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
- A rapidly growing elderly population with significant levels of physical disability and mental impairment
- The almost universal rejection of nursing home care by younger persons with disabilities and their advocates
- A strong preference of the elderly for in-home and community-based services rather than nursing homes.
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 document the characteristics of board and care homes, how much they had grown in the United States since the initial studies of the 1980s, and the role they play in meeting the need for long-term care
- To describe the characteristics of board and care residents, particularly the extent of frailty and disability among residents
- To assess the quality of care received by board and care residents and examine the effect of State regulation on the quality of that care.
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.