Defining assisted living and differentiating it from board and care has proved a challenge in recent years. And a common definition or understanding of assisted living remains unlikely as state policy makers, regulators, legislators, consumers, and providers develop models that address local circumstances. In many states, there is considerable overlap between board and care and assisted living rules. Assisted living is both a generic concept and a specific model. Facilities and state regulators in states with board and care rules often use the terms assisted living and board and care synonymously and include the ability to age in place and offer higher levels of care under their board and care rules. A review of state polices finds that four states use assisted living and board and care interchangeably: Alabama, Rhode Island, South Dakota, and Wyoming. Yet other states describe assisted living as a specific model that has a consumer centered philosophy, apartment settings, residential environment, and a broad array of services which support aging in place.
Assisted living policy in other states generally differs from board and care rules in three primary areas:
Assisted living statutes/regulations often contain a statement of philosophy that emphasizes privacy, independence, decision-making and autonomy.
Assisted living is more likely than board and care to emphasize apartment settings shared by choice of the residents.
Assisted living allows facilities to provide or arrange nursing or health related services and to admit or retain residents who may meet the level of care criteria for admission to a nursing facility.
Some states have gone even further with their efforts to differentiate services. Washington state has developed Medicaid regulations which differentiate assisted living, residential care, and enhanced residential care. Assisted living contractors must offer private apartments and may provide limited nursing services. Enhanced adult residential care providers may provide limited nursing services while adult residential care contractors may not. Adult residential care and enhanced adult residential care providers are not required to offer private units with bathrooms and kitchens, while assisted living facilities are required to do so.
TABLE 1. Assisted Living and Board and Care: Washington
States may create a new assisted living licensing category and retain older categories (e.g., residential care facilities, personal care homes) which allow shared bedrooms and limited services. Other states have consolidated categories and now have one general set of assisted living rules that might cover assisted living, board and care, multi-unit elderly housing, congregate housing and sometimes adult family or foster care (e.g., Maine, Maryland and North Carolina). Still others set core requirements for licensed facilities and require an additional license to offer limited nursing services or a higher level of care. To add to the variation, Wisconsin has changed its category from assisted living to residential care apartment complexes.
States also differ in their description of the focus of assisted living. Connecticut and Minnesota see assisted living as a service, and license the service provider (which may be a separate entity from the organization that owns or operates the building). Others states see assisted living as a building in which supportive and health related services are provided. The operator of the building is licensed, and services may be provided by the operator's staff or contracted to an outside agency.
Draft rules in Louisiana establish core rules and separate modules for assisted living facilities, personal care homes, and shelter care facilities. The modules contain separate requirements for administrators, staff training, and living units. The draft rules state that the purpose of the regulations is to promote the availability of appropriate services for elderly and disabled persons in a residential environment; to enhance the dignity, independence, privacy, choice, and decision-making ability to the residents; and to promote the concept of aging-in-place. This extends the principles of assisted living to other categories while requiring (1) more training for administrators and staff, and (2) apartment units in assisted living settings. Oregon, which was the first state to adopt principles of assisted living, and Washington have extended the principles to other categories of care.
Will There be Consensus?
Reaching consensus on a definition of assisted living can only occur if the federal government sets standards as they have for nursing facilities. However, federal standards are unlikely for several reasons. The federal government is not likely to become a major payer of assisted living. The expansion of Medicare managed care has generated expectations that assisted living can offer HMOs an excellent vehicle for managing rehabilitative services and providing a supportive environment for frail HMO members. Medicare HMO membership continues to grow, from 3.1 million in December 1996 to 5.7 million in May 1998, and the Congressional Budget Office projects enrollment will reach 15 million by 2007.
Although many experts predict coverage of assisted living through HMOs with Medicare risk contracts, it is the flexibility of the Medicare capitation payment which encourages HMOs to provide added or alternative services. Medicare HMOs are required to cover all regular Medicare benefits, and they may cover additional services. One of the attractions of Medicare HMOs is their coverage of additional services such as physical exams, prescription drugs outside a hospital, eye glasses, dental care, and others. But even if HMOs begin to cover services in assisted living, assisted living is not likely to become a regular Medicare benefit. As Congress and a Commission explore ways to protect the future of Medicare, further benefits, especially non-medical benefits, are not likely to become a regular covered benefit.
Second, Medicaid payments for assisted living are expanding, but, here again, assisted living is most often covered as a service under home- and community-based waivers. Personal care services in assisted living can also be covered under the state Medicaid plan, but assisted living itself is not covered. Room and board cannot be covered by Medicaid except in hospitals and nursing homes. States have the responsibility for setting provider standards, and regulations governing assisted living facilities participating in Medicaid remain a state responsibility. Further federal action through regulation is unlikely given the manner of Medicaid coverage, state options, and continuing state responsibility in this area.
Third, quality-of-care concerns could stir federal interest in assisted living but, historically, quality, standards, and monitoring have been a state responsibility. During the late 1970's and early 1980's Congressional hearings were held on the quality of care in board-and-care homes. Little federal action followed, and states retained licensing and monitoring responsibility. In the current political climate, government responsibilities are more likely to shift to states rather than flow from states to the federal government.
Without a major federal financial interest or a major change in federal-state responsibilities, there is little likelihood that federal action will be forthcoming in the near future. Assisted living will continue to be defined through legislation and regulation on a state-by-state basis and through marketing and advertising by facilities. The result is likely to be continued divergence, differences, and innovation as states develop definitions, licensing criteria, and standards that reflect the priorities and philosophy of each state.