Performance Improvement 1997. Analysis of the Effect of Regulation on the Quality of Care in Board and Care Homes



This study assessed the effects of State board and care home regulations on the quality of care provided by those institutions. The investigators also attempted to identify the characteristics of the board and care environments in the States selected for the study and to determine whether licensed and unlicensed homes differed in terms of those characteristics or in the quality of care provided. The evaluation concluded that extensive State regulation and licensure can improve the quality of care provided by board and care homes.


This investigation examined the quality of care in board and care homes in 10 Statesþ5 with extensive regulatory systems and 5 with more limited regulatory systems. For the purposes of this study, board and care refers to nonmedical, community-based residential settings that house two or more unrelated adults and provide such services as meals, medication supervision or reminders, organized activities, transportation, or help with activities of daily living.

The principal purpose of the study was to analyze and compare State board and care regulations and their effects on the quality of care received by board and care residents. Investigators attempted to do the following:

  • Identify the characteristics of the board and care environments in the selected States, including the characteristics of the homes, operators, staff, and residents.
  • Determine the effect of State regulation on the quality of care and the experience of board and care residents.
  • Explore differences between licensed and unlicensed homes, particularly with respect to quality of care.

To accomplish these objectives, the study analyzed data on State regulatory systems, constructed a sample frame of licensed and unlicensed homes, and implemented a complex multistage sample design. In addition, the investigation compared data with the findings of earlier studies of board and care and with current data on the characteristics of other residential long-term care settings to clarify the role played by board and care homes.


Changes in population demographics and a number of policy initiatives have increased demand for residential facilities that offer support services for the aged and disabled. Chief among these are a rapidly growing elderly population with significant levels of physical disability and mental impairment, an almost universal rejection of nursing home care by younger persons with disabilities and their advocates, and a strong preference among the elderly for in-home and community-based services as opposed to traditional nursing home care. While family efforts continue to be the primary source of long-term care for elderly and disabled loved ones, different types of residential settings with support services have emerged to supplement the efforts put forth by families.

There are approximately 34,000 licensed board and care homes in the United States, with more than 613,000 beds. These homes fall into one of three basic types of licensed facilities: those serving mentally retarded or developmentally disabled persons, those serving mentally ill persons, and those serving a mixed population of physically frail elderly, cognitively impaired elderly, and persons with mental health problems. Not all board and care homes are licensed, however, and by some estimates, unlicensed homes are as numerous as licensed facilities. Thus, the total number of persons living and receiving care in all types of board and care homes may be as high as one million.

While the Federal Government has traditionally played only a limited role in monitoring or regulating the quality of services provided by board and care homes (leaving primary oversight to the States), the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in HHS has maintained a long-standing interest in the potential of board and care homes to meet the needs of elderly and disabled persons for residential services. This becomes particularly important in light of the strengthened Federal oversight of nursing home quality required by the Omnibus Budget Reconciliation Act of 1987.

The present analysis stems from Federal concerns regarding the lack of systematic information on board and care residents, changing levels of disability among the population served, adequacy of care, protection from health and safety risks, and the significant numbers of unlicensed and unregulated homes in the United States.


To accomplish the goals of the investigation, the study design incorporated several activities, including a major collection of new data. However, all activities focused on the main study goals of facilitating cross-sectional comparisons among facilities and residents based on the licensure status and regulatory environment under which the homes operated.

After reviewing current State regulatory approaches, the investigators selected 10 States for inclusion in the study; these States represented the extremes on a continuum of regulatory systems, ranging from very extensive regulation (California, Florida, New Jersey, Oklahoma, and Oregon) to very limited regulation (Arkansas, Georgia, Illinois, Kentucky, and Texas). A stratified, multistage, cluster design was used to select probability-based samples of homes, staff, and residents in each State. A sampling frame of eligible unlicensed homes was created using the Social Security Administration's State Data Exchange (SDX) tapes and network sampling of State and local agencies.

Primary data collection was then undertaken in 385 licensed and 129 unlicensed board and care homes, including interviews with 490 operators, 1,138 staff, and 3,257 residents. Site visits were conducted at each facility and extensive information was collected on characteristics of the home, including patient and payer mix; characteristics of the staff, including knowledge of aging and caregiving; resident demographics, health status, and satisfaction; and quality of care, including the physical environment, adequacy of staff, unmet health needs, and patient satisfaction. Data were analyzed using descriptive statistics and logistic and linear regression models.


This inquiry found substantial and widespread positive effects of both regulation and licensure on the quality of care in board and care homes. States with extensive regulatory systems had a significantly smaller proportion of unlicensed facilities than States with limited regulation (7 percent versus 25 percent). Extensive regulation also had a positive effect on several quality-of-care and quality-of-life indicators, such as lower use of psychotropic drugs and medications contraindicated for the elderly, more operator training, and greater availability of social aids (e.g., reading materials and community rooms) and supportive devices (e.g., grab bars in showers and call buttons in bathrooms).

Licensure also had a positive effect on many of the quality-of-care measures explored. For example, licensed homes were more likely to have operators with training and to make more social aids and supportive devices available to residents. Licensure also enhanced the availability of key services and the prevalence of safety features. A significant finding is that licensure was effective in raising homes above a minimum level of acceptable performance, or "preventing" the worst performance. Thus, licensed homes were less likely to have the lowest scores on such measures as availability of social aids, physical amenities, safety features, and an environment with little diversity and a very institutional atmosphere.

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

Finally, the report noted that the niche for board and care homes appears to be different in States with extensive regulatory systems compared with States with limited systems. States with extensive regulatory systems have higher-than-average board and care bed supply and lower nursing home bed supply. Homes in States with extensive regulation have residents with higher levels of disability than homes in States with limited regulatory systems. Thus, it appears that States with extensive regulatory systems were using board and care beds as substitutes for nursing home beds, particularly in comparison with States with limited regulatory systems.

Use of Results

The study findings have several important implications for key participants in the board and care sector. Findings point to a board and care population that is considerably more frail and disabled than it was 10 years ago. Furthermore, the mix of physically frail elderly, cognitively impaired elderly, and residents with mental illness and developmental disabilities (some of whom are nonelderly) presents a complex caregiving challenge. These factors should prompt a reexamination of the health and safety issues that confront board and care providers and the States' systems for regulating the industry. Of primary importance are the range of services, staffing patterns, and staff training and knowledge needed to meet the needs of today's residents.

This study confirms that there is a well-defined role for board and care homes in the provision of long-term care. The findings specifically suggest the following:

  1. States can improve the quality of care in board and care homes through appropriate regulation.
  2. States can improve other aspects of quality by requiring licensure of board and care homes.
  3. The Federal Government can support State and provider efforts to improve the quality of care by developing and disseminating information.
  4. The board and care industry should work closely with State Governments to improve the quality of care.

Agency sponsor:

Office of Disability, Aging, and Long-Term Care Policy

Federal contact:

Floyd Brown
PIC ID: 4720

Performer organization:

Research Triangle Institute, Research Triangle Park, NC