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.
2.3.1 Exclusion of Homes Licensed for Special Populations
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.
2.3.2 Defining Unlicensed Board and Care Homes
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.
- Inclusion of “Traditional” Board and Care Homes. A facility was eligible if it provided room, meals, some type of 24-hour protective oversight or supervision, and one or more eligible services (e.g., personal care, transportation to medical and dental appointments, organized recreational activities, medication reminders) to two or more adults who were not related to the operator/owner.
- Inclusion of “Assisted Living” Facilities and Apartments. A place with only apartments was considered eligible if it provided either all the “core” criteria listed above (i.e., three meals, 24-hour staff supervision, services) or provided a more significant or intensive level of supportive services (e.g., medication storage and supervision, money management, and assistance with ADLs).