driven, flexible, individualized and maximizes consumer indepen dence. choice, privacy, and dignity. Assisted living is a special combination of housing, supportive services, personalized assistance and health care designed to respond to the individual needs of those who need help in activities of daily living. Supportive services are available, 24 hours a day. to meet the scheduled and unscheduled needs, in a way that promotes maximum independence and dignity for each resident and encourages the involvement of a resident's family, neighbors, and friends. American Senior Housing Association (ASHA) American Association of Retired Persons (AARP) US Health Care Financing Administration (HCFA). Medicaid Home and Community Based Waiver 1915c A coordinated array of personal care, health services, and other supportive services available 24 hours per day. to residents who have been assessed to need those services. Assisted living promotes resident self direction and participa tion in decisions that emphasize independence, individuality, privacy, dignity, and residential surroundings. Group or congregate living arrangements that provide room and board as well as social and recreational opportunities: assistance to residents who need help with personal needs and medications: availability of protective oversight or monitor ing: and help around the clock and on an unscheduled basis. Assisted living is one of two categories of Adult Residential Care under a 1915c waiver. It is defined as: Personal care and services, homemaker, chore, attendant care, companion services, medication oversight (to the extend permitted under State law), therapeutic social and recreational programming, provided in a licensed community care facility, in conjunction 7 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. with residing in the facility. This service includes 24 hour on site response staff to meet scheduled or unpredictable needs and to provide supervision of safety and security. Other individuals or agencies may also furnish care directly, or under arrangement with the community care facility, but the care provided by these other entitles supplements that provid ed by the community care facility and does not supplant it. Care is furnished to individuals who reside in their own living units (which may include dually occupied units when both occupants consent to the arrangement) which may or may not include kitchenette and/or living rooms as well as bathrooms. Living units may be locked at the discretion of of the client except when a physician or mental health pro fessional has certified in writing the client is sufficiently cognitively impaired as to be a danger to self or others if given the opportunity to lock the door. (This requirement does not apply where it conflicts with the fire code.) Each living unit is separate and distinct from each other. The facility must have a central dining room, living room, or parlor, and common activity centers) (which may also serve as living rooms or dining rooms). Routines of care provision and service delivery must be client-driven to the maximum extent possible. Assisted living services may also include: • home health care • physical therapy • occupational therapy • speech therapy • medication administration • intermittent skilled nursing services • transportation specified in the plan of care However, nursing and skilled therapy services are incidental, rather than integral to the provision of assisted living service. Payment will not be made for 24-hour skilled nursing care or supervision. Medicaid assistance is not available in the cost of room and board furnished in conjunction with residing in an assisted living facility. Payments for adult residential care services are not made for room and board, items of comfort or convenience, or the cost of facility maintenance, upkeep, and improvement. Payment for adult residential care services does not include payments made, directly or indirectly, to members of the recipients immediate family. 8 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. US Department of Housing and Urban Dev elopment (HUD) National Association of Residential Care Facilities National Association of State Units on Aging (NASUA) Assisted Living means a public facility, proprietary facility, or facility of a private nonprofit corporation that is used for the care of the frail elderly, and that: 1. Is licensed and regulated by the state if there is no state law providing for such licensing and regulation by the state, by municipality or other political subdivision in which the facility is located; 2. Makes available to residents supportive services to assist the residents in carrying out activities of daily living... 3. Provide separate dwelling units for residents... Residential care facility means a home or facility of any size, operated for profit or not-for-profit which undertakes through its owner/s or management to provide food, housing, and support with activities of daily living and/or protective care for two or more adult residents not related to the owner or administrator. Residential care homes are also known as: assisted living facilities, foster homes, board and care homes, sheltered care homes, etc. NASUA subscribes to a definition of assisted living which acknowledges the deep desire of America's elders to reside in their own homes or in a homelike environment. Accordingly, the Association views assisted living as referring to a home like congregate residence providing individual living units where appropriate supportive services are provided through individualized service plans. Assisted living is first and fore most a home in which residents independence and individual ity are supported and in which their privacy and right to self- expression are respected. RESEARCHERS DEFINITIONS One attractive emerging option is assisted living, which under some state licensure features single-occupancy apartment units with full bathrooms and kitchenettes. Such programs serve three meals a day and provide on-site staff. Individually planned care is brought to the consumers own apartments. Assisted living is any group residential program that is not licensed as a nursing home, that provides managed care to persons with needs for assistance in the activities of daily living, and that can respond to unscheduled need for assist ance that might arise. Victor A Regnier. 1994. "Assisted living is a long-term care alternative which involv- Asisted Living Housing es the delivery of professionally managed personal and health for the Elderly care services in a group setting that is residential in character and appearance in ways that optimize the physical and psych ological independence of residents” (p. 2/5). Rosalie A Kane & Karen Brown Wilson. 1993. Assisted Living in the United States Rosalie A Kane & Robert L. Kane. 6/7/95. JAMA 9 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Joann Hyde. 1995. draft report of People fVith Dementia: Toward Appropriate Regulation o f Assisted Living and Residential Care Settings Donna Yee. August 1995. cited in Currents in reference to a Brandeis University study. PRINT MEDIA DEFINITIONS NY Times 1/3/93 Contemporary Long Term Care 2/93 New Orleans Magazine 2/94 Pension World 3/94 Milwaukee Business Journal 4/2/94 Brown University Long term Care Quality Letter 8/15/94 Assisted living is a service-rich residential environment designed to enable individuals with a range of capabilities, disabilities, frailties and strengths to reside in a homelike setting as long as possible. Assisted living is defined in the study as programs that offer congregate housing and supportive services with explicit or implicit commitment to respond to individual preferences for help with health care access, personal care and household maintenance. "Residents live independently...while receiving 24 hour supervision, assistance with daily living, meals, housekeeping transportation, and recreational programming. M inimum health care or nursing assistance is provided as needed” (p. 2/6). Housing and Community Development Act of 1992. Assisted living facilities are “public, proprietary or private/nonprofit facilities that: Are licensed and regulated by the state: make available to residents supportiv e services to assist in carrying out activities of daily living: and provide separate dwelling units for residents, each of whom may contain full kitchen and bathroom. "Designed for the elderly who are still able to care for them selves. ..They offer pleasant, safe surroundings in which the elderly can live independently. But they also provide such services as nursing care, transportation, and housecleaning as needed” (p. 2/7). "A senior-living complex with physical features designed to assist the frail elderly with staff personnel and programs that assist residents with the activities of daily living” (p. 2/7). Assisted living draws from two populations: I) people who do not require continuous medical care, but occasionally need someone to help them get dressed, or remind them to take medication” and 2) "health and active seniors who simply want to shed some of the burdens of home ownership. ” "An alternative model of supportive housing... In Oregon, private apartments are shared only by choice. Everyone agrees that assisted living should provide at least congregate services (meals, housekeeping, laundry, transportation, and group activities)” (p. 2/7). 10 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Building Design & Construction 8/94 Postgraduate Medicine i/95 The Washington Post 1/9/95 Provider 2/95 Tampa Bav Business Journal 4/28/95 Nursing Homes 5/95 PRNewswire 8/8/95 “A communal residence for senior citizens who don't require 24 hour care of nursing homes, but who nevertheless need some assistance with the activities of daily living' (p. 2/7). Residential facilities that provide supervision and care for individuals who have lost some degree of self-care capacity .. these facilities fill a niche between independent living arrangements and the full supervised care offered in nursing homes. Assisted living facilities grew out of boarding homes-social places-and have prospered by offering the frail elderly greater independence in exchange for less security than assured by the rigid, essentially medical boarding of a nursing home. What the industry calls assisted living the state knows variously as board and care, sheltered living protect homes, and domiciliary care, either registered or licensed. As ALF (assisted living facility) is defined by HUD as a not- for-profit or for-profit facility for the frail elderly that is licensed and regulated by the state, or. if there is no state law providing for such licensing and regulation, by the municipal ity or other political subdivision in which the facility is located. The ALF may be freestanding or a part of a complex of other facilities. The concept is simply to make senior citizens feel like they are at home rather than in an institution. The dwellings pro vided by the company come with a yard, a porch, and a kitchen. Residents are encouraged to eat in a common dining area, which doubles as a game room and meeting area. .. there are few. if any. alternatives for patients in the middle of the spectrum-those who are unable to live independently, yet don’t require skilled nursing care.. .because assisted living residents are not bound by the same regulations that govern nursing homes, we have the opportunity to be more flexible and creativ e with respect to physical environment and delivery of services.. .Each facility houses 50 to 60 residents, yet has a cozy, informal environment that is as home-like as possible. Assisted living services provide greater opportunities for seniors to live independently through a selection of services such as assistance at meal time or with bathing. 11 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Similarities Many obvious similarities exist among the various definitions of assisted living as defined in current literature. The most common similarities in these definitions are among phrases such as: to remain independent (47%); to have choices (41%); to preserve dignity (35%); a private/home-like environment (65%); and individuality (35%). All definitions propose supportive services for activities of daily living and congregate services including meals, laundry, housekeeping, transportation, and recreational activities. Additionally, all definitions include availability of 24 hour care to respond to unscheduled needs. Oregon’s definition of assisted living incorporates all of these components in its definition of assisted living and will be used as an industry standard for this study. Oregon stands out in the literature as one of the most innovate state systems for assisted living. Although the Oregon model will be discussed in depth in a future chapter, it is referred to often throughout this thesis. Oregon’s 1915c Medicaid waiver defines assisted living as a “program approach, within a physical structure, which provides or coordinates a range of services, available on a 24 hour basis, for support of resident independence in a residential setting. Assisted living promotes resident self direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence, and home-like surroundings” (Oregon 1915 c Medicaid waiver, 1995, apx. A, exb. 4, p. 2). 12 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. From Oregon’s definition, it becomes clearer how a common definition might be formulated. Gathering the themes expressed within the various definitions, the Oregon state model succinctly combines these ideas into an understandable, collective whole. Standardizing the language is of predominant importance because of the possibility of differing interpretations. For the purpose of this study, the following terminology (as defined in the Oregon waiver) and their definitions are as follows: • Choice—viable options created for residents to enable the individuals to exercise control in their lives. Choice is supported by providing sufficient private and common space to provide opportunities for selecting where and how to spend time and receive personal assistance. • Dignity—providing support in such a way as to validate the self-worth of the individual. Dignity is supported by designing a structure which allows personal assistance to be provided in privacy and delivering services in a manner which shows courtesy and respect for a resident’s right to make decisions. • Independence—supporting resident capabilities and facilitating use of those abilities. Independence is supported by creating barrier free structures and careful design of assistive devices. • Individuality—recognizing variability in residents’ needs and preferences and having the flexibility to organize services in response to the needs and preferences. 13 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. • Privacy—a specific area and/or time over which the resident maintains a large degree of control. Privacy is supported by designing living space which is not shared, except by personal choice, with others. Privacy is supported with services that are delivered with respect for the resident’s civil rights (pp. 3-4). Initial Concerns Assisted Living Today (Aug/Sept, 1996) asked three industry professionals, Robert Jenkins, Robert Mollica, and Rachelle Bemstecker to express their opinion (as a result of extensive research in the field) concerning assisted living and its role in the future of long term care. One particular question posed to these individuals concerned the lack of federal regulation of assisted living which results in a more lenient regulatory environment than that of a skilled facility in some states, thereby possibly putting elders at risk. The regulatory environment will be examined in chapter II. Specifically, the question was, “What particular issues or services in assisted living receive increased scrutiny from regulators and where do you see states coming down on these issues? More flexible, more restrictive” (p. 31)? Answers included statements pertaining to: (1) physical plant requirements being too lax thereby possibly jeopardizing the safety (fire codes, handicap accessibility etc.) of residents; (2) living unit requirements (e.g., size, occupancy) and the line between nursing home regulations and assisted living; (3) Medicaid reimbursement; (4) oversight and monitoring without being too bureaucratic; and (5) possible neglect of residents without regulations to oversee treatments. 14 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. A literature review through January 1997 suggests that the above concerns are justifiable. The task of assisted living advocates and state regulators becomes one of working closely to develop a comprehensive system of outcome oriented regulations which will oversee operations without being too task focused. The following review of current literature will examine studies completed and progress in the rapidly developing and changing field of assisted living. This review will cover topics related to regulations/licensure, funding alternatives for assisted living, the Oregon model, and the current California system of licensure under Residential Care Facilities for the Elderly (RCFEs). 15 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. CHAPTER II Literature Review R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Regulations and Licensure In contrast to skilled nursing facilities which are highly regulated and task specific, many believe that the optimal regulatory environment in assisted living should focus more on outcome rather than a specific task orientation. This form of regulation allows facilities to operate in a more flexible regulatory system, thereby enabling the state to focus on reducing operating costs. This approach allows the states to regulate according to consumer demand; to introduce alternative funding sources; and to place strong emphasis on the needs of the resident population residing in assisted living facilities. Keren Brown Wilson, Ph.D. (1996), an assisted living researcher, advocate and developer, suggests that many fear regulating assisted living will result in prescriptive standards that will limit innovation and consumer orientation in assisted living. Others believe that regulatory standards are essential in protecting the consumer, state, developer(s), and funding sources. Although regulations are a vital component of quality assurance, they need to be constructed to focus on consumer satisfaction if they are to succeed in assuring quality that is meaningful to consumers. The States Some states are on the forefront of innovative techniques and systems for implementing assisted living. A study by Mollica (1996) that reviewed state assisted living policies indicated that currently fifteen states have licensure regulations for assisted living 17 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. facilities. Regulations are being developed by an additional nine states. Twenty two states reimburse or plan to reimburse assisted living as a Medicaid service. Policies in fourteen states include a statement of philosophy which describes assisted living as a model which emphasizes consumer or resident independence, autonomy, dignity, privacy, and personal decision-making. Mollica’s work suggests that assisted living approaches in many states reflect attempts to combine minimum standards of regulation with market forces to produce quality. One thing remains clear among all states (even those adopting a more regulated environment): assisted living is a model which attempts to provide long-term care in a residential setting instead of a medical setting although medical services may be provided. The purpose of this study is to compare and contrast Oregon and California because these states represent opposite ends of a development spectrum for assisted living. The following brief overviews of Oregon and California will set the stage for how these two states currently operate. Each state’s assisted living program is examined in more detail in chapter HI. The Oregon Assisted Living Program Oregon has developed a regulatory environment monitored by the state Senior and Disabled Services Division (SDSD) through State or Area Agencies on Aging. Oregon is of particular interest because it has gone further than any other state in defining assisted living through regulations. SDSD staff review service plans of residents for compliance. 18 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Progress reports are intended to assess functional abilities, psycho-social well-being, stability of medical conditions and client/family satisfaction are examined. Oregon’s regulations require that licensed assisted living programs provide certain amenities within the residential setting. The facility must provide a single occupancy apartment (unless double occupancy by choice) with a full bathroom, kitchenette with refrigerator and cooking capacity, individual temperature controls, and lockable doors. Units must provide at least 220 square feet of living space. Oregon law also requires sprinkler systems and alarms. Three meals must be served each day in a dining room large enough for all residents of the facility. Although Oregon regulations appear more prohibitive than other states, many studying the assisted living field suggest Oregon’s regulations are extremely outcome oriented. Mollica (1996) states, “Oregon has developed a more flexible approach to regulation describing goals and outcomes while allowing individual facilities to develop policies and procedures that achieve them” (p. 179). Outcome oriented is defined as an approach which focuses on the end product rather than the specific steps taken to get to the end product. Such an approach is consumer driven in that while it takes safety and the regulatory environment very seriously, it still allows the resident and the facility considerable flexibility in creating an individual specific care plan. The increasing heterogeneity of an older adult population demands a system that will incorporate a variety of services while recognizing the importance of a regulatory environment. 19 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. [ California’s Residential Care Facilities Confusion is abundant in many states as to what distinguishes an assisted living facility from a Residential Care Facility for the Elderly (RCFE). The use of numerous definitions of assisted living are likely responsible for this confusion. California is currently offering some assisted living services through licensure of RCFEs, a licensed board and care model of housing for the elderly. Mollica (1996) defines RCFEs in California as “a housing arrangement chosen voluntarily by the resident or the resident’s guardian, conservator or other responsible person; where 75% of the resident’s are 62 years of age or older, or, if younger, have needs compatible with other residents and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times or reappraisal” ( p. 67). One expert in the field states: “Assisted living is often inclusive within a definition of RCFE, as all types of facilities within this category (residential facility, adult group homes, family care, adult foster homes, board and care, personal care homes, catered living, domiciliary care, rest homes, sheltered care, and assisted living) serve as a bridge between independent living and nursing care” (Golant, 1992, p. 246). A study by Regnier (1996) suggests that assisted living has evolved into an attitude about long-term care rather than narrow service parameters. This attitude supports developing a home-like atmosphere; preserving independence and dignity; a sense of privacy; and the importance of allowing each resident and family to play a major role in the care plan. This attitude toward the consumer is where assisted living often sets itself 20 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. apart from traditional models within the RCFE umbrella. Specific differences between Oregon’s assisted living model and California’s RCFE system will be compared in Chapter V. According to California state law, RCFEs may not admit or retain anyone who requires 24 hour skilled nursing or intermediate care. Residents also may not be bedridden except for temporary illness (14 days) or for recovery from surgery. Bedridden means someone who requires assistance in turning and repositioning in bed and is unable to leave a building unassisted under emergency conditions. Residents who would be bedridden more than 14 days may be retained if the facility submits a physician’s statement to the Department of Health stating that the condition is temporary and contains an estimated date upon which the resident will no longer be confined to bed (Mollica, 1996). Although the above restrictions are necessary (because of state regulations) for most RCFE type facilities, many states with the ability to adhere to less stringent regulations under the assisted living licensure, allow the provisions of more medical services. For example, Mullen (1997), suggest that: ‘In many states, unless a patient is permanently bedridden; requires intravenous feeding or medical injections; or is a highly complex medical care patient, he/she can be successfully cared for in an assisted living facility that is prepared to care for a patient who might otherwise be in skilled care” (p. 7). Medical technology is rapidly expanding to enable assisted living facilities to offer more medical services under one roof without the need for a skilled care facility placement outside of the assisted living facility. Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Currently, California includes assisted living under the RCFE umbrella. The state’s appropriation legislation for FY 97 directed that the Department of Health conduct a study of state approaches to assisted living. In January, 1997, a study was completed and signed off on by the committee in April 1997. As of April, 1997 no action had yet been taken other than the study of state approaches. The state suggests that further study is essential but interest in offering a full continuum of care under one roof could be valuable for California. Assisted living is proving itself a vital component to the continuum of elderly care. Mollica (1996) suggest that, as state policy makers watch residents in board and care settings grow (as a population) older and frailer, they are amending regulations to allow for a higher level of service provision in those settings in order to prevent an explosion of demand for more expensive nursing home beds. Assisted living facilities are focusing on offering higher levels of service provisions under an inclusive continuum of care. The following section will describe long-term care and the goal of an inclusive continuum of a coordination of services with in long-term care. Long-term Care and the Continuum of Care Long-term care is a broad term used to describe an array of services, populations, and funding sources. Long-term care is often thought to loosely and broadly encompass a wide array of health services such as hospitals, nursing homes, home health agencies (public and private), and adult day care (Evashwick, 1996). Long-term care optimally 22 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. organized can provide an organized “continuum of care.” Evashwick (1996) describes the continuum of care as “a comprehensive, coordinated system of care designed to meet the needs of patients with complex and/or ongoing problems efficiently and effectively. A continuum is more than a collection of fragmented services. It includes mechanisms for organizing those services and operating them as an integrated system” (pp. 6-7). Ideally, the continuum of care organizes care at all levels of an individual’s assistance needs. From home health services and independent living to skilled care and acute needs, a continuum of care will provide and organize services, funding and environmental needs for the patient. The goal of the continuum of care is to facilitate the client’s access to the appropriate services quickly and efficiently. Evaswick (1996) states, the goals of a continuum of care are to: match resources to the patient’s condition, avoiding duplication of services and use of inappropriate services. monitor the client’s condition, and change services as the needs change. coordinate the care of many professionals and disciplines, integrate care provided in a range of settings, streamline patient flow and facilitate easy access to services needed, maintain a comprehensive record incorporating clinical, financial, and utilization data across settings. 23 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Movement Through Long-term Care When an older adult needs extra assistance with ADLs and/or IADLs, the individual may decide to obtain services such as home health care. Services delivered directly to the individual’s home such as meal delivery, housekeeping assistance, money management support, and more, are considered to aid the individual in the home environment so that he/she may stay as independent as possible for the maximum amount of time. When the need for assistance surpasses what can be delivered in the home (physically or financially), an individual might then opt for a type of retirement housing. Retirement housing options include (but are not limited to), retirement communities, retirement apartments, congregate care facilities, and even residential care facilities for the elderly (RCFEs). Services can include but are not limited to some assistance with instrumental activities of daily living (IADLs) (e.g., transportation, money management, shopping) and assistance with activities of daily living (ADLs) such as toileting, ambulating, and/or eating. If the need for services rises to a certain level, an individual may be recommended or required to move to a skilled level of care because of state regulations or facility policy Skilled nursing facilities, sometimes referred to as nursing homes, are often considered a last resort for a resident. At this level the individual may require 24 hour supervision and multiple service provisions. Skilled care and sub-acute care often provide for rehabilitative services. 24 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Through all of the levels of long-term care movement a bit more independence, dignity, and choice is lost to dependence and decline. The terminal decline may reach stages in which the individual requires admittance to an acute-care hospital. The individual may expire prior to acute-care needs, or he/she may have transferred in and out of this level. Assisted living attempts to be the alternative with the optimally balanced continuum of care setting. By coordinating services through a continuum of care, “assisted living settings are attempting to achieve cost-effectiveness by maximizing the use of resources; enhancing quality and patient satisfaction through appropriateness, ease of access, and ongoing continuity of care; and increasing provider efficiency” (Evashwick, p.7). Where Assisted Living Fits As discussed previously assisted living is intended to eliminate much of the need for skilled care facility placement. Because the services offered by assisted living facilities may duplicate some nursing home services, assisted living facilities often overlap in long term care services to offer a continuum of care under one roof. This continuum will allow the individual to age-in-place (aging-in-place will be discussed in “Oregon’s Model” section). A cost-effective, homelike, independent, service oriented, outcome focused, alternative seems to be exactly what the older populations desire. The results are promising for states’ reduction of overall healthcare spending. This reduction obviously R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. meets the goals and needs of the consumer, the investor (public or private), and the third party payor (usually the state Medicaid department). This section has examined the regulatory environments and types of settings in the assisted living industry. Another critical issue for states adopting or transitioning into assisted living is the extent to which financial assistance is available in the state. Some states have systems already in place to assist in financing assisted living services. Other states will need to assess what they currently have and how they might develop a new system or alter the current one. Some alternatives are discussed in the following section. Funding Alternatives Redfoot (1993) suggests, “though assisted living is the fastest growing segment of the senior housing industry, the costs associated with this type of service have generally been out of reach for older persons with low or moderate incomes. For developers, capital has been expensive and hard to raise because of the perceived risks associated with a new industry. One of the main factors that has driven up costs has been investor uncertainty caused by the lack of public insurance (with a few notable exceptions such as the Oregon Medicaid waiver plan) to cover the risks of potentially high costs of long term supportive services” (p. 519). Funding alternatives are now available in many states and are expanding to cover low income elderly. Medicaid reimburses services in some states. SSI commonly supplements Medicaid to cover room and board fees. Some long-term health care insurance policies 26 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. t I are expanding to cover assisted living services. Medicaid waiver programs are becoming a potential contribution to the growth of assisted living. Obviously many alternatives are available and expanding to meet consumer demands. Krupa (Aug/Sept. 1996) suggest that increases in funding alternatives are growing rapidly due to the “Graying of America.” Wall Street is now extremely interested in the assisted living industry due primarily to the growth potential of this market. Simply stated, a growing market/population demands that its needs be met. As older individuals require more assisted living services and as they realize these services can be available in an optimal environment (emphasizing independence, dignity, privacy, and individuality) this population will desire assisted living facilities. It has been estimated that 90 percent of assisted living residents are paying privately for these services (Nichols, 1995). However, because many individuals require funding assistance, alternatives are expanding rapidly to meet the demands of this growing population. Medicaid and Supplemental Security Income For low income residents in approximately 22 states assisted living costs can be reimbursed jointly through Medicaid and SSI. Medicaid often covers the cost of health care services while SSI covers the costs of room and board. Room and board costs include the physical surroundings, food, and food service costs. Medicaid covers the cost of most medical and personal care services. 27 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Medicaid Waivers As a result of the Omnibus Budget Reconciliation Act (OBRA) of 1981, Congress established a waiver program through Section 1915c of the Social Security Act to offer states alternatives to traditional long term care services. Funding is now offered in some states for programs that are designed for developing cost-effective alternatives for delivering long term care services (Lewin-VHI, 1996). As shown in the following table from the National Academy for State Health Policy (1996), some states receive funding for assisted living through Medicaid reimbursement. Other states now fund assisted living through Medicaid waivers. Medicaid waivers allow Federal money to be allocated to each state in order to relieve some of the burden of state funding. The Health Care Financing Administration (HCFA) has developed ways to account for services in assisted living so that states can reimburse the service component under Medicaid waivers. Most assisted living facilities are proprietary (for profit) including those which receive Medicaid residents. Many states are turning to Medicaid waivers not only as a funding alternative but as a way to cut costs associated with nursing home/skilled care. Many of these waivers allow assisted living facilities to operate under a less stringent regulatory environment than that of skilled care facilities. As a result of Medicaid waivers, states are now able to focus on outcome rather than specific tasks. Different states have adopted different types of reimbursement alternatives. The following table describes a comparison of state assisted living regulations and Medicaid 28 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. financing. According to the National Academy for State Health Policy (1996, p. 18-19), there are states which license and/or certify all facilities called assisted living. Others license assisted living and provide Medicaid reimbursement (e.g., Oregon) while some states provide Medicaid reimbursement but do not have a state licensure category for assisted living. Still other states have task forces developing assisted living policy options or recommendations (e.g., California) while some states have no activity at all. 29 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 1 Comparison of State Assisted Living Regulations and Medicaid Reimbursement License all facilities License and Medicaid reimbursement Medicaid only Task force/ studying Alabama Alaska Arizona Alabama Connecticut Florida Illinois California Louisiana Iowa Minnesota Delaware Kentucky Hawaii New Mexico Idaho Maryland Kansas New York Illinois Rhode Island Maine North Dakota Indiana Tennessee Massachusetts Ohio Nebraska Utah New Jersey Texas New York Wyoming North Carolina Oreson South Dakota Virginia Wisconsin Washington Oklahoma T aken from the National Academy for State Health Policy, 1996, p. 19* 30 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Many states fear reimbursement from Medicaid because of the threat that government funding carries a promise for tighter regulation. States ultimately fear regulation because of probable increases in expenditures that are required to meet regulatory requirements. According to Kane and Wilson (AARP, 1993) Oregon is an innovative state that has gone further than any other in defining assisted living through regulations. Oregon is also seen as an example that waivers are associated with greater regulation of assisted living. Reimbursement requirements make it imperative that states tighten up their regulations because state regulatory departments must adhere to specific guidelines and task specific checklists in order to justify financing facilities and individuals using Medicaid and SSI. Oregon has used regulations to their advantage by demonstrating how increased regulation leads to positive quality outcomes. The positive outcomes for Oregon have lead to governmental support in developing a more flexible approach to regulation, describing goals and outcomes while allowing individual facilities to develop policies and procedures that achieve them. This topic will be explored further in the “Oregon Model” section. Thus far Oregon demonstrates that tighter regulatory environments are not hindering the overall goal of cost containment. Mollica (1996) suggests that Oregon warrants the top listing for being proactive in assisted living development because it was the first to incorporate many key assisted living principles in public policy through its state wide Medicaid waiver. The state views assisted living as a residential long-term care model. It allows settings to provide personal care and skilled services to people who meet the level of criteria for admission to a nursing 31 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. home. This long term care approach has opened up the eyes of many long term care insurance providers as discussed next. Long-term Care Insurance For private paying residents, long term care insurance policies are expanding to cover assisted living. Some states are even beginning to prevent insurance companies from using narrow definitions of assisted living in order to deny coverage (Michael Krupa, 1996). The Health Insurance Association of America (HLAA) reports that trends in the insurance industry are very significant for the assisted living industry. In HIAA’s annual survey of 1991, they found that nine out of the top fifteen insurance companies that provide long- term care offer some sort of alternative care benefit (AARP, 1993). Following are two examples of how assisted living is treated in long term care insurance policies: • If you would otherwise qualify for benefits, we will consider paying for the cost of services you require under a written alternative plan of care. Such alternate care must be a medically acceptable alternative to LTC or Home Health Care. The alternative plan of care must be initiated by you. It must be written by your physician and consistent with generally accepted medical practices. Those parts which are mutually agreeable to you, your physician and us will be adopted. It may include but not be limited to. (1) special 32 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. treatments; (2) different sites of care; (3) modifications to your residence to accommodate your needs. • Alternate Care Facility means a facility that is engaged in providing ongoing care and related services to at least ten inpatients in one location, and; 1. provides 24-hour-a-day care and services sufficient to support needs resulting from a Functional or Cognitive incapacity; 2. has trained and ready to respond employee on duty at all times to provide that care; 3. provides three meals a day and accommodates special dietary needs; is licensed by appropriate licensing agency (if any( to provide such care; 4. has formal arrangements for the services of a doctor or nurse to furnish emergency medical care; and 5. has appropriate methods and procedures for handling and administering drugs and biologicals. Long-term care insurance is expanding to cover the assisted living market but with some restrictions. Funding sources such as long-term care insurance are likely to be more common in the future if Medicaid models of care become too expensive for states to fund. State Medicaid offices are often poorly staffed and under-funded thereby making the task and burden of developing a enthusiastic stance for assisted living particularly difficult. Although the majority of assisted living residents are privately paying for services, low income residents require services which they are unable to afford without assistance. For this reason Oregon passed their state-wide Medicaid waiver to provide assistance to low income elderly in the state. The Oregon model is described in the following section. 33 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. I The Oregon Model The National Academy for State Health Policy (Mollica, 1996) describes the general approach of the Oregon model as one that has adopted assisted living regulations and policies in 1992 to substitute for nursing home care and offer home-like environments which enhance dignity, independence, individuality, privacy, choice and decision making. Facilities are required to have written policies and procedures which describe how they will operationalize these principles. At the end of August 1996 a total of 69 facilities with 3200 units were licensed with six new facilities under construction or in the planning stages. Medicaid recipients occupied 858 units. Although Medicaid recipients occupy less than 27 percent of the total beds, this number is growing. Oregon Health Care Association (OHCA) now reports as of spring 1997, a total of 81 facilities are licensed in Oregon with a capacity of about 4,500 units. Additionally, construction is underway at 25 more facilities around the state with 30 percent being covered by Medicaid (Taggart, 1997). A definition of assisted living, previously described in terms of the Oregon model, defines assisted living as “an approach, within a physical structure, which provides or coordinates a range of services, available on a 24 hour basis, for support of resident independence in a residential setting.” The literature suggests that the Oregon model is a system that has set the stage for many other states exploring and implementing assisted living facilities. Although many other states have systems of assisted living that are quite successful and operate differently 34 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. from the Oregon system, this study analyzes the Oregon model as a prototype that California could consider in developing its own form of assisted living. Specific Oregon Regulations According to Brown-Wilson, (1996) regulatory models for assisted living should be designed to maximize the efficiency of limited oversight resources (e.g., low staff to resident ratios) in order to assure a good quality of life for all residents. The reason for implementing this type of regulatory environment is to enable assisted living facilities to be cost effective by operating at a “minimum of service provisions.” The lack of services and staff in assisted living facilities may not interfere with the safety of the residents. Rather, limiting staff and overabundant services allows the facility to target specific needs by allocating services and staff to monitor scope and frequency with as little oversight as safely possible. Oregon has gone further than many states in developing a regulatory framework which maintains a base of minimum licensing standards to ensure safety, health, and minimum environmental standards while using flexible mechanisms to promote high-quality care. These mechanism are described by Brown-Wilson (1996, P. 14) as: 1) Consumer-oriented outcome measures, 2) Having an escalating mechanism to adjust the degree of regulatory oversight to both the characteristics of the population served and the historical performance of the provider; and 3) Adjustments to the level of regulatory intervention 35 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. depending on the potential risks of the failed outcome as well as the capacity and willingness of the provider to work well with the tenants and regulators. Consumer-oriented refers to the model of regulation which focuses on the needs and desires of the resident and the resident’s family/caregiver. The consumer oriented model has been discussed previously as being more flexible for the facility and the resident. A task centered model is the opposite of the consumer focus in that task specific model regulations constitute a type of continual check list of must do’s. The consumer model is an outcome oriented system emphasizing an end result of a regulation. For example, an assisted living facility is required to document all services rendered for a particular individual. An outcome/consumer oriented model would involve the resident and his/her family in the care planning and would ultimately assess whether the care plan is successful by reassessing the individual, his/her satisfaction, the families opinion, etc. at a later date (perhaps in six months). A task specific model tends to be more regulated and medical in its focus because regulations require task specific functioning. Such an approach may involve the physician, a case manager, family, a director of nursing, and all staff working with the resident to document exact services, time, location, state of resident (physical and psychological), medication amounts, times per day, etc. This model differs in amount of staff required (costs), medical intervention specifics, state law requirements for documentation, and amount/type of services rendered. Oregon favors the consumer-oriented model of assisted living as well as an escalating enforcement system. This system enables the Oregon facilities to adjust the degree of 36 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. oversight of each individual resident based on his/her degree of need. An individual who has limited needs for assistance with IADLs and has difficulty with two ADLs would receive less oversight than the individual with three IADL impairments and four ADL impairments. This may sound logical to the average reader, however, the task specific model requires that each individual be monitored on the typical rounds which a staff member is required to follow on each shift/staff rotation regardless of his/her physical or mental state. Flexibility within an escalating enforcement system also enables the facility to develop a positive or negative quality of care distinction. Facilities operating at less than competent levels for running a safe environment develop a reputation within the state regulatory departments as being places they need to frequent in order to ensure quality services. A facility that passes inspections with flying colors on a regular basis develops a reputation that allows state regulators to be less specific and less frequent in their inspections. Adjustments in regulatory intervention are also common to the Oregon model. These regulatory adjustments may come as a result of a failed outcome or as the attitude and willingness of the provider to work with the tenants and regulators changes. In clearer terms, this relates to the escalating system of basing the need for regulatory intervention on the severity of a problem or need of a resident. A provider’s capacity or willingness to improve conditions and/or cooperate with regulators ultimately affects the flexibility of the regulations. 37 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Oregon has been described by some critics in the field of assisted living as the example of how governmental assistance in funding leads to more stringent regulatory environments. Medicaid waiver programs which allow the states to use federal funds to pay for assisted living are often connected to regulations that make cost containment for assisted living next to impossible. Oregon on the other hand has used its regulatory requirements to its advantage. Regulations enable the assisted living facility to offer more services under one roof because more quality assessment tools are required and thus, more services are regulated by the state within the single setting. The Oregon Medicaid waiver has also ratified the facility to be less restricted by regulations if the facility develops a reputation for repetitive quality performance and service delivery. Still some industry observers suggest that the state of Oregon is an example that waivers are associated with greater regulation of assisted living. One recent article explores the implications of expanded Medicaid waiver opportunities of assisted living facilities in terms of the potential for greater oversight and regulation (Fitzgerald, 1995). Oregon, which has used Medicaid waivers more extensively than any other state, is reportedly also the most demanding in its regulation and oversight of assisted living. Fitzgerald (1995) states, “Industry leaders in Oregon, Minnesota, and Florida have indicated that states will continue to use regulations of assisted living as a way to contain Medicaid costs as waivers make assisted living a viable option for a large number of low income frail elderly persons for the first time” (p. 15). 38 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Regulation and oversight are not seen by all professionals in the field to be a hindrance for assisted living facilities. Rachelle Berstecker of Marriott Senior Services states, “If the industry can demonstrate to the satisfaction of the regulators and consumers, that it can consistently deliver quality care in the absence of prescriptive regulations, I do not believe that we will see government advocating for stricter regulation” (1996, p. 32). Another professional in the field of assisted living, Robert Jenkins of AARP public policy suggests, that “AARP believes consumers and the industry need a strong quality within the context of assisted living philosophy. Without a strong and functioning regulatory system in place, states will have no choice but to move toward traditional prescriptive regulations when accidents, abuse, or neglect are uncovered in the industry” (1996, p. 31). Oregon’s Medicaid Waiver On October 1, 1991, Oregon’s Department of Human Resources (DHR), as the designated single state Medicaid agency, passed the first Home and Community-Based Services waiver under section 1915c of the Social Security Act (1915c waiver, 1995). This waiver allows for the provision of home and community-based services to eligible individuals when the services are an alternative to institutional placement in a nursing facility. “The waiver is working toward overall savings in both state and federal expenditures because the strong and unabated increase in eligible growth of aged and disabled persons is being accommodated in less expensive home and community based 39 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. programs, rather than being funded in more expensive nursing facilities. This outcome reflects the intent of Congress in establishing the waiver” (1995, p. 23). With the passing of this waiver, assisted living facility services (among others) are now provided by the Senior and Disabled Services Division (SDSD) as an alternative to nursing facility care. According to the current 1915c waiver, assisted living facilities provide living units for six or more persons and make available on a 24-hour basis a range of services to address all ADLs. Room and board costs are not covered under this Medicaid waiver; however, SSI will frequently cover the gap of costs and supplement room and board costs. The service payments of the 1915c waiver are intended to reimburse the cost of direct care staff who assist with or provide care to residents. Assisted living facilities in Oregon are licensed by the Senior and Disabled Services Division. SDSD has established a detailed set of standards and enforcement policies. Oregon’s rules require providing for ongoing monitoring by the state SDSD staff of its designee, usually an area agency on aging (AAA). The staff review the service plans of residents for compliance. Written outcome measures covering functional abilities, psycho social well-being, stability of medical conditions and client/family satisfaction are examined (Mollica, 1996). The purpose of these rules is to establish standards for assisted living. The standards promote the availability of appropriate services for elderly persons in an optimal environment with a coordinated continuum of care option. The purpose of these rules is also to promote the concept of aging-in-place. 40 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Aging-in-Place The concept of aging-in-place is defined in the Oregon waiver as: ‘The process by which a person chooses to remain in his/her living environment despite the physical and/or mental decline that may occur with the aging process. For aging-in-place to occur, needed services are added, increased or adjusted to compensate for the physical and/or mental decline of the individual” (1995, p. 2 ). Assisted living facilities in Oregon and in many other states have adopted the concept of aging-in-place as a way to fulfill a desire of the aging individual to remain in a familiar environment through all stages of decline. Uprooting an individual from familiar settings can be very traumatic both mentally and physically. Assisted living facilities that address aging-in-place as a prominent desire are now developing ways in which to offer more services within the assisted living facility, avoiding institutionalization (a costly alternative). Mollica’s (1996) national study of assisted living suggests that a major component of assisted living is the flexibility of the service arrangements with no set package of services. Providing services to meet scheduled and unscheduled needs of the resident allows the individual to comfortably age-in-place (preface). Aging-in-place is referred to by professionals in the field as a very critical component within an assisted living facility focusing on the autonomy and independence of the consumer. Oregon prides itself on its success thus far in assisted living facilities based on aging-in-place environments. 41 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Financing in Oregon Although most funding of assisted living is still provided by the private resident, Oregon provides five levels of payment for services to Medicaid recipients. The National Academy for State Health Policy (1996) outlines Oregon’s service priority categories and payment rates based on priority in the two tables below. Levels are assigned based on a service priority score determined through a thorough assessment ( p. 180,182). Table 2 Service Priority Categories A Dependent in 3-6 ADLs B Dependent in 1-2 ADLs C Requires assistance in 4-6 ADLs D Requires assistance in 3 critical (e.g., toileting, bathing)ADLs E Requires assistance in 2 critical ADLs F Requires assistance in 3 ADLs G Requires assistance with 1 critical ADL and meets conditions of at least 1 other essential factor or requires assistance with I critical ADL and 1 less critical ADL. 42 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 3 Service Priority and Payment Rates im i Level V Service priority AorB and dependent in the behavior ADL. $1586 $396.70 $1982.70 Level IV BorC with assistance required in the behavioral ADL. $1283 $396.70 $1679.70 Level HI CorD with assistance required in the behavioral ADL $978 $396.70 $1347.70 Level n DorE with assistance required in the behavioral ADL $736 $396.70 $1132.70 Level I EorF or priority G with assistance required in the behavioral ADL. $553 $396.70 $949.70 *$396.70 room and board fees are paid in addition to service rates and are not covered by Medicaid financing. Supplemental Security Income in many cases will cover R & B fees. Oregon and California have very different systems for financing low income residents. At this time, RCFEs in California do not receive any Medicaid financing assistance for services. The Oregon model of assisted living is a pioneer for assisted living as a separate licensure category for long-term care. Oregon emphasizes offering a broad continuum of care within a single setting or on a shared campus. Oregon’s assisted living philosophy focuses on a residential setting with goals of preserving resident’s independence, individuality, autonomy, privacy, and personal choice/decision making abilities. California, in contrast, offers separate licensure for assisted living type services within RCFEs, nursing facilities, board and care homes, etc. California is taking action to devise 43 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. a better system of long-term care that might adopt an assisted living philosophy. The following section will examine the current California system and state concern over adopting assisted living licensure. The California System California licenses about 5,000 RCFEs with approximately 110,000 residents. About 70% of these facilities serve fewer than six residents. The state’s appropriation legislation for FY 97 has directed that the Department of Health conduct a study of state approaches to assisted living. The state is beginning to view the licensure of assisted living as a possible budget neutral, cost containing alternative to long-term care (Mollica, 1996). In California, an 18 member group composed of members of the Departments of Health, Social Services, Aging, assisted living providers and legislative staff met to discuss the definition of assisted living and where it fits or how it compares to the current RCFE model; how assisted living differs from RCFEs, what services should be allowed; and whether assisted living should be considered a bundle of services. Issues addressed included: defining assisted living; needs of consumers; scope of services to be covered; and the place of assisted living in the continuum of care and whether a new licensure category is needed or appropriate. The issues, concerns, questions and facts are to be the focus of a hearing by the Senate Subcommittee on Aging from which legislation would be drafted for submission to the 1997 session (Mollica, 1996). 44 f R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. [ Common California Concerns Financing for residents and for a budget neutral system change is always a concern for a state adopting a new system or transitioning from an old one. Financing for low income elders is a major concern in California. One common uncertainty emerging from California’s system is Medicaid waivers for financing low income elders. Many believe that this type of waiver would lead to a medical model of stringent regulations and costly predictions. Another concern is from the aging community which believes that there are too many licensure categories already. New ones only serve providers seeking higher levels of reimbursement without really increasing the services provided (Mollica, 1996). Finally, the concern from the Department of Health is that residents meeting the nursing home level of care criteria should not be served in settings that are not licensed. Three Assisted Living Models California’s Department of Health Services (1997) recently completed a state summary of assisted living programs. Their assessment suggests that three models for assisted living currently exist. These models are characterized as either, institutional; new housing and service oriented; or services only models. These models are described by the Department as follows: • Institutional—allows for multiple occupancy rooms and separate bathrooms shared by more than two residents. They do not allow for Nursing Facility (NF) level clients, nor do they allow performance of skilled services, nor have 45 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. the ability to adjust level of care upon the changing needs of the recipient to facilitate aging in place. States included in this model are: Colorado, Georgia, Illinois, Missouri, Montana, Nevada, South Dakota, and Virginia. • New Housing and Services—an alternative approach to assisted living, considered “new” because of the emphasis on private apartments, or at least, private sleeping quarters. This approach minimizes the institutional type setting. Also, there is a provision for NF level services. Both of these elements increase the cost however. States operating this model are: Arizona, Hawaii, Iowa, Kansas, Oregon, and Washington. • Services Model—provides for a State certified or licensed provider of service, that is, the building is not certified. Several states chose this model and use a funding source (HCSB Waiver) of defined service requirements rather than creating a licensure category. This model can be further broken down to services available only in apartments or services available in a range of residential settings. States operating this model include: Minnesota, North Dakota, Ohio, and Wisconsin (apartment only), Alaska, Florida, Maine, Maryland, Massachusetts, New Jersey, New Mexico, New York, North Carolina, Texas, and Vermont. California has not yet adopted any of the above models but is considering a combination approach that would be California specific. Apparently, California is a state 46 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. I to watch because of the state’s interest in the assisted living philosophy and how it might be integrated into current RCFE licensure. The question remains as to how and what aspects of the Oregon model California might adopt into current RCFE licensure. Therefore, the purpose of this study is to examine what components of the Oregon model are adaptable to California, and what components are not feasible at this time. The following chapters explain the methodology and findings of a series of key informant interviews from Oregon and California. The qualitative methods used for this study are in-depth case studies of Oregon and California and the use of key informants. Specific case studies are used in qualitative iesearch for the purpose of gathering comprehensive, systematic, and in-depth information about each case. Case studies are particularly valuable when the evaluation aims to capture individual or unique variations from one setting, program, organization, time period, or state to another (Patton, 1990). California and Oregon serve as unique variations from one state to another. The key informant qualitative research gathering will be discussed next. The following chapter will present data collected from nine informants and examine the lessons that were learned from their varied responses. 47 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. CHAPTER lit Methodology Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. As Chapter II case studies of Oregon and California suggest, an in-depth evaluation examined the unique variations between these states. Along with the case study method of qualitative research gathering, key informant data were gathered. Personal contacts via telephone interviews; electronic mail interviews; and face to face interviews were conducted over a six month period. A total of nine key informants working in the field of assisted living or related licensure categories were interviewed on their involvement and opinions of the current and future development of assisted living in their state (Oregon or California). Key informant strategies were used as important sources of information based upon individuals who are particularly knowledgeable and articulate. These individuals provided insight that has been particularly useful in helping this researcher to understand what is happening in the field of assisted living. This chapter describes the procedures for data collection; the characteristics of each participant; the interviewing protocol; and some limitations of the methods of collection. Procedures A total of nine interviews were conducted. From December of 1996 to May of 1997 interviewees were contacted via electronic mail with a list of research questions followed by telephone interviews. Participants were contacted through electronic mail to prepare for the interviewing process. More specifically, notes were transcribed during the interviews and analyzed based on the similarities and differences of the responses. This 49 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. type of qualitative research gathering is referred to by Patton (1987) as the Interview Guide approach. The outline prepared prior to the interviewing process “increases the comprehensiveness of the data and makes data collection somewhat systematic for each respondent. Logical gaps in the data can be anticipated and closed. Interviews remain fairly conversational and situational” (1987, p. 116). Participant Selection Five participants represent the state of Oregon while the remaining four represent California. These key informants were chosen based on their diversity in representing the assisted living market from all areas. Participants range from state Departments responsible for licensure and financing to private developers. Policy involvement varied greatly from participants. Some were very involved in developing policy within assisted living while others knew very little about assisted living policy development in either state. Participants were also chosen based on their availability to participate. From the state of Oregon, four informants are private developers while only one utilizes the Oregon Medicaid waiver to assist low income residents in his facilities. Three developers from Oregon are proprietary developers and operators who do not participate in the Oregon Medicaid program. The private developer in Oregon who utilizes the Oregon Medicaid waiver believes that it is a very valuable asset to his facilities. Also from Oregon, a Program Coordinator for assisted living services at Oregon’s Senior and Disabled Services Division (SDSD) was interviewed. 50 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. From California two informants were chosen from regulatory agencies. One represents California’s State and Social Services Department (DSS) while the other represents California’s Department of Health Services (DHS). California Assisted Living Facility Association (CALFA) is represented by its Executive Director. Another proactive informant for assisted living in the state of California, Vice President of Operations for ARV assisted living facilities was interviewed as a representative of an operator of several RCFE facilities in the state of California with an assisted living philosophy focus. Interviewing Protocol All key informants were asked a series of open-ended questions and were allowed to expand and develop their answers in broad and/or specific context. For example, about six of the nine interviews were 15-25 minutes in duration while the other three interviews continued for an hour to an hour and a half. Specific question asked were as follows: 1. What is your Company/Organization, department, and title? 2. How are you working with assisted living? 3. Where do you see assisted living development in Oregon and/or California? 4. What are you currently working on within assisted living (e.g., policy, studies)? 5. What do you see as California and/or Oregon’s biggest challenges within assisted living as a specific licensure? 6. Any other comments? 51 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. r Limitations As with most studies, limitations play a role in the analysis of the data. This study was based on a relatively small number of participant responses chosen for the diverse organizations they represent. According to Patton (1990) key informant strategies often possess the danger that the perspectives of the interviewees can be distorted and biased, thus giving an inaccurate picture of what is really happening. This potential limitation was controlled for as much as possible by using the same interviewing protocol for all informants. Also, because of the rapidly changing field of assisted living, some data may be quickly outdated. In an attempt to control for outdated information this researcher used only current literature and kept in close contact with key informants throughout this study The selection approach was to use these key informants based on the credibility of their continuing research, current developments and their representation of the field as a whole. Participants who were less informed in the sample represent the portion which will be described as needing to be more educated in the state of California in the next chapter on findings. Findings were explored based on the similarities and diversity of responses in the next chapter. Results represent a variance based on the diverse backgrounds of the chosen key informants. The following chapter suggests possible lessons for California’s current operations of assisted living services based on the findings of the states’ representatives responses to the questions asked. 52 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. CHAPTER IV Findings R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Findings relevant to the questions asked of the nine key informants were varied and represent each participants background. The following chapter will discuss the similarities and differences among the participant responses. Each interview question will be compared and contrasted based on state, participant background and organization, and/or current activity (individually or at state level). QUESTION#! What is your company/organization, department, your title? Of the nine participants in the study, four are involved on a policy level. From California, the Executive Director of California Assisted Living Facilities Association (CALFA), and the Department of Social Services (DSS) and Department of Health Services (DHS) representatives work at a policy level of assisted living development. CALFA’s Director is a very proactive policy analyst for the state of California with a mission for his organization to promote assisted living as a critical step in the long-term care continuum. Both DSS and DHS representatives are more reactive participants in the long-term care field. Both of these individuals are Associate Governmental Program Analysts for California’s DSS and DHS. The public official for the state of Oregon is the Program Coordinator for all assisted living services for Oregon’s Senior and Disabled Services Division (SDSD). This Department is responsible for licensing and monitoring all assisted living facilities in Oregon. 54 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. I f The remaining five key informants have been grouped into developers of assisted living. Three private developers are owners of several proprietary free-standing assisted living facilities throughout Oregon. These individuals represent the private sector of assisted living development in Oregon. The other private developer is a 35 year veteran in the long-term care industry. He owns a fully developed company in the state of Oregon. The company currently owns a total of ten facilities (some retirement communities) with approximately 1000 beds. With the help of the Oregon state wide Medicaid waiver, this developer and his company have opened five assisted living facilities and are at fixll capacity. Seven more facilities are currently in the development stages. Up to 90 percent of residents in some of these facilities are Medicaid residents. This developer represents Oregon’s Medicaid waiver success. Another developer of assisted living is a representative of California’s proactive RCFE industry m adopting an assisted living philosophy within existing RCFEs. This developer’s company, ARV Assisted Living, is expanding rapidly in California. The company goal is to provide the home-like, independent environments of assisted living facilities. Current California licensure of RCFEs has not kept ARVs from developing their facilities with an assisted living philosophy. The assisted living industry is represented in a broad spectrum for the purpose of this study. Because of the rapidly expanding and changing industry, this researcher found this broad spectrum vital. 55 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. QUESTION # 2 How aware are you of assisted living development in your state? Although key informants have previously been categorized into policy officials and developers, the following table describes their involvement in the assisted living field by comparing each participants knowledge of what is currently happening in his/her state. Some individuals are shown to have very little understanding of current activities while others seem to grasp the facts quite well. California state representatives at the DSS and DHS were relatively unaware of state developments in the field. Activity in Oregon and California will be further explored in following sections. This table reflects participant’s understanding of the direction of development in their respective states. Table 4 Awareness of State Level Assisted Living Development CALFA Informant Private Developer Three Private Developers California DHS and (CA) (CA) (OR) No Medicaid DSS Officials SDSD Informant Private Developer (OR) (OR) Medicaid Lessons learned from participant responses to state activity show private developers in Oregon having some knowledge but not politically informed of state development. On the 56 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. other hand, those developers in the state that receive Medicaid financing and thus must adhere to fairly stringent regulations are very apprised of political state development. An interesting development was discovered through interviews of California’s DHS and DSS representatives. Both officials showed little concern or knowledge of state activity in assisted living. This stems from the topic not being on the political agenda in the state. One official suggested that, “assisted living has not become political enough yet for any action to be taking place.” Conversely, CALFA’s Director suggests that the state is rapidly expanding its long-term care continuum to incorporate assisted living services in an aging-in-place atmosphere. This informant showed considerable knowledge of assisted living development for the state of California and spoke positively of the future of assisted living for California. CALFA’s Director referred this researcher to the representative of California’s proprietary market for assisted living. This informant suggested that the expanding elderly population in the state will soon demand that needs be met through an assisted living philosophy. She is also very aware of California’s current licensure of assisted living services under the RCFE licensure. She suggests that this environment will suffice for assisted living development if future developers are properly informed on how to transition current RCFE environments to assisted living facility, age-in-place environments. Private developer and the Medicaid waiver representative for Oregon along with Oregon’s SDSD informant were highly knowledgeable in terms of how the regulatory 57 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. environment and Medicaid waiver functioned. Both suggest that the state has taken a very proactive stance in enabling developers to have the freedom to be innovative with individual facilities. Oregon has gone further than most states in enabling managers, developers, and staff to have flexibility to offer a home-like, independent environment for their residents. These informants also suggest that this freedom may be potentially detrimental to experienced developers. Because of the flexible environment and return on investment available in this rapidly expanding market, some inexperienced developers are opening facilities and operating at less that optimal quality standards. The potential for neglect and poor quality assessments could ultimately spread a negative reputation for flexible assisted living regulations in Oregon. The once thought flexible environment of assisted living could develop into the dreaded medical regulatory environment of skilled nursing facilities. This lack of standards in credentialing and licensure for developers could lead to uncontrolled growth and reduced quality. QUESTION #3 Where do you see assisted living development moving in your state? Lessons learned from key informants in Oregon and California suggest that development is continuing to expand. Oregon continues to develop assisted living as a specific licensure with a state wide Medicaid waiver to aid in financing for low income elderly. California continues to study assisted living models with a strong likelihood that the assisted living philosophy will be adopted within current RCFE licensure. 58 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. QUESTION # 4 What are you currently working on in the assisted living industry (e.g., policy, studies)? In Oregon, those investing their time and efforts in private development suggested they were most interested in continuing growth and development of more properties. Oregon developers using the Medicaid waiver tended to be more interested and involved with state development of assisted living trends. Oregon’s developer who participates in the Medicaid waiver, for example, is very active in developing and implementing new ideas that he envisions will be a future demand. Oregon’s developers who do not use the waiver tend to develop in higher socioeconomic areas where increased income levels exist. All of these developers are working on continued development of assisted living projects. Six of the nine informants identified specific projects in developing facilities for assisted living. Oregon’s SDSD representative, as the coordinator of all assisted living development for the state is extremely busy. Development is expanding rapidly. She has some concern over too rapid development which will be discussed later. CALFA is working with the state legislature to develop a California specific model for assisted living. From interviewing CALFA’s Director, it was learned that the state will most likely develop regulations for assisted living but such facilities will remain licensed as RCFEs. Many state models (including Oregon) are being studied for key elements that might work for California, but it does not seem likely that one specific model will be adopted. Rather, many components will be combined to form California’s specific model. 59 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Similar to CALFA’s informant, ARV Assisted Living’s informant is proactive in her company’s philosophy of assisted living. She is expanding and opening new sites licensed as RCFEs with an assisted living philosophy and environment. Aging in place is the future of long-term care according to this informant. Two respondents were not working in the area of assisted living. California representatives of state Departments of Health Services and Social Services are extremely reactive to legislative decree. Unless action is requested, DSS and DHS stay status quo with what is most demanding at the current time. QUESTION # 5 What are your biggest challenge(s) within assisted living as a specific licensure? Private developers in Oregon suggest they shy away from Medicaid residents because of the potential restrictive regulatory and financial environments that commonly attach themselves to assisted living facilities which accept Medicaid residents. These developers have very few problems with assisted living as a specific licensure. However, they do not plan on accepting Medicaid financing through Oregon’s waiver any time soon. The two informants who are working with and using the Oregon Medicaid waiver suggest that their biggest challenges are due to the rapid development of the market. Assisted living is a profitable industry in Oregon and relatively open to any developer with money to fund a project. These informants fear that the open market may lead to an abuse of the industry based on the availability of a good return on investment. Lenders are 6 0 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. working to screen those developers who have little experience from entering the assisted living market in order to avoid over-building and over-saturation of assisted living facilities. California is fairly uninformed at the level of regulation and financing (DSS and DHS). A general lack of knowledge of key figures may be the largest challenge California faces with assisted living as a specific licensure. CALFA’s Director and ARV’s representative suggest this lack of understanding will possibly deter development until a time when the older populations demand a change and/or the long-term care industry is forced to develop a better system of care. DHS and DSS officials believe this demand is not yet strong enough to force the current RCFE system to change. Finally, what does the general lack of information about assisted living and the fear of regulations and funding alternatives mean for California? This current system will eventually demand a change which will force legislative decree. Along with legislative awareness will come a better understanding of assisted living options. Oregon represents a successful model in itself. For the state of Oregon a state-wide Medicaid waiver is possible. In California with a larger population, such a system may not be feasible. This researcher foresees the possibility of a capitated payment rate through Medi-Cal reimbursement for assisted living services. Capitated refers to offering an amount of financing to each individual or service rendered with a cap on how much funding can be allocated. When this cap is reached, the individual becomes responsible for payments above the capitated rate. Capitation is similar to purchasing insurance in that, 61 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. insurance often only covers a certain amount of reimbursement for services. This type of a system could end up maintaining current RCFE licensure while simultaneously financing services based on a capitation. For California’s larger population of elderly, this capitiated system of financing could enable Medi-Cal to assist the mass market. More possible scenarios for California’s system will be discussed in the following chapter. 62 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. CHAPTER V Applications and Discussions R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. As we approach the twenty-first century, technological advances are allowing assisted living facilities to be able to offer services to a more dependent population. Systems for internal feedings; assistive devices, staff on-call pagers; computer data systems; automatic medication dispensers and much more will possibly alleviate much of the burden of staff required to administer treatments and assistance. Oregon has established the Nurse Practice Act which permits non-nurse and non-relative staff to perform many nursing functions if trained on-site by a nurse for certification of the service rendered. Some states are now implementing such acts in order to reduce expenditures on staffing. The Nurse Practice Act in Oregon has allowed the state to cut back on probably the highest facility and state expenditure: staffing of highly qualified personnel who require higher salaries. An obvious downside of allowing non-professionals to perform services usually done by a licensed professional is the fear that mistakes could lead to lawsuits. Without insurance which covers professionally licensed individuals, a facility could be at risk when allowing non-professionals to perform service delivery for residents. Oregon attempts to cover this liability by certifying the skills required to perform certain services (e.g., administering medications, taking blood samples). Another concern common to California and other many states now licensing or considering licensure of assisted living as a separate category of long-term care is the regulatory restriction most often accompanying Medicaid waivers for financing low income elders. Oregon has, by definition, created a more stringent regulatory environment to enable the state to be able to offer more services in each individual facility. Ideally, this 64 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. system adheres to the aging-in-place consumer preference theory, that is, adopting a system that allows a more dependent resident to remain in the setting for a longer period of decline. This system is attempting to replace most of the need for the traditional nursing facility services. Ultimately, assisted living facilities could substitute for RCFE services as well as some skilled services. CALF A representative (1997) has suggested that the current RCFE setting is not likely to be replaced, but rather restructured toward an assisted living type setting and philosophy. This informant also suggests that competition for reimbursement for many categories of licensure will not be necessary in California because the current RCFE licensure will not be replaced (personal contact, telephone interview, April, 1997). RCFE facilities offer a needed service as do skilled nursing facilities. This researcher proposes that being able to offer these services in a shared setting offers the consumer/resident the comforts of familiarity throughout many stages of decline. This desire for a familiar environment represents a critical psychological and physiological need with increased dependency. Obviously, the need to adopt a budget neutral system and hopefully a reduction in overall health care spending are as important as the desire to offer a consumer oriented model. Oregon is currently studying the results of its assisted living system as it relates to overall health care spending and consumer satisfaction. Thus far, the state is satisfied and continuing to develop more assisted living properties. 65 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. [ California’s current licensure for RCFEs is fulfilling a need that is necessary for those individuals requiring minimal assistance with ADLs and LADLs. Skilled nursing facilities, board and care homes, home care service delivery, foster homes, and sheltered care homes also fulfill a critical need for California’s older populations. The implications for California transitioning from many of its current licensures that could be offered in a combined assisted living facility requires more investigation by the state. Adopting a system which incorporates many of the provisions of services offered in the above settings seems viable if cost savings are proven; consumers appear satisfied; and financing for low income elders is readily available. The question remains: can California justify transitioning to this type of system? In a complex and rapidly changing field, it is much too simplistic to make assumptions; to attempt to create theory; or to suggest a perfect case study. This researcher makes no claims that assisted living as it operates in Oregon is “the model system.” However, many states are using it as a prototype. The following comparison of Oregon’s assisted living model and California’s RCFE system offer some insight as to what fundamentals California might assess or adopt from Oregon’s model. Differences in RCFEs and Assisted Living Facilities As mentioned previously, a common concern in California is whether RCFEs are offering all of the needed services that an assisted living facility would provide. And, if so, 66 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. why would the state need to license another category of long-term care when the current long-term care system is underfunded? Some answers lie within the profile descriptions (previously described) of Oregon’s assisted living and California’s RCFE models. The following table examines the most common differences between Oregon’s assisted living model and California’s RCFE system based on some important fundamentals such as consumer focus; environment, facility philosophy; services provided; funding for low income elderly; and the regulatory environment. The implications for California adopting a new system or transitioning its current model depends upon many state specific fundamentals. Although some companies and facilities operate and develop with an assisted living philosophy, assisted living continues to be licensed within RCFEs. The comparisons between Oregon’s assisted living system and California’s RCFE licensure do not reflect the philosophy of those facilities in California which are currently operating with an assisted living focus. Similarly, these comparisons will not take into account the few facilities in Oregon operating as RCFEs or board and care homes. These fundamentals are described to depict overall state models for assisted living in Oregon and RCFEs in California. 67 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 5 Assisted Living and RCFE’S Oregon and California Fundamentals Assisted liviog ia Oregon RCFEs in California Consumer satisfaction and service focus Environment Philosophy Continuum of Care Financing Regulations Highly focused on consumer and outcome oriented services High environmental standards Philosophy of privacy, individuality, dignity, and independence built into rules Broad continuum with age- in-place philosophy State-wide Medicaid waiver for assisted living Stringent regulations because of expansive continuum of services; Nurse Practice Act Less consumer focus, more focus on task oriented services History of publicized quality scandals No strong values for privacy or autonomy No care beyond meals to moderate levels of personal care No Medicaid financing for RCFEs Detailed proxies for quality—e.g., fixed staffing ratios Consumer satisfaction might be used synonymously with choice. The focus of an assisted living facility based on choices enables the facility, the resident, and his/her family to work cooperatively to provide services that the consumer desires and needs. This focus considers the outcome of total satisfaction and the relationship between the facility and the consumer to be of utmost importance. Task oriented facilities tend to focus on the operations of the facility and less on the desires of the consumer. High environmental standards also appeals to the consumer. Recall the assisted living philosophy of a desire for a “home-like” environment. Assisted living attempts to create a 68 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. ! ! home-like atmosphere in order to display a comfortable place to live. Although not all RCFEs lack strong environmental standards, some history of quality disrepute have tainted their reputation. Along with the home-like environment, assisted living facilities tend to focus on an overall environmental standard that exceed many retirement housing options. An appeal of strong aesthetic charm accompanies most assisted living facilities. The assisted living philosophy of privacy, individuality, dignity and independence have been referred to frequently throughout this thesis because this philosophy is known to be the most valuable fundamental within the assisted living field. Even though the RCFE licensure stands for California, more and more facilities are adjusting their facility philosophy to mirror the assisted living philosophy. Key informants in California have been quoted as desiring this philosophy for their facilities even though they will continue to be licensed as RCFEs. The continuum of care goal within the assisted living facility has been mentioned previously as necessary for the resident to be able to age-in-place. If this goal is obtained, the resident will be cared for through more levels of care and at a lesser cost than any other single setting. RCFEs in California are said to provide little services beyond meals and moderate levels of personal care. Financing and regulations continue to be struggles for each state. Fortunately, Oregon has been able to offer state-wide assistance through the Medicaid waiver for assisted living No Medi-Cal financing is available for RCFEs in California. Some services offered in RCFEs, however, are also covered in Oregon under the waiver. This researcher 69 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. suggest the possibility of Medi-Cal financing for assisted living services as the state would choose to define them. Oregon might serve as a good model for defining these services. This would enable the state to continue licensure of assisted living services under RCFEs while allowing some compensation for low income residents. Regulations provide many positives and some negatives as well. Depending on the state, regulations can help or hinder progress and development in long-term care. Oregon’s state regulations have enabled the state to (through the Medicaid waiver) focus on more outcome oriented goals in each facility. Some ways in which this has transpired has been through Oregon’s Nurse Practice Act. As mentioned previously, this act has approved the use of non-medical staff to be trained to administer medical services within the assisted living facility. Being able to cut back on high salaried positions affords these facilities a substantial cost savings. California has not yet been able to offer such an act for the state but is looking into the possibilities. Again, these fundamentals represent a majority but not an inclusive total of the state facilities for assisted living in Oregon and RCFEs in California. Similarly, not all facilities in California could adopt an assisted living philosophy. This chapter addresses the implications for California in adopting an assisted living licensure or transitioning current RCFE licensure to focus on assisted living philosophies. California has a state-specific, complex system of long-term care that the state will likely continue to adhere to. The adjustments to this system are what will enable 70 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. California to develop or adopt a new long-term care model that can support a rapidly growing older population. California’s Department of Health Services has conducted a study of state approaches to assisted living which will serve as a groundwork for future state activity. California’s combination approach will most likely be developed from variations of the three models previously mentioned in chapter II (California’s System) along with state specific adjustments to the current system. A Combination Approach The alternative state models for assisted living previously illustrated (Chapter II) by the California Department of Health Services (January 1997 study) described three models that are currently being used in various states (Institutional, New Housing and Services, Services). Oregon currently operates under the “New Housing and Services” model because of its focus on an alternative to institutional type settings. California might optimally use elements from each model based on California’s specific needs and limitations. DHS outlines its current situation and the pros and cons of adopting parts of the various models. If a system is to be used as a Medi-Cal (Medicaid) funded assisted living option, the system must provide for the following, (p. 19). System must: • Be tailored to California’s needs and goals • Be tailored to geographic, urban and rural needs • Allow for rates to be tailored to regional needs 71 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. • Allow for population diversity • Be a collaborative product of private and governmental efforts Current Issues: • No model to follow, has not been tested in California • Fiscal assumptions are conjecture • Varies from other state’s requirements, providers in multiple states must adapt • Current programs must be coordinated to prevent duplication of services in some areas and absence of services in other areas The precautions California is taking in its approach show that some proactive work is being done by the state. This study has also outlined some issues which will require resolution before California can take a proactive stance for assisted living (p. 21). Some of the issues are: • Identification of the forces which are driving the trends in demand for and supply of assisted living facilities • Consideration of whether California can combine minimum standards and limited regulations, allowing market forces to produce quality of service • Determination of living unit requirements, apartment settings, or both apartments and shared rooms • Determination of tenant admission/retention criteria, require that residents have stable medical conditions and do not need 24 hour skilled nursing care or a series of conditions that residents may or may not have to be served • Determination of level of services, a specific package of services or latitude to allow for aging-in-place • Determine reimbursement methodology, allow for levels of care and regional differences, or by type of setting, or fee for service • Complete fiscal analysis of proposed assisted living program after details are determined 72 with perm ission of the copyright owner. Further reproduction prohibited without perm ission. ! Assisted Living Philosophy Some of California’s issues are state specific and many of its issues reflect similarities to other states. Oregon, in particular, has a philosophy of assisted living based on consumer preference, a quality product, and a home-like environment which focuses on aging-in-place. These philosophies are also important to California. Assisted Living Licensure Licensure of assisted living in Oregon also follows many of the guidelines that California has outlined as critical components. A quality assessment/screening process for facilities and residents, a regulatory system that allows flexibility, a system of financing for low income elderly (state wide or region specific), and a budget neutral overall functioning are all similar to both Oregon and California needs. Again, it is believed by many in California that a separate licensure for assisted living is less likely than an adjustment to the current RCFE licensure. Just the same, the Oregon model does provide an example of how the above components within an assisted living focus perform optimally. Although Oregon is operating assisted living facilities at 80 percent and less of total nursing facility expenditure, California operates a state specific system of care that may not be flexible enough to adopt another state program entirely. No data has yet been released to prove that assisted living will save California money. Being budget neutral is requested but whether the state will actually save money requires further investigation. 73 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Rosalie Kane and her project coordinator, Shirley Huck, at the University of Minnesota are currently working on a project funded by the Robert Wood Johnson Foundation. This study is investigating many aspects of Oregon’s assisted living facilities that are saving the state money, specifically focusing on aging-in-place theories (Shirley Huck, telephone interview, April 1997). This study is not yet complete but when finished should provide valuable insight for the development of assisted living in the United States. Implications for California are state specific. State activity is apparent yet warrants further investigation. The future of long-term care in California will demand a better continuum of care (coordination of services). California’s legislature is interested in options which will satisfy the consumer, be cost effective, and still be able to serve a growing population. Oregon continues to be a state of innovation and flexibility. The state is also still in the experimental phases. Thus far Oregon serves as a prototype for many states looking into the assisted living market. This study has been a comparative study of state approaches to assisted living, an examination of perspectives of those in the industry, and a current literature review. At this time Oregon is reflected upon in much of the literature as a state that is taking the risks and coming out on top. Although California will devise a state specific model, the literature (and this researcher) suggests that Oregon serves as a valuable model for California to reflect upon and mirror in many aspects of assisted living development, either as a separate licensure or as a philosophy. 74 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. BIBLIOGRAPHY R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. I i Assisted Living Today (1996, summer). Taking the pulse of assisted living regulation. Assisted Living Today. 1 (4), 25-33 Bonder, B.R. (1994). Functional performance in older adults. Philadelphia: F A. Davis Company. Evashwick, C J (1996). Definition of the continuum of care. In C J. Evashwick (2n d Ed.) The continuum of long-term care: An integrated systems approach. (pp. 3-12). Albany: Delmar Publishers. Fitzgerald, S. (1995). Increased access. Assisted Living Today. 1 (2), 15-19. Golant, S.M. (1992). Housing America’s elderly: Many possibilities few choices. Newbury Park: SAGE Publications, Inc. Kane, R.A., & Wilson, K.B. (1993). Assisted living in the United States: A new paradigm for residential care for frail older persons. Washington, DC: AARP Krupa, M. (1996). Wall street’s infatuation with the assisted living industry Residential Life. 7.176-185. Lewin-VHI, Inc. (1996, February). National study of assisted living for the frail elderly Washington, DC: Office of the Assistant Secretary for Planning and Evaluation. (HHS-100-94-0024) Mollica, R.L , & Snow, K.I. (November, 1996). State assisted living policy. National Academy for State Health Policy. Portland, ME. (HHS-100-94-0024). Mullen, A.J. (1991). The assisted living industry: An assessment: Retirement Housing Report. (5). 6-7. Nichols, S. A. (1995, January). Assisted living forum. The Consultant Pharmacist. 10 (1), 60-67. Oregon Senior and Disabled Services Division. (1995, November). 1915c Waiver for Aged and Disabled Persons. Social Security Act. Patton, M.Q. (1990). Qualitative evaluation and research methods. Newbury Park. SAGE Publications, Inc. Patton, M.Q. (1987). How to use qualitative methods in evaluation. Newbury Park: SAGE Publications, Inc. 76 Reproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Redfoot, D.L. (1993). Long-term care reform and the role of housing finance. Fannie Mae, 4 (4), 497-537. Regnier, V. (1996, December). Critical issues in assisted living. National Resource and Policy Center on Housing and Long-term Care. Los Angeles, CA; Andrus Gerontology Center Taggart, B. (1997, May). Has assisted living boomed in Oregon? Oregon Health Forum. 10- 11. Wilson, K.B. (1996). Assisted living: Reconceptualiying regulations to meet consumers’ needs and preferences. Washington, DC. AARP. 77 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.

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Asset Metadata

Creator Chamberlain, Jodi Lyn (author)

Core Title Assisted living. Oregon and California: Two models compared

School Leonard Davis School of Gerontology

Degree Master of Science

Degree Program Gerontology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Gerontology,OAI-PMH Harvest,sociology, public and social welfare

Language English

Contributor Digitized by ProQuest (provenance)

Advisor [illegible] (committee chair), [illegible] (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-14913

Unique identifier UC11341338

Identifier 1387815.pdf (filename),usctheses-c16-14913 (legacy record id)

Legacy Identifier 1387815.pdf

Dmrecord 14913

Document Type Thesis

Rights Chamberlain, Jodi Lyn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA