The survey asked state respondents to list three top issues facing public policy makers with regard to assisted living. The responses covered a broad range of areas: financing, regulation, quality of care, services, staff training, and the future and direction of assisted living. Policy makers are searching for ways to make assisted living accessible and affordable. Sixteen states identified a range of issues related to affordability. Several are interested in developing public funding for low-income residents or funding ways to make it affordable to residents whose income is too high to meet Medicaid eligibility requirements and too low to pay privately.
A number of general regulatory issues were raised such as whether and how to regulate assisted living, transitioning from licensing to an accreditation model, and dealing with unlicensed facilities. One respondent noted that greater consistency in the application of regulations by survey staff was needed, and another state is seeking ways to improve dealing with facilities that consistently have violations of rules that are not severe enough to warrant termination of the license. The role of the Fair Housing regulations and ADA were cited as a concern.
States also support but express concern about many of the main tenants of assisted living. How do you balance safety and maximum autonomy and independence? What levels of care are appropriate? How should state policy facilitate or deal with aging in place, and what are the best ways to monitor facilities serving residents with a mix of health and functional needs? The needs of residents with Alzheimer's disease and control of access issues were mentioned by four states.
A number of policy makers dealt with quality in stating their priorities. States are searching for the right level of oversight, developing outcome measures, dealing with abuse and neglect, and handling facilities that admit residents that they are not staffed to serve appropriately.
Several respondents were concerned about the lack of consensus about the definition of assisted living and the potential for medicalizing what is now seen as a social or home-like model of care. Another was concerned that over time the more flexible approach to regulation might give way to more prescriptive regulation. Precedents in licensing and regulating nursing homes were mentioned. Concerns that the spiraling growth of facilities and the emerging dominance by a limited number of chains may undermine what has until now been a "consumer-driven" market were described. A few states were concerned about recruitment and retention of enough trained staff as the number of facilities expands. While states worry about over-supply, some seek to stimulate development in rural areas where the supply has been far slower to develop.
Appropriate training for administrators and staff was cited by three states. Several states are focusing on medication management and the training of staff administering medications. Regulations in most states allow administration of medications and many allow unlicensed staff to administer medications under nurse delegation procedures.
Among the issues related to services, state respondents listed integration of services, linkages between assisted living and other Medicaid waiver services, and the coordination of home health services and assisted living services as areas to explore.
Negotiated service agreements are another area that differentiates assisted living from board-and-care rules, yet states are concerned that consumers do not understand these procedures and may not use them to their full advantage. The need for an effective assessment process and the offering of meaningful activities to residents were also cited.
A few states were interested in exploring how assisted living could serve people with chronic mental illness or adults with physical disabilities.