The information in this appendix is presented in three major sections:
The first section provides an overview of the state's long term care system, with a primary focus on the Medicaid program. Although a state may pay for services in residential care settings through the Medicaid program, the program's financial eligibility criteria and related financial provisions for home and community services can present barriers to serving Medicaid clients in these settings. Thus, the first section of each state's description presents detailed information about rules related to financial eligibility, spousal financial protections, and cost sharing requirements.
The second section describes the state's residential care system.
The final section presents the views of respondents interviewed for this study on a range of issues related to Medicaid coverage of services in residential care settings in their state.
Because the information in the first two sections is intended to serve as a reference, some information is presented under more than one heading to reduce the need for readers to refer back to other sections for relevant information.
Unless otherwise cited in endnotes, all information presented here was obtained from the sources listed at the end. Supplemental Security Income levels, the federal poverty level, federal spousal protection provisions, state supplemental payments, and state reimbursement rates are for 2003, unless otherwise noted.
Oregon requires most elderly and disabled Medicaid beneficiaries to enroll in managed care. They receive their Medicaid-covered acute care services through a managed care plan, as well as certain services, such as home health care. Nursing home care, residential care, and most in-home services are carved out of the managed care initiative and remain in the fee-for-service system.
Oregon has a statewide nursing home pre-admission screening process. Individuals who enter a nursing home are approved for varying lengths of stay, depending upon the reason for admission and the likelihood of, and timetable for, improvement, and are reviewed periodically to evaluate their potential for discharge to the community.1 Because the state has a "mature" long term care system that is widely known among community organizations, service providers, referral sources, families and consumers, it has a strong capacity to divert people from nursing homes.2
There are two groups financially eligible for nursing home services:
Group A includes individuals who are eligible because they are receiving SSI, or they have incomes no higher than the SSI/SSP level.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which is $1,656. This group must spend all of their income (minus a personal needs allowance and other permitted deductions) on nursing home care before the state will begin to pay.
Asset limits for both groups are $2,000 for an individual and $3,000 for a couple when both members of the couple are in a nursing home. When only one member of a couple applies and there is a community spouse, spousal impoverishment protections apply.
The monthly personal needs allowance is $30 for individuals and $60 for couples.
Because Oregon does not have a Medically Needy program,3 in accordance with federal law, categorically eligible individuals in need of nursing home care--whose income exceeds the special income standard but is insufficient to cover the cost of care--may place income in excess of the special income level in a Miller Trust, and receive Medicaid coverage for nursing home care and other Medicaid state plan services.
Federal Medicaid law requires states to have estate recovery programs, which allows the states to claim assets, such as a home, that could not be counted when calculating eligibility. Oregon has the nation's most effective estate recovery program, in 1997 collecting nearly 5 percent of its Medicaid nursing home expenditures, far more than any other state.4 In 2002, the state collected an average of $1 million a month.
Community spouses may keep any income in their own name, and the state allows the institutionalized spouse's income to supplement the community spouse's income up to $1,515 per month.5 Community spouses are also allowed additional amounts for rent or mortgage payments (including insurance and taxes) and are permitted a standard utility allowance.
Community spouses may keep the higher of either the first $18,132 of total nonexempt assets or one-half of the total non-exempt assets owned at the time care began, up to the maximum protected resource amount of $90,660. For example, if the couple's assets are $30,000, one half is $15,000, but the state will protect $18,132 for the spouse at home. If the couple's assets are $250,000, one half is $125,000, but the state will protect only $90,660 for the spouse at home.
Oregon does not allow family supplementation to pay for private rooms. Families may pay for anything not related to services as permitted under federal law.
To receive Medicaid coverage of nursing home care, individuals must have functional limitations that match at least one of the following levels:
Services to about 3,600 people in levels 14 to 17 were eliminated in budget reductions in early 2003, and were not restored. Oregon's 2003-2005 budget continues long term care services for people in levels 1 through 11. Subject to federal approval, the budget also restores funding for services to people in levels 12 and 13--about 1,200 clients who need help in such areas as mobility and eating.
In 1981, Oregon received the very first Section 2176 Medicaid Home and Community-Based Waiver. At that time, the state decided that home and community services would be treated as an entitlement, which meant that no waiting lists would be developed except for lack of providers.7
Oregon's waiver program provides in-home nursing, personal care, and housekeeping services, adult day services, and assisted living services. About three quarters of all in-home services are provided through a consumer-directed program--the Client Employed Home Care Program--which allows clients to hire, supervise, and fire, if necessary, their own workers, who can be friends, relatives or home care professionals. The state provides clients with administrative support (including the actual payment of wages, unemployment insurance and FICA), and will also help the client find suitable in-home workers.
A key feature of Oregon's waiver program is the use of nurse delegation, which has played an important role in its success. In 1987, the state enacted legislation directing the Board of Nursing to adopt rules allowing licensed registered nurses to delegate basic and special nursing tasks to unlicensed personnel. These tasks include almost all nursing tasks except injections. Nurse delegation has enabled home and community services to be provided at much lower cost than if licensed nurses had to provide all nursing care. The use of nurse delegation has been particularly important in the development of the state's adult foster homes and assisted living facilities.8
Two groups are financially eligible for waiver services:
Group A includes individuals eligible for SSI, or who have incomes no higher than the SSI/SSP level.
Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which was $1,656.
Asset limits for both groups are $2,000 for an individual and $3,000 for a couple if both are receiving services. When only one spouse applies and the spouse resides in the community, spousal impoverishment protections apply.
The state does not allow spend-down to HCBS waiver eligibility levels but does allow excess income to be placed in Miller trusts. An individual places all their income in the trust, which is a conduit for all spending on behalf of the individual. The trust provides the individual with a personal needs allowance, and pays room and board and any other allowable expenses based on rules for determining cost sharing responsibility. Any remaining money must be spent on the cost of care. If the amount is insufficient, Medicaid pays the balance.
Even if there are sufficient funds in the trust to pay the full cost of long term care services, the person is still eligible for Medicaid state plan services. However, if the funds in the trust at any point in time equal or exceed the cost of one month's stay in a nursing home ($4,300 in 2003), the person will no longer be eligible for Medicaid.
For persons in Group B, there is a cost sharing requirement. The share of cost is calculated by subtracting the following amounts from the monthly income of the person receiving care:
Personal needs allowance of $553.70, which is the protected monthly income for individuals receiving waiver services (SSI $552 + the state supplement of $1.70);
At-home spouse income allowance and dependent family allowance;
Incurred medical and remedial care expenses not paid by Medicaid or a third party. Remedial care includes medical costs recognized under state law, but not covered under Medicaid, such as dentures.
Residents of assisted living facilities are permitted to retain $104 as their Personal Needs Allowance, leaving $449.70 for room and board costs, the maximum that a facility can charge a Medicaid-eligible resident.
Community spouses may keep any income in their own name, and the state allows the institutionalized spouse's income to supplement the community spouse's income up to $1,493 per month.9 Community spouses are also allowed additional amounts for rent or mortgage payments (including insurance and taxes) and are permitted a standard utility allowance.
Community spouses may keep the higher of either the first $18,132 of total non-exempt assets or one-half of the total non-exempt assets owned at the time care began, up to the maximum protected resource amount of $90,660. For example, if the couple's assets are $30,000, one half is $15,000, but the state will protect $18,132 for the spouse at home. If the couple's assets are $250,000, one half is $125,000, but the state will protect only $90,660 for the spouse at home.
Oregon does not allow family supplementation to pay for private rooms in any residential care setting. Families may not pay for anything related to room, board or services.
Waiver applicants have to meet the same level of care criteria as nursing home applicants.
The state covers Medicaid state plan personal care services only in private homes and not in residential care settings.
The state's Oregon Project Independence program provides in-home services and adult day care to persons who do not meet the financial eligibility criteria for Medicaid. Project Independence serves individuals over 60 years of age, and people under 60 with Alzheimer's or other dementias, who meet the same criteria as for nursing home and waiver services.
In 1981, the state mandated that long term care services be delivered in the least restrictive setting possible, and that nursing homes be reserved as the placement of last resort.10 Apart from the 1981 legislation, six other state initiatives were instrumental in reconfiguring Oregon's long term care system, which paved the way for the growth of assisted living and other residential care options:11
In 1981, Oregon was the first state to obtain a 1915(c) waiver.
Use of a nursing home certificate-of-need program to limit nursing home growth.
Relatively low nursing home reimbursement has minimized the incentive for nursing homes to accept Medicaid entrants.
Expansion of the home and community services infrastructure, focused on developing adult foster care, assisted living, and other non-medical residential settings.
Enactment of the most liberal nurse delegation act in the nation, enabling more individuals to be cared for in home and community settings at an affordable cost.
Development of a strong case management system that enabled clients to receive the care they needed in their homes or community settings.
The 1981 legislation also stated: "…. that the elderly and disabled citizens of Oregon will receive the necessary care and services at the least cost and in the least confining situation. (and) that savings in nursing home...allocations...be reallocated to alternative care services…"12
These new concepts led to the development of a different approach to service delivery in congregate settings, one where safety is not considered the most important value, but one of several equal values including dignity, independence, choice, privacy and individuality.13
The success of Oregon's approach is reflected in the numbers of people served in residential care settings compared to those in nursing homes. In July 2002, the state's Medicaid long term care caseload was distributed as follows:
In-Home Care Services clients = 14,556
Nursing Facility clients =
5,782;
Adult Foster Care clients = 5,399
Assisted Living Facility
clients = 3,662
Residential Care Facility clients = 1,867.14
Oregon has three major types of residential care facilities and separate licensing and regulatory requirements for each of them: Adult Foster Homes (AFHs), Residential Care Facilities (RCFs), and Assisted Living Facilities (ALFs). The state also has a number of Specialized Living Facilities of varying sizes that are targeted to serve special populations, e.g., persons with head injuries, quadriplegia, and persons with AIDS. Each of these facilities is unique and has its own reimbursement system. These facilities were developed both because of the desire of these clients to have focused services, and the difficulty in caring for them in regular home and community care programs.15
Residents of the three major types of residential care facilities can receive Medicaid waiver services as long as the facilities meet the regulatory requirements for providing these services.
Adult Foster Homes (AFHs) are private residences licensed to provide care to five or fewer residents. They offer room and board and personal care from a caregiver who lives in the home 24 hours a day. Planned activities and medication management are available, and some homes provide transportation services, private rooms, and nursing services.
During the 1980s, state officials vigorously promoted adult foster care as an alternative to nursing home care by recruiting families willing to convert their homes into an adult foster care setting. In some cases, case managers negotiated deals under which facilities received higher reimbursement than was technically allowed under state law. A new system, implemented in March 1998, raises the standard foster care reimbursement rates but makes it harder for case managers to negotiate exceptions to those rates.16
Residents of AFHs have varying needs, from minimal personal assistance to assistance with all ADLs and skilled nursing services. The care provided depends on the client's needs and the skills, abilities, and training of the provider.
Oregon's AFH Program includes Relative Adult Foster Homes. These homes permit relatives (excluding the spouse) to become adult foster home providers and care for the client. They are usually limited to one client who must be eligible for Medicaid.17
By 1996, Oregon had approximately 6,500 adult foster care facilities serving approximately 15,000 persons, with roughly one-third of these persons being supported by Medicaid through the waiver program, making Oregon the only state in which adult foster care was a mainstream long term care option. Some analysts believe that the program probably grew too fast with insufficient attention paid to quality assurance. By 1999, state audits confirmed some problems with quality and the state legislature demanded greater regulatory oversight.
The private pay market for Adult Foster Homes declined as adults who needed and could afford care gravitated toward assisted living facilities, and the supply of foster care began to exceed demand. Consequently, many facilities became increasingly reliant on Medicaid dollars, although 60 percent of residents remain private pay.18 Shared rooms are not exclusively for Medicaid residents, but Medicaid residents are more likely to reside in shared rooms than are private pay residents.
Residential Care Facilities (RCFs) serve six or more residents. Many of them are small and even though they typically have shared rooms, they are more homelike than nursing homes. The state has two classes of RCFs. The regulations contain staff ratios for Class I and Class II facilities that vary by time of day and the number of residents.
RCFs used to serve both the elderly and persons with serious mental illness (SMI) and developmental disabilities (DD) until the Senior and Disabled Services Division (SDSD) transferred oversight of RCFs in which more than half of the residents had SMI or DD to the state mental health agency. SDSD kept responsibility for the RCFs in which more than half of the residents were elderly persons. Over the following years, the RCFs assigned to the different agencies admitted only SMI, DD, or elderly persons. As a result, RCFs now serve a homogenous population.
The primary difference between RCFs and assisted living facilities (ALFs)--a third type of residential care in Oregon--is the physical setting. RCFs provide single or double rooms with shared baths. Typically, residents share rooms, which must be 80 square feet per resident and are limited to two residents. Toilets must be provided for every six residents and a tub/shower for every ten residents.19 Private rooms are not required for Medicaid clients.
The state limits the amount that providers can charge Medicaid eligible residents for room and board to $449.70. This amount is equal to the combined SSI/SSP payment of $553.70 minus $104 for a personal needs allowance.20 There is no limit on what facilities can charge private residents.
Those who qualify for SSI are automatically eligible for Medicaid. The state supplement is provided to every SSI recipient in specified living arrangements, including their own homes, adult foster homes, residential care facilities, assisted living facilities and nursing homes.21 Persons living in institutions such as a state hospital are not covered.
RCFs offer room and board with 24-hour supervision, assistance with physical care needs, medication monitoring, planned activities, and often transportation services. If clients in RCFs need delegated nursing services, then the facility must have an R.N. consultant. Oregon's contract nurses are paid by the state to provide consultation services in RCFs.
Class I RCFs provide ADL assistance only and cannot serve anyone who is non-ambulatory, is medically unstable, who requires feeding or is totally dependent in any ADL.
Class II RCFs offer a full range of services without any restriction on acuity levels.
Oregon assesses RCF residents and assigns a payment level based upon the individual's need for assistance with ADLs. In the state's 2003 budget, the RCF base service rate for all clients was $917.00 per month. Depending on impairment level, there are 3 add-on levels. Base plus 1 add-on is $1,142.00; base plus 2 add-ons is $1,367.00; base plus 3 add-ons is $1,592.00. The add-on is based primarily on how dependent a persons is with ADLs.
The Medicaid program is the only source of public funding for RCFs.
The only distinction between assisted living facilities (ALFs) and other models of residential care in Oregon is that ALFs have private apartments. Other settings have both private and shared rooms and private and shared baths.
Oregon began developing a nursing home replacement model of assisted living facilities in 1987. The basic concept of assisted living is to combine apartment living with all of the non-skilled nursing services available in nursing homes plus assistance with activities of daily living (ADLs). Twenty HCBS waiver slots were designated for a facility in Portland as a test of this concept and the state developed administrative rules guaranteeing residents the rights of privacy, choice, independence, individuality and dignity.
In 1990, the state adopted assisted living regulations and policies to substitute for nursing home care and offer home-like environments which enhance dignity, independence, individuality, privacy, choice, and decision making. Facilities are required to have written policies and procedures which describe how they will operationalize these principles.
In some respects, the regulations are specific, e.g., ALFs must provide private apartments. In other ways, however, the rules are vague, e.g., there are no mandatory staff-to-resident ratios. and few service requirements. Residents negotiate service packages that cover everything from hours of personal care to the type of housekeeping services that will be provided.
ALFs serve a predominantly elderly clientele. As of December 2002, the state had 184 licensed ALFs, with a capacity of 12,200 units. About 37 percent of ALF residents are Medicaid clients.
Level II RCFs and ALFs can serve the same population but they operate under different regulations. When Oregon decided to regulate assisted living, it chose not to replace existing RCF rules, instead adding a new licensing category for assisted living with requirements that differ somewhat from its RCF rules, most notably with regard to physical plant requirements.
The state initiated a moratorium on assisted living facilities from August 2001 through June 2005.
ALFs have six or more single occupancy apartments that are fully accessible with a lockable door, private bathroom, and kitchenette facilities. Units must provide 220 square feet of space, not including a private bathroom. Units in pre-existing structures may provide 160 square feet, not including the bathroom.
To assure personal choice, an individual written exception is required for each resident who chooses to share a unit with someone other than his/her spouse.
The state limits the amount that providers can charge Medicaid eligible residents for room and board to $449.70. This amount is equal to the combined SSI/SSP payment of $553.70 minus $104 for a personal needs allowance.22
Those who qualify for SSI are automatically eligible for Medicaid. The state supplement is provided to every SSI recipient in specified living arrangements, including their own homes, in-home, adult foster homes, residential care facilities, assisted living facilities and nursing homes.23 Persons living in institutions such as a state hospital are not covered.
ALFs are required to offer three meals, laundry and housekeeping services, assistance with ADLs and personal needs, and a program of social and recreational activities. Required health services include providing a licensed registered nurse to conduct health assessments and periodic monitoring, assigning the basic tasks of nurse delegation, and providing intermittent nursing services for residents with stable and predictable medical needs. Before billing Medicaid, ALFs are required to pursue other potential sources of reimbursement such as insurance benefits and Medicare.
Nursing tasks may be delegated. These tasks include almost all nursing tasks except for intra-muscular, intra-venous, and intra-dermal injections. Nurse delegation is done by licensed nurses for each individual client as deemed appropriate by the nurse. The nursing task is delegated in writing to an individual non-licensed provider and cannot be expanded without the approval of the nurse. Staff or volunteers under 18 years of age may not assist with medication administration or delegated nursing tasks, and must be supervised when providing bathing, toileting or transferring services.
Facilities are required to provide medication management and administration, and they must have policies and procedures to assure that all administered medications are reviewed every 90 days. Medication and treatment administration systems must be approved by a pharmacist consultant, registered nurse, or physician.
Facilities also must coordinate home health services for residents with complex, unstable or unpredictable needs, and hospice services for those who meet eligibility criteria for Medicare's hospice program.
Each facility must have sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident and to respond in emergency situations.
Oregon assesses ALF residents and assigns a payment level based upon the individual's need for assistance with ADLs. Effective September 2003, the rates are:
Level 1 651.69
Level 2 887.16
Level 3 1,173.56
Level 4 1,534.74
Level 5 1,894.75
The state does not regulate admissions. Consequently, facilities have total discretion over who they will admit. admissions. Facilities may care for residents for whom they are able to provide appropriate services; there are no other limitations. The facility determines whether a potential resident meets its admission requirements. Prior to the resident moving in, the facility performs an assessment to determine the prospective resident's service needs and preferences and the facility's ability to meet those needs and preferences.
Providers with Medicaid contracts are not obligated to admit Medicaid recipients if they do not believe they can meet their needs. When considering an admission, the Medicaid contract permits the facility to determine if it can meet the needs of person in addition to the needs of the residents they already have.
Facility capabilities vary and some facilities can take care of people who have high needs and impairments. The state's regulations set the minimum standard of what a facility must provide, but facilities generally go above that standard. Just how much above the standard requirements usually correlates to the resources available to the facility.
Facilities with Medicaid contracts may not discharge a resident who has spent down to Medicaid eligibility. Conditions under which they may ask residents to move are: if their needs exceed the level of ADL services available; the resident exhibits behaviors or actions that repeatedly interfere with the rights or well being of others; the resident, due to cognitive decline, is not able to respond to verbal instructions, recognize danger, make basic care decisions, express need, or summon assistance; the resident has a complex, unstable, or unpredictable medical condition; or for non-payment of charges.
Facilities without Medicaid contracts are not obligated to keep a resident who spends down to Medicaid eligibility.
There is no mandatory bed hold, but a facility can not discharge a resident as long as they pay room and board. If a resident breaks a hip, goes to the hospital, and then to a nursing home for rehabilitation, the assisted living facility may not discharge them. As long as they continue to pay the $449.70 while they're out of the facility, the facility will hold their unit.
If a managed risk plan is needed it must be developed with the resident's input or that of their designated representative and be included in the care plan. Facilities are responsible for determining when a risk plan is needed and developing it according to guidelines in state regulation. The results of the agreement must be included in the service plan and the plan must be reviewed at least quarterly and more often if needed.24
Persons who are unable to recognize the consequences of their behavior or choices may not enter into or continue with a managed risk plan. There is no uniform or systematic method used to determine whether a person is capable of doing so. The state allows the facility administrator and RN to determine if a person can recognize the consequences of their behavior relative to entering into a managed risk agreement.
We consulted with three state staff and policy makers regarding the technical details of the state's programs and interviewed two of them. In addition, we interviewed the founding director and a former director of Oregon's Senior and Disabled Services Division (SDSD) (since renamed Seniors and People with Disabilities (SPD). These two respondents are now private long term care policy consultants. In addition, we interviewed six stakeholders, including representatives of residential care provider associations, residential care providers, consumer advocates, the state ombudsman program, a nurse who works in the program, and a county agency that administers the Medicaid waiver program.
The interviews focused on respondents' views about several key areas and issues. This section summarizes their views and provides illustrative examples of their responses. These comments are not verbatim quotes, but have been paraphrased to protect the respondents' anonymity and edited for brevity. A list of information sources for the state description and the individuals interviewed can be found at the end of this summary.
Most felt that people in Oregon who need long term care have a wide choice of community residential options, depending on their preferences.
If you like bed and breakfasts, you'll probably prefer an adult foster home. If you like hotels, you'll prefer assisted living.
Several noted that because ALFs offered private apartments and were newer relative to many residential care facilities (RCFs) and adult foster homes (AFHs), not surprisingly they were the preferred option for many private pay and Medicaid eligible individuals.
Some of the older adult foster homes and residential care facilities (RCFs) are not as desirable to consumers who have a choice. Very few RCF's offer private rooms and if they have them, they are generally kept for private pay residents.
A few mentioned variation in the physical setting of RCFs and AFHs, some being "very nice" and others less so. The most important feature, most agreed, was that there is a sufficient supply of all types of facilities to guarantee a choice of residence for consumers, with two caveats. First, there is some geographic maldistribution of ALFs, with some areas of the stated being overbuilt and others' not having an optimal supply. Second, most felt that with the budget cuts in 2003, many facilities would go bankrupt.
One noted that the state had a certificate of need program only for new nursing facilities, and did not have the methodology to determine appropriate capacity for ALFs. However, data on the current population receiving services--their level of impairment and needs--and projections of population growth would give some idea of future need.
Respondents agreed that the state was right in limiting the use of the term assisted living to facilities that offered private apartments. Compared to the other five states, no one mentioned public confusion about the different types of residential care as an issue.
Everyone interviewed agreed that Oregon's primary goals in using Medicaid in residential care settings were (1) to reduce nursing home utilization, and in so doing, save money, and (2) to increase community alternatives to nursing homes, thereby providing consumers with more choice. In particular, respondents felt that the program's success lay in its offering Medicaid waiver clients the same residential care options available to the private pay market. As one said, "if the private pay market gets privacy and independence, then so should the Medicaid client." All believed that the state had met its goals and that assisted living had filled a gap in the continuum of care between Adult Foster Homes and Residential Care Facilities, and nursing homes.
The state wanted a balanced long term care system, where nursing homes were caring for skilled patients who could not be cared for in any other setting, mostly hospital discharges that still need sub-acute care. It wanted to get to the point where nursing homes were not a high-priced alternative to community care. Assisted living became another tool in the goal--it fit a good niche.
When the state started expanding home and community services in the early eighties, it depended primarily on adult foster homes for residential care. There was a big push to recruit adult foster homes. It made sense because the economy was down and people were out of work. We could sell the concept of using your own home or buying one and taking in older people, combining a social good with a way to make money. For the state, it was a really quick way to increase residential care capacity.
There was a real desire on behalf of program planners to come up with a model that afforded predominantly seniors with a more private and independent residence outside the home. We had lots of experience with adult foster homes and congregate settings--where common space is shared and most residents share bedrooms. We wanted a more private and independent model.
We saw assisted living as another alternative to the nursing home. We were already using Medicaid in adult foster care and residential care facilities. Assisted living was one more option. We knew we could both save money and give people what they wanted by providing more options in the community. Services in AFHs and RCFs had been covered from when the state first got a waiver, so we just added assisted living to the existing waiver by developing rules for ALFs, thereby getting around the need for legislative approval. The state views assisted living as just another form of residential care that it wanted consumers to have as an option.
We used the waiver rather than the personal care option because you could qualify people for the waiver under a higher income standard (300 percent rule) and you have more flexibility under the waiver.
Initially the state needed to save money and private pay folks needed to save money--and the nursing home model back then was very institutional and people didn't like it. So the rationale was to improve quality of life for people who needed long term care and to contain costs. Both were equally important. We figured, we can do this in a different way, give people more control--greater independence and choice. We can do both.
The public has a lot more options and because Medicaid participates in the funding of residential care services, it is a more egalitarian system. Giving people private rooms has been very successful. The downside is that the state has not invested in the physical upgrading of nursing homes--which are stuck in the 50's and 60s.
We have RCFs that look like assisted living but because they do not exactly meet the physical plant requirements, they cannot call themselves assisted living--e.g., you need to have a roll in or flat shower. In every other area they could be identical to assisted living. The good thing about the assisted living physical plant requirements is that there is a greater degree of accessible housing for persons with disabilities. These facilities have offered a housing option for the younger disabled who want privacy and independence but need some oversight and services. Assisted living has been very good for them.
A large number of facilities participate in the Medicaid program, which means there is no access issue for low income persons. Of course, providers with many Medicaid residents will be more vulnerable if reimbursements are cut.
Everyone interviewed agreed that there are no barriers to serving Medicaid waiver clients in all residential care settings, including apartment style assisted living settings. They felt that Oregon had an adequate supply of ALFs, and that access was good for both Medicaid-eligible and private pay individuals. However, many felt that the impact of the budget cuts on rates and eligibility for waiver services could put some facilities out of business, especially those with a higher proportion of Medicaid residents.
Very few felt that licensing and regulatory requirements posed a major obstacle to affordable assisted living in Oregon.
There were varying views on whether the licensing requirements and regulations assured quality. Most acknowledged that quality problems had been a major issue in the program's early years.
The state did a poor job in the eighties and has been catching up ever since. The quality now is good--certainly compared to states like Texas and North Carolina. The state of Washington does the best on quality assurance because they looked at Oregon's mistakes and learned from them and did it right. They bring everyone into the quality assurance system--case workers and surveyors. They also have new training rules but their budget crisis may slow down implementation.
Some thought the regulations were good overall but felt some fine tuning was needed.
The RCF rules are outdated and are being updated by the state--they will be more like the assisted living rules when completed. Many changes will be to administrative requirements, e.g., the need for signatures on specific forms. Others will address major issues such as staffing requirements.
The assisted living regulations are good. The last revision minimized the aging in place requirements and the rules now recognize that individual facilities may have limits on what services they can provide. The state sets the minimum and facilities are permitted to have different ceilings. A small facility may have only one staff person for 8 clients and be unable to do two person transfers.
A few thought that there were ongoing quality issues and that a lot more work on quality needs to be done in all three types of residential care.
There's nothing about Oregon's model that provides better care. What it provides is a wonderful environment that is conducive to a better quality of life. Our track record regarding care is no better than anywhere else--we have individual providers with problems like everywhere else.
A number had complaints about the regulations and varying views on enforcement.
I think Oregon has a good regulatory structure. What's lacking is consistent enforcement.
There is enforcement about silly things like storage and sign placement--things which don't equate to good care. New staffing regulations may also not be related to better care. Nursing homes are over regulated and that hasn't equaled good care.
Increasing the choices tenants have and letting care be directed by the client are good things but new regulations are making it more difficult. They give more responsibility and liability to the provider. For example, there is a prohibition on restraints and bed rails are considered restraints, but some residents may want bed rails because they've had them at home and it makes them feel safer.
I'm very concerned that given the high cost of new prescriptive regulations, Medicaid clients will end up in double occupancy RCFs and assisted living will be only for the private pay market. With the current cut-backs, most providers have stopped taking Medicaid clients until they see what's going to happen.
Two respondents expressed a desire for more outcome based measures of quality.
The types of things needed to really assure quality, such as performance based outcomes, would be better put into the Medicaid provider contracts than in licensing and regulatory requirements.
The regulations are getting too prescriptive. Oregon started with a resident centered program because the state wanted people to direct their own care. Now it's getting towards a more prescriptive model. The cause could have been a bad situation prompting media coverage. I prefer the more outcome based regulations--though I don't always know the best outcomes.
A number of respondents mentioned that the state needs to do a better job assuring sufficient nursing consultation, noting that most providers are keeping residents longer even though the state does not require aging in place. Several felt that some regulatory changes were needed to address the increased acuity levels of residents in residential care settings because the average age of residents in these facilities has increased to 85 and people at these ages have more medical needs, whether they are private pay or Medicaid eligible. One respondent disagreed, stating that acuity levels have not increased since the mid-eighties.
The current regulations assume that most ALF residents will self-direct their care, and the facility will assist them to do so. This works if the person has intact cognition and can make good decisions. But this is not always the case. Residents in these settings need and want more medical and health services from an RN or certified nursing assistant (CNAs). We do not currently require any of our residential care settings to hire CNAs. They can hire people off the street and train them.
We are seeing an increase in acuity in all residential care settings. In nursing homes, 80 percent of clients stay fewer than 90 days and 30 percent fewer than two weeks. Most are post acute. Many of the nursing home residents go from a 3.8 day hospital stay to a short stay in a nursing home and then back to a residential care facility or home.
When Oregon started paying for waiver services in residential care settings, the state did not understand chronic care management and focused on ADLs only. It's now obvious that there is a need for more nursing in these settings and it should have been brought in sooner. But it's not a nursing service model that's needed, it's a teaching nursing model.
One respondent noted that changing the regulations to increase the amount of nursing provided would necessitate an increase in the reimbursement level and finding the right balance would be difficult. Another noted that providers were worried the state will go too far with regulations, but stated "if they are going to do chronic care management, they need nursing." One stated that is was unclear how much nursing care should be provided in ALFs.
There are increased levels of medical acuity and complexity. Some people say there is not enough nursing in assisted living as care needs have escalated. The residents say they need more and there is expectation--regulators expect there to be more nursing care--but there are no additional rules regarding the provision of nursing care or increases in reimbursements to match this expectation.
People also want more prevention to reduce hospital admissions from assisted living facilities. But many facilities don't have 24 hour nursing available. The staff may know how to take a blood pressure, but they do not know how to interpret it. If a person has a stroke he may want to go back as soon as possible after hospital or nursing home discharge to his assisted living facility, but the facility does not have the staff to do the monitoring needing three days post discharge; maybe seven days.
There are a lot of questions about how nursing should be provided in assisted living. There is an expectation that assisted living should be able to do certain things, but facilities do not have nurses available at all times. There are lots of questions. Who has access to what drugs and when? How actively should facilities be involved in assessing and monitoring changes in clients' condition? Currently, how often it happens depends on the facility--whether they have a lot of high or low acuity residents. Some facilities have a director of nursing services, some use RN consultants.
Assisted living facilities are not required to do health assessments unless a resident has a nursing need. If they are diabetic and take oral hypoglycemics, they are considered to not need a health assessment; if they need daily glucose testing then they do need one.
Most concerns about quality related to staffing issues, particularly that fact the providers may not have sufficient staff to care for their residents due to problems with recruitment and retention.
The basic quality problem is that the staff do not know and do not recognize signs of need. The state does criminal background checks. The really bad things we find are not system problems. Staff incompetence and neglect are the problems. The best nurse managers go to other settings to work, even though they like the business. They don't' like working with untrained staff who are not contributing to the health and well-being of the residents.
The biggest quality problem is the lack of training for staff in residential care facilities. Sometimes I'm appalled at the lack of knowledge of basic common sense things. It makes me wonder if they have received any training.
There are major issues with the workforce. Huge turnover due to low pay, no benefits. Managers don't know how to manage people with low skills. It will get worse with less money. Housing is relatively cheap now with low mortgage rates, but the money squeeze on services will lead to staff cuts and quality will become more of an issue.
Recruitment and retention is a major issue. Direct care worker turnover rates are very high. They work in a traditionally undervalued field for low pay and do not have benefits or paid time off. Some solutions are simply monetary, but there is a need to identify ways to make care giving a more attractive profession.
There was consensus that lack of pay and benefits, lack of a career ladder, poor management and oversight, and in some cases, an unpleasant work environment were responsible for many of the staffing problems. When asked whether the state should require staff to resident ratios, the response was ambivalent:
Mandatory staff to resident ratios can help to assure adequate staff, but it's so hard to find staff--some facilities may just not be able to stay within regulatory requirements. For safety reasons and prevention of potential abuse--I'd rather see tighter regulations, but I understand the other side.
One respondent stated that overall, the regulations for dementia care are "pretty good," and that the state has an overlay of rules for RCFs and ALFs for dementia clients, but they are not applicable to AFHs because they serve such a small number of residents.
Providers have to have a higher ratio of caregivers to residents. Adult foster homes and smaller RCFs tend to take care of them. These facilities are usually smaller and better for people with dementia.
The solution to providing good dementia care is not regulations, but enforcement of existing ones. If providers are not meeting the needs of residents with dementia, there should be sanctions.
Most felt that Oregon's standards were good, even if they needed fine tuning in a few areas. One noted that it was highly unlikely that Oregon, or any other state, would adopt national standards, because states do not like to use other's rules. One noted a need for standards and said that good ideas are always welcome but strongly opposed the mandating of national standards.
Any time you mandate standards you get what is in nursing homes--very prescriptive and not necessarily leading to better care. I don't want federal oversight and a one size fits all approach. Best practices? Absolutely. National oversight? Not on your life. We have quite enough oversight with the waivers. There is no need for federal oversight of residential care.
The state does not subscribe to a continuum of care model, where those with the most severe impairments are cared for only in nursing homes. There is a strong belief that unless a person needs 24-hour medical/nursing oversight, they should be able to be served in the their home or the community if that is their choice. While the state's goal is to serve people with a high level of need in residential care facilities, some felt that this goal is met more by AFHs, and RCFs than ALFs.
Oregon's experience is the same as Washington's--the AFHs take care of sicker and more impaired folks. Why? In general, assisted living is run by large corporations. They're good at creaming; they don't want to be in the position of taking care of very impaired people, don't want to hire the staff, and don't want to be exposed to the risk of fines and bad publicity.
A lot of providers try to skim; they try to get rid of the high level folks. Regulations are too permissive--they only require disclosure about discharge. I don't know if there is a regulatory solution. The goal of aging in place is problematic given the insurance and lawsuit issues. Oregon's idea was to do a nursing home replacement model with a better living environment. If assisted living is a replacement model, then assisted living should do all it can to care for residents until they need 24 hour nursing oversight. Aging in place used to be a key factor, but now the state is getting away it.
If providers are going to get Medicaid money, they should be prepared to provide as much care as possible. Small facilities with 30 beds can't do three person lifts. But there needs to be a commitment to keep people as long as possible.
Oregon is not like New Jersey and Florida--saying that when you reach a particular level of need you have to go to a nursing home. Admission is not an issue, but retention and discharge requirements are--determining when people in assisted living have become impaired or have greater medical needs and need to be moved to a higher level of care.
Some providers have difficulty finding a higher care setting that will take a particular resident. Some people in assisted living do not want to move. A facility may be able to take care of one or two people with greater needs but not five or six.
Only a few respondents had views on this topic.
Generally, in assisted living, the concept of managed risk is incorporated into specialized service planning. Specific risk factors are addressed as part of a person's service plan. There is new language in the assisted living regulations stating that incompetent residents can't enter risk agreements. Competence is determined by physicians or an assessment by facility staff and other health professionals. There is no standardized process for determining competency.
This is a big red herring. These risk agreements are not significant--very few clients have them. The regulations state that service plans shall include them if there is one. They are nothing but service planning around a problem. You don't need a risk agreement, you need a good service plan. A big problem is that consumer advocates want autonomy for elderly persons, but they also want to hold the facility responsible for negative consequences.
We have lots of diabetics who want to cheat. What we want to do is have the facility and the resident agree on the times they will cheat so we can have a plan to test blood sugar and have sliding scale insulin coverage. But if they don't adhere to the planned time, then the facility is blamed for not identifying the onset of hypoglycemia.
I'm not a fan of negotiated risk agreements (NRAs). To do them right requires a great deal of skill--relying on the informed choice of a consumer. I believe that facilities are responsible for watching over their residents to be sure their needs are being met. Facilities shouldn't be able to relinquish this responsibility. With good providers I'm not as concerned. The norm is more of a "cookie cutter" approach.
It's an easy way to release a facility from the responsibility to carefully work with the residents to help them maximize what they need to do to manage their own care. Oregon's licensing requirements state that a facility has to have ongoing active involvement to help residents manage if they are going to self manage. It's a challenge for facilities to deal with resident's wishes. I've seen these agreements end up as excuses for the facility not doing what they need to do.
A few noted that because Oregon set a cap on room and board rates for Medicaid eligibles--particularly for ALFS, which provide private apartments--the state has to pay enough for services to attract providers. In general, most felt that ALF rates were high relative to rates for ACHs and RCFs.
Setting the initial assisted living rate at 80 percent of the nursing home payment was a clear signal to the industry that the state was encouraging this model.
The state gave a generous rate structure to providers to encourage assisted living development and the availability of assisted living for Medicaid eligibles. This policy has come under attack every legislative session because the rate is higher than what is paid to other residential care settings. The high service rate has always been an eyebrow raiser in Oregon.
Oregon spends more on services in assisted living settings than any other residential care setting. The lobby for assisted living is the same as for nursing homes--AHCA and AHSA. The persons representing foster care can not compete. The lowered flat rate being proposed for assisted living during the current budget crisis would certainly narrow the payment gap between assisted living and adult foster care.
Oregon is thinking about paying the same set service fee dependent on level of impairment to all three types of residential care but this will be difficult politically.
Rates were OK for a while but they have not kept pace with inflation. We get insurance increases every year, but no rate increase. With the coming cuts, some facilities will close--especially those that are highly dependent on Medicaid.
A few noted that if the state wants people to age in place, the reimbursement rate structure has to take into account that certain people take more time to take care of.
Those with behavioral problems or who need a 2-person transfer cost more. If the state won't pay it, they will wind up in institutions when they could have been served in the community.
The state has chronically under-funded providers in order to let case loads grow. We need to fund them adequately. Assisted living has had a reasonable rate but not AFHs. You can't starve one side of the system to serve another. The state does not require AFHs, RCFs, and ALFs to have cost reports. The rates bear no relationship to the delivery of services. Initially they were generous enough to get providers to participate. But acuity levels have gone up but not the rates.
The state has starved nursing homes. All of the parts of the long term care continuum used to fight each other for funding but we then realized that the entire continuum needs adequate funding. If the proposed budget cuts go through there will be a complete collapse of the Oregon long term care system.
A number of respondents made specific suggestions for improving the system:
The state should allow family supplementation for private or larger rooms for Medicaid residents in AFHs and RCFs. Washington state allows families to contribute the difference in cost between a studio and a one bedroom.
Get away from prescriptive regulations. Tell facilities that if they kick Medicaid folks out too early they won't get any more residents. Give providers incentives to keep people as long as possible. Give them enough money--the amounts in the past were sufficient, but recently have not kept pace with inflation, especially the increases in insurance.
What I would do is move to a standardized assessment tool for providers and develop quality indicators for this tool. You can't track quality without it. The current assessment is not a facility tool. It is used to determine Medicaid eligibility.
We need a quality assurance system that moves to the culture of patient safety--where you identify problems and then try to fix them.
Other than getting higher service rates--rates that accurately reflect costs--I would like the program to have a chronic disease management focus to save money on both the acute and long term care side. The length of stay in nursing homes and hospitals are so short, we have more people in the community with significant health issues. We need to look at the provision of health services in the community. There is a lack of health care in the service component. We need to know what are good outcomes. What level of falls are acceptable in the community. We can't have the same expectations as in nursing homes--that no one will ever fall or develop a decubiti. I'd also like to address the polypharmacy issue. There are too many people on 8 or more medications. I'd also like to replace physicians with nurse practitioners in all settings. The physicians do not understand the setting. They think they can call a nurse and have something done like in a hospital.
We need research on systems for assuring quality in community settings. We need information on best practices. How to teach unlicensed personnel about disease management? How to manage the non-compliant diabetic? How to provide palliative care? How to provide care to the anxious COPD patient with air hunger? All when you don't have nurses available on a 24 hour basis. We need special training for medication administration. We spend a lot of money on training using a train the trainer approach. But reimbursement needs to recognize the need for substitute staff when the regular staff are out of the facility to obtain training.
We need a career ladder for direct care workers.
One respondent noted that one of the reasons the number of assisted living facilities grew so fast was because the state had a financing mechanism through the housing agency, but the state should have placed requirements on the providers who received these loans.
Loans were made with general obligation bonds. About 25-30 percent of assisted living facilities a few years ago were all financed with these bonds. If the state gives a provider a low interest loan, the provider should be required to take a certain proportion of Medicaid clients until the loan is paid off.
One respondent said that consumers needed more information about the quality of services in each facility. Even though the state has a website, this respondent felt it did not provide sufficient information for consumers to make an informed choice.
One respondent stated that in the absence of a budget crisis Oregon would probably want to expand and improve the current HCBS system, noting that the state is pretty close to a balanced system. Another said that the state's program has changed since its inception and it will continue to change, noting that it is important for the state to continually assess the strengths and weaknesses of its program and make changes accordingly. For example, the State is currently updating its RCF rules and is examining the role of community nurses in all residential care setting. They are also working on initiatives related to person-centered planning.
Another noted that the state's 18 categories of level-of-care criteria has been helpful in times of budget cuts in that it provides a mechanism for the state to reduce the number of people being served based on level of need. However, the respondent said that it's not perfect and that the state wants to revise the criteria to incorporate more risk factors, such as chronic care needs and acuity.
Reflecting Oregon's extensive experience covering Medicaid services in a range of residential care settings, respondents had many specific recommendations. Many felt that Oregon's experience could provide guidance for state's looking to make a range of residential care options available for both the private pay market and the Medicaid client. Most did not mention the importance of making the room and board component affordable, because they assumed it was a given. When specifically asked about room and board, they agreed that it is not possible to provide assisted living to the Medicaid population unless the room and board component is affordable.
Several mentioned the importance of addressing quality assurance from the outset.
Pay attention to quality assurance from the outset. ALFs need to be surveyed on a regular basis--not the same focus as nursing homes but similar. You have to use a different model of quality--look at protection, service needs being met, and livability.
The state should have paid as much attention to quality assurance as to the requirements for the physical plant. It would have taken a few more steps to assure quality and it would have slowed down provider interest in the beginning, and the state would not have met its obligation to save money. The state stayed in this mode until the mid-eighties, and then we had horror stories, and started to pay more attention to quality. Now Oregon has good quality overall. States should start with a well defined idea of what the service package will be and what quality outcomes are expected.
In the beginning, providers didn't know--even though it was in the rules--exactly what services they needed to provide. They did have a better sense of service needs than in some other states, where the providers getting into assisted living come from the housing world--they don't know services. Assisted living has been sold as a light care model and staffing capacity was based on this--that there would not be highly impaired residents. But you would expect that with aging in place, there would always be a portion of heavy care clients, and you need to plan for this.
One problem when the state started was they it did not fully appreciate quality issues and chronic care needs--and how to put in systems to assure that quality was assured and needs were met. It was not an intentional oversight--it was naïve. They believed that ADLs were the key. But chronic care management and acuity are just as important.
One respondent said that the state was very concerned about dementia care and had issued special rules for facilities that market themselves as special care units.
A number stressed the importance of not paying for services in assisted living by the hour.
Some states fund assisted living like they do home care--they provide so many hours of services and treat it like home care. They do that in Georgia. But you can't grow it that way. States shouldn't pay for services on an hourly basis. Set tiered levels--treat assisted living like a nursing home without room and board. Set it up as a reimbursable entity under the waiver.
Some mentioned the need to address legislators' concerns about induced demand.
There will definitely be an increase in clients when you expand HCBS but you can handle this if you set it up right. HCBS can save money if you target it right. Indiana has twice as many folks in nursing homes as in HCBS. But even though Indiana's per capita spending is lower than Washington's, Indiana's costs are higher than Washington's because Indiana serves more people in nursing homes than in HCBS, whereas Washington does the reverse.
One respondent said that if the state were starting over, it would probably be willing to compromise on each apartment having a full kitchen, because most people don't use them.
You could require a refrigerator and microwave and sink--but most kitchens are quite small. You do need to put some minimums in regulations, however, to ensure that at least the minimum is provided.
One respondent stated that an immense advantage the State had in setting up its system was that their authority for long term care policy rests in one administrative agency that designs and regulates the entire system and pays for Medicaid.
This is a huge advantage in making sure that licensing rules will be effective for both private pay and Medicaid clients. The most important thing is the ability to manage things collectively under one agency--which allows us to implement our vision--to work with advocates--because we control licensing and everything else about the system. The only thing we didn't control was the Oregon Board of Nursing. But we worked extensively with them to get what we needed. You need to put a lot of energy into these efforts to make them happen.
One respondent said that states wanting to use Medicaid to fund services in residential care needed four things: (1) a method to make room and board affordable for Medicaid eligibles; (2) a funding stream to buy the services you want; (3) a regulatory agency that subscribes to your philosophy; and (4) flexible oversight and quality improvement activities that are designed to take more of a teaching role rather than an inspection and sanction role.
With regard to the third requirement, this respondent noted:
Regulatory agencies are often not connected to Medicaid--they're concerned about health and safety and often have a strict continuum of care approach. They don't think you should be putting impaired folks in residential care facilities.
States need to enable all settings to provide care and to write regulations to support them to do so. To design and develop a complete system--you need both strong home care and congregate care for the people who can't live alone. Another important approach is to design purchasing to buy things that can also be bought by the private sector. There should be no special programs for Medicaid--with the rest of the public stuck in an old model.
One respondent stressed the importance of having the public understand the various options.
Be sure that clients have sufficient information about the different types and levels of care provided in different types of facilities; that they understand the limits; that they can not have unfettered expectation of staying on one level for ever. There is a continuum of care. You can sometimes stretch what's provided in a community setting but not always.
Another addressed more political issues:
Don't bash nursing homes to promote assisted living. Don't sell assisted living as saving money by taking people out of nursing homes or diverting them from nursing homes. Even if there are no cost savings, it's still better to have more options. You also need a good case management system in place to support home and community care and it's expensive. The reason to do assisted living is that consumers want it and it's good for them.
Finally, given the current budget crisis in Oregon, which will cause some Medicaid clients in ALFs to be dropped from the waiver program, one person said that if a state is planning to use Medicaid to cover services in residential care facilities, it should use a separate waiver program for assisted living only and limit the number of slots. This will help to assure that during a budget cutback there will be less pressure to take away services from people who are already receiving them.
Gibson, M. J. and Gregory, S. R., Across the States 2002: Profiles of Long-Term Care, AARP, 2002.
Kane, R. L., et. al., Oregon's LTC System: A Case Study by the National LTC Mentoring Program, University of Minnesota, April 1996.
Kassner, E. and Williams, L., Taking Care of their Own: State-funded Home and Community-based Care Programs for Older Persons, AARP, September 1997.
Kassner, E. and Shirley, L., Medicaid Financial Eligibility for Older People: State Variations in Access to Home and Community-Based Waiver and Nursing Home Services, AARP, April 2000.
Manard, B. et. al., Policy Synthesis on Assisted Living for the Frail Elderly: Final Report, submitted to Office of the Assistant Secretary for Planning and Evaluation, December 16, 1992. [Executive Summary]
Mollica, R.L., State Assisted Living Policy: 1998, Report (ASPE and RTI) June 1998. [Full Report]
Mollica, R.L., State Assisted Living Policy: 2000, National Academy for State Health Policy; funded by The Retirement Research Foundation (LTC13). August 2000.
Mollica, R.L., State Assisted Living Policy: 2002, National Academy for State Health Policy, November 2002.
Mollica, R.L., and Jenkens, R., State Assisted Living Practices and Options: A Guide for State Policy Makers, A publication of the Coming Home Program, funded under a grant from The Robert Wood Johnson Foundation, September 2001.
O'Keeffe, J., People with Dementia: Can They Meet Medicaid Level-of-Care Criteria for Admission to Nursing Homes and Home and Community-Based Waiver Programs?, AARP, August 1999.
Smith, G. et. al., Understanding Medicaid Home and Community Services: A Primer, U.S. Department of Health and Human Services, Office of the Assistant secretary for Planning and Evaluation, October 2000. [Full Report]
Sparer, M., Health Policy for Low-Income People in Oregon, Urban Institute, September, 1999.
State Assistance Programs for SSI Recipients, January 2001, Social Security Administration, Office Of Policy, Office Of Research, Evaluation, and Statistics, Division Of SSI Statistics and Analysis.
Stone, J.L., Medicaid: Eligibility for the Aged and Disabled, Congressional Research Service Report for Congress, updated July 5, 2002.
2003 Information Memorandum: Medicaid contract insurance requirements for Assisted Living and Residential Care http://www.dhs.state.or.us/policy/spd/transmit/im/2003/im03093.pdf
2003 Legislative Session http://www.dhs.state.or.us/publications/reports/03sessionwrapup/stories.html
Administrative Rules, Seniors and People with Disabilities http://www.dhs.state.or.us/policy/spd/alpha.htm
Administrative Rules, Chapter 411, Division 056, Assisted Living Facilities http://www.dhs.state.or.us/policy/spd/rules/411-056.pdf
Aged, Blind and Disabled Medicaid Eligibility Survey http://www.masterpiecepublishers.com/eligibility/
Department of Human Services http://www.dhs.state.or.us/seniors/
DHS Community-based Care http://www.dhs.state.or.us/seniors/choosing_care/comm_care.htm
Governor's Task Force on the Future of Services to Seniors and People with Disabilities http://www.dhs.state.or.us/spd/publications/gtf.htm
Oregon Project Independence http://www.dhs.state.or.us/seniors/publications/opi.htm
Oregon Revised Statutes http://www.leg.state.or.us/ors
Oregon Supplemental Income Program http://www.dhs.state.or.us/seniors/publications/osip_2003.htm
Spousal Impoverishment Law http://www.dhs.state.or.us/seniors/publications/sp_impov_2003.htm
The Oregon Model, presentation by Roger Auerbach, Administrator, SDSD, Oregon Department of Human Resources, 1998 http://www.sdsd.hr.state.or.us/about/oregon_model.htm
Roger Auerbach, President
Auerbach Consulting, Inc.
Former
Director, DHS Senior and Disabled Services Division
Margaret Carly, Deputy Director and Legal Counsel
Oregon Health Care
Association
Michael DeShane, President and CEO
Concepts in Community Living,
Inc.
Barry Donenfeld, Director
Area Agency on Aging
District 3 Office
Mid-Willamette Valley Senior Services Agency
Ruth Gulyas, Executive Director
Oregon Alliance of Senior and Health
Services
Cindy Hannum, Administrator
Oregon Department of Human Services
Office of Licensing and Quality of Care for Seniors and People with
Disabilities
Dolores Hubert, Chair
Health and Long Term Care Committee
Governor's Committee on Senior Services
Richard Ladd, Long Term Care Policy Consultant
Ladd & Associates
Former Director, DHS Senior and Disabled Services Division
Jeff Miller, Policy Analyst
Oregon Department of Human Services
Seniors and People with Disabilities
Margaret Rickles, R.N.
Preadmission Screening Nurse
Clackamus
County
Dennett Taber
Assisted Living Program Coordinator
Oregon
Department of Human Services
Seniors and People with Disabilities
Nursing Home Relocation Services, begun in 1982, are still an important part of Oregon's long term care system, though the average nursing home resident in 2002 is much more impaired. Because HCBS care coordination staff caseloads are high, some Area Agencies on Aging have created relocation specialist positions. Relocation costs may be paid by exempting resident income generally paid to the nursing home, or through the HCBS waiver program.
Mollica, R.L. and Jenkens, R., State Assisted Living Practices and Options: A Guide for State Policy Makers, Coming Home Program, Robert Wood Johnson Foundation, September 2001.
Prior to February 2003, the state had a Medically Needy Program for the aged, blind and disabled, which covered only prescription drugs and mental health services, but not long term care. The program was terminated due to budget constraints.
Sparer, M., Health Policy for Low-Income People in Oregon, Urban Institute, September, 1999.
The state plans to increase the amount in 2003.
A computerized scoring system weights and adds multiple measures of physical and mental functioning to determine if the criteria are met. The scoring system is also used to determine reimbursement levels for services provided through the waiver program.
Sparer, M. op. cit.
Kane, R. L., et. al., Oregon's LTC System: A Case Study by the National LTC Mentoring Program, University of Minnesota, April 1996.
The income amount will be increased in July 2003.
Kane, 1996, and Sparer, 1999, op. cit. It designated the newly created Senior Services Department (later renamed the Senior and Disabled Services Division and now called Seniors and People with Disabilities) as the state agency responsible for supervising and coordinating the various long term care programs for elderly persons. The legislation also delegated to the local Area Agencies on Aging (AAAs) the responsibility for developing a single point of entry for persons seeking long term care services.
Kane, 1996, and Sparer, 1999.
Oregon Revised Statutes 410.010.
Kane, 1996.
Oregon's Long Term Care Medicaid Caseload by Care Setting, July 2002, cited in Executive Summary of Governor's Task Force on the Future of Services to Seniors and People with Disabilities, Initial Report, September 2002.
Kane, 1996.
Sparer, 1999.
Kane, 1996.
Kane, 1996, and Sparer, 1999.
Mollica, R.L., State Assisted Living Policy 2000, National Academy for State Health Policy; funded by The Retirement Research Foundation (LTC13). 2000.
The state's SSI supplement is $1.70 per month, the minimum amount required by federal law as state maintenance of effort when the SSI program was first enacted in the early 1970's.
Federal SSI limitations apply except that the transfer of a home may render a person ineligible for a state supplement for up to 30 months, based on the amount of uncompensated value.
The state's SSI supplement is $1.70 per month, the minimum amount required by federal law as state maintenance of effort when the SSI program was first enacted in the early 1970's.
Federal SSI limitations apply except that the transfer of a home may render a person ineligible for a state supplement for up to 30 months, based on the amount of uncompensated value.
Managed risk: OAR 411-056-0015(2)(i) - (L) The facility must document the information set forth in (j) of this rule.
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