U.S. Department of Health and Human Services

Report on the Effects of Regulation on Quality of Care: Analysis of the Effect of Regulation on the Quality of Care in Board and Care Homes

Executive Summary

Charles Phillips, Linda Lux, Judith Wildfire, Angela Greene, Catherine Hawes, George Dunteman, Vince Iannacchione, Vincent Mor, Rebecca Green and Diana Spore

Research Triangle Institute and Brown University

December 1995

This report was prepared under a contract between the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE) and Research Triangle Institutes. In addition to ASPE, other support for the study was provided by HHS's Health Care Financing Administration, Office of Research and Demonstrations. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.shtml or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Floyd Brown.

SUMMARY OF RESULTS

A variety of demographic factors and policy initiatives have led to increased demand for residential facilities that offer supportive services for the aged and disabled. Over the past 20 years, board and care homes have emerged as the most common setting for the provision of such care outside nursing homes. As a result, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services (DHHS) has had a long-standing interest in the potential of board and care homes to meet the needs of aged and disabled persons for residential services.

In line with this interest, ASPE was concerned with reports that raised questions about the effectiveness of State regulation of these homes and about the adequacy of care provided. Thus, in the early 1990s, ASPE initiated a new examination of board and care homes and their role in the long-term care system. The policy interest was threefold:

• To document the characteristics of board and care homes, how much they had grown in the United States since the initial studies of the 1980s, and the role they play in meeting the needs of the disabled for long-term care
• To describe the characteristics of board and care residents, particularly the extent of frailty and disability among residents
• To assess the quality of care received by board and care residents and examine the effect of State regulation on the quality of that care.

The study results reported here deal with the effects of regulation on the quality of care in board and care, or domiciliary care, facilities. The database for the study included data gathered in 512 board and care facilities in 10 States. These data were collected through interviews in 386 licensed homes and 126 unlicensed homes with 512 facility operators, 1,138 facility staff, and 3,257 facility residents.

This report presents the analysis of the effect of regulation and licensure on the quality of care in board and care homes. It also briefly reviews the study purpose and methodology, as well as a description of the homes and residents; however, these topics are addressed in greater detail in two other project reports: A Description of Board and Care Facilities, Operators, and Residents (Wildfire et al., 1995) and Report on Study Methods (Hawes et al., 1995).

The remainder of the report explores the findings about the effect of regulation and licensure in great detail; Exhibit 1 summarizes those findings. As the data surninarized in that exhibit demonstrate, this inquiry found substantial and widespread positive effects of regulation on quality in board and care homes.

1. Reducing Prevalence of Unlicensed Homes

   First, we found that States with extensive regulatory systems had a significantly smaller proportion of unlicensed facilities. Regulation seems to reduce the prevalence of unlicensed homes.

2. Improving Quality of Care

   Second, we found that extensive regulatory systems were associated with better quality of care. Several findings suggest that homes in States with extensive regulatory systems were better prepared to cope with needs of residents who are frail and disabled. For example, homes operating under more extensive regulatory systems were more likely to have operators trained in care of the elderly and disabled, to have lower use of psychotropic drugs, and to have lower use of inappropriate prescriptions for the elderly. Also, staff in licensed homes in States with extensive regulatory systems were more knowledgeable about and more willing to refer residents and families to the longterm care ombudsmen programs. In addition, licensed homes made a wider array of key supportive services available to residents. Finally, both extensive regulation in large homes and ficensure in all sizes of homes were associated with greater availability of devices, such as grab-bars in showers, call buttons in bathrooms, and raised toilet seats, that support residents' abilities to function more independently and with greater safety. Thus, both licensure and extensive regulation were associated with key aspects of better quality of care.

3. Improving Quality of Life

   Third, the study found a consistent pattern with respect to many of the features that promote quality of life for residents. Homes in States with extensive regulatory systems, for example, had greater availability of social aids for residents, such as reading materials, a community room, and a working television and radio. Also, contrary to the expectations of some observers who fear that regulation will lead to more "institutional" environments, the study found that neither extensive regulation nor licensure was associated with more institutional environments when one considers such factors as personalization of residents' rooms; diversity in furniture, wall colors, and floor coverings; and lighting in the homes. In fact, extensive regulation and ficensure made a facility less likely to have a "low" score on such diversity. Taken together with the positive impact on social and recreational aids, such findings suggest that regulation has a positive effect on key aspects of quality of life in facilities.

4. Improving Safety

   Fourth, like other studies, we found that regulation had a positive effect on the safety of the residents' environment. Licensed facilities had a wider array of the safety features considered important by residents and others who study the ability of a facility to meet the needs of frail and disabled individuals (Moos and Lemke, 1988). Compared to unlicensed facilities, including apartments, licensed facilities had a higher percentage of safety features, such as smoke detectors, a fire extinguisher in the kitchen, secure handrails on stairs, and supportive devices, such as grab-bars in the shower, call buttons in the bathroom, and grab-bars by the toilet.

5. Preventing the "Worst" Performance

   Fifth, the study found that regulation, mainly through licensure alone, succeeds in what many view as the main role of regulation: preventing homes from being in the lowest range of performance on key aspects of quality. Licensed homes were less likely than were unlicensed homes to have the lowest scores on safety, physical amenities, and social aids. They were also less likely to have low diversity or a very institutional environment.

6. No Positive Effect

   Finally, the study also found that neither extensive regulation nor licensure had a positive effect on some aspects of quality, including a requirement for preservice training of staff and staff knowledge of care and monitoring as well as medication management. Regulation also had no significant effect on the cleanliness of homes and availability of amenities or the likelihood that a home would have any licensed nurses (RNs or LPNs) on staff. Further, there was little variation among homes on such issues as unmet health care needs, residents' rights, and indicators of resident satisfaction.

These findings and their implications for public policy are discussed in detail in the sections that follow.