U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
This report was prepared under contract #HHS-100-89-0031 between HHS's Office of Family, Community and Long-Term Care Policy (now the Office of Disability, Aging and Long-Term Care Policy) and the Research Triangle Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The Project Officer was Floyd Brown.
Drug data entry and related analyses were funded by a grant from the Geriatric Drug Therapy Research Institute to Brown University. Diana Spore was supported by the Agency for Health Care Policy and Research Training Grant T32-HS00011 awarded to Brown University.
A variety of demographic factors and policy initiatives have increased demand for residential facilities that offer supportive services for the aged and disabled. These factors include
Although families continue to be the major source of long-term care, a variety of residential settings with supportive services have emerged to supplement their efforts. These arrangements support families whose members need more care than the family can provide and those elderly and disabled who have no family. Other than nursing homes, the most common form of residential setting with services for people with disabilities is board and care homes. This term is used in a variety of ways across the States. For this study, however, “board and care” refers to nonmedical community-based residential settings that house two or more unrelated adults and provide some services such as meals, medication supervision or reminders, organized activities, transportation, or help with bathing, dressing, and other activities of daily living (ADLs).
There are approximately 34,000 licensed board and care homes in the United States with more than 613,000 beds (Clark et al., 1994). These homes fall into one of three basic types of licensed facilities (Clark et al., 1994): (1) homes serving a clientele with mental retardation or developmental disabilities; (2) homes serving a clientele with mental illness; and (3) homes serving a mixed population of physically frail elderly, cognitively impaired elderly, and persons with mental health problems. The majority of homes fall into this last category. Not all board and care facilities, however, are licensed, and there is little uniform or comprehensive information about such homes. Unlicensed homes are as numerous as licensed facilities by some estimates (U.S. House, 1989). Thus, the total number of persons living and receiving long-term care in all types of board and care homes may be as high as 1 million (Clark et al., 1994; Hawes et al., 1993; Moon et al., 1989; U.S. House, 1989). As a point of comparison, there are an estimated 17,000 licensed nursing homes with approximately 1.68 million beds serving more than 1.5 million nursing home residents (DuNah et al., 1993).
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services (DHHS) has a long-standing interest in the potential of board and care homes to meet the needs of aged and disabled persons for residential services. ASPE commissioned a study in the early 1980s by Denver Research Institute (DRI) that described board and care homes and residents in five States and investigated the effect of regulation on quality of care (Dittmar and Smith, 1983). Other studies during the 1980s also attempted to describe homes and residents, the regulation of these homes by States, and the role these facilities play in providing long-term care (i.e., Reichstein and Bergofsky, 1980; Sherwood et al., 1981).
In the early 1990s, ASPE initiated a new examination of board and care homes and their role in the long-term care system. This time the policy interest was threefold:
To address these questions, ASPE launched two related initiatives. The first by Lewin-VHI, Inc., was a national survey of State licensure agencies to determine the number and types of home and to generate a list of homes (Manard et al., 1990). The second initiative is the study reported here, and it addresses concerns related to board and care quality. ASPE placed a high priority on the need to evaluate board and care quality for several reasons.
First, the Federal expenditures directed at home and community-based services for persons with disabilities in all types of community-based residential settings was increasing rapidly in the early 1990s. Nevertheless, the Federal government played only a limited role in monitoring or regulating the quality of those services. The regulation of board and care was primarily a State responsibility, with the Federal role largely limited to the oversight specified in the Keys Amendments.1 The emphasis on strengthening Federal oversight of nursing home quality required by the Omnibus Budget Reconciliation Act of 1987 served to highlight the lack of systematic information on board and care residents and the effect of State regulations on their well-being. Second, there was a belief that the residents of board and care homes were far more disabled than they had been a decade before. Third, concerns were raised by the U.S. General Accounting Office, congressional hearings, and other studies that residents were not receiving adequate care or protection from health and safety risks (Avorn et al., 1989; Budden, 1985; GAO, 1989; 1992a; 1992b; Hartzema et al., 1986; U.S. House, 1989). These studies reported evidence of unsafe and unsanitary conditions, wide-spread use of psychotropic medications, lack of staff knowledge about medication administration, and other health and safety problems. Fourth, several reports raised questions about the effectiveness of State regulatory efforts (ABA, 1983; Dobkin, 1989; GAO, 1989; Hawes et al., 1993; Newcomer and Grant, 1988; Reichstein and Bergofsky, 1980; Stone and Newcomer, 1985; U.S. DHHS Inspector General, 1990). In addition, there were assertions that significant numbers of board and care homes were unlicensed and unregulated (U.S. House, 1989).
This is the second in a series of four reports that summarize study findings and methods. This report presents descriptive findings on the characteristics of board and care facilities, operators, staff, and residents. Section 2 briefly describes the study design and sampling and analytic methodology; more detailed discussion is presented in the Technical Report Study Methods. Section 3, Section 4, Section 5, and Section 6 describe the facilities, operators, staff, and residents in the board and care homes in this 10-State study.
The goals of this project were to describe the quality of care in board and care homes and how it varies across licensure and regulatory systems. Accomplishment of these objectives required a study design that incorporated several activities, including a major collection of new data. The study design included:
This section of the report provides an overview of these study methods, which are described in more detail in the technical report Project Study Methods (RTI, 1995).
The objective of this study was to determine whether regulation affects the quality of care in licensed and unlicensed board and care homes. Specifically, the study was designed to determine whether an extensive regulatory system is associated with better quality of care and, if such an association is found, to determine whether regulation affects licensed and unlicensed homes differently.
We chose a “polarized” approach to test the main hypothesis. If regulation affects quality of care, the association will be most apparent in the extremes of the regulatory environment. That is, for a given sample size, the best chance of detecting regulatory effects on quality is afforded by restricting the sample to homes located in States with the most extensive and most limited regulatory systems. If licensure status (licensed/unlicensed) is included with regulatory environment as a second factor, the result is a two-factor by two-level (i.e., 2x2) factorial design.
In the sections that follow, we discuss the definition of the study population and the sample design, including the selection of States and the selection of probability-based samples of board and care homes, their staff, and residents. We also summarize our strategies for measurement construction and analysis.
We produced a comparative ranking of the regulatory environments among the 50 States. We are confident that the States in the extensively regulated range have more stringent regulations, monitoring, and enforcement policies than do those on the limited end of the continuum. However, we did not assess the States’ regulatory environment with respect to a “gold standard” of very strong regulations. The 10 study States were: California, Florida, New Jersey, Oklahoma, and Oregon in the extensive regulatory stratum and Arkansas, Georgia, Illinois, Kentucky, and Texas in the limited regulatory stratum.
Each study State had different definitions or criteria for licensure of board and care homes, and, even within States, there were multiple categories of homes and multiple agencies that licensed homes. Because of this variation, we adopted decision rules about inclusion and exclusion for both licensed and unlicensed homes.
As a first step, we limited the study population by excluding homes specifically licensed to serve only special populations--children, the chronically mental ill, mentally retarded/developmentally disabled (MR/DD), and substance abusers. These facilities often operate under different licensure standards and have different programmatic funding compared to the vast majority of homes that are licensed to serve an unrestricted population. Because the main goal of the study was to assess the effectiveness of regulation and to describe the most prevalent homes and residents, this exclusion was necessary.
Once this exclusion was made, we included in the sample all other facilities licensed as board and care homes in the State. However, the construction of the sampling frame for licensed homes was complicated by the need to “capture” all relevant licensed homes, even those referred to by other names and those licensed by more than one agency or division. This meant, for example, that in some States, such as Oregon, we included three types of board and care homes serving an elderly/mixed population: adult foster care homes, residential care homes, and assisted living facilities. However, in California we included only residential care facilities for the elderly (RCFEs) and excluded residential care facilities (RCFs) that served only persons younger than 60 with chronic mental illness and developmental disabilities.
Given the variety of definitions of licensure across the 10 study States, developing criteria for the inclusion of unlicensed facilities was even more challenging. Because of licensure standard variations, for example, homes that were legally unlicensed in Texas (e.g., adult foster care homes with five or fewer beds) were required to be licensed in California and Oregon. Similar variation was found for facilities, often referred to as “assisted living,” that housed residents in apartments but whose residents received services similar to those in more traditional board and care homes. In some States, “assisted living” facilities must be licensed under the board and care regulations; in others, they are specially excluded from these licensure requirements. In all States, we expected to find some facilities that required licensure as a board and care home ignoring the requirement and operating “illegally.”
We developed an operational definition for an eligible unlicensed board and care home that we used across the States. We also defined specific criteria for inclusion of “assisted living” facilities and other places that included apartments, did not provide three meals a day or 24-hour staffing, but did provide key personal care services (e.g., medication reminders or supervision, money management, assistance with personal care). Thus, we defined two sets of criteria for inclusion of a place as an eligible unlicensed home in our sampling frame.
The sample design is a stratified, three-stage, cluster design. First-stage sampling units are counties, second-stage units are facilities, and third-stage sampling units are residents and staff of selected homes. Additionally, because we expected home size to affect quality, we stratified facilities to control the distribution of small, medium, and large facilities. Greater detail can be found in Iannacchione et al. (1994).
The development of instruments to describe residents, homes, operators, and staff and to capture key elements of quality was another major task.
We developed three basic types of measures: (1) those used to describe homes and residents, (2) those used as covariates in the analysis of the effect of regulation and licensure on quality, and (3) those used to evaluate the quality of care and life in the homes.
We used fairly straightforward measures to describe residents and homes. Most come directly from individual items on the various survey instruments. In addition to these variables, we constructed several composite measures (e.g., facility occupancy rate, average payment per month per resident, counts of the number of different services offered by the facility, and an aggregate case mix classification describing the bulk of facility residents). Additionally, we used several scales to characterize residents’ physical and emotional functioning: a count of the number of ADL dependencies, the five-item Mental Health Inventory (McHorney et al., 1994) and a three-level mental health status measure that was constructed from the Blessed Scale, and, for residents with proxy respondents, ratings of the resident’s cognitive function using the Cognitive Performance Scale (Morris et al., 1994).
During the summer and early fall of 1993, RTI field interviewers (FIs) conducted in-person interviews in the sampled facilities with operators, staff, and residents in 10 States. In addition, interviewers followed a protocol to conduct a structured observational “walk-through” of the home, rating various qualities of the facility. We conducted site visits to 386 licensed and 126 unlicensed board and care homes. In these visits, we conducted interviews with 490 operators, 1,138 staff, and 3,257 residents and observed the physical environment and care of residents in each facility.
A detailed summary of the topics and items covered during each interview and the structured walk-through observation can be found in the technical report, Project Study Methods (RTI, 1995).
Licensure status and the extensiveness of regulation in the two groups of States were the independent variables against which facility and resident quality measures were compared. Consistent with the sample design and original study power calculations, we used a probability level of 0.05 as the determination of statistical significance.
To study the relationship between regulation, licensure, and quality of care constructs at both the facility and the resident level, we used multivariate modeling techniques that control for multiple explanatory variables. For continuous quality measures we used linear regressions. When the outcome was binary, logistic regression was the technique of choice. Because no single measure of quality of care summarized all aspects of care, we fit multiple models with dependent variables that characterized the different aspects of care. The results of these analyses are presented in a separate report.
All analyses were conducted using weighted estimates of the number of homes and residents within the group based on the sampling design. To account for the multistage, complex cluster sampling techniques used, we used software that adjusts the standard errors of estimate for the intercorrelation among sampled units within clusters (SUDAAN). SUDAAN produces unbiased variance estimators for linear (or nonlinear) statistics no matter how subsampling occurs within FSUs.
Operators in 490 board and care facilities completed two questionnaires about their facilities’ characteristics and policies. These data suggest that there was enormous diversity among places known as board and care homes in size, price, setting, service mix, resident mix, and available services. This chapter presents our findings on these facility characteristics. We also examine whether there were significant differences between licensed and unlicensed facilities and licensed extensively regulated homes and licensed homes in States with limited regulations.
The widespread perception that board and care homes are small, “homelike” settings is misleading. The facilities in our study ranged in size from places with 2 beds to those with more than 1,400 and included family homes as well as multilevel facilities that also had congregate apartments and a skilled nursing home. More than 70 percent of the licensed and nearly 50 percent of the unlicensed homes were small (Exhibit 3-1). However, in licensed homes, 25 percent of the residents lived in medium-sized homes (11-50 beds), and 52 percent lived in large, licensed homes (51+ beds). Among residents of unlicensed homes, more than 80 percent lived in large facilities. These large unlicensed homes included assisted living facilities and retirement communities that provide meals, protective oversight, and some services.
| EXHIBIT 3-1. Facility Size |
 |
Less than 20 percent of all facilities were nonprofit, with licensed facilities being less likely to be nonprofit than unlicensed homes. Specifically, only 15 percent of small licensed homes were nonprofit compared to almost 40 percent of small unlicensed homes (Exhibit 3-2). In looking at licensed facilities, we observed that licensed homes in extensively regulated States are less likely to be nonprofit than those in States with limited regulations.
Overall, less than 10 percent of board and care homes were attached to nursing homes (Exhibit 3-3). Virtually no small homes reported affiliation to a nursing home compared to almost one-third of the large homes. However, licensed homes in States with limited regulations are twice as likely to be attached to nursing homes (see Table A-9).
Perhaps an indication of the rapid growth experienced by the board and care industry recently is the fact that about one-third of the operators reported owning or operating another board and care facility in addition to the one included in the study. Almost 10 percent reported owning or operating a nursing home.
| EXHIBIT 3-2. Nonprofit Facilities by Licensure Status, Regulatory Environment, and Size |
 |
| EXHIBIT 3-3. Facility Affiliation with Nursing Homes and Ownership Patterns | ||
|---|---|---|
| Total Population | ||
| % | SE | |
| Attached to a nursing home | 7 | 1.5 |
| Operator owns/operates another board and care facility | 33 | 4.8 |
| Operator owns/operates a nursing home | 8 | 1.8 |
We observed no consistent differences in occupancy rates across various types of facilities, with the average occupancy rate being about 80 percent. Although the occupancy rates were similar, we found that the average monthly revenue per resident in licensed extensively regulated homes was over $300 higher than in licensed homes in States with limited regulations. In particular, licensed small and medium homes had significantly higher average per-resident monthly revenue than did comparably sized unlicensed homes (Exhibit 3-4).
| EXHIBIT 3-4. Facility Average Monthly Revenue per Resident by Size, Licensure, and Regulatory Environment |
 |
Because a large proportion of board and care residents take prescription medication, it is particularly important for facilities to have appropriate medication management practices. Licensed and unlicensed homes reported significantly different practices. Regardless of size, licensed homes were more likely to allow at least some residents to manage their own medications (Exhibit 3-5).
| EXHIBIT 3-5. Medication Management Practices by Licensure and Size |
 |
Board and care facilities varied immensely on criteria for admittance to their facilities. Almost half of the facilities reported that they would not admit residents who were mobility-impaired. Twenty-three percent would not admit incontinent residents, and 19 percent would not admit SSI recipients. Almost all facilities reported accepting residents with behavior problems (Exhibit 3-6).
| EXHIBIT 3-6. Facility Admission and Discharge Policies | ||
|---|---|---|
| Total Population | ||
| % | SE | |
| Will not admit residents who are/have | ||
| Mobility impairment | 46 | 5.4 |
| Behavior problems | 2 | 0.8 |
| Incontinent | 23 | 3.2 |
| SSI recipients | 19 | 3.7 |
| Will discharge residents who become/develop | ||
| Mobility impairment | 35 | 8.0 |
| Behavior problems | 2 | 2.1 |
| Incontinent | 8 | 4.1 |
| SSI recipients | 2 | 3.3 |
However, perhaps even more important to a resident who wishes to “age in place” is a facility’s discharge policy for residents who develop debilitating conditions while residing in the facility. We asked operators who reported that their facility did not admit residents with certain characteristics (e.g., incontinence, mobility impairment) whether the facility would discharge a resident who develops the conditions after being admitted to the home. Seventy-five percent of the facilities that did not admit mobility-impaired residents (35 percent of all facilities) reported discharging residents who became impaired while living in the home. Less than 10 percent of all facilities reported discharging residents who became incontinent, developed behavior problems, or started receiving SSI after moving to the facility.
Differences by Regulatory Environment. There were no differences in admission or discharge policies by regulatory environment, with the possible exception that licensed homes in extensively regulated States were significantly more likely to report that they will admit “no” SSI residents than was the case in limited regulation States (21 percent vs. 10 percent) (see Table A-11).
Differences by Licensure Status. We also examined resident admission and discharge policies for licensed homes compared to unlicensed. Large licensed homes were significantly less likely to admit mobility-impaired residents and were more likely to discharge them than were their unlicensed counterparts. Although licensed homes were somewhat more likely to report admitting SSI-funded residents than were unlicensed homes, almost no homes reported discharging residents once they became SSI recipients (see Table A-3).
As the board and care population becomes increasingly impaired, the experience, training, and knowledge of staff who care for them become more critical. An examination of facility staffing factors raises concerns about quality.
Nearly 20 percent of the operators in licensed homes and 33 percent in unlicensed homes reported that they did not require training for staff (Exhibit 3-7). Of those who required training, only 23 percent of licensed homes and 15 percent of unlicensed homes required staff to complete all training before they began providing resident care (i.e., preservice). Another 35 percent of operators in licensed homes and 22 percent in unlicensed homes reported that they required some preservice and some on-the-job training for staff.
There were large differences in the number of hours of training required of board and care staff in licensed homes in extensively vs. limited regulation States. Over half of those in extensively regulated States required 2 or more days of training compared to about one-third in States with limited regulation (Exhibit 3-8).
| EXHIBIT 3-7. Facility Policies on Staff Training |
 |
| EXHIBIT 3-8. Staff Training Hours Required in Licensed Homes by Regulatory Environment |
 |
On major area of concern relates to staff qualifications and medication usage in board and care homes. As noted in Section 3.6, virtually all homes reported providing medication storage or supervision. In addition, three-quarters of the residents reported receiving assistance with medications, and many were taking psychotropic drugs (see Section 6.3 and Section 6.8). Despite this, only 21 percent of the homes had any licensed nurse on staff (Exhibit 3-9). This included full- or part-time nursing staff and registered nurses (RNs), as well as licensed practical or vocational nurses (LPNs/LVNs). Interviews with operators and staff showed that most staff who reported passing medications, 73 percent, were not licensed nurses even though only one State (Oregon) had a program for training and certifying nonnursing staff to pass medication. Eighteen percent reported being LPNs or LVNs, and only 10 percent were RNs. Of the staff passing medications, 26 percent reported they received no training on medication supervision or management. Of staff who reported giving injections to residents, only 21 percent were RNs, 51 percent were LPNs or LVNs, and 28 percent were not licensed nurses.
The influence of more extensive regulations was seen in the greater experience of operators and the more stringent staff training requirements they reported. Although they clearly indicate compliance with State regulations, these structural measures characterizing the training of staff are not necessarily evidence that more extensive regulation improves the quality of the home. Nonetheless, training of board and care home staff was one of the features our expert panel (TAG) felt could make a difference in the lives of the residents who are so dependent upon their caregivers.
| EXHIBIT 3-9. Training of Staff Who Pass Medications and Give Injections | ||
|---|---|---|
| Total Population | ||
| % | SE | |
| Facilities with licensed nurse on staff | 21 | 2.6 |
| Staff passing medications | 70 | 6.2 |
| Training of staff who pass medications | ||
| LPN/LVN | 18 | 4.6 |
| RN | 10 | 2.6 |
| Not a licensed nurse | 73 | 5.6 |
| Staff who give injections | 17 | 3.2 |
| Training of staff who pass medications | ||
| LPN/LVN | 51 | 11.8 |
| RN | 21 | 4.2 |
| Not a licensed nurse | 28 | 12.8 |
In almost one-fourth of the homes, the operator was the only paid staff person. We observed no difference in the average number of residents per direct care staff as a function of regulatory extensiveness. However, there was a significant difference between licensed and unlicensed homes of most size categories. Unlicensed medium and large homes had, on average, more residents per direct care staff than did comparably sized licensed homes. The average ratio in large unlicensed homes was almost 12 times that of large licensed homes (see Table A-5).
In considering the “social environment” of the home, indicators such as operators eating with the staff or family living and/or working in the home were thought to represent more “homelike” and less institutional facilities. Although licensed home operators in a limited regulatory environment were more likely to report always eating with residents, family were more likely to always eat and live in licensed homes in the more extensively regulated States. These homes were usually a family business, although not necessarily a family home. Overall, operators and/or their families lived in almost two-thirds of the facilities (see Table A-12).
For all of these homes, the resident mix was quite complex (Exhibit 3-10). Approximately three-quarters of the homes reported having one or more residents with cognitive impairment. Over half of the homes reported having residents with a diagnosis of mental illness or prior stay in a psychiatric hospital. One-third reported having residents with mental retardation or developmental disabilities. Moreover, board and care homes also coped with more complex problems. Forty-two percent of homes reported having one or more residents with alcohol abuse problems, and 15 percent said they had residents with a past history of drug abuse problems.
Some homes also housed residents with significant health problems and functional impairments. Almost 30 percent of the homes reported having one or more residents who stayed in their room all day in bed or in a chair because of health problems, and almost 60 percent of the homes reported having residents with urinary incontinence.
| EXHIBIT 3-10. Resident Case Mix Characteristics for Facilities by Licensure and Regulatory Environment | |||||||
|---|---|---|---|---|---|---|---|
| Case Mix Characteristics | Total Population | Licensed Homes | |||||
| Extensive States | States with Limited Regs | ||||||
| % | SE | % | SE | % | SE | pa | |
| Summary measure | b | ||||||
| 90%+ behavior problems | 21 | 4.1 | 16 | 2.8 | 36 | 4.1 | |
| 90%+ elderly | 56 | 4.4 | 62 | 3.8 | 36 | 4.7 | |
| Other resident mix | 23 | 2.8 | 22 | 3 | 29 | 4.1 | |
| Facility has residents who are/have | |||||||
| Bedfast | 5 | 1.9 | 5 | 1.8 | 5 | 1.7 | |
| Chairfast | 29 | 2.4 | 32 | 2.6 | 16 | 3.2 | b |
| Cognitively impaired | 71 | 3.3 | 74 | 3.9 | 62 | 5.3 | c |
| Alcohol problems | 42 | 2.8 | 43 | 4 | 35 | 4 | |
| Drug abuse | 15 | 2.6 | 14 | 2.6 | 18 | 2.1 | |
| HIV+ | 1 | 0.8 | 1 | 0.7 | 1 | 0.1 | |
| MR/DD | 34 | 5.8 | 30 | 4.4 | 48 | 4.3 | b |
| Psychiatric history | 57 | 4.9 | 56 | 4.4 | 60 | 3.8 | |
| Incontinent of urine | 59 | 2.4 | 66 | 4.1 | 44 | 4.6 | c |
|
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Board and care homes differed in their mix of residents (Exhibit 3-10). Some homes had a mainly elderly mix of residents. Over 60 percent of the licensed homes in States with an extensive regulatory system reported that residents were primarily elderly (65 and older). Only 36 percent of the homes in States with limited systems had this elderly resident mix. Other homes, even though not specifically licensed as such, housed mainly persons with persistent mental illness or developmental disabilities (MR/DD). Sixteen percent of the licensed homes in States with extensive regulatory systems and almost 40 percent in States with limited systems reported having primarily nonelderly residents, most of whom had a chronic mental illness or MR/DD. Slightly over 20 percent of licensed “extensive” homes reported having a mixed population that included the frail elderly and persons with cognitive impairment, compared to 29 percent of facilities in “limited” States.
Licensed extensively regulated homes were more likely to house chairfast, cognitively impaired, and incontinent residents than were licensed homes in States with limited regulations.
In spite of similarities in admission and discharge policies (discussed in Section 3.2.2), the resident care mix across licensure status was considerably different (see Table A-2). Small licensed facilities were more likely to house 90 percent or more elderly residents than were small unlicensed homes. Indeed, 70 percent of small licensed homes reported housing all elderly residents compared to half of small unlicensed homes. The opposite was true in large homes, with about 75 percent of large licensed facilities reporting a primarily elderly population compared to 88 percent of large unlicensed homes. No consistent differences in case mix indicators measuring functional level or frailty were observed, although small unlicensed homes were more likely to house some residents with psychiatric histories than were small unlicensed homes. Finally, compared to unlicensed homes, licensed homes, particularly small and large facilities, had significantly higher proportions of residents who were SSI recipients.
To meet the needs of the complex mix of residents, some board and care homes offered a wide range of services. However, available services varied considerably from homes offering little more than room, meals, oversight, and a few services to places that provided or arranged for extensive and skilled nursing services and therapies.
More than three-quarters of the homes reported providing medication storage or supervision, organized activities, recreational trips, and transportation (Exhibit 3-11). Approximately one-quarter of all homes reported providing nursing services.
| EXHIBIT 3-11. Services Provided in Facility | ||
|---|---|---|
| Services Provided | Total Population | |
| % | SE | |
| Personal care/assistance | 92 | 2.0 |
| Medication storage | 99 | 0.7 |
| Reminders to take medication | 81 | 3.8 |
| Organized activities | 88 | 2.9 |
| Recreational trips | 80 | 3.8 |
| Transportation | 89 | 2.7 |
| Nursing care | 25 | 2.9 |
| Therapy | 16 | 1.6 |
| Money management | 39 | 4.5 |
Differences by Licensure Status. By and large, licensed homes of all sizes were significantly more likely to provide therapy directly to their residents than were unlicensed homes. A “responsible” person is more likely to be present in medium and large licensed homes than in comparably sized unlicensed homes, and large licensed homes are more likely to provide transportation than are large unlicensed homes. Regardless of size, licensed homes were more likely to report providing personal care services. A similar pattern is observed for medication reminders and medication storage (see Table A-7). The average number of health services in a facility was greater in licensed homes of all sizes (Exhibit 3-12). Social services were more prevalent in large licensed homes than in comparably sized unlicensed homes (4.2 compared to 2.9).
With respect to arranging for outside services, the differences were not as consistent. Although small licensed homes were more likely to arrange for nursing and long-term care for their residents than were small unlicensed facilities, large licensed facilities were more likely to arrange for outside transportation for their residents than were large unlicensed homes; most other externally arranged services did not consistently differ by licensure status.
Differences by Regulatory Environment. The pattern of service availability in licensed facilities in limited and extensively regulated States was remarkably similar. We observed few significant differences. Licensed homes in limited regulation States were more likely to manage their residents’ money (64 vs. 31 percent) and to provide medication reminders (90 vs. 79 percent) than licensed homes in extensively regulated States (see Table A-15).
| EXHIBIT 3-12. Average Number of Health Services Provided by the Facility by Size and Licensure |
 |
Half the homes reported that outside agencies, such as home health agencies, provided nursing care to residents who needed such care on a temporary or episodic basis. In addition, as seen in Exhibit 3-13, 25 percent of the extensively regulated licensed and 23 percent of the licensed homes in States with limited regulation reported that agencies provided ADL/personal care to residents. Approximately one-third reported that some residents attended Senior centers or adult day care programs. About 30 percent of the homes reported that some residents attended sheltered workshops or day activity programs.
No significant differences were observed in the type, or number, of outside provided services arranged by the home, except that in limited regulation States homes were more likely to arrange for sheltered workshop programs than was the case in extensively regulated homes.
Although most homes reported providing many services directly and through external agencies, homes differed on whether residents who needed nursing care could remain in the home. Part of this variation is a function of the facility’s willingness and ability to provide or arrange care. In addition, licensing regulations in some States prohibited board and care homes from admitting or retaining residents who need daily nursing care. A few States, such as Florida and Oregon, allowed daily nursing care to be provided by some classes of board and care homes. Other States limited the services such homes could provide. As a result, there was considerable variation in how homes dealt with residents who needed nursing care. Over half of all facilities reported they provided services with facility staff or arranged for a home health agency to provide care if the resident needed only temporary nursing care. However, 28 percent of the homes reported that they sent the resident to a hospital/emergency room if the resident became ill and needed temporary nursing care (less than 14 days). More than half of all homes reported they would discharge a resident to a hospital or nursing home if the resident needed nursing care for more than 14 days (Exhibit 3-14).
| EXHIBIT 3-13. Services Provided by an Outside Agency to Facility Resident | |||||||
|---|---|---|---|---|---|---|---|
| Services Provided by an Outside Agency | Total Population | Licensed Homes | |||||
| Extensive States | States with Limited Regs | ||||||
| % | SE | % | SE | % | SE | pa | |
| Personal care/assistance | 25 | 3.7 | 25 | 2.9 | 23 | 3.9 | |
| Senior center/adult day care | 34 | 4.5 | 34 | 4.2 | 36 | 3.8 | |
| Transportation | 55 | 4.9 | 55 | 5.0 | 54 | 4.2 | |
| Nursing care | 53 | 3.5 | 55 | 3.6 | 46 | 4.4 | |
| Case management | 44 | 3.4 | 44 | 4.4 | 47 | 4.9 | |
| Shelter workshop/day activities | 32 | 5.0 | 28 | 3.8 | 43 | 3.8 | b |
|
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Homes differed in terms of the services covered by the monthly rate. These monthly rates generally cover room, board, personal laundry, special diets, and assistance with eating, dressing, and toileting in all homes. However, in over 10 percent of the homes, there was an additional charge if the resident needed a special diet or personal assistance with eating, dressing, and toileting. Nearly three-quarters of the homes charged extra for incontinence supplies (Exhibit 3-15).
| EXHIBIT 3-14. Facility Response to a Resident’s Need for Nursing Services |
 |
| EXHIBIT 3-15. Services Covered by Monthly Rate | ||
|---|---|---|
| Services Covered by Daily Rate | Total Population | |
| % | SE | |
| Personal laundry | 93 | 2.2 |
| Incontinence supplies | 29 | 2.6 |
| Special diets | 85 | 3.0 |
| Assistance with eating, dressing, or toileting | 89 | 1.8 |
The environmental surroundings of long-term care residents enhances or detracts considerably from the quality of care and life for residents. We defined several quality measures to characterize different aspects of the facility’s physical surroundings. These measures included scores that summarized the prevalence of safety features, assistive and supportive devices, social and recreational aids, and physical amenities. To create the structural measures, we combined varying numbers of elements (ranging from 4 to 21) and then calculated a percentage score for the number of factors present. A description of these results follows.
Facilities scored the lowest on components contributing to facility safety. The average facility safety score was 58 percent, indictating that about one-third of the safety features measured were absent from the average facility. Facilities scored higher on the prevalence of assistive and supportive devices and social and recreational aids, with average scores of 65 and 69 percent, respectively (Exhibit 3-16). Average scores of 72 and 74 percent on measures of physical attractiveness and evnvironmental diversity indicated that most facilities were clean, pleasant, and at least somewhat diverse.
It is important to note that the safety measure used in these analyses does not represent a gold standard for what constitutes a “safe” facility. It presents a summary measure of the 10 characteristics that contribute to a safe environment: smoke detector, fire extinguishers, fire sprinkler, call buttons in bathrooms and bedrooms, nonskid stair surfaces, adequate lighting, presence of obstructions in the halls or on the stairs, and an outside area that is visible to the front desk (Moos and Lemke, 1978). A closer look at the components of the measure indicate that the three most frequently missing safety characteristics of the facilities in this study were fire sprinklers (only 29 percent of the facilities had working systems) and call buttons in the bathrooms and bedrooms.
Board and care homes, though perceived as substantially less institutional than nursing homes, actually varied quite a bit in terms of environmental features or practices that many observers regard as “homelike.” Board and care homes varied from places in which three or four residents shared a room to places in which residents lived in private apartments. Most had common areas, which included community rooms or living rooms and outside sitting areas, although only about half of all homes allowed residents access to a kitchen to fix a snack, a cup of coffee, or a soft drink. Homes also differed in the degree to which the environment was “homelike” or more institutional and whether residents were allowed to bring their own furniture or only a few private possessions, such as quilts, photographs, and other small mementos.
Since the role of regulation also is to prevent the occurrence of “snake pits,” we also looked at facilities to determine which had very low scores on these measures. Only 6 percent of the facilities had the lowest possible scores in one or more of these areas. Another 27 percent had inadequate or barely adequate lighting. (A total of 32 percent of the homes had such lighting, but 5 percent had other environmental problems as well.) We defined lighting as problematic if it was absent, clearly inadequate, or barely adequate (e.g., low or glaring).
| EXHIBIT 3-16. Summary Quality Indicators | ||
|---|---|---|
| Total Population | ||
| Percent | SE | |
| Facility Indicators | ||
| Average prevalence | ||
| Safety features | 58 | 0.9 |
| Supportive devices | 65 | 2.2 |
| Social/recreational aids | 69 | 1.8 |
| Physical amenities | 80 | 0.6 |
| Average facility cleanliness/attractiveness | 72 | 0.6 |
| Average environmental diversity | 74 | 1.0 |
| Working fire sprinkler system | 29 | 3.9 |
| Staff Indicators | ||
| Staff knowledge of (total score = 100% | ||
| Normal aging | 14 | 1.5 |
| Basic care/monitoring | 66 | 2.5 |
| Ombudsman program | 65 | 2.9 |
| Use of physical restraints and/or psychotropics | 15 | 3.3 |
| Prevalence of physical and/or verbal abuse or punishment | 15 | 2.5 |
| Resident Indicators | ||
| Resident can eat whenever she wants | 64 | 3.0 |
| Visiting hours are anytime | 69 | 2.9 |
| Visiting hours area every day | 98 | 1.0 |
Well-trained and knowledgeable staff are essential to provide high-quality care. The average staff knowledge scores ranged from 14 to 66 percent on three different measures. Staff scored lowest on questions about the normal processes of aging and highest on questions about basic care and medications monitoring.
We asked staff members which of the following were normal processes of aging: becoming incontinent, becoming forgetful or confused, becoming quarrelsome, or being sad and depressed. Almost three-fourths of all staff members reported that it is normal to become forgetful or confused with aging; over half of the staff members said that becoming incontinent and being sad or depressed were expected with aging.
To determine staff knowledge about basic care and medications monitoring, we presented four scenarios describing changes in a resident’s condition or a resident’s reaction to medication. We then asked staff to select an appropriate course of action. We also asked staff about monitoring residents on specific medications and what side-effects to watch for. Based on answers to these seven questions the average staff score was 66 percent.
We found that the prevalence of physical restraints, although serious, was not widespread. Fifteen percent of the staff reported use of physical restraints, an intervention that is widely viewed as inappropriate for behavior control and ill-advised as a means of addressing the possibility of falls. A similar number of staff reported witnessing other staff engage in verbal abuse, threats, or similar forms of punishment (e.g., withholding food, isolation) to address difficult behaviors among residents.
The operators’ views of the level of regulatory control were assessed in several questions about the number of inspections and whether the home operated under some regulatory corrective action.2 We observed that two-fifths of small and mid-sized licensed homes reported having experienced multiple inspections in the past year, a significantly higher rate than their unlicensed counterparts. As might be expected, licensed homes of all sizes were more likely to have been subject to corrective action in the last year than were unlicensed homes (see Table A-6).
Reflection on the “Niche” Served by Board and Care Homes. It seems clear that board and care homes do, in fact, fit in the “niche” between residential settings with few services and nursing homes. Moreover, while there is “overlap” between board and care homes and these two other modalities at either end of the continuum, it is apparent that board and care homes provide a distinct service.
In terms of services, board and care homes provided more care and services than congregate apartments and boarding houses. However, even with the addition of services provided by home health agencies, visiting nurses, and others, the average board and care home provided fewer skilled and rehabilitative services, less routine monitoring, assessment and care planning, and less nursing and restorative care than nursing homes. The fact that less than a quarter of the board and care homes had a full- or part-time RN or LPN on staff emphasizes the difference in services. Furthermore, most board and care homes, as noted, were unable or unwilling to provide nursing services for an illness that lasted longer than 14 days, and a substantial proportion reported being unable to handle even a temporary need for nursing care.
Operators tended to be female (80 percent), white (62 percent), and married (64 percent). However, African Americans and Asian Americans made up a significant percentage of the operators, 21 and 14 percent, respectively (Exhibit 4-1). The demographic profiles of operators in licensed and unlicensed facilities were virtually the same.
As shown in Exhibit 4-2, the educational background of operators in licensed homes was very similar to that of their unlicensed home counterparts. However, operators in licensed extensively regulated homes and those in comparable homes in States with limited regulation had very different educational backgrounds. Operators of licensed homes in extensively regulated States were better educated and more likely to have had prior experience in health care and training before becoming an operator than was true of operators in licensed homes in States with limited regulation. Almost one-fourth of the operators in the limited States had not completed high school compared to 13 percent of those in the extensively regulated States. Only 22 percent of operators in the limited regulated States has completed college, while almost one-third of those in the extensively regulated States were college graduates.
| EXHIBIT 4-1. Operator Demographic Profile |
 |
| EXHIBIT 4-2. Operator Training and Experience | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Total Population | Licensed Homes | Licensed Homes | Unlicensed Homes | |||||||||
| Extensive States | State with Limited Regs | |||||||||||
| % | SE | % | SE | % | SE | pa | % | SE | % | SE | pb | |
| Previously worked in health care sector | 72 | 3.7 | 77 | 3.4 | 59 | 4.8 | c | 73 | 3.7 | 51 | 9.7 | c |
| Received training prior to operating the home | 67 | 2.1 | 70 | 3.8 | 57 | 4 | 67 | 2.1 | 57 | 6.4 | ||
| Education | d | c | ||||||||||
| Less than high school | 11 | 3.4 | 13 | 2.4 | 23 | 4 | 15 | 3.6 | 22 | 5.7 | ||
| High school or vocational education | 18 | 2.0 | 16 | 2.5 | 22 | 3.6 | 23 | 2.9 | 26 | 5.5 | ||
| Some college | 37 | 4.0 | 38 | 3.6 | 34 | 4.7 | 32 | 5.5 | 25 | 5.8 | ||
| 4-year college graduate | 18 | 3.2 | 20 | 2.5 | 9 | 2 | 18 | 3.3 | 9 | 2.7 | ||
| Postgraduate | 13 | 1.9 | 12 | 2.7 | 13 | 3.5 | 12 | 1.9 | 18 | 5.2 | ||
|
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An overwhelming majority of operators (72 percent) reported having prior experience in the health care sector. Almost 70 percent of the operators received training on operating a board and care home and caring for residents before becoming an operator (Exhibit 4-2).
Operator training, however, differed considerably for licensed homes by whether it was in an extensively regulated State or not. Seventy percent of operators in the extensively regulated States were trained prior to becoming a board and care operator compared to 57 percent of those in States with limited regulations.
| EXHIBIT 4-3. Prior Health Care Experience of Operators by Facility Licensure Status and Size |
 |
There were also differences between licensed and unlicensed homes in operators’ prior health care experience (Exhibit 4-3). Operators of small licensed homes were much more likely to have previously worked in health care institutions (e.g., nursing home, hospital, home health agency) than operators in small unlicensed homes. This pattern persisted across all sizes of licensed and unlicensed homes.
There was wide disparity in personal income reported by board and care operators. About one-fourth of the operators reported a total annual income from all sources less than $15,000. Conversely, slightly more than one-fourth reported income over $50,000 as shown in Exhibit 4-4.
| EXHIBIT 4-4. Operator Personal Income | ||
|---|---|---|
| % | SE | |
| <$7,000 | 6 | 2.0 |
| $7,000-14,999 | 20 | 1.7 |
| $15,000-24,999 | 16 | 1.6 |
| $25,000-49,999 | 31 | 2.7 |
| $50,000-75,000 | 15 | 1.4 |
| >$75,000 | 13 | 3.3 |
We interviewed 1,138 staff members of board and care homes. Of these staff members, about one-third were facility operators who provided direct care to residents (70 percent of all operators), thus they also completed the operator questionnaires. We will refer to these as “direct care” operators in this discussion to distinguish them from other staff.
Almost half of the board and care home staff members (47 percent) were between the ages of 35 and 54. Another 29 percent were younger than 35, including 10 percent who were younger than 25. Only 6 percent were 65 or older. The mean age of staff in board and care homes was 43 (Exhibit 5-1).
Licensed facilities employed more very young staff members (<25 years of age) than unlicensed facilities (10 vs. 1 percent). Unlicensed facilities employed slightly more elderly staff members than licensed facilities (9 vs. 6 percent).
Large facilities employed more young and fewer elderly staff members than small facilities. Large facilities were three times more likely to employ very young staff; 10 percent of staff in small facilities were age 65 or older, compared with only 4 percent of staff in large facilities (Exhibit 5-2). The mean age of staff was 41 in large facilities and 47 in small facilities.
Board and care staff were primarily white (62 percent) and overwhelmingly female (90 percent). Only 11 percent of the board and care home staff members were Hispanic. There was virtually no difference between the racial/ethnic staff distributions by licensure size. Staffing characteristics, however, did differ by size of the home. Large facilities employed more white staff members than small facilities (72 vs. 53 percent), while small facilities employed more Asians or Pacific Islanders than large facilities (18 vs. 3 percent).
Direct Care Operators. Twenty-five percent of the direct care operators had at least a college degree. Another 38 percent attended vocational or trade school, had some college, or were 2-year college graduates. About one-fifth (21 percent) were high school graduates. Perhaps the most disturbing fact was that 17 percent of these operators were not high school graduates (see Exhibit 5-3). There was no difference in the educational background of staff by facility licensure status.
| EXHIBIT 5-1. Demographics of Staff in Board and Care Homes by Licensure Status of Home | |||||||
|---|---|---|---|---|---|---|---|
| Licensed | Unlicensed |
Significance Level |
Total | ||||
| % | SE | % | SE | % | SE | ||
| Age | a | ||||||
| <25 | 10 | 2.1 | 1 | 0.9 | 10 | 2.1 | |
| 25-34 | 19 | 1.9 | 29 | 5.3 | 19 | 1.8 | |
| 35-44 | 28 | 1.6 | 19 | 7.6 | 27 | 1.6 | |
| 45-54 | 19 | 3.3 | 27 | 5.7 | 20 | 3.2 | |
| 55-64 | 19 | 1.5 | 15 | 3.0 | 19 | 1.5 | |
| 65+ | 6 | 0.9 | 9 | 1.2 | 6 | 0.9 | |
| Mean Age | 43 | 0.6 | 45 | 0.9 | 43 | ||