Sixteen states have adopted or proposed a negotiated risk process to involve residents in care planning and to respect resident preferences which may pose risk to the resident or other residents. Washington provides for negotiated risk agreement that is developed as a joint effort between the resident, family members (when appropriate), the case manager, and facility staff. The negotiated risk document specifies that the agreement's purpose is to "define the services that will be provided to the resident with consideration for preferences of the resident as to how services are to be delivered." The agreement lists needs and preferences for a range of services and specific areas of activity under each service. (See table.) A separate form is provided to document amendments to the original agreement. Signature space is provided for the resident, family member, facility staff, and case manager. If assistance with bathing is needed, the process allows the resident to determine and choose what assistance will be provided, how often, and when. It allows residents to preserve traditional patterns for eating and preparing meals and engaging in social activities. The negotiated service agreement operationalizes a philosophy that stresses consumer choice, autonomy, and independence over a facility-determined regimen that includes fixed schedules of activities and tasks that might be more convenient for staff and management of an efficient "facility." It places residents ahead of the staff and administrators and helps turn a "facility" into a home.
The process allows the participants to identify a need and determine with what tasks the residents themselves wish to receive help. For example, if the resident has difficulty bathing, the resident may prefer help getting to the bathroom and unfastening clothing. Yet a resident may prefer to undress and get into the tub and bath herself/himself even though the staff member and perhaps a family member feel the resident may be placed at risk of falling. The risk is expressed but the final decision to bathe rests with the resident.
TABLE 3. Washington Negotiated Service Agreement Areas
|Nursing||Health monitoring, nursing intervention, supplies, services coordination, medication, special requests|
|Personal service||Toileting, bathing, AM preparation, ambulation, PM preparation, hygiene|
|Food service||Dietary, eating|
|Environmental||Safety, housekeeping, laundry|
|Social/emotional||Family intervention, information/assistance, counseling, orientations, behavior management, socialization|
|Administration||Business management, transportation|
Values assume a prominent role in shaping policy in several states. Many states use values language developed in Oregon. The Oregon definition says that "assisted living promotes resident self direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and home-like surroundings." Each facility must have written policies and procedures which incorporate the above principles. Services plans are reviewed for the extent to which the resident has been involved, and the resident's choices as well as the principles of assisted living are reflected.
New Jersey defines managed risk as the process of balancing resident choice and independence with the health and safety of the resident and other persons in the facility or program. If a resident's preference or decision places the resident or others at risk or is likely to lead to adverse consequences, such risks or consequences are discussed with the resident and, if the resident agrees, a resident representative. A formal plan to avoid or reduce negative or adverse outcomes is negotiated. The rules provide that choice and independence may need to be limited when the resident's individual choice, preference, and/or actions place the resident or others at risk. The managed risk process requires that staff identify the cause for concern, discuss the concern with the resident, seek to negotiate a managed risk agreement that minimizes risk and adverse consequences and offers possible alternatives while respecting resident preferences, and document the process of negotiation or lack of agreement and the decisions reached.
Ohio added managed risk provisions to its residential care facility rules in 1996. The rules allow facilities to enter into agreements with residents to share responsibility for making and implementing decisions affecting the scope and quantity of services provided by the facility.