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An analysis of how auspices and administrator preparation affect who is served by board and care homes for the elderly

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An analysis of how auspices and administrator preparation affect who is served by board and care homes for the elderly

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Content AN ANALYSIS OF HOW AUSPICES AND ADMINISTRATOR PREPARATION AFFECT WHO IS SERVED BY BOARD AND CARE HOMES FOR THE ELDERLY by Sister Linda Marie Stevenson A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY May 19 85 UMI Number: EP58923 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Ofsssirtation PVbiisSrtg UMI EP58923 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 uHïVERsny or souTHsm califormia LEONARD PAULS SCHOOL Of GEHONTOLOGV unVERSITV PARK LOS MGELES, CALIFORNIA 90007 Q-^rOf) 3û97f7^ T fti6 by __________Sister Linda Marie Stevenson________________ undeA the. dÀAe,cton. he r TkeJ>tJi C o m m tttz z , and appK ovzd b y a t t t t b membeAô, h o i bee.n pA.e- 6e.ntzd t c and acce.pte.d b y the. Ve.an The. Le.onoAd V a v tà S c h o o t 0^ G e ^ o n to to g y , t n p o A tta Z {^at{^tZZme,nt o i t h z AzqtUAeme,nt6 the. de.gAe.e. MASTER OF SCIENCE IN GERONTOLOGY_______ ______________________ ^ Ve.an V a tz ^ A ts/S tS —_________ THESIS COMMITTEE ChoAjunan 11 ACKNOWLE DGMENT S This thesis would not have been possible without the encouragement, support, and prayers of my religious com munity, the Congregation of the Sisters of Charity of the Incarnate Word. Raymond M. Steinberg, D.S.W. deserves special thanks for helping me to realize the importance of applied research and for inviting me to be a part of the research team of the study. Gatekeeping in Board and Care for Older Adults: The Marginal Resident. Catherine Chase Goodman, D.S.W., who directed the study, provided me with guidance and assistance during the entire process and will be included among my friends for years to come. Jon Pynoos, PhD who collaborated on the study with us, was a source of ideas, concepts, and a gentle strength. Thanks to the interviewers who spent many hours traveling to the four corners of Los Angeles County, in order to interview our respondents. Special thanks to the board and care administrators who gave of their valuable time to talk with us and answer our lengthy interview questions. I wish to express my personal appreciation to my thesis committee who gave of their time, knowledge, and expertise as I strived to record the essence of this study. Ill TABLE OF CONTENTS Page ACKNOWLEDGMENTS . • . ii LIST OF TABLES .. .. . .. . .. . . . ... V Chapter I. STATEMENT OF THE PROBLEM . . . . . . 1 Introduction Rationale of This Study Hypotheses II. REVIEW OF THE LITERATURE . . . . . . . 7 Definitional Problems Development of Board and Care for Older Adults Benefits of Board and Care Homes Problems of Board and Care Homes Diversity of Board and Care Homes III. METHODS . . . . . . . . . . . . . . . . 40 Introduction Sample Data Collection Interview Form Measurement Scale Development Analysis IV. RESULTS . . . . . . . . . . . . . . . . 47 IV Chapter Page V. SUMMARY, CONCLUSIONS, RECOMMENDATIONS, AND LIMITATIONS .......... 60 BIBLIOGRAPHY . . . ........ .......... 68 APPENDIX: Provider Interview . 75 V LIST OF TABLES Table Page 1. Education of Administrators . . . 48 2. Administrators Training . . . . . . . . . . 49 3. Type of Board and Care Home by Services Offered ............. 51 4. Comparison of Residents Asked to Leave and Problem Residents Retained . 53 5. Top Three Considerations in Evict Decision; Open Ended Questions . . . 55 6. Three Types of Board and Care Homes by Characteristics of Evicted .... . 56 7. Characteristics of Retained Resident . 58 CHAPTER I STATEMENT OF THE PROBLEM Introduction The general purpose of this study is to describe a random sample of Los Angeles County board and care homes for the elderly. Data on services offered, census data, administrator characteristics and ownership will be provided in order to examine the limits of board and care, in terms of resident care. A comparison will be made of family homes (one to six residents); non-profit homes (charity run), and for-profit homes to determine how they differ in who they evict and who they retain, in relation to resident characteristics and home circumstances. Specifically, the study addresses the questions: 1. What are the characteristics of Los Angeles County family, non-profit, and for-profit board and care homes in terms of services provided, census data, and administrator characteristics? 2. What are the limits of family, non-profit, and for profit board and care homes in terms of who can and cannot be served? Specifically, how those who are asked to leave differ in behaviors, family supports, and age as • -compared-with_those_who__are retained?_____ _________________ 2 This thesis is divided as follows; Chapter II, a Review of the Literature on board and care, is divided into three sections covering the development of board and care, some of its benefits and problems, and a description of this diverse group of facilities. Prior to this review, a brief discussion of some definitional problems of board and care homes is presented. Chapter III will cover the methods used in this study and Chapter IV will show the results obtained for this study. Chapter V will present the summary, conclusions, recommendations, and limitations drawn from the preceding materials. Finally, Bibliography and the Appendix will be presented. Rationale of This Study There are several reasons for doing this study. One involves the increasing need for alternatives in long-term care for the elderly who do not require institutionaliza tion. During the past 2 0 years, attention has increasingly been given to developing alternatives in long-term care and to preventing the need for long-term institutionaliza tion for certain groups of people. As a result of this state of affairs, there has been a proliferation of alternative community-based programs for individuals who cannot live independently in their own home or apartment, but who do not need to be placed in nursing homes, chronic 3 care hospitals, or state institutions. Findings from interviews with 25 0 experts in long-term care for the elderly, pointed to board and care homes as a key component in the long-term care continuum and as a viable alternative living arrangement for at least some of these individuals (White, 19 84). According to the Directory of Community Care Facilities, published by the State of California Department of Social Services, June 29, 19 84, there were 452 licensed board and care homes in Los Angeles County, who care for elderly residents, 65 years or older. They vary in size, ownership, and the services they provide (typically meals, housekeeping, medication management, and sometimes personal care, such as help with bathing, laundry, and transporta tion). These homes are impacted by external and internal constraints resulting in wide variation in who they serve. First, with the changes in the external environment, board and care homes are impacted by changing policies in other institutions, for examÿ^le, with the onset of Medicare payment by Diagnostically Related Groups (DRGs) many patients are forced out of the hospitals earlier, which results in increasingly disabled elderly clients who apply for admission. Many times the urgency and number of referrals made by different agencies may limit the information administrators have available to them in order to assess incoming residents. Often they are faced with 4 the problem of deciding if applicants should be accepted into the board and care home or rejected. Second, administrators must decide whether residents who are exhibiting problems should be "evicted" or allowed to remain in the home. This decision is based on many factors, such as the physical and mental health of each resident, his or her financial status, the services the facility has to offer, both within and in conjunction with community resources, the home * s financial status, and the method of payment. These are but a few of the character istics which help the administrator decide whether a resident is allowed to stay or is asked to leave. Another factor that enters into this decision making process is the ownership and size of the board and care home. By looking at descriptive data and interviews with board and care administrators, who were asked to describe residents who had been evicted and those who had problems, but had been retained in the homes, it is possible to examine the characteristics of Los Angeles County board and care homes, their limitations in terms of who can and cannot be served and to compare the different types of homes in relation to whom they evict and whom they retain. As the continuum of care changes, many elderly slip through the cracks and cannot be adequately served by the existing care institutions. This information would also 5 provide a basis for recommending ways services can be expanded for a more comprehensive care-graded system. Hypotheses The previous section has outlined the rationale for this study. In addition to these descriptive objectives, data were gathered and compiled to test a series of hypotheses concerning the conditions of board and care homes and characteristics of residents which influenced whether a resident is allowed to stay in the home or is evicted. The following hypotheses will be tested in this study: H^. The administrator of a non-profit home has more education and preparation than the administrator of a family or for-profit home. H2. The administrator of a non-profit home offers more services (both within the home and through community resources) than an administrator of a for-profit home. H^. The resident who exhibits "acceptable" social behavior and has the support of family and friends is more apt to be allowed to stay in the home than the resident who lacks these characteristics. H^. Non-profit board and care homes are less likely to use behavior problems as a reason for eviction than for-profit homes. . Non-profit homes exhibit stronger tendencies to retain residents with behavior problems than for-profit home s. Hg. Non-profit board and care homes will allow residents with problems to remain in the home for a longer period of time than family or for-profit homes. CHAPTER II REVIEW OF THE LITERATURE Definitional Problems As stated in Gatekeeping in Board and.Care for Older Adults: The Marginal Resident; Board and care homes represent a relatively unstudied option in the Long Term Care con tinuum. While there is considerable litera ture on board and care for mentally ill and mentally retarded, studies of this alternative for elderly are scant. Research on housing options for elderly have focused instead on congregate housing, on public housing, and on nursing homes. One of the reasons for this lack, is the overlap between housing categories and the general lack of agreement on definition of board and care for elderly. Board and care is referred to using a wide array of terms: domiciliary, family care, foster care, group homes, retirement hotels, homes for the aged, residential care, congregate living, and others. Several studies recently have devised a definition based on legal regulatory specifications under the Keys Amendment (1976). This definition includes (a) non-medical facilities, that is those which are not Medicaid-eligible; (b) facilities that provide room and board; and facilities that provide some protective oversight. Protective over sight might include knowledge of the resident's whereabouts, or supervision of basic activities such as bathing or dressing. In contrast, congregate living facilities sponsored under Housing and Urban Development Act (19 70) involve central dining but no other services (Carp, 1977). While this definition of board and care provides some clarity, it still includes a wide array of facilities, varying in size from small family-like homes with under 5 residents to large, corporate or charity run facilities of over 150 residents. (Goodman, Pynoos, & Stevenson, 19 85, pp. 1-2) Development of Board and Care for Older Adults Three major factors have contributed to the develop ment of board and care under this current definition. These will be reviewed as they occurred nationally and as they occurred in California. First, with a growing population of elderly, the number of older adults in need of a protective living setting is increasing. Between 1900 and 1970, persons age 65 and older have increased much faster than the rest of the population, and those persons age 75 and older (the group most likely to be institutionalized) has grown even faster. Moreover, the number of Americans age 65 and over is expected to approach 50 million by the year 2025, nearly double the current figure of 26 million. The elderly now account for 11.6 percent of the population. However, projections by the U.S. Census Bureau! are that the elderly will account for 13.1 percent of the population in the year 2000 and 21.7 percent in 2050. The number of older adults in California in need of a protective living setting is increasing as well. Cali fornia now has almost two and a half million elderly. The 9 number is expected to increase to almost three and a half million by the year 2 000. The most vulnerable group (80 and over, currently almost a half million) is expected to more than double (Goodman et al., 1985). With approxi mately 4 percent of the elderly in nursing homes, the institutionalized population in California is estimated to be about 100,000 currently. This represents a sizable public expense, since a large proportion is paid through medical (Medicaid). Recent changes in Medicare payments to hospitals through the use of DRGs has put pressure on hospital staff to discharge patients as soon as possible. Similarly, utilization review in nursing homes have become more stringent so that some who may benefit from more skilled care are discharged (Steinberg & Trejo, 1984). These demographic shifts and recent changes in hospital administration and funding have and will continue to create a larger market for board and care (Goodman et al., 1985). Second, the move away from institutional care in the mental health system has stimulated the development of community alternatives. In the mid-195 0s, with the development of psychotropic drugs, especially the pheno- thiazines which made socially aberrant, and sometimes dangerous behaviors controllable outside institutional settings, a need was recognized for a process to assist these persons in their transition from the institutional 10 setting to a more independent lifestyle., Thus, a greater number of residences with different levels of programming and greater amounts of support services in the community were needed in order to alleviate the effects of long-term institutionalization and to reintegrate these persons into the community, and this all required large amounts of money (Dittmar et al. , 19 83). According to Dittmar et al. (1983), by the mid-1950s states had drained their budgets in an effort to support these persons and were in need of resources to develop and implement new programs. In a response to this need, Congress responded with the Mental Health Study Act in 1955, which financed the Joint Commission on Mental Illness and Health. In 1961, this Commission recommended the develop ment of small State mental hospitals which would be linked to a community-based after care system. However, this recommendation was partially rejected by the newly created National Institute of Mental Health who, instead, proposed the development of a community-based care system inde pendent of state hospitals. This latter proposal was supported by President Kennedy, and later became the basis for the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 196 3. Through this Act the provision of care and treatment to the mentally disabled and elderly in the community became a national goal (Dittmar et al., 1983). 11 With the inclusion of mental illnesses in the definition of disabling conditions that would qualify a person for Aid to the Totally Disabled (ATD) in 196 2 and the passage of the Medicaid Program in 1965, direct financial aid was available to fund the care of deinsti tutionalized persons. According to Dittmar et al. (1983), Medicaid (Title XIX of the Social Security Act), a medical assistance program for the financially needy facilitated the transfer of thousands of persons from state institu tions to nursing homes, and over the years has been a major resource for states attempting to move persons out of state institutions. In 1974, the administration of ATD was transferred to the Social Security Administration and became a part of the Supplemental Security income (SSI) program, a cash assistance program for the needy elderly, blind, and disabled. In California, the Short-Doyle Act in 1957 provided state funds on a matching basis (50 percent) for county and city mental health programs. The Short-Doyle Act was amended in 196 3 to increase the state's contribution to 75 percent. In 196 8, the Community Mental Health Services Act raised the state's contribution to 90 percent and shifted some responsibility- for state hospital patients to the county (10 percent). These acts and the Lanterman Petris Short Act (LPS) which eliminated indefinite commitments to mental hospitals, started the relocation of 12 mental patients to community facilities. The state, hospital population declined from 35-40,000 patients in the 1950s to only 5,000 patients in 19 75 (Derry, 19 83). Between 1963 and 196 8 a project was launched to reduce the number of inappropriate commitments of aged persons in state hospitals. California evidenced a reduction of over 7,000 elderly state hospital residents, a 64 percent reduction (Derry, 1983). This stimulated the development of board and care homes and single room occupany hotels (Goodman et al., 1985). There currently exists, both within and independent of most state human services delivery systems, a range of facility types which provide care for mentally disabled and elderly persons. These facilities most often include nursing homes, halfway houses, foster care homes, crises centers, board and care homes, and psychosocial réhabilita tion centers. While these facility types vary in size, ownership patterns, funding arrangements, and affiliations with formal agencies or programs, they commonly provide room and board and various levels of personal care, protective oversight, and rehabilitation services (Dittmar et al., 1983). Board and care has been central to provid ing residential care for the elderly and deinstitutional ized persons for many years. Public interest in the quality of care being provided in board and care facilities began in the mid-19 70s and 13 continues today. Initially, most efforts addressed the conditions existing in facilities and included local press coverage of death or injury due to fires and other personal tragedies which had occurred in facilities, state level investigative reports, federally funded studies of local conditions, congressional hearings held by the House Select Committee on Aging, and investigative reports by federal agencies such as the U.S. General Accounting Office (GAO) (Dittmar et al., 1983). As the reports of negative conditions increased, it became apparent that board and care homes were in need of a system of control and monitoring. Therefore, the Keys Amendment was passed in 1975. Until the passage of this Act, the federal Supplemental Security Program (SSI) which provided funds for these persons in board and care homes, required no regulation of facilities which served SSI recipients. The persons served in these facilities ranged from clients who were almost completely independent to clients who were extremely dependent. Thus, the Keys Amendment to Public Law 94-566, was both a response to the lack of control over the quality of the services pro vided and a stimulant to the development of residential alternatives to institutionalization. The Keys Amendment mandated the enforcement of standards for "any category or institutions, foster homes, or group living, arrangements in which (as determined by the State) a significant number 14 of recipients of Supplemental Security Income benefits is residing or is likely to reside" (Section 505e, [1], PL 94-566). Later regulations helped clarify the Amendment to include small homes in which only one or two SSI residents might live. Under California law, all board and care homes must be licensed. Without a license,- the home is not permitted to provide care (California Administrative Code, Title 72, Article 2, Section 80103). Homes are licensed by the State Department of Social Services for one year with renewals of up to two years. Since the rate paid by SSI is higher for board and care than for boarding homes, there is incentive to maintain a licensed facility (Goodman et al., 1985). Benefits of Board and Care Homes Board and care homes can serve at least two functions for elderly individuals. First, they can be used for the deinstitutionalization of those who live in mental hospitals, chronic care facilities, nursing homes, and other institutions but who are not debilitated enough to warrant board and care and, therefore, can be placed in less restrictive settings. Second, board and care homes can serve elderly persons who, for a variety of reasons, are no longer able to live independently in the community and who otherwise might have no option but institutional- __ization^ (Sherwood & Seltzer, 1981). These two distinct 15 populations each bring special needs to the board and care home, although the needs of the deinstitutionalized group will probably be more severe (Bradshaw et al., 1976; Sherwood et al., 1980; Watt, 1971). Findings from a study of board and care for the elderly (Dittmar et al., 19 83) indicate that prior to coming to the board and care home, the residents most commonly reported having lived either alone in their own home or apartment (25.4 percent), in the home of a family member (18.3 per cent), in another board and care facility (12.7 percent), in a nursing home (9.1 percent), or in a state mental hospital (8.5 percent). The most commonly cited reason for leaving the previous residence was a decrease in functioning (27.4 percent). A significant number (probably those coming from nursing homes or hospitals) also cited an improvement in functioning (17 percent) as the primary reason for their coming to the board and care home. Others cited death of a family member with whom they were living or not liking the previous facility as the main reason for moving to the board and care home (Dittmar et al,, 19 83). Another benefit of board and care homes is the ser vices provided, which usually consist of personal care, professional services, and staff oversight. The most frequently reported types of services needed by these residents, as noted by Dittmar et al., (1983) were help 16 washing clothes, cleaning their room, managing their money, shopping, taking their medicine, bathing, and getting around outside the residence, i.e., escort service. Pro fessional services consist of obtaining medical, mental, or health care, appointments, and various therapies when needed (Dittmar et al., 19 83). Unfortunately, in many cases these needs are not adequately met by board and care facilities. However, in this same study, the level and appropriateness of staff oversight was found to be appropriate (Dittmar et al., 1983). Social activity both within the board and care home and outside in the community are services which are needed by the residents, but are not always available. However, at times residents are restricted in their participation in community and recreational activities by physical and mental impairments, and by limited financial resources. Many residents have friends and family that live near to the board and care home, thus enabling them to maintain close ties with them. In the study by Dittmar et al. (19 83), 6 0 percent of the residents reported that they had a relative who lived within 2.5 miles of the facility. Many family homes and foster homes attempt to provide a "family-like" environment for the elderly resident. Some residents have friends visit or go out with friends on a periodic basis. Although this does not occur as frequently as is desired by the residents (Dittmar et al., 1983). 17 An important factor which must be noted is that the provision of benefits varies from one board and care home to the next, since there is such a diversity among the homes in the areas of size, type, ownership, funding, and administrator characteristics. Similarly, the needs of residents differ from home to home, due in part to the heterogeneity of the clients being served. Just as board and care homes offer many benefits, the administrators encounter problem areas in operating board and care homes. The following section will describe some of these problems as discussed in the literature. Problems of Board and Care Homes Until relatively recently, particularly until the advent of Medicare and Medicaid, elderly persons who were not living independently or with relatives or friends tended to reside in chronic hospitals, nursing homes, old age homes, or rest homes. Federal funding programs imposed important distinctions between facilities providing direct care with, in-facility medical staff and resources and those providing varying amounts and types of non-medical personal care. Old age homes and rest homes provide room and board and may provide personal care and protective oversight for their residents. Although they appear to be essentially board and care type facilities, there was no literature dealing with either staffing patterns or 18 problems of operation and management as late as 19 81 (Sherwood & Seltzer, 1981). Although the state regulations provide explicit required staffing patterns, e.g., staff- resident ratios, and, therefore, to the extent that they are complied with, they present a general and widely variable picture of the staffing patterns of such facilities. Similarly, the regulations anticipate a number of resident management problems--special diets, medication administration, security, emergency and disaster plans, and other ongoing operational problems. However, with the implementation and completion of a national study of board and care homes across seven states by the Social Systems Research and Evaluation Division of the Denver Research Institute at the University of Denver and the study of board and care homes in California by the Com mission on California State Government Organization and Economy, better known as the "Little Hoover Commission," problems of board and care homes for the elderly came to light. The problems discussed in the Denver study focused on staffing, services, and socialization and recreation. Just as these areas were noted as benefits in the previous section, they also are associated with problems. While the board and care facilities for the elderly were the largest facilities in terms of average number of clients served, as compared to board and care homes for 19 the mentally ill and the mentally retarded, they hired relatively fewer staff per resident. Nearly one of five facilities (18.7 percent) had a resident/staff ratio greater than 4. Coupled with this, 41 percent of the administrators said that hiring and/or retaining staff was difficult. The primary reasons cited for this difficulty were insufficient pay (61 percent of those found hiring/ retaining staff difficult), and unmotivated applicants-- "they don't care," "no one wants to work anymore"-- (51.2 percent of those who found hiring/retaining staff diffi cult) according to Dittmar et al. (19 83). Similar findings were surfaced by the Little Hoover Commission in Cali fornia, high turnover was attributed to the minimal wages paid to staff who found that they could not live on this amount of money and would leave. Many who did stay were found to be poorly trained and lacking of motivation to really care for the elderly residents. The Commission reported The system for screening individuals applying for facility licenses is inadequate; staff working in facilities are not screened for criminal histories, there are no educational requirements to receive a license, and operators are not even required to know what the state regulations require. The services provided by board and care homes for the elderly, described by Dittmar et al. (1983), were seen as maintenance or custodial in nature, rather than habilita- tive. In the facilities surveyed, the needed personal 20 care and support services of the residents were, for the most part, being provided. One primary problem was noted in meal services, more than half of the board and care homes for the elderly (51.7 percent) were serving three meals (breakfast, lunch, and dinner) within a 10-hour period. To prevent excessive periods of fasting and accompanying weakness, the recommended standard for institutions is that no more than 14 hours should elapse between dinner one evening and breakfast the next morning (Dittmar et al., 19 83). Although the study of board and care in California did not specifically focus on meals as a problem, they did tend to provide custodial type services. In both studies, the residents of board and care for the elderly had limited activities available within the facilities and even less interaction with the community. Dittmar et al. (19 83) found that the typical resident reported watching television 3.1 hours per day, sitting and "doing nothing" 3.2 hours per day, and lying in bed (sleeping or not sleeping) 9.7 hours per day. Since they are, for the most part, unemployed, the remainder of the day is presumably devoted to meals, chores, activities, or visiting (Dittmar et al., 1983). These responses to questions about their socialization and recreation painted a rather bleak picture. Nearly half (4 6.4 percent) of those assessed in need of planned social activities outside 21 of the residence had received none during the year pre ceding the interviews in the Denver study (Dittmar et al., 1983). Some of the reasons given by the interviewers who participated in the Dittmar et al. (19 83) study, residents were most frequently restricted in their participation in community and recreational activities by physical impair ments (19.1 percent), their finances (13.4 percent), staff/outside support (21.8 percent), and transportation problems (14.9 percent). An interesting assessment was, nearly half (41.5 percent) were restricted by a lack of motivation to participate, a "giving up" that may be indicative of a high incidence of depression among these residents (Dittmar et al., 1983). Another important part of the residents' socialization is their interaction with family and friends. Of the 89 percent of the residents in the Denver study, 6 0 percent reported that they had a relative who lived within 25 miles of the facility, yet only 39.9 percent of the residents acknowledged that a relative visited them at the facility , at least once a month, and even fewer (29.7 percent) reported that they left the facility at least once a month to visit a relative. Half (52.4 percent) said that they had friends who lived elsewhere, yet only 16.5 percent of the residents reported that their friends visited at least once a month, and somewhat fewer (14.4 percent) left the 22 facility at least once a month to visit a friend (Dittmar et al., 1983). It is interesting to note, that in this same study, those family members who participated in the survey (orily 17.5 percent of the residents had family members who were successfully contacted) were much more concerned with their relatives than the above data indicate- Nearly two-thirds (65.3 percent) said they visited the resident at the facility at least once a month, and close to half (42.8 percent) reported having the resident visit in their home at least once a month. The implications drawn by the investigators is that family members who participated in the survey were not repre sentative of all family members of board and care elderly residents. Just as there are problems with patient services, staffing, education, and preparation of the staff, and residents' socialization, there are problems which must be acknov/ledged and solved by board and care administrators. One of,the most common complaints heard from community care administrators is that they hear only "bad news" from the state--that is, when their facilities are out of compliance with laws and regulations. News stories, too, tend to focus on cases of criminal abuse in community residential care, causing the industry as a whole to suffer the loss of public confidence that follows (Little Hoover Commission, 19 83). However, since the Commission 23 considered it equally important to acknowledge that there are community care administrators who provide quite satisfactory care at a low cost and, in such cases, operate truly model facilities, the Commission stated that "they deserved to be commended and imitated" (Little Hoover Commission, 1983). In addition, they felt that if excellent, facilities were identified and publicized as such, the medical profession and the general public would be better able to make intelligent selections. The attitudes, policies, and practices of adminis trators with respect to which residents will be allowed to stay in the board and care homes when they exhibit problems, is another area of concern which continously must be addressed. Drawing from a sample of 312 California elderly housing projects, in a study of the decision making processes of administrators in congregate housing in relation to who they would not admit and who they would ask to leave, a discrepancy was found among the adminis trators' attitudes, policies, and experiences or practices in which they had actually asked tenants to leave or tenants had left voluntarily (Bernstein, 1982). Some situations that were frequently cited as reasons for asking tenants to leave were not those most frequently cited as formal project policy. It is possible that such problems as drinking and drug abuse, mental decline, emotional problems, incontinence, accident proneness, prominent 24 attitude and practice items are too sensitive to delineate in advance via a written statement. On the other hand, such problems as tenants .who need daily supervision and/or skilled nursing care and tenants who pose a health.or safety hazard to themselves and others, were cited in all three areas, that is, in attitude, policy, and practice (Berstein, 1982). A distinction made by respondents on practice issues further divided this aspect of tenant retention into two categories: (1) problems that tenants and their families acknowledge as seriously interferring with their capability to handle independent living and that often results in their moving voluntarily; such problems include severe illness, needing frequent monitoring of medication and well-being; and being frequently bedridden; and (2) problems less easily acknowledged by tenants and their families that require more active management intervention, that is, asking the tenant to leave ; such problems include mental decline or emotional imbalance, posing a safety hazard to self and others, and having a problem of alcohol and/or drug abuse (Bernstein, 19 82). The study indicated a compromise position was the most typical approach used by administrators in deciding whether a resident had to leave or could stay. The compromise position, however, did not give tenants a clear indication of what the actual management policy was and. 25 therefore, might not offer adequate guidance for tenants and their families who need to plan ahead for the possibil ity of a future move. Additionally, most elderly housing projects also consulted such outside advisors as social workers, public health nurses, private physicians, county conservators, and community planning and service agencies. This consultation, however, usually took place when a tenant problem had become relatively serious and either supportive, on-site services were needed or a decision regarding asking a tenant to leave was imminent. Given the current low-to-moderate level of training and experi ence of bn-site staffing in problems of aging and elderly housing, there may be a need for additional involvement of community agency staff in planning and implementing admission and tenant retention policy (Bernstein, 19 83). This study is very relevant to board and care administration, even though it is focused on congregate housing, because board and care administrators deal with almost the same set of problems on an ongoing basis. This problem area will be discussed further in relation to characteristics of those residents who were allowed to remain in board and care homes in Los Angeles County, as compared with those who were asked to leave. Another problem that relates to many of the areas that have already been discussed is the problem of adequacy of funding for board and care services. The Little Hoover 26 Commission estimated the cost to the public for providing community residential care services for foster care children, the elderly, and developmentally and mentally disabled clients in California would be at least $5 83 million in 19 8 3-19 84. This amount represented direct service costs only. That is, it excluded administration, licensing, and case management costs. The study went on to say there is no way to evaluate whether that amount is too much, too little, or about right. The authors of this report were quick to point out that community care facility administrators would disagree with them that $15 per day might be adequate. They noted that some undeterm inable number of community care residents were in fact living in safe, healthful conditions at the current level of funding. However, the Commission did admit that since the SSI rate sets the board and care rate for the majority of board and care residents and the government-approved SSI cost of living adjustment (COLA) determines the annual price increase, providers must charge those residents with private resources more than the $459 per month that SSI clients can pay, in order to pass on cost increases that exceed the SSI COLA. One example of this practice cited by the study was that of some facilities which charged their private pay residents as much as $2,500 per month for board and care— an amount which is more than double 27 the average Medical payment for skilled nursing care (Little Hoover Commission, 1983). The Commission went on to describe the difference in funding for the developmentally and mentally disabled client groups and the elderly clients. Community care administrators who are approved— "vendorized"--by a regional center to provide residential care for developmentally disabled clients, for example, are eligible to receive payments directly from the regional center to supplement SSI/SSP-based rates. Such differ ential funding is limited to approved vendors and rates are based on the level of staffing and/or the provision of "specialized services" (Little Hoover Commission, 1983). It should be noted that while advocates for the developmentally disabled have successfully made the case for differential rates for residential care, this is not the case in relation to the mentally disabled and the elderly. Later, when the Legislature apparently found that inequity compelling enough to authorize supplementary funding for the mentally disabled (Chapter 1194, Statutes of 1979, .SB 951), they found that they were constrained by insufficient revenue from ever appropriating the required funds (Little Hoover Commission, 1983). Such differences suggest that more flexibility in paying for community residential care is desirable for all client populations. In most cases, the SSI/SSP-based rate 28 is considered adequate by the Commission, not by most board and care administrators, to support individuals in need of basic residential services. However, even the Commission states due to individual client differences or changes, that rate sometimes is not ade quate to purchase an appropriate level of additional care. In that situation, it is patently inequitable to supplement funding available to persons with one set of disabilities and who purchase services in the same system in which persons with other sets of disabilities are denied supplemental funding. Problems with funding of board and care facilities are not limited to the State of California. In a study of board and care facilities across the nation the investi gators found that the fees charged to residents varied from state to state (Dittmar et al., 1983). The mean fee charged by a board and care facility for the elderly was $442 per month. However, the mean fees ranged from $613 in Washington to $34 7 in Texas. The Texas figure is in flated by the overrepresentation in the sample of elderly persons in the state's very small foster care program. Elderly SSI recipients in Texas generally had only $24 0 per month to spend on their care. Less than half (45.6 percent) of the administrators reported that their fees were determined by a public service agency and only in about one-third (32.7 percent) of the facilities did every resident pay the same fee. When fees were established by 29 the owner/operator of the facility, the basis for setting the fee was most often the resident’s ability to pay (76.7 percent). This latter finding confirms the problems, as reported by the interviewers, of the hesitancy of some administrators to take public clients when there is some probability of their getting a higher fee from a private pay person and explains the reported difficulty of the poor elderly in competing for bed space with those of greater financial resources (Dittmar et al., 1983). This is an important consideration in relation to board and care for the elderly since many clients have difficulty gaining admission to board and care homes or obtaining necessary supportive services due to this lack of funds. It would seem that supplemental funding on the basis of need would be one way in which to address this very real problem. Although there are many other problems faced by both clients and providers in the arena of board and care, the areas that were previously discussed are the most relevant for the purposes of this study. They have been presented in order to provide a foundation for the approach used in this study of board and care. As has already been mentioned, the various benefits and problems vary from one board and care facility to the next because of the divers ity of the type of facilities. It would seem that: further explanation of this scope of diversity is warranted, therefore, the last section of this literature review 30 will briefly describe the diverse group of facilities which comprise board and care homes for the elderly. Diversity of Board and Care Homes A variety of terms are used to describe board and care housing. These include residential care facilities, community care homes, personal care homes, domiciliary care homes, supervisory care homes, sheltered care facilities, adult foster care, family homes, group homes, transitional living facilities, and half-way houses. As has already been stated, board and care facilities also vary in terms of size, ownership, resident population, administrative or regulatory auspices, services, and funding sources (Newcomer & Stone, 19 85). However, for the purposes of this study, attention will focus on discussion of those homes which are specifically for the elderly client; residential care facilities, domiciliary care homes, adult foster care, family homes, and group homes. A residential facility for the elderly is defined by Title 22, Division 6, the regulations for Residential Facilities for the Elderly, as a housing arrangement chosen voluntarily by the residents, or the resident's guardian, conservator or other responsible person, where 75 percent of the residents are at least 62 years of age or, if younger, have needs compatible with other residents 31 as specified in Section 8 77 02, and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal (State of California, 1984). The board and care homes that were chosen for this study were licensed in accord with the Title 22 regulations and thus met the qualifications of a residential facility for the elderly as previously defined. The fact that each residential facility for the elderly is unique and different from the others is not readily evident when one reads the definition However, when one visits different board and care homes this fact is very evident. Homes range widely in size, structure, and ownership, yet they are all licensed under this definition. Some homes are small, with six or fewer residents and are often referred to as "family homes." Part of the reason for this term is that they are frequently owned by one person or a couple or a partnership. Another group of board and care homes are the for-profit homes which are usually commercially run, often owned by a person or corporation which own a group of homes. These homes also vary in size and services, but tend to be larger than family homes. The non-profit homes are charity or government-operated and usually have multiple levels of care (i.e., independent living, skilled nursing). The ownership of board and care homes is mentioned, not only to describe the different types of home, but to raise the 32 issue of whether ownership effects the type of adminis trator who is placed in charge of daily operations, the services offered and the administrative practices in rela tion to retention of residents who exhibit problems. As has already been stated, research in the area of board and care for the elderly has been limited and no research on the relationship of ownership and board and care was found upon reviewing the literature. However, the effects of ownership has been studied in relation to nursing homes !%#lwcll, 1984; Fottler et al. , 1981; O'Brien et al. , 19 83 ; Ripotella-Muller & Slesinger, 1982). Even though the scope of this study is not to examine the effects Of ownership on the quality of care, the questions surfaced in these studies and their findings are noteworthy in describing the diversity of board and care homes for the elderly. In a study of the relationship of ownership and size to quality of care, Ripotella-Muller and Slesinger (1982) reported two perspectives on quality of care in the same Wisconsin nursing homes, measured by both adherehce to governmental regulations and officially recorded patient complaints. The findings from this study suggested that there were differences in the quality of care given in nursing homes by size and ownership classifications. For code violations they found that (a) small non-profit homes had fewer violations than small profit homes, but large 33 non-profit homes had more violations than profit homes of the same size, and (b) small homes had fewer violations than large homes. The complaint data showed that (a) non profit homes had fewer complaints than profit homes, and (b) small homes had fewer complaints than large homes. An unexpected, yet interesting, finding was the inter action between ownership and bed size. The quality of care in profit homes, as measured by the violations, was worse than in non-profit homes only when bed size was under 10 0. There was some convergence on the number of violations for homes between 100 and 15 0 beds and, with bed size over 15 0, non-profit homes had more violations than profit homes (Ripotella-Muller & Slesinger, 1982). Ripotella-Muller and Slesinger (19 82) suggested that small non-profit homes were more likely than profit homes to have high quality care as a primary goal of their organization and they, therefore, were more likely to be in compliance with federal and state regulations. In addition, small homes might be more integrated into the community support system that enables them to draw on the social resources of the community. Profit homes might have other goals that direct their resources away from investments that had to be made in order to comply with the regulations. That this would be true regardless of the size of the profit home seemed to be borne out by the data. They also postulated that efficiency made a 34 difference among large homes through attention to economics of scale, provision of services, and compliance with regulations. Thus, as homes get larger, striving for efficiency of operation may have led to the differences discovered between profit and non-profit nursing homes. A study of skilled nursing facilities in California found that higher quality of care was associated with lower profitability (Fottler et al., 1981). But other studies have indicated that there are few major differences in treatment resources based on type of ownership (Kart & Manard, 1976; Kosberg, 1973; Kosberg & Tobin, 1972; Levey et al., 1973). Vladeck (1980) suggests that the best voluntary homes are the best there are, whereas the worst nursing homes are almost exclusively proprietary, but that there is substantial overlap between proprietary and voluntary homes. Kart and Manard (1976) indicate that voluntary non-profit homes have better staff attitudes and social milieu; public homes (i.e., government-operated), the worst; and proprietary homes, intermediate. But Vladeck (1980) suggests that voluntary homes may be more discriminatory and more reluctant to accept Medicaid patients and persons with greater disabilities, and Elwell (1981) found that voluntary homes had more custodial environments. Thus, according to Ward (19 84), there is no simple or clear relationship between nursing home quality and type of ownership. 35 Although the literature seems somewhat divided on whether ownership affects quality of care, it does seem to support the importance of such a question and the need for further investigation. Since no known study of the role of ownership in board and care homes has been done, then a focus on this issue, as one area of examination would seem warranted. Although residential facilities for the elderly is the definition and type of facilities used for this study, another type of facility often referred to in conjunction with board and care is the domiciliary care facility. According to the administrator of Veterans Affairs, with the Veterans Administration Thè. care we provide in our domicilaries will bridge the gap between the hospital, nursing home care, and full integration into independent community life. All of the VA will contribute to the same process of therapy and rehabilitation under this new approach to comprehensive care for the aging. (Chase, 1979). Dr. John D. Chase, VA chief medical director, explained that the domiciliary program had its origins after the Civil War, when "Old Soldiers Homes" were established as the first formalized federal program for veterans. From these homes or domiciliaries, as they later became known, the present VA medical care system grew. By 1979 the VA had 16 domiciliaries, which housed 9,0 00 patients (many veterans of World War I). The domiciliaries provided;not 36 only the support necessary for the resident to recover his independence, but also offers incentives for returning to the community, with the veteran making his own decision whenever possible (Chase, 1979). The program approach involves therapeutic concepts emphasizing better integra tion with senior citizen groups in the surrounding com munity, according to Dr. Chase. The last type of facility to be discussed in relation to board and care homes for the elderly is Foster Family Care, often referred to as "foster care," "family care," and in New York "personal care." These terms have been variously used to describe service delivery systems in which individuals supervised by an authorizing agency provide personal supervision and care to former patients of adult age who live with them in their homes (Miller, 1977). According to the New York Board of Social Welfare and State Department of Social Services, The goal of the services is to enable the socially, physically or mentally handicapped or isolated adult to resume or continue life within a family unit, in his/her own community near friends and relatives, eliminating or postponing the need for institutional care. The individual who chooses to accept service under the Foster Family Care for Adults Program . . . may expect a wholesome family life in which he can expect to participate within limits of his own and the family's desires. . . . He must not expect that a strange family will take him in immediately as a member of the inner circle of the family. Also it is not expected that all clients will want or be able to use this type of closeness. (Bulletin No. 188, pp. 2-12) 37 In New York, the State Department of Social Services, the State Board of Social Welfare, and local social service districts share responsibility for the approval and super vision of foster family care homes and family-type proprietary homes for adults (Sherman & Newman, 1977). Although Sherman and Newman (1977) recommended enlargement of foster home care programs, Brody (1977) feels this to be premature. She points out that before this can happen a concerted effort to bring some semblance of order and decent health and social care to the industry loosely called "foster care" is needed. .Brody goes on to say, at this time, statements are unwarranted that foster care "avoids institutionalization" or the "negative aspects of institutionalization" or that it is a viable alternative to institutional care for the minimally impaired aged. Such conclusions could be drawn only after careful evalu ative research of the effects (negative and positive) of this type of care and in the framework of identifying the magnitude of the potential population and their needs and characteristics. In a later study by Newman and Sherman (19 79), inter views were conducted with caretakers in 100 foster family care homes housing from one to four clients, at least one of whom was 60 years of age or older. An 85-item inter view schedule was constructed to assess, in addition to the "family nature" of the homes, the demographic 38 characteristics of caretakers and residents, operation of the homes, relationship with the agencies, and community reaction to the foster care program. Various measures of families were designed to include the four dimensions of affection, social interaction, ritual, and social distance These measures seemed to indicate that family integration and participation do occur in those foster family homes for adults, and that in the majority of cases, the homes could be termed surrogate families. It appeared that on most of the indicators used, about three quarters of the 100 caretakers in the sample were scored positively. There also appeared to be some evidence that the relationship between the caretaker and the resident was most frequently familial than that which existed within the group of residents themselves, which was rated as familial in only about half of the homes. The data on home use seemed to indicate some maintenance of social distance. Only one controlled study has looked at the impact of foster care versus inpatient hospitalization, but this was for a psychiatric population that included elderly (Linn & Caffey, 1977). Linn and Caffey (19 7 7) found that those in foster care had less social dysfunction and better adjustment. In this section of the Literature Review, a brief description of the diversity of board and care homes for the elderly has been provided. The discussion focused on 39 residential care facilities, which included an examination of such issues as ownership and its relation to services and quality of care, as represented in the literature on nursing homes. The importance of the size of the facility in relation to care was also alluded to in this descrip tion. Family and group homes were included in the generic term of residential facilities, as well. Domiciliary care homes were defined in reference to the development of this alternative care within the Veterans Administration. The discussion of board and care homes concluded with a review of the research on adult foster care homes for the elderly. It would seem that in describing these different types of board and care, just as many issues and questions were surfaced as were answered. Yet these questions, when answered will provide a more comprehensive description of board and care and future care as a viable alternative to institutionalization. In summary this literature review has focused on the development of board and care, some of its benefits and problems, and a description of the diverse group of facilities that comprise the category of board and care. Much of the literature used for this review was from related levels of care, since board and care literature is scant. The following chapters will focus specifically on board and care for the elderly in Los Angeles County. 40 CHAPTER III METHODS Introduction This thesis is a report of the author's sub-study of the study of residential board and care in Los Angeles County, Gatekeeping in Board and Care for Older Adults : The Marginal Resident," by Catherine Chase Goodman, D.S.W., in collaboration with Jon Pynoos, PhD., and Sister Linda Marie Stevenson, M.S.G. candidate. Both studies were part of a larger study. Staying at Home, a three-year study of Los Angeles County, which examined current public policies, govern mental and non-governmental programs and interorganizational practices which affect opportunities for vulnerable older persons to reduce the number of impaired elders who may be unnecessarily institutionalized. (Steinberg & Trejo, 19 84). The Staying at Home project was funded by the John Randolph and Dora Haynes Foundation and was co-directed by Raymond M. Steinberg, D.S.W. and Monika White, PhD at the Andrus Gerontology Center. In two parallel studies of the long-term care system both "key informants" and front-line practitioners rated board and care for the elderly as a major area of concern 41 (Steinberg & Trejo, 1984; White, 1984). Thus, a follow-up study entitled Gatekeeping in Board and Care for Older Adults ; The Marginal Resident was initiated and developed in the fall of 1984. This provided a storehouse of data relevant to the research questions addressed in this thesis. Sample A stratified random sample of 100 board and care homes was drawn from all the homes licensed as Residential Care Elderly in Los Angeles County. The list of homes drawn were made up of 44 small or "family" homes (44 per cent) with a capacity of six or less and 56 large board and care homes. The large homes were later divided into the category of ownership, non-profit, and for-profit. All the small homes fell into the for-profit category. The Los Angeles County list contained 452 homes as of July 1984, 44 percent of which had six or fewer residents. Hence, a representative sample was drawn. Data Collection The investigators met with an advisory group made up of persons who work in areas which relate to board and care (i.e., ombudsman, licensing, social services, mental health, etc.), as well as board and care administrators, to gain input and guidance in relation to the focus of the study. After the instrument was developed a pretesting 42 was done with administrators of four board and care homes in order to test for areas in need of revision. Data collection was done by the investigators and five inter viewers who were hired and trained for data collection. The interviewers were graduate students of the Leonard Davis School of Gerontology and Andrus volunteers. The board and care homes in the sample were sent a letter of introduction, followed by a telephone contact. An appoint ment was set up with each board and care administrator, and then verified prior to the interview both in writing and via a phone call. Interview Form A 29-page survey form was devised for the study by Dr. Goodman, who drew from the descriptive questions in the instrument from Dittmar et al. (1983). A board and care survey fact sheet was sent to each board and care home administrator, who was instructed to complete the form prior to the interview, so that the interviewer could collect it and clarify any questions at that time. A copy of the cover letter, fact sheet, interview form, and subject release form will be found in the Appendix. Measurement In. addition to drawing on the descriptive questions from Dittmar et al. (1983), direct questions, open-ended questions and scales were developed and used to gather 43 data for this study. Also, administrators were asked to describe a resident who had been asked to leave or "evicted," and one who had been a problem, but who had been retained. Direct questions were developed to assess the education and preparation of each administrator inter viewed. Question 6 9 asked, "How much formal education have you had?" Seven categories were listed ranging from less than high school to graduate degree. Administrator's preparation is defined as "special training" and was a yes or no answer (question 70). Board and care census data were gathered through a series of direct questions on the "Board and Care Survey Fact Sheet" (see Appendix). Most of the census factors are self-explanatory. The variable "occupancy rate" was derived from combining the occupany number and the capacity of the home. The variable "services" is defined as a combination of personal care services, other services, and outside pro fessional services. "Personal Care Services"' consists of questions on bathing, dressing, eating, brushing and combing hair, brushing teeth/cleaning dentures, shaving and toileting. The scale is the number of services the home provided for the resident. "Other Services" consists of questions on non-personal services provided by the home to any resident who needed them. Such services were. 44 accompanying residents on shopping trips, writing letters for residents, making telephone calls for them or helping them to make calls, transportation, money management, making appointments and many more (question 24). The scale is the number of "other services" the house provided. "Outside Professionals" were the number and types of out side professionals who came into the home. The scale is the number of outside professionals who come into the house (question 54b). The "Community Connections" variable was devised by combining the answers from direct questions on community resources and outside social programs needed by the evicted resident (questions 15-20), and the resident who was retained (questions 36-41). "Evicted" is defined as the resident who was asked to leave the board and care home, for whatever reason, this does not refer necessarily to a "formal eviction." In fact, a formal eviction was rarely ever mentioned by the administrators. The "retained" resident is defined as the resident who was almost asked to leave the home, but for some reason was allowed to stay. The administrator was asked twice to answer open- ended questions concerning the reason(s) the resident was evicted (questions 5, 21a, 2lb, and 21c). The first question asked the most important reason for evicting the resident, while question 21 allowed the administrator to 45 list three reasons for eviction in order of importance. The questions concerning the resident who was retained were presented in the same way (questions 26, 42a, 42b, and 42c). Resident problems were defined as "physical health problems" and "behavior problems." Physical health problems consisted of ambulation problems, eyesight, hearing, overall health and other physical health problems as listed by the administrator, for both the evicted resident and the retained resident. Behavior problems consisted of depression, suicidal tendencies, verbally aggressive, physically combative, abusive of alcohol and drugs, wandering, mentally confused, mentally retarded, and other behavioral problems as specified by the administrator (questions 8, 9, 29 and 30). The variable "acceptable behavior" consisted of those behaviors which were seen in relation to the resident who was allowed to stay, as acceptable by the administrator. Other factors such as 1ikability, family support, and support of friends were considered in relation to "acceptable behavior" for the purpose of analysis. Scale Development The specific items which have been defined were devised through feedback from a group of board and care administrators. Once the measure was devised it was tested on four board and care homes. 46 After data was collected, the items that were thought to group together theoretically were factor analyzed to discover how they would group statistically. Some items formed one group or scale, while other items factored into two sub-components or two scales. The items that factored together or formed one factor were then summed. Finally, scales describing the resident were named: personal care service needs, likability, social participation, and behavior problems. Final scales describing the home circumstances were named:home resources, vacancy, and community connections. The behavior problem scale and community connection scales were simply a count of differ ent problem behaviors; or different agency ties so a single concept was not being measured in these scales. Analysis Analysis of the descriptive data consisted of examina* tion of frequency distributions and when appropriate use of chi ëquare. Home types (family, non-profit, and for- profit) were compared using two-way analysis of variance and chi square. 47 CHAPTER IV RESULTS The study results are presented in an order which corresponds to the hypotheses tested in this thesis. H^. The administrator of a non-profit home has more education and preparation than the administrator of a family or for-profit home. Administrators of family, non-profit, and for-profit homes differ in whether or not they have graduate educa- 2 tion (x = 10.64, p < .01). A comparison of the adminis trators showed that 64.3 percent of the administrators of non-ppofit homes had completed some graduate work or held a graduate degree, while 11.8 percent of the administrators of family homes had graduate work and 25.8 percent of the administrators of for-profit homes (Table 1) Preparation refers to "specialized training" provided to the administrators prior to assuming the role of board and care operators (Table 2). Ninety-two percent of the administrators of non-profit homes had preparation as compared to 76.5 percent of the family home administrators and 73.5 percent of the administrators of for-profit 00 CO ■H LO in CN 00 •H ro •H o \ o m m MO ■H in I —I -H I —I rH -H rH 4J 00 00 o \ o r —I 00 in I —I I —I ■H o LO I —I ■H -H X ( U ■H I —I o o o\ o O o o o rH ro I —I LO LD 0 \ o ro CN VD CN I —I ■H ■H I —I CN -H I —I in in oV ro ■H ro ro in CN I —I rH rH rH •H 50 homes. However, the difference is not as great as in the area of formal education. The data supports the first hypothesis that admin istrators of non-profit board and care homes had more education and training than the administrators of family and for-profit homes. . The administrator of a non-profit home offers more services (both within the home and through community resources) than an administrator for a for-profit home. Services provided are presented in three categories: personal care services, other services, and outside pro fessionals, which represent community resources (Table 3). No significant difference is found among the homes in the category of personal care services. However, a significant difference does exist in the frequency with which other services were mentioned. It should be noted that the services were listed according to reports of administrators Analysis of variance post-hoc contrast show for-profit homes to have significantly more "other services" than family homes and non-profit homes (p < .001). Outside professionals was also a significant difference between groups. Analysis of variance post-hoc contrasts show family homes to have significantly fewer outside profes sionals than non-profit homes and for-profit homes (p < .01). 51 en Xi EH C ü u <D m m 0 œ S • i H > U 0) 01 >1 Xi § S ( Ü u Ô TJ g U M < D m m 0 1 13 -H > O u P4 e n g •H > 5 H (Ü en s: I I i >i|Q en f d k k O m C M m C M m œ CM ■je ■je 00 e n o m CM CM m I —I o 00 CM •je C M C T » O e n C M VD C M O 00 C M 0 1 -H 0 1 0 -P 6 p f d 01 f d 0 1 (d MH f d p P 0 1 ro vo -p 13 P e u CM 00 G C O 6 • • i o f d O O CM CM co ü ü Æ 1 —1 • % . ü -p ü >1 o "H O M Æ 4H Æ -H (O - 4 » o 1 o 1 6 CM co LO -p u P f d 1 « 1 0 1 04 01 4H CM co 1 —1 o 1 O _ Pu c 04 13 o G < D C C ü f d LO co lO ü ü rH lO co C 13 o P t • • fd c f d -H LO o 1 —1 •H f d - r i 4H rH p P O 0 1 f d >1 f d p e u > M > p4 • ü •H 1 0 1 -H 1 fw g UH P m > H O f d O O g rH H C D f d 4H 4H g f d ( ü en C ü 1 01 0 1 01 xi C en Xi 13 01 rH 1 —1 •H C Q) 0 o H 0 1 ■H CÜ f d rH O 0 1 C ü 01 C üp 0 1 C ü C ü 0) 0 14H a O O >1 C ü >1 C ü•H 5 H H Xi O ■P 0 0 rH 1 5 rH 3 P 0 ) f d + - ) ■H P u -H f d p fd P O u O > O A 0 1 g C ü g C ü P < XI PU Ç Ï 4 ÇU f d Xi 0 1 0 1 1 C ü C ü c ü ü o o O o C ü C ü p a p 13 C ü 0 1 C ü O p C ü p f d p g p •H o ■H P 13 Xi 13 -H P P p P O c •H O P fd p f d 0 4 ü O ü 1 -H p •H p p 0 4 P o •H 1 •H p O p 0 u > o t P O ■H p -H C ü 0 1 13 0 1 Cü O p O f d O C ü X Xî XI 0 1 > 1 œ 13 52 Statistical analysis of data on services only parti ally supports the second hypothesis. Although non-profit homes bring in more outside professionals than family homes, for-profit homes offer more non-personal (other) services than.the non-profit and family homes. The resident who exhibits "acceptable” social behavior and has the support of family and friends is more apt to be allowed to stay in the home than the resident who lacks these characteristics. This hypothesis was only partially supported by the data. Evicted cases had less social participation than retained cases (t = 2.06, p < .05). However, likability, family support and support of friends were not sig nificantly different for the retained and evicted cases (Table 4). The focus of this hypothesis was on residents' behavior in relation to eviction and was not analyzed in relation to the three types of homes. The following hypotheses will be tested by type of home. H^. Non-profit board and care homes are less likely to use behavior problems as a reason for eviction than for- profit homes. Behavior problems were a significantly more important consideration in evict decisions for family and for-profit 2 homes than non-profit homes (x = 12.59, p < 0.01). Specifically, only 19,4 percent of the non-profit administrators included behavior problems among the three H* O ) I —I EH T3 T3 d CD f d d •H C D fd > 44 f d CD C D o: X t C D O d 4 - ) *H ( d t 4 - » C D C D ^ 04 C Q < w 4J w d t3 44 C D (D d ' X i 44 C D - t - i ü >0 w -H •H O > w oü H C D Pi S C D 1 + 4 iH O XI O d M O 04 m -H H fd Oa g o u 4J Q W Q W 13 Ü3 ü +j ü î ’ H H +J C D C 4J C D ü t ( T J •H J h ü 3 ( d (2 5 fü -H U H C /D C M 54 most important reasons given, compared to 54.2 percent family and 56.9 percent for-profit (Table 5). Comparison of behavior problems of the evicted on the detailed scales rating of the three types of homes by characteristics of evicted residents, show no statistical significance (Table 6). However, it should be noted that there are significant contrasts between non-profit and family homes; and between non-profit and for-profit homes in the age of the residents when evicted, the non-profit had the oldest residents upon eviction and the residents of non-profit homes had been in the home longer (p < .05). It should be noted that the reason the scales reflect different or opposite findings is that Table 5 consists of what administrators voiced as the three most important reasons to evict residents, however. Table 6 is the reasons for eviction given in reference to specific evict cases. Thus, it would seem that the administrators* perceptions are different from what actually occurs. Although the difference in behavior is not sig nificant on the scaled rating, the direction of the ratings indicate that this hypothesis is supported by the data, non-profit homes evict fewer residents with behavior problems than the other homes. 55 •rH M - l o\ o va m ' e y LO I — I o% ro o o LO LO ro f N j o a\ ro LO LO ro ■H LW m N lO lo LO -H CN ro LO LO LO o o CN CN CN ro -H CN r o CN LO o\ o o o I —I r - H o o rH CN CN 4-1 MH o ro oo CN oV rH LO LO LO CO 00 00 LO CN LO LO I — I LO CN rH O D O 0 ) f f i 0 ) 13 O I —I < y \ LO •rH ^ O U OT > 4J -H ( U M nJ rH > !T> <U 4:5 fd ÎH C rC; 0 0 0 f d +j cq M w P O I —I CN •H 56 LO (N CN O 00 CN n ro CN O D K CD VO LO 00 LO -H m U -H n j > U M VO i ' ^ LO 00 • t D U U “ H a i 4J CO LO CN •H M - 1 LO 00 CO C O CN •H m •H -H ■P c •H •H 4” ^ M-1 (D •H ^ "H m -H •H •H “ H 57 Non-profit homes exhibit stronger tendencies to retain residents with behavior problems than for-profit home s. The comparison of retained problem cases between non profit homes and for-profit homes (family homes had too few retained cases to make a viable comparison), indicates there is no statistical difference between the non-profit homes and the for-profit homes in behavior problems which would indicate that non-profit homes are more likely to retain residents with behavior problems than others (Table 7). However, it should be noted that there is a significant difference between years in the home (p < .04) which indicates that non-profit homes did retain their problem cases longer, even though they were not necessarily those with behavior problems. Thus, hypothesis five is not supported by the data in this study. Non-profit board and care homes will allow resi dents with problems to remain in the home for a longer period of time than family or for-profit homes. Significant contrasts exist between non-profit and family homes, and betv/een non-profit and for-profit homes, in the years in home (p < .05). The non-profit homes allowed the residents to stay in the home longer than family or for-profit homes before they were evicted. It should be noted that these are the cases that the administrators chose to discuss and are not necessarily 58 0 ) rH A f d Eh « s S * ( h rH 00 o 1 — 1 r o o * rH O CN +j Q in at ' •H cn • » m r" n] rH 0 P P4 -p P a) o ro r- n fp VO VO •iH S . * » m o CN CN o 00 « (Ü C r —4 rH o •H +J Q in CN 00 nJ -H CO • ■ • - P M - l TP ,H <D 0 « P 04 < 4 - 4 1 O 1 — 1 l - t a t 0 ro o VO in 13 s • • • Ü 1 — 1 in CN •H 00 - P •H P 00 n 0 ) m CO 00 - P Q ■ * • U r H CO ro ( d ( d p - P ( d O in 1 — 1 r- A h B-i in VO a . ■ « s o CO CN 00 3 VO r o 0 ) u • H 0 + J g in O •H 5 - 4 +i Q ) G P G - P -H . 0 0 O •H f d in > •H p p 0 in f d 0 0 0 ^ C n 0 0 U < C > H P Q o ÇU ■ K 5 9 representative of all the residents (see Table 6). These data do support the hypothesis that non-profit board and care homes will allow problem residents to remain in the home for a longer period of time than the other homes. It should be noted that any unintentional reporting of error could not be controlled for, since much of the data are based on administrators' reported cases of resi dents evicted and retained. 60 CHAPTER V S UMD4ARY , CON CL USIONS, RE COMMEN DAT I ON S AND LIMITATIONS Summary The general purpose of this study was to describe a random sample of Los Angeles County board and care homes for the elderly. Administrators of 6 6 board and care homes were interviewed in order to collect data on services offered, census information, admissions policies, administrator characteristics, and ownership. A comparison was made of family homes (one to six residents); non-profit homes, and for-profit homes to determine how they differ in who they evict and who they retain, in relation to resident characteristics and home circumstances. The major findings of the study indicated that not only were the board and care homes different, but that they had both strengths and problems which warrent atten tion and assistance. However, even with these findings it is suggested that board and care for the elderly is and should remain a viable.alternative to institutional care for the elderly. 61 Conclusions The major findings of this study focus on the three types of board and care homes, the ways in which they differ, and how these differences affect the services provided to their elderly residents. The first major finding was that administrators of non-profit homes have more education and preparation than administrators of family and for-profit homes. All administrators (10 0 percent) of non-profit homes had college and graduate education as compared to 70 percent of the family home administrators and 80.6 percent of the for-profit administrators (see Table 1). In addition, almost all of the non-profit administrators (92.9 percent) had received specialized training as compared to family home administrators (76.5 percent), and for-profit administrators (73.5 percent) (see Table 2). The second major finding, although there is no significant difference among the homes in the provision of personal services, the non-profit homes bring in more professionals from the outside than the family or for- profit homes. In contrast, the for-profit homes provide more "other" or non-personal services than the non-profit or family homes. These types of services included; taking the residents shopping, writing letters for them, transportation to medical and dental appointments, beautician services and many more. 6 2 It should be noted that these findings were based on the reports of the administrators interviewed and no control was made for errors. Also, most of the non-profit homes had multiple-levels of care, therefore, persons who worked for the non-profit homes at different levels of care, were counted as outside professionals. The third finding was residents who exhibited social participation were more apt to be retained in the homes, while being likable and having the support of family and friends was not statistically significant. However, an argument can be made that the number and types of problems of the evicted resident may have overshadowed the importance of the support of family and friends and whether the resident was likable as reported by the administrators. The fourth finding focuses on a comparison of non profit and for-profit board and care homes in relation to the importance of behavior problems as a reason to evict residents. Of the reasons given by administrators, behavior was considered the most important reason by for- profit and family homes, while non-profit considered health problems as a more important reason for eviction. Also, while a statistical significance was not found in relation to behavior problems between the homes, the non profit did have the oldest residents, who had been in the home the longest before eviction. This may indicate that 63 that non-profit homes manage residents with behavior problems more effectively than the other homes. When administrators were asked why they retained a problem resident, the most important reason was behavior change or service needs could be met. Other reasons given were social supports of the resident and social participa tion and compassion of the administrator. Another interesting finding was that non-profit homes operated at a 80.8 percent capacity, which disproves the common perception held by many people that non-profit homes are filled with "waiting lists." Compared to this, for-profit homes operated at a 78.9 percent capacity and family homes at only 62 percent capacity. Clearly the family homes were experiencing the most difficulty in attempts to remain financially viable. In fact, sig nificantly more of the family homes were closed when we called to arrange an interview, 25 percent compared to 5.4 percent of the larger homes. Recommendations It was surprising to find that the for-profit home administrators had much less education and specialized training for their role than the non-profit administrators, since many of these homes were larger with more residents. The family home administrators were co^iparable to the for- profit administrators in education and preparation and yet 64 they never have more than six residents. It would seem that the family homes provide a more "family" environment than the other homes, and while preparation and ongoing in-service is needed, the administrators of for-profit homes and non-profit homes are in greater need of ongoing education. Therefore, it is recommended that the board of licensure for residential elderly board and care homes require that administrators, especially of the for-profit and non-profit homes, attend continued education workshops in order to stay abreast of new developments in service provisions and to assist them in becoming a more cohesive group. Not only should the board require this, but it should be involved in facilitating the provision of these ongoing educational seminars and workshops. Another area of concern was family homes had sig nificantly fewer connections with outside professionals than other types of homes and operated at a lower capacity, thus closing more frequently than the other homes. It is believed that family homes have a certain type of service to offer, in that it has the potential to foster a family like environment among the small group of residents. Perhaps these homes need assistance in marketing their services and in developing linkages with other homes and outside agencies. It would be sdd to see the family home continue to struggle and eventually to decline or dis appear. 65 The third and last recommendation relates to the provision of services to those elderly persons who need more services (mostly protective oversight) than the board and care homes could,provide. In open-ended questions, a third of the administrators suggested that a level of care between board and care and intermediate care was needed. When asked specifically if this would be a solution, 71.2 percent of the administrators said "yes," even more than any other solution. Similarly, multiple-levels of care were suggested as a viable option. Therefore, it is recommended that a process be developed to identify those elderly persons who are in need of additional services so that additional money could be given in order to provide this extra care (extra staff, more oversight, etc.). Of course it is recognized that some form of monitoring is warranted in order to assure that the extra money would be used for this purpose, thus it would seem that case management would be one way in which this service pro vision and monitoring function could be implemented. Another option, would be to encourage the development of more multi-level facilities like those of the non-profit homes. This may facilitate the provision of needed services and continuity of care, vfithout the added trauma to the resident of being moved to a different facility every time his/her service needs change. 66 The recommendations suggested in this thesis are only the major recommendations and are not the only solutions to the problems and needs of board and care homes and their residents' needs. Other areas of concern were surfaced as well as other areas in need of further study. Therefore, it was necessary to limit recommendations to the major findings of this thesis. Limitations of This Study As has been stated previously,.this' study did not examine quality of care in the board and care homes investigated. However, this is an area of concern that should be addressed in future research. Perhaps a differ ent methodology could be used for further research concern ing board and care homes, such as interviewing the resi dents and their perceptions of services provided by the homes, or interviewing outside professionals that come into the homes or the residents' family members concerning how they rate the quality of care in the home. Another limitation of this study was that the data were collected from interviews with administrators who were asked to remember the last resident they evicted or "almost" evicted, but retained. More than likely, the administrators recalled those cases which were most prominent in their memory, not necessarily the last cases they had managed. 6 7 A third limitation of this study was that in response to the request to recall the last resident whom they almost evicted, the administrators of family homes had great difficulty in recalling such a case. This resulted in a very small number, therefore, some statistical analysis was not possible in attempts to compare the three types of homes. One last area of interest for further research would be to investigate the decision making processes used by administrators of board and care homes in relation to not only admissions, evictions, and problem solving, but to examine the effects of these decisions on service provision. As has been illustrated both in this study and in the limitations of this study, there are many questions concerning board and care homes for the elderly that are still in need of further examination. Thus, this level of care continues to warrant attention in order to not only describe it, but to assist board and care in its continued growth as a viable alternative to institutionalization. 68 BIBLIOGRAPHY 69 BIBLIOGRAPHY Benedict, R. C. 19 77. Integrating housing and services for older people. In W. T. Donahue, M, M. Thompson, & D. J. 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Los Angeles, CA: Ethel Percy Andrus Gerontology Center, University of Southern California, July. 75 APPENDIX PROVIDER INTERVIEW 76 COPY UNIVERSITY OF SOUTHERN CALIFORNIA Ethel Percy Andrus Gerontology Center University Park--MC0190 Los Angeles, California 90089-0191 December 17, 1984 Dear We are writing to ask for some of your time to give us your point of view about the problems you face as operators of homes for the elderly. Your views will help us to formulate recommendations to decision-makers in long-term care. Last year our organization conducted a study of strengths and weaknesses of the long-term care system across Los Angeles County. More than 250 knowledgeable leaders listed priority needs. High among these priorities was expanded board and care. Therefore, this year we are taking a closer look at practical suggestions for growth in the areas needed. We think that a down-to-earth view of present problems and practical suggestions can best be obtained from operators such as you. We selected your name randomly from a list of facilities; your participa tion is strictly voluntary and confidential. We appreciate that your time is limited but we need your experience and suggestions. Please see the attachment for more details or call one of us at (213) 743-5981 if you have questions. We.will call you within the next two weeks to arrange an appointment at your convenience. Sincerely, Catherine Chase Goodman, DSW Research Consultant Sister Linda Marie Stevenson Jon Pynoos, Ph.D. Specialist in Health Care Director, Institute for Policy Administration and Program Development 77 “Staying at Home“ is a study of long-term care in Los Angeles County conducted by the Institute for Policy and Program Development, Andrus Gerontology Center, University of Southern California, and funded by the John Randolph and Dora Haynes Foundation. Special Study on Board and Care As part of, the "Staying at Home" project a special study on board and care will look at problems faced by operators and administrators in providing for residents. Findings will be presented to decision makers in long-term care at a conference in June 1985. Investigators : Catherine Goodman, DSW Sister Linda Marie Jon Pynoos, Ph.D. Research Consultant Stevenson Director, Institute Technical Assistant for Policy and Program Development Why the Study Findings from interviews with 250 experts in long-term care for the elderly point to board and care homes as a key component in the long term care continuum. Yet board and care operators face the sometimes inconsistent task of running a business and providing high quality care for a changing group of elderly. The typical resident in a facility requires more care than in the past. Many have grown older in your homes and now are incapacitated. Many have serious temporary illnesses that require special care for a short time. We're interested in what you consider the major problems in running a facility. We want to know how you handle these problems and how you decide who you should accept as a resident in your facility. We want to know what happens when someone already in your home becomes too ill or disabled to stay there, and how you decide it's necessary to ask a resident to make other living arrangements. Obviously, you want to run a business that's financially sound. You must consider both the characteristics of the person you're dealing with and the situation within your home at the time. Many issues enter into your decisions. We want to find out what these considerations are and which are most important. If we can find out what you consider problems and what's important to you in handling problems that arise, we'll know better what changes in the community might make things easier for you and for the many older persons for whom board and care would be the most suitable living arrangement. While our study is primarily intended to better understanding of how board and care homes function, it is possible our findings may point to changes in the way board and care fits in with a continuum of care provided by nursing homes, hospitals, and home health agencies. We may recommend opportunities for technical assistance for operators, changes in board and care regulation, or additional funds to help residents with special needs. 78 Whc W1n Partic1 pate Sixty board and care operators will be interviaved from large and small homes. The interview takes 1-1/2 hours and is arranged ahead by appointment. A representative of board and care operators will also be invited to the decision-makers conference to be held in June 1985. Examples of Questions to be Explored ° problems faced by operators ° changes in residents' health needs for extra care, costs ° selection criteria of residents ° conditions for relocation of residents ° resources provided, if any, by outside agencies Row the Information will be Used The investigators will compile the findings and provide a report to all participating operators. A summary report will be presented to a conference of decision-makers who will set priorities for action to improve the continuum of care in Los.Angeles County. The investiga tors will also disseminate findings through scholarly channels in order to build an appreciation of board and care as an important component in the long-term care system. Confidentiality We want you to know that all answers to our questions will be confi dential. Your name or any identifying information about you or your home wi11 not appear in any report on the study. A refusal to participate or refusal to answer particular questions will not result in the denial of any right, privilege or benefit to you, the facility, or any residents of the facility. There is no risk to you, or benefit beyond contributing to knowledge about problems of managing board and care homes. Please feel free to call with questions at (213) 743-5981. 79 COPY University of Southern California Ethel Percy Andrus Gerontology Center University Park--MCQ19lJ Los Angeles, California 90089-0191 December 20, 1984 Dear This is to confirm our meeting on ____ __ at _ ___ at your office. I look forward to talking with you about the challenges and problems of operating a board and care home. We will also need some information which describes your home and I have attached a fact sheet. If possible, fill it out before our interview. We appreciate your cooperation. Sincerely, Catherine Chase-Goodman, D.S.W, Interviewer, Andrus Gerontology Center 80 COPY BOARD AND CARE SURVEY FACT SHEET Instructions: I'm sending you this fact sheet since it may be more convenient to look up some of the information ahead of our interview. If possible, please fill it out before our appointment. Please put the correct number in the box provided, or circle the number representing the correct answer. Disregard the small numbers or print at the far right Facility Number_ _ _ _ 1-3 1. How many residents live in your facility right now? 4-6 2. Of this number, how many have lived here six months? 7-9 3. What is the maximum number of residents this place can house at one time? (Do not include owner/operator, family, friends of owner operator or live-in staff) 10-12 4. How many residents have you admitted in the last six months? 13-14 5a. Do you have a waiting list? Circle the number representing yes or no. Yes. . . . . . . . . 1 No (Skip to 6),..2 15 5b. If yes, how many people are currently on your waiting list? _____ 16-17 6a, Do you accept both male and female residents? 18 Men only (skip to 7)... 1 Women only (skip to 7)...2 Both. . . . . . . . . . . . . . 3 6b. If both, how many of each do you have living here now? men I | | 19-21 women j i 22-24 81 7a. Do you accept persons other than the elderly (62 or over)? 25 Yes...... 1 No (Skip to 8)...2 7b. (If Yes) how many persons who are not elderly (62 or over) live here now? 26-28 7c. (If Yes) What types of resident other than elderly are accepted? Mentally retarded... 1 Mentally ill. . . . . . . 2 Other, specify _ _ _ _ _ 3 8. How many bedrooms do you have for the residents to use? 30-32 9. How many are private, that is, have only one occupant? 33-35 10. How many have two occupants? 36-38 11. During the past six months, have any of your residents died either in your home or within two months of being transferred? If NONE, put 00. If SOME, write the number who died. 39-40 12a. During the past six months, how many residents have left here to be institutionalized or to live else where? If NONE, put 00. If SOME, write the number who moved. 41-42 12b. (If 12a is not zero) where did these residents go when they left? How many went there (RECORD THE NUMBER OF RESIDENTS WHO WENT TO EACH TYPE OF LIVING ARRANGEMENT) (DO NOT FILL WITH 00s). 82 General Hospital. . . . . . . . . . . . . . . 43-44 Specialty Hospital Psychiatric State mental hospital ....... ._ 45-46 VA hospi tal . . . . . . . . . 47-48 Other Psychiatric hospital _______ 49-50 Other specialty hospital .... 51-52 Nursing Home (includes SNFs and ICFs)... ___ - 52-54 Residential Care Facility (detoxifica tion centers, treatment center for physically handicapped, residential treatment for emotionally disturbed). . 55-56 Other Board and Care Fad 1ity........... - 57-58 Other Residences Hotel or single room occupany........ 59-60 Residence of Family. ...... ' 61-62 Residence of friends...... . . . . . . . . . ■ 63-64 Own home or apartment (living alone). _ _ _ _ _ 65-66 Left, destination unknown. ...... ' 67-68 13. I want to know some information about the people who work here, that is, the paid employees of this facility. How many people including yourself, but excluding residents, work here? 69-70 14. How many people, including yourself, work 40 hours or more a week? 71-72 THANK YOU FOR COMPLETING THIS SURVEY Card number 1 73 83 COPY PROVIDER INTERVIEW (To be read to the operator at the time of the interview.) The purpose of the study, as explained in my letter to you, is to find out about the problems faced by board and care managers and operators. We want to know how you manage problems within the home; and how you decide you must ask a resident to leave your home. In order to find out, we'll ask you about a specific resident (without names or identifying information) that was asked to leave and one who had a serious problem that was almost asked to leave. The purpose of the study is to get a better understanding of how board and care homes function, but we also hope to be able to recommend changes to policy makers about how board and care operators can be helped to better serve the elderly. Having explained the purpose of this study to you, and the fact that all data obtained in the study wil1 be confidential and no names or identifying information will appear in reports on the study, I would like for you to sign in the space provided to indicate that we have your permission to interview you. As we explained in our letter, your refusal to participate or answer any questions will not result in denial of any right, privilege or benefit to you, the facility, or any residents of the facility. There is no risk to you or benefit beyond the satisfaction of contributing to knowledge about problems of managing board and care homes. The identifying information on this page will be used in case we need to clarify one or more answers. If you wish further information about the study, you may contact Dr. Cathy Goodman, DSW, at the Andrus Gerontology Center, 743-5984 or Sister Linda Marie Stevenson, MSG Candidate, 743-4302. Signature of operator/date Name of interviewer/date Name of Facility___ _ _ _ _ Address of Facility___ Phone of Facility ___ 84 1. Facility I.D. # . | | | | | 1-3 2. Interviewer I.D. # | [ 4 3. Respondent's position with facility: 5 Owner. . . . . . . . 1 Owner-Operator/Administrator. . . . 2 Operator/Administrator (non-owner)..3 Business/Financial Manager..........4 Servi ce/Program Di rector ... .5 Other (Specify) ____ _______ 4. What have you found to be the biggest problem running a facility for the elderly? (ASK QUESTIONS OPEN-ENDED. CODE ANSWERS BY CIRCLING THE CORRECT CATEGORY, OR "OTHER" CODE ANSWER ONLY). 6-7 Licensing regulations.........— ..... 01 Maintaining qualified staff --- .02 Dealing with problems of residents............03 Getting residents referred to the facility....04 Placing difficult residents......... 05 Being able to make adequate income. . . . 06 Getting cooperation from outside agencies.....07 Other.... 08 No response. ... .09 5. (READ) Please think back about the last elderly resident (62 and over) that had a problem that resulted in your asking him/her to leave your home. Briefly describe this person in your own words and explain your main reason for asking him/'her to move. 85 Now I'd like you to describe some specific things about this resident who had a problem that resulted in your asking him/her to leave your home. Describe him/her at the time of crisis when you decided to ask him/her to leave. (CIRCLE THE NUMBER TO CODE THE ANSWER) 5. First I want to know about the person's financial situation. Was he/she No Yes No Answer (a) Receiving SSI? 1 2 4 8 (b) Were you satisfied with the rate he/she was paying? 2 1 4 9 (c) Did you have trouble getting paid? 1 2 4 10 (d) Would more money have made a difference dealing with his/ her problem? 1 2 4 11 (e) Anything else about this resident's financial situation that's relevant to his/her problem, please specify? (CODE BY COUNTING AND LISTING NUMBER IN BOX) , , 12 7. Now I want to know what servi ces this resident needed from your home at the time you asked him/her to leave your home. Did he/ she need: No Yes No Answer (a) A special diet? 1 2 4 13 (b) Help bathing? 1 2 4 14 (c) Help dressing? 1 2 4 15 (d) Help doing personal laundry? 1 2 4 16 (e) Medication supervision? 1 2 4 17 (f) Your (staff) help with transportation to a doctor/ professional service? 1 2 4 18 (g) Require meals in served in the room? 1 2 4 19 (h) Your (staff) help making appointments for medical/ professional services? 1 2 4 20 Yes Yes No Some Much No Answer (k) Any other services? (GODE BY ENTERING NUMBER 8. Now I'Tl ask about this person's physical health problems, if any. Was he/she (a) Confined to a wheel chair? (b) Bedfast, that is, confined to bed? 86 7. (Continued) (i ) Help ambulating (e.g., help getting in and out of bed, or accompani ment to the dining room? (IF YES, DID HE/SHE NEED SOME OR MUCH HELP?) 1 2 3 4 21 (j) Help using the toilet or managing incontinence? (IF YES, DID HE/SHE NEED SOME OR MUCH HELP?) 1 2 3 4 22 23 No Yes No Answer 1 2 . 4 24 1 2 4 25 Good Fair Poor No Answer 1 2 3 4 26 1 2 3 4 27 (c) Was his/her eyesight good, fair or poor? (d). Was his/her hearing good, fair or poor? (e) Was his/her overal1 health good, fair or poor? 1 2 3 4 2B; (f) What other health problems did this resident have? (LIST EACH PHYSICAL HEALTH PROBLEM MENTIONED. CODE BY COUNTING EACH ONE AND ENTERING NUMBER IN THE BOX) 29-30 No/Not a Probl èm Mildly/or Sometimes Severely/ or Often No Answer 87 9. Next, I'll ask about behavioral problems or mental health problems the resident you asked to leave may have had. Please answer using the words on this card: NO/NOT A PROBLEM, MILD MILDLY/OR SOMETIMES, SEVERELY/OR OFTEN. Was he/she: (a) Depressed/ cried a lot? 1 (b) Suicidal (threatened or 2 3 4 31 attempted? 1 (c) Verbally aggressive/ 2 3 4 32 hostile? 1 (d) Physically 2 3 4 33 combative? 1 (e) Abusive of 2 3 4 34 alcohol? 1 (f) Abusive of 2 3 4 35 drugs? 1 (g) Mentally con fused or dis 2 3 4 36 oriented? 1 2 3 4 37 (h) Wandering? 1 2 3 4 38 (i) Running away? 1 (j) Mentally 2 3 4 39 retarded? 1 (k) Troubled by 2 3 4 40 mental illness? 1 2 3 4 41 (1) Other behavioral problems, MENTIONED) pi ease specify. (CODE NUMBER 42 88 10. Now I'11 ask you about this person's strengths and social behavior at the time you had to ask him/her to leave. Answer using the words on this card: NEVER OR SELDOM, SOMETIMES, USUALLY. Was he/she: Never/ Some No Seldom times Usually Answer (a) Pleasant/ likable 1 2 3 4 43 (b) Helpful to others? 1 2 3 4 44 (c) Well groomed? 1 2 3 4 45 (d) Interested in activities? 1 2 3 4 46 (e) Alert? 1 2 3 4 47 (f) Known in the past as pleasant/ likable? 1 2 3 4 48 (g) Liked by most other residents? 1 2 3 4 49 (h) Like by other residents in the past? ' 1 2 3 4 50 (i) Irritating to many other residents? 1 2 3 4 51 (j) Able to get along with a roommate? 1 2 3 4 52 Not applicable...... ...... . 8 (j) Other social strengths. specify. (CODE NUMBER MENTIONED 1 1 53 89 11. Here are a few more basic question: 12 1 : 1 How old Was the male was the person? person you asked (c) I I I to leave or female? Male .. . . ...... 1 Female. .... .2 What was the ethnic/racial back ground of this person? White (non-Hispanic) . . . . . . . . 1 Hispanic. ... 2 B1 ack. . . . . . . 3 Asian/Pacific Islander.. . . . . . . 4 American Indian/Alaskan Native 5 Other ... 6 (d) How long had this person lived in your home? years l months (e) Was he/she motivated to remain your home? Not at al 1 ...... 1 Yes, somewhat....... 2 Yes, extremely . . . . . . 3 The next questions are about family and friends of the person you asked to leave. (a) Did he/she have family? No (Skip to 12e).. 1 Yes. . . . . . . . . . . . . . 2 ANSWER THE NEXT QUESTIONS USING THIS CARD: NEVER/SELDOM, SOMETIMES, OFTEN. 54-56 57 58 I 1 L_l 59-60 61-62 63 64 (b) Was family avail able by phone or in person? (c) Was family co operative? (d) Did family pro- . vi de extra care? Friends (e) Did friends help him/her? (f) Did other residents .he|)p him/her? Never/ Seldom Some times Often No Answer 1 65 66 67 68 69 (g) Were there others who helped (not paid or professional), but informal sources, such as neighbors, friends at work, etc., please specify (CODE BY ENTERING NUMBER MENTIONED , ____ _____ _ _ _ _ _ _ _ _ _ _ _ _ _ L_j 70 card number 2 71 facility id # 90 1-3 Now we'd like you to describe the circumstances at your home at the time you asked this person to leave. We've talked so far about the characteristics of the person you asked to leave. Now I want to know what was happening in your home at the time. Of course, any decisions you make must take into consideration management issues within your board and care home. 13. The next questions are about the vacancy rate in your home at the time you asked this person to leave. (a) (b) (c) (d) No Yes No Answer Did high vacancy rates present a financial problem at the time? 1 2 4 4 Was it hard to get new applicants? 1 2 4 5 Were rooms available at the time? 1 2 4 6 Anything else about vacancy rate relevant to your decision? (CODE NUMBER MENTIONED 14. The next questions are about staffing and resources in your home at the time you asked this resident to leave. No Yes Yes Some All No Answer (a) Could staff provide the services this person needed? If yes, would you say SOME or ALL services? (b) Was your home licensed to care for this type of resident? 1 No (c) Were staff specific ally trained to care for this type of resi dent? If yes, SOME or MUCH training? (d) Did staff spend extra time with this resident? Uf yes, SOME or MUCH time?) No 2 Yes 2 Yes Some No Answer Yes Much No Answer lOi 11 91 14. Continued No High Average Low Answer (e) Were staff stable, that is, was turnover HIGH, AVERAGE, or LOW? 1 2 3 4 12 (f) What other staff issues effected your decision? (CODE NUMBER MENTIONED _ _ _ _ _ _ _ _ |_ j 13 The following questions are about connection between your home and community resources that could help this resident. In the next questions, tell me if the resident needed this type of help and if so, whether or not he/she got it. 15a. Did this resident need dealing with Social Security over an SSI problem? Not needed (Skip to 16)...... 8 15b. If help was needed, did the resident get help? 14 No (Skip to 16).........r. ... .1 Yes.. . . . . . . . . . 2 No Answer. ...... 4 15c. If yes, who was the main person who helped straighten things out? Board and Care Staff..— . . . . . . 1 Family or Friends. . . . 2 Social Agency. . . . . 3 0 th er_ ■ - - . ____ ;_4 15 16a. Did this resident need help getting admitted to a hospital? NOT NEEDED (SKIP TO 17)... . . . . . . . . ..8 I 16b. If help was needed, did the resident get help? 16 No (Skip to 17).... 1 Yes....... .2 No Answer. . . . . 4 16c. If Yes, who made most of the arrangements? 17 Board and Care Staff. ... 1 Family or Friends. ... ....2 Social Agency.. . . . . . . .3 Other_ _ _ _ _ _ 4 17a. Did the resident need extra help from a home health care agency? NOT NEEDED (Skip to 18)......... ......8 17b. If help was needed, did the resident get help? IE No (Skip to 18). . . . . . 1 Yes........ .2 No Answer 4 . 92 17c. If Yes, who made most of the arrangements for this help? 19 Board and Care Staff/. .... 1 Family or Friends.... ...... 2 Social Agency .. 3 Other_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4 18a. Did this resident need help finding.an alternative placement? NOT NEEDED (Skip to 19).. .8 18b. If help was needed did the resident get help? 20 No (Skip to 19)...... ^ .1 Yes........ ....2 No answer..... ...4 18c. If Yes, who provided this help? 21 Board and Care Staff. . . . . .1 Family or Friends. ...... .2 Social Agency .... 3 Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4 19. Did volunteers come to visit and help with this resident in any way? 22 No . . . . . ....1 Yes........ .2 No answer. .... .. . . . . . . . . ........4 20. I,want to know if some social program outside your board and care home provided service for this resident. I'll read a list and you tell me whether or not the resident needed this type of help from an outside agency (in addition to whatever your residency provided). If so, did an outside agency provide it? Not Needed Needed Outside Agency Needed Not Provided Provided Day care 8 1 2 23 Hospice 8 1 2 24 Alcohol treatmeht 8 1 2 25 Drug treatment 8 1 2 26 Outpatient medical treatment 8 1 2 27 Psychiatric treatment 8 1 2 28 Agency transportation program 8 1 2 29 Recreation/activities 8 1 2 30 Other 1 2 31 1 2 32 20a. Were any other outside agencies involved with this resident? If so, specify. (CODE THE NUMBER MENTIONED) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I__ I 33 93 21. Now tell me your reasons for asking this person to leave your home in order of importance. (ASK OPEN-ENDED, THIS WILL BE CODED LATER). a. What was the most important reason you asked him to leave? ^ ________________ J_ I __ L 34-35 b. What was the second most important reason for asking him/her to leave? c. What was the third most important reason for asking him/her to leave? 35-37 38-39 (TO BE CODED LATER) resident's financial limitations..... .01 resident's service needs . . . ...02 resident's health problems. . . . . . . . 03 resident's behavior problems 04 resident's lack of social strengths. ... 05 resident's lack of support from family/friends....06 vacancy rate in the home. . . . . . . . . .07 staff resources in the home..... .... .08 lack of community resources to help. . . . . . . ....09 Other _ _ _ _ _ _ _ _ _ _ _ 10 22. I'll read a list of considerations that may have affected your decision to ask this person to leave your home. Tell me whether or not each consideration affected your decision. Answer using this card: NOT IMPORTANT, SOMEWHAT IMPORTANT, OR VERY IMPORTANT? (CIRCLE ANSWER) SOME- NOT WHAT VERY IMPORT- IMPORT- IMPORT- NO ANT ANT ANT ANSWER (a) Resident's financial limita tions, e.g., lack of money? 1 2 3 4 4C (b) Resident's need for many services? 1 2 3 4 41 (c) Resident's health problems, e.g., illness or handi caps? 1 2 3 4 42 (d) Resident's behavior problems, e.g., aggressiveness, poor 94 SOME NOT WHAT VERY IMPORT- IMPORT- IMPORT- NO ANT . ANT ANT ANSWER 22. Continued (d) continued memory, substance abuse? 1 2 3 4 43 (e) Resident's lack of sociability, or compatibility with other residents? 1 2 3 4 44 (f) Resident's lack of support from family and friends? 1 2 3 4 45 (g) Vacancy rate, e.g., having few rooms available or many applicants? 1 2 3 4 46 (h) Staff resources, e.g., high turn over, not enough trained staff? 1 2 3 4 47 (i) Outside resources, e.g., lack of agency/volunteer help? 1 2 3 4 48 COMMENT: 23. What do you think would have made it possible for this resident to stay in your home? (DON't CODE) | | | 49-50 No Yes No Answer 24. Do you think this resident should have been supported and allowed to stay in your home? 1 2 4 51 25. Where did this person go?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 52 26. (READ) Please think back about the last elderly resident (62 and over) that had a problem that ALMOST resulted in your asking him/her to leave your home. This would be someone with a serious problem but a situation in which you allowed the person to stay, Briefly describe this person in your own words and explain your main reason for ALLOWING HIM/HER TO STAY. 95 Now I'd like you to describe some specific things about this resident who had a problem that ALMOST resulted in your asking him/her to leave your home. Describe him/her at the time of crisis when you decided to allow him/her to stay. (CIRCLE THE NUMBER TO CODE THE ANSWER) 27. First I want to know about the person 's financial situation. Was he/she: No Yes No Answer (a) Receiving SSI? 1 2 4 53 (b) Were you satisfied with the rate he/she was paying? 1 2 4 54 (c) Did you have trouble getting paid? 1 2 4 55 (d) Would more money have made a difference dealing with his/her problem? 1 2 4 56 (e) Anything else about this resident's financial situa tion that's relevent to his/ her problem, please specify. (CODE BY COUNTING AND LISTING NUMBER IN BOX). 57 28. Now I want to know what services this resident needed from your home at.the time you ALLOWED him/her to stay in spite of serious problems. Did this person need: No^ Yes No Answer (a) A special diet? 1 2 4 58 (b) Help bathing? 1 2 4 59 (c) Help dressing? 1 2 4 60 (d) Help doing personal laundry? 1 2 4 61 (e) Medical supervision? 1 2 4 62 (f) Your (staff) help with transportation to a doctor/ professional service? 1 2 4 63 (g) Meals served in the room? 1 2 4 64 (h) Your (staff) help;making appointments for medical/ professional services? 1 2 4 65 96 28. Continued (i) Help ambulating (e.g., help getting in and out of bed, or accompaniment to the dining room)? (If yes, did he/she need SOME or MUCH help?) (j) Help using the toilet or managing incontinence? (If yes, did he/she need SOME or MUCH help?) (k) Any other services? (CODE BY ENTERING NUMBER) 29, No Yes Yes Some Much No Answer 3 4 66 3 4 67 68 card number 3 69 facility id ^ i i i i i 1-3 Now I'll ask about this person's physical health problems, if any. Was he/she (a) Confined to a wheelchair? (b) Bedfast, that is confined to bed? (c) Was his/her eyesight GOOD, FAIR, or POOR? (d) Was his/her hearing GOOD, FAIR, or POOR? (e) Was his/her overal1 health GOOD, FAIR or POOR? No 1 1 Yes No Answer 4 4 Good Fair Poor No Answer 4 4 (f) What other health problems did this resident have? (LIST EACH PHYSICAL HEALTH PROBLEM MENTIONED. CODE BY COUNTING EACH ONE AND ENTERING NUMBER IN THE BOX) 30. 97 Next, I'll ask about behavior problems or mental health problems the resident you allowed to stay may have had. Please answer using the words on this card: NO/NOT A PROBLEM, MILDLY/OR SOMETIMES, SEVERELY/OR OFTEN. Was he/she No/ Mildly/or Not a Some Severely No Problem times dr Often Answer (a) Depressed/ cried a lot? 1 2 3 4 11 (b) Suicidal (threatened or attempted? 1 2 3 4 12 (c) Verbally aggressive/ hostile? 1 2 3 4 13 (d) Physical 1 y 14 combative? 1 2 3 4 (e) (f) Abusive of alcohol? Abusive of 1 2 3 4 15 drugs? 1 2 3 4 16 (g) Mentally con fused or dis oriented? 1 2 3 4 17 (h) Wandering? 1 2 3 4 18 (i) Running away? 1 2 3 4 19 (j) Mentally retarded? 1 2 3 4 • 20 (k) Troubled by mental illness? 1 2 3 4 21 (1) Other behavioral problems , please specify) (CODE NUMBER MENTIONED u 22 31 9 8 Now I'll ask you about this person's strengths and social behavior at the time you decided he/she could stay in spite of serious problems. Answer using the words on this card: NEVER OR SELDOM, SOMETIMES, USUALLY. Was he/she: Never/ ii (g) (h) ( 1) (j) (k) Se dora Some times No Answer Pleasant/likable? 1 2 3 4 23 Helpful to others? 1 2 3 4 24 Well groomed? 1 Interested in 2 3 4 25 activities? 1 2 3 4 26 Alert? 1 Known in the past as 2 3 4 27 pleasant/likable? 1 Liked by mo s t ot he r 2 3 4 28 residents? 1 Liked by other resi 2 3 4 29 dents in the past? 1 Irritating to many 2 3 4 30 other residents? 1 Able to get along 2 3 4 31 with a roommate? 1 Not applicable.. ... . . . 2 3 4 . . .8 32 Other social strengths, specify (CODE NUMBER MENTIONED) 32. Here are a few more basic questions. (a) How old was the person (b) Was the person you ALMOST asked to leave male or female? Maie ... 1 Female........ ..2 (c) What was the ethnic/racial back ground of this person? White (non-Hispanic) .... . .1 Hispanic ... .2 Black.... 3 Asian/Pacific Islander... .... 4 American Indian/Alaskan Native 5 Other. ...... 5 (d) How long had this person lived in your home? years (_ months , 33 34-36 37 38 39-40 41-42 99 32. Continued (e) Was he/she motivated to remain in your home? 43 Not at all...............,....,.....! Yes, somewhat..._ _ _ _ _ _ _ _ _ _ _ _ _ 2 Yes, extremely ... .3 33. The next questions are about family and friends of the person you ALMOST asked to leave, but decided to allow to stay. (a) Did he/she have family? No (Skip to 12e) 1 44 Yes. . . . . . . 2 (ANSWER USING THE WORDS ON THE CARD: NEVER/SELDOM, SOMETIMES, OR OFTEN.) Never/ Some- No Seldom times Often Answer (b) Was family available by phone or in person? 1 2 3 4 45 (c) Was family cooperative? 1 2 3 4 46 (d) Did family provide extra care? 1 2 3 4 47 Friends (e) Did friends help him/her 1 2 3 4 48 (f) Did other resi dents help him/ her? 1 2 3 4 49 (g) Were there any others who helped (not paid or professional), but informal sources such as neighbors, friends from work, etc., please specify. (CODE BY ENTERING NUMBER MENTIONED) ________________ : _______________ - w 50 Now we'd like you to describe the circumstances in your home at the time you ALMOST asked this person to leave, but allowed him/her to stay. We've talked so far about the characteristics of the person who had a serious problem. Now I want to know what was happening in your home at the time. Of course, any decisions you make must take into consideration management issues within your board and care home. 34, 35 100. the time you decided this person coul d stay. ($) Did high vacancy rates present a financial No Yes No Answer problem at the time? (b) Was it hard to get new 1 2 4 51 appl icants? (c) Were rooms available 1 2 4 52 at the time? (d) Anything else about 1 2 4 53 vacancy rate relevant to your decision? (CODE NUMBER MENTIONED) 54 The next questions are about staffing and resources in your home at the time you ALMOST asked this resident to leave. No Yes Some Yes All No Answer (a) Could staff provide the services this person needed? If so, SOME or ALL. of the Services? 1 2 3 4 (b) Was your home licensed to care for this type of resident? 1 2 4 (c) Were staff specially trained to care for this type of resi dent? If so, SOME or MUCH training? 1 2 3 4 (d) Staff spent extra time with this resident? If so SOME or MUCH time 1 2 3 4 High Average Low No Answer (e) Were staff stable, that is, was turn over HIGH, AVERAGE, or LOW? 1 2 3 4 (f) What other staff issues effected your decision? (CODE NUMBER MENTIONED . ____ 55 56 57 58 59 60 101 The following questions are about connection between your home and community resources that could help this resident. In the next questions, tell me if the resident needed this type of help and if so, whether or not he/she got it. 36a. Did this resident need help dealing with Social Security over an SSI problem? NOT NEEDED (Skip to 37).............. 8 36b. If help was needed, did the resident get help? 61 No (Skip to 37)...... 1 Yes.. . . . . .2 No Answer . . . 4 36c. If yes, who helped straighten things out? 62 Board and Care Staff .. 1 Family or Friends .. . . 2 Social Agency ........ 3 Other_ _ _ _ _ _ _ _ _ 4 37a. Did this resident need help getting admitted to a hospital? NOT NEEDED (Skip to 38).. . . . . . . . . . . . 8 37b. If help was needed, did the resident get help? 63 No (Skip to 38). . . . . . . . . . 1 Yes.... 2 No Answer . . . . . . . . . . . 4 37c. If yes, who made most of the arrangements? 64 Board and Care Staff..... . . . 1 Family or Friends .. 2 Social Agency. . . . . . . . . . . . 3 01 he r _ _ _ _ _ _ _ _ _ 4 38a. Did the resident need extra help from a home health care agency? NOT NEEDED (Skip to 39).................8 38b. If help was needed, did the resident get help. 65 No (Skip to 39). . . . . . . . . . 1 Yes........ 2 No Answer.... 4 38c. If yes, who made most of the arrangements? 66 Board and Care Staff...... 1 Family or Friends .. 2 Social Agency. . . . . . . . . . . . 3 Other 4 102 39a. 39b. 39c. 40. Did this resident need help finding an alternative placement? NOT NEEDED (Skip to 40)...__ ..._ _ _ _ _ ..8 If help was needed, did the resident get help? No (Skip to 40)___ 1 Yes... . . . . . . . . . . . . 2 No answer .. 4 If yes, who provided most of this help? Board and Care Staff.... . . . 1 Family or Friends... .....2 Social Agency. .... .3 0 the r _ _ _ _ _ _ _ _ _ 4 Did volunteers come to visit and help with this resident in any way? No. . . . . . . . 1 Yes. . . . . . . . . . . . . . . . . . 2 No answer. . . . . 3 67 68 card number facility id* II I 70 1-3 41a. I want to know if some social program outside your board and care home provided service for this resident. I'll read a list and you tell me whether or not the resident needed this type of help from an outside agency (in addition to whatever your 41b. Outside Agency Not Needed Needed Not Needed Provided Provided Day care.. . .. . . . . . 8 1 2 4 Hospice. ..... ..... 8 1 2 5 A1cohol treatment --- 8 1 2 6 Drug treatment. . . . . . 8 1 2 7 Outpatient medical treatment....... 8 1 2 8 Psychiatric treatment... 8 1 2 9 Agency transportation program.. . . . . . . . 8 1 2 10 Recreation/Activities... 8 1 2 1 t Other 1 2 12 1 2 Were any other outside agencies involved with this resident? 13' If so, specify. (CODE THE NUMBER MENTIONED) 1 1 14 103 42 Now tell me your reasons for ALLOWING THIS PERSON TO STAY in your home in order of importance. (ASK OPEN-ENDED: THIS WILL BE CODED LATER). (a) What was the most important reason you allowed him/her to stay? (b) What was the second most important reason for allowing him/her to stay? (c) What was the third most important reason allowing him/her to stay? for 15-16 17-18 19-20 (TO BE CODED LATER) Resident's financial situation....... 01 Resident's service needs were manageable. . . . . . . . 02 Resident's health problems improved/ manageable. . . . . . . . . . . . . . . . . . . 03 Resident's behavior problems improved/manageable. . . . . . . . . . . . .04 Resident's social strengths . . . . ...05 Resident's support from family/friends....06 Vacancy rate in the home... — . . . 07 Staff resources in the home........ .....08 Community resources to help. . . . . . . . . . 09 Other. ... 10 43. I'll read a list of considerations that may have affected your decision to allow this person to stay in your home. Tell me whether or not each consideration affected your decision, and if so, was it SOMEWHAT important. or VERY important? (CIRCLE ANSWER) Not Some what Very Import Import Import No ant ant ant Answer (a) Resident's financial situation. e.g., money helped? 1 2 3 4 21 (b) Resident's service needs could be met? 1 2 3 4 22 (c) Resident's health problems, e.g., ill ness or handicaps improved/manageable? 1 2 3 4 23 104 43. Continued Not Import ant (d) Resident's behavior problems, e.g., aggressiveness, poor memory, substance abuse improved/ manageable? (e) Resident's socia bility, or com patibility with other residents? (f) Resident's support from family and friends? (g) Vacancy rate, e.g., having rooms available or few applicants? (h) Staff resources, e.g., low turn over, enough trained staff? (i) Outside resources, e.g., agency/ , volunteer help? COMMENT: Some what Import ant Very Import ant No Answer 24 25 26 26 28 29 44. Do you think this resident should have been allowed to stay in your home? No 1 Yes No Answer The next questions are about admissions criteria and resident characteristics. 45a. Do you accept persons confined to wheelchairs? Yes. . . . . . . . . . . . . . . . . . . . 1 No (Skip to 46). . . . . . . . . . . . 2 45b. If yes, ask : How many wheelchair bound persons are living here now? 30 31 32-33 46a. 46b. 50. 105 Do you accept persons who must use a walker, cane or crutches? Yes. . . . . . . . . . . . __ ...1 No (Skip to 47)......... 2 34 If yes, ask: How many of your current residents use one of these devices in order to get around? 47a. Do you accept bedfast persons, that is, persons who cannot get around on their own at all? Yes. . . . . . . 1 No (Skip to 48)........ 2 47b. If yes, ask: How many bedfast persons are living here now? 35-36 37 48a. Do you accept persons who are legally blind? Yes. . . . . . . . . . . 1 No (Skip to 49). . . . . . 2 48b. If yes, ask: How many blind persons are living here now? 38-39 40 49a. Do you accept persons who are deaf? Yes.......... 1 No (Skip to 50). . . . . . 2 49b. If yes, ask : How many deaf persons are living here now? 41 -42 43 44-45 I'm going to read you a list of behaviors that are sometimes used to decide whether or not a person can be accepted into a particular residence. I would like for you to tell me whether or not you would accept a person with the characteristics I read Each behavior or characteristic should be judged entirely by itself (on its own service requirements apart from any other considerations such as empty beds, multiple impairments, etc.). 106 ANSWER YES, NO, OR MAYBE Would you accept a person who (a) Needs medication super vision... ... .. . . . . (b) Needs special diet. ..... (c) Has a recent history of being verbally aggressive/ hostile to others (within 30 days)..... ...... (d) Has a recent history of being physically combative (within 30 days). . . . . (e) Is mentally confused/ disoriented..,,.,., (f ) Wanders ..... ..... (g) Has been treated for mental illness within last year... (h) Is mildly or moderately ' mentally retarded, u. (i) Is known to abuse alcohol one or more times a week... (j) Is known to abuse drugs one or more times a week... (k) Has long periods of depression/cries a lot..... (1) Has threatened or attempted suicide within the past year (m) Runs away....... .... (n) Incontinence Yes 1 1 No .2 2 46 47 48 49 50 51 52 53 54 55 56 57 58 59 51a. If you had to move a resident out of here because his/her behavior was not acceptable or he/she was no longer functioning sufficiently well to live here, is there someone you could call who would attempt to find the person another place to live? Yes. . . . . . 1 No (Skip to 52).... 2 60 51b. If yes, ask: What Agency for the agency aged.. does this person 1 work with? 61 Social services/welfare. . . . . . 2 Mental health. . . . . . 3 Mental retardation. . . . . . . . . 4 Licensing ..... 5 Other, specify_ _ _ _ _ _ _ _ _ _ _ _ 6 Not ascertained. . . . . . . . . . . 9 107 52. What do you think would be a solution to deal with older adults who need more or specialized care. (ASK OPEN-ENDED, THEN READ SOLUTIONS LISTED) (TO BE CODED LATER) Yes (a) Extra money for special needs...... . ...... 1 (b) An additional level of care for long term custodial care needs (between board and care and nursing home care)..... 1 (c) Special training for operators and staff. ... 1 (d) More available home-health services that could help people in board and care homes . . . . . . . . . . . 1 (e) Better connection between board and care homes and community service agencies.. 1 Provision of Services No 2 Maybe 3 . 52-63 64 65 66 67 68 53a. Volunteers: Do you have volunteers from the community who come here and either do things for the residents or take them places? Yes . . . . . . . 1 No (Skip to 54). ... 2 69 Not ascertained-- ...4 53b. About how often do volunteers come here? Daily (7 days a week).1 3-6 days a week.... 2 1 -2 days a week. ... 3 2-3 days a month. . . . 4 About once a month.... 5 Less than once a month. . . . . . . 6 Not ascertained.... 9 70 54a. Service Agency Personnel. Do professionals from one or more service agencies come here to see some or all of the residents? Yes. . . . . . .1 No (Skip to 55)... 2 108 71 card number 5 72 facility id# 1-3 (CODE AGENCY FOR EACH SERVICE PROVIDER NAMED, ASK:) Approximately how often does (NAME OR SERVICE PROVIDER) come here? (CODE FREQUENCY) Agency Codes Frequency Codes Mental Health.. . . . . .1 Daily. . . . .... . .1 Physician. . . . . . . . . .2 3-6 days a week.... 2 Aged Agency..... . . .3 1-2 days a week.... , .3 Social Service/Welfare. .4 2-3 days a month.....4 Home Health... .... .5 About once a month. ..5 Public Guardian.... .6 Less than on ce/mo....6 Other, specify 7 54b, Tell me who these persons are and what agencies they represent. AGENCY CODE FREQUENCY CODE List other agencies 4-5 6-7 8-9 10-11 12 54c About how many of the residents are being seen here at this facility by a professional service provider? 13-14 1Q9 Facility Provided Services 55. My next set of questions are about services that this facility may or may not provide. I will read you a list of services and for each one I need to know whether or not it is currently being provided on a routine basis to one or more residents. I'll begin with person care type services. Do you or your staff regularly help any of your residents with: Personal Care Yes No Bathing..... 1 2 15 Dressing. 1 2 16 Eating 1 2 17 Brushing or combing hair. .... 1 2 18 Brushing their teeth/ cleaning dentures 1 2 19 Shaving. 1 2 20 Toileting.. . . . 1 2 21 Servi ce 56a. Does this facility serve meals? 22 Yes. . . . . 1 No .... 2 56b. If yes, ask: How many days a week do you serve? 1. 57. Do you or your staff (or volunteers) routinely: Yes No Accompany residents on shopping trips?. . . . . . . . . . . . . . . . . Shop for residents? ........ Write letters for residents or help them make calls?. . . . . . . Make telephone calls for residents or help them make calls?.. . . . Help them use public transportation? ....... 23 Yes No 56c. Do you have a recreation/activities director? 1 2 24 56d. Does your facility provide beautician/barber services? 1 2 25 Other Services 2 2^ 2 27 2 28 I 2 29 2 30 Yes Provide transportation for pro fessional service needs such as medical appointments, worshops, etc.?.. . . . . . . . . . . Provide transportation for resident's personal errands?... Assist residents in obtaining appointments for medical, dental, or other professional services?... Manage residents' spending money (hold and disburse it)? :..... Provide sheets and towels for residents' use? ........ Do residents' personal laundry for them?. . . . . . . . . . . . . Provide free washing machines for residents' use?......... Provide coin-operated washing machines?. . . . . . . . . . . . . . . . Clean residents' rooms other than floor care?.. . . . . . . . . . . . . . Take residents on planned outings?... Have parties and get-togethers for special occasions? -- ---- No 2 2 2 2 2 2 2 2 2 2 1 110 31 32 33 34 35 36 37 38 39 40 41 Is there any other routine service that you provide that I have not mentioned? (IF YES, PLEASE LIST) Ownershi p 58a. Could you tell me who owns this business? Individual or couple..... 1 Other related individuals, fami 1 y business. . . . . . . . ......2 Other unrelated individuals, partnership ...... 3 Church/charitable organization.... 4 Public agency (non-profit). . . . . . . 5 Other non-profit (Specify). . . . . . . 6 Other Profit (specify).. . . . . . . . . 7 Not ascertained. . . . . . . . . . . . . . 9 58b. Is this business incorporated? Yes.... 1 No . . . . . . . . . . . . . . 2 Not ascertained ... 9 42-43 44 48 Ill 58c. Do you (the owners of this facility) own other residential care facilities? 46 Yes ... 1 No.. . . . . . . . . 2 Not ascertained...... 9 59. Does this facility have some formal relationship with a public agency that places or refers residents? That is, is the facility certified by an agency to serve certain types of residents, is it in a contract with an agency, or does it receive reimbursement from an agency in return for taking certain groups of people? 47 Yes. . . . . . . . . . . . . 1 No........ 2 Not ascertained. — 9 Funding 60. Are all residents charged the same monthly amount to live here? 48 Yes. . . . . . . 1 No (Skip to 62). . . . . . . . . . 2 Not ascertained. . . . . . . ....9 61. If Yes ask: How much is your basic monthly charge? $11111 49-52 62a. What is the lowest amount currently being charged to any resident to live here? $ I I I I I 53-56 62b. What is the highest amount charged to any resident? $ I I I I I 57-60] 62c. What is the amount charged to most residents? $11 I Li 61-64 113 Licensing 63. What licenses do you have to operate this facility? (ASK FOR EACH LICENSE THEY NAME: DON'T READ THE LIST.) Who issues this license? (DETERMINE THE AGENCY AND CITY/ COUNTY/STATE STATUS OF LICENSING AGENCY— CODE APPROPRIATELY) Agency Code Level of Government Code Health. ........... . .1 State. ... . . . . . . . 1 Fire Department__ _ _ _ 2 County.... .. . .2 Social Service/Welfare....3 City......... 3 Agency for the Aged.. . .4 City/County.... 4 Housing... . . . . . . . . .5 Not ascertained....9 Other: Specify 5 Not Ascertained.. . . . . .9 AGENCY CODE LEVEL/GOV. CODE 64. Do you have any problems with licensing regulations? 65-66 67-68 69-70 card number 6 facility id# | | | 71-72 73 1-3 Characteristics of Respondents We also need some information about the people who are running board and care homes so the next few questions focus on you as a pro vider of care. 65. Sex: 66. Age : male... 1 female___ 2 4 5-6 113 57. Race/Ethnicity 7 White (non-Hispanic). . . . . . . . . . 1 Hispanic. . . . . . . . . . . . . . . . . . 2 Black. ..... 3 Asian or Pacific Islander. ...4 American Indian or Alaskan Native..5 Other. . . . . . . . . . . . . ...... 6 68. Marital Status 8 Never married.. . . . . . . . . . . 1 Married. . . . . . . . . . . . . . . . . . 2 Separated. . . . . . . .3 Widowed. ..... 4 Divorced.. .. . . 5 69. How much formal education have you had? 9 Less than high school graduate 1 High school graduate. . . ...... 2 Trade, technical or vocational school.. . . . . . 3 Some college. . . . . . . . . . . . . . . 4 Bachelor's degree .. . . . . . . . . 5 Some graduate work. ... 6 Graduate degree...... ...... 7 70. Have you had any specialized training that was designed to help you run a residential facility? 10 Yes. . . . . . . . . . . . . 1 No.... . . . . . ...... 2 Not ascertained. ... 9 71. Altogether, how many years of experience do you have either operating or working in a residential care setting? I I 11-12 72. Do you plan to stay in this type of business? 13 Yes (THANK RESPONDENT- CLOSE INTERVIEW)......1 No .. 2 Uncertain. ....... 3 114 73. (IF NO OR UNCERTAIN, ASK:) Why not (why are you uncertain)? OPEN RESPONSE. CIRCLE ALL THAT ARE APPLICABLE) Reasons Financial reasons (can't make any money). . . . . . . . . . . . . . . Personal reasons (ill health, too old)... Regulations too hard to meet (over regulated) . . . . . . . . . . Zoning restrictions. . . . . . . . ...... Community acceptance/attitudes..... Other, specify _____ _ _ _ _ _ _ __ Yes No 1 2 14 1 2 15 1 2 16 1 2 17 1 2 18 19 THIS ENDS THE INTERVIEW. THANK YOU. YOU'VE BEEN VERY HELPFUL INTERVIEWER COMMENT: What do you feel were the main problems experienced by this operator? What else stands out about this interview? What did you learn about operating a board and care home?

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Asset Metadata

Creator Stevenson, Linda Marie (author)

Core Title An analysis of how auspices and administrator preparation affect who is served by board and care homes for the elderly

Degree Master of Science

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

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-408172

Unique identifier UC11658397

Identifier EP58923.pdf (filename),usctheses-c37-408172 (legacy record id)

Legacy Identifier EP58923.pdf

Dmrecord 408172

Document Type Thesis

Format application/pdf (imt)

Rights Stevenson, Linda Marie

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