The review of state policy and activity shows that before long nearly every state will have reviewed their regulations governing residential care settings. State assisted living policy continues to follow multiple paths. While some states have developed a new category in addition to older board-and-care categories and view assisted living as a distinct model, others are consolidating multiple categories under a single term. Assisted living is increasingly used as a term to define the model of care, although the term has varied meaning across states. Regulations in twenty-two states now contain a statement of the philosophy of assisted living which distinguishes it from other residential care models. States that do not create new categories or use the term assisted living are updating their regulations and allowing a higher level of care to be provided.
This survey found that several states have moved or are seeking to combine multiple licensing categories under a single assisted living category that may include assisted living, board-and-care, multi-unit conventional elderly housing, and adult foster care. Arizona, Maine, Maryland, and New York are joining New Jersey and North Carolina in this approach.
Since the last study, broad, more flexible admission/retention criteria have been developed in Hawaii, Kansas, Maine, Vermont, and Wisconsin. These criteria treat assisted living much like a person's single-family home or apartment. In their own home, people can receive high levels of home health service. Recent state regulations allow a similar level of care as long as the facility has the capacity to deliver care or acceptable arrangements are made with outside agencies.
States are also focusing on the needs of people with Alzheimer's disease and dementia and on state regulations concerning this population. Fourteen states now have requirements that staff be trained in the needs of this population. Regulations also address the environment, activities, and disclosure statements for special care units.
Medicaid coverage of assisted living is likely to expand to more states, and the number of tenants who are Medicaid beneficiaries will also grow in the coming years. In the past, facilities targeted a wealthier, less-impaired population. Over time, supply has expanded, competition for tenants increased, tenants have aged-in-place, and Medicaid coverage has expanded. Today, in order to maintain occupancy levels, facilities are more interested in serving tenants with higher impairment levels. Several assisted living companies are now developing products to serve older people with low- and moderate-incomes. However, participation is still quite low and more work needs to be done.
To facilitate use of this housing and services model for people who can no longer live in their own home or apartment, states need to address both their payment rates and the training of case managers and other staff who serve older people through home- and community-based service programs. The experience in Washington and other states suggests that rates can be set that are compatible with the rates charged to private-pay residents which are lower than Medicaid nursing home rates. State policy makers may need to work with housing finance agencies and providers to understand the room-and-board costs that cannot be covered under Medicaid as well as the service costs that can be covered. To be able to move into assisted living residences, frail older people with low incomes will need to retain sufficient income to pay for the room and board costs.
As the supply of facilities and Medicaid coverage grows, hospital staff, home health agencies, home-care case managers, and other professional staff will need to become more familiar with assisted living and the opportunity it offers frail older people. States that have not developed or updated their regulations might consider revisions that address the institutional character of older "board-and-care" rules and develop assisted living as an affordable and home-like setting that provides a level of care that enables people to age-in-place.