Earlier NASHP studies of state assisted living policy described three approaches to categorizing state models that highlight particular features of state policy. Based on further policy developments, a fourth approach has been added to better define state approaches to licensing, unit requirements, and the service level. The approaches are:
- New housing and services model,
- Service model, and
- Umbrella model.
Institutional models are based on older board-and-care regulations. They allow shared bedrooms without attached baths and either do not allow nursing home eligible residents to be admitted or do not allow facilities to provide nursing services. Two states, Alabama and Rhode Island, adopted "assisted living" as the name for their board-and-care licensing category. South Dakota and Wyoming re-named an existing category as assisted living and allowed a higher level of service to be provided without changing the unit requirements. Arkansas and Illinois are two states that do not allow anyone requiring nursing home services to be served in a board-and-care facility. Some states allow skilled nursing services to be provided for limited periods by a certified home health agency. The upgraded board-and-care approach recognizes that residents are aging-in-place and need more care to prevent a move to a nursing home. State policies have allowed these facilities to admit and retain people who need assistance with activities of daily living (ADLs) and some nursing services. Mutually exclusive level of care criteria have been revised to allow people who would qualify for admission to a nursing home to be retained. The model retains the minimum requirements for the building and units (usually multiple occupancy bedrooms with shared bathrooms and tub/shower areas).
The new housing and service model licenses or certifies facilities providing assisted living services which are defined by law or regulation. These models require apartment settings and allow facilities to admit and retain nursing home eligible tenants. Depending on the state, rules may allow some or all of the needs met in a nursing home to also be met in assisted living. Policies in states with this approach included a statement of philosophy that emphasizes resident autonomy and creates a prominent role for residents in developing and delivering services. By licensing the setting and services, states distinguish these facilities from board-and-care and have attempted to develop more flexible regulations. Examples of this approach to licensing can be found in Hawaii, Kansas, Oregon, and Vermont and Medicaid waiver standards in Arizona, North Dakota and Washington.
The service model focuses on the provider of service, whether it is the residence itself or an outside agency, and allows existing building codes and requirements--rather than new licensing standards--to address the housing structure. This model simplifies the regulatory environment by focusing on the services delivered rather than the architecture. Unfortunately, newer residential models serving frailer residents may not be as familiar to local building inspectors and code enforcement officials who may want to apply more institutional requirements than are needed. Service regulation approaches may include requirements that define which buildings (apartment units, minimum living space) may qualify as assisted living, but the licensing agency's staff do not otherwise apply their standards to the building's characteristics. The service model can be developed for apartment settings (Connecticut) or multiple settings (Texas Medicaid waiver program).
States using an umbrella model issue regulations for assisted living that cover two or more types of housing and services: residential care facilities, congregate housing, multi-unit or conventional elderly housing, adult family care, and assisted living. States representing this approach include Florida, Maine, Maryland, Louisiana, New Jersey, Maryland, New York, North Carolina, and Utah.
Elderly Housing or Assisted Living?
Assisted living can be regulated as a service in a purpose built facility and in elderly housing buildings. Purpose built facilities involve new construction or renovation of a building that is designed to serve frail residents. The term is clear as it refers to a building in which all the residents receive some level of care. Buildings which are built explicitly to operate as assisted living settings can be built to existing codes for multi-unit residential environments.
Assisted living may also be regulated as a service that can be provided in a conventional elderly apartment complex. To some extent, existing elderly housing buildings can also be considered assisted living. Because a significant percentage of, but not all, residents need service, the assisted living component may be considered a more comprehensive, organized service package provided in subsidized housing with a mix of residents, some of whom are impaired and others who function independently. In this setting, comparisons with in-home service programs and confusion between independent and dependent residents concerning the type of building they live in is more likely.
Questions can be raised about approaches that regulate the service rather than the setting. In some settings, differentiating assisted living from more common community based services programs becomes difficult. As a new trend, the term "assisted living" may be expected to mean something different from board-and-care or in-home-services models of care. Policy makers need to respond to aging-in-place that is occurring in conventional elderly apartment complexes since many residents have both health and personal care needs. The key question is: when does an apartment building become an assisted living residence? For residents who are receiving personal care and some nursing care, elderly housing may resemble buildings that were designed and built as an assisted living residence. For independent residents, it's an apartment building. Even if all the residents required some supportive services, many contend that the building would not constitute an "assisted living" site because of licensing and architectural characteristics.
Participants at a 1995 round table on assisted living discussed the environmental differences between conventional elderly housing and assisted living. Buildings designed and built as assisted living tend to have higher lighting levels in common spaces, more common spaces for activities and socialization, different flooring, small refrigerators raised above floor level, handicapped accessible bathrooms in every unit, roll-in showers, wider corridors with hand rails, two-way voice communication, and other features. Conventional elderly housing generally may not have been renovated to accommodate the decreasing independence of residents needing care.
The important factor is that residents receive the service they need to maximize functioning in the most independent and autonomous way possible. Whether the term "assisted living" is applied broadly or more narrowly may be a function of the presentation of the concept in a way that generates the level of political support to make the resources available. Regarding assisted living solely as a service, not a place, may omit setting important requirements for living units. In licensing or certifying assisted living as a service, however, state regulations can require that assisted living services be provided in buildings with apartments or private rooms and attached baths while still allowing state and local building codes to govern the structure itself. Connecticut, New Jersey (assisted living program category), and North Carolina (multi-unit housing category) are examples of this approach.
Connecticut licenses assisted living service agencies which provide assisted living services in managed residential communities. Living units in these communities are defined as a living environment belonging to a tenant(s) that includes a full bathroom within the unit including water closet, lavatory, tub or shower bathing unit, and access to facilities and equipment for the preparation and storage of food. The housing owner or operator does not need a license to manage the residential property.
New Jersey defines assisted living as "a coordinated array of supportive personal and health services, available 24 hours per day to residents who have been assessed to need these services including residents who require formal long term care." In this state, assisted living services can be provided in three settings: assisted living residences, comprehensive personal care homes, and assisted living programs. The assisted living program model is provided in elderly housing projects. New Jersey wanted a model that was suitable for urban environments, assuming that limited land availability and high costs limit new construction in major cities. To develop its assisted living program model, the state funded a two-year pilot project in a large elderly housing site. Prior to the pilot, residents who needed assistance received one meal in a congregate dining room, one or two hours of housekeeping a week, laundry, and shopping.
As part of the pilot, personal care, additional meals, medication assistance, and escort services to doctors appointments were added, and wellness and health education programs (flu shots, health fair, guest lectures, referrals to podiatrists, dentists, and physicians) were available to all tenants. In addition, a health clinic was established using a vacant apartment that was staffed by a geriatrician and a geriatric nurse practitioner two and a half days a week. Security guards were used to implement a 24 hour emergency response capacity. Twenty-four hour, on-site staff coverage was not identified as a need. Twenty-five percent of the participants met the nursing home admission criteria. The evaluation found the program was cost effective, consumer centered, and worthwhile.
Based on the results, regulations were drafted and issued for public comment. The New Jersey rules now refer to assisted living residences (purpose built facilities), comprehensive personal care homes (previously licensed homes which meet new standards), and assisted living programs which are services provided to residents in publicly subsidized housing sites. These regulations took effect January 1, 1997.
North Carolina has developed requirements for registration and disclosure for a category of assisted living residences called multi-unit assisted housing with services. Services in these settings are arranged by housing management but provided by a licensed home care or hospice agency and not the housing provider, unless the housing management company is also licensed as a home care agency. The disclosure statement describes the services which may be arranged, the cost of services, tenant admission/retention criteria, a list of service providers, a grievance procedure, and any financial relationships between service providers and the housing management. This category seems to formalize but not alter the existing in-home delivery system serving residents in elderly housing sites.
While the primary vehicle for reimbursing care in residential settings in North Carolina is through the Medicaid state plan, the combination of rules and Medicaid funding create some interesting contrasts. North Carolina reimburses assisted living residences in adult care homes and multi-unit assisted housing with services models. Personal care in adult care homes is reimbursed as a state plan service while the Medicaid HCBS waiver may cover eligible residents in multi-unit assisted housing with services settings. Participants must meet the nursing home level of care criteria while adult care home residents must have ADL impairments. It has not been determined whether residents in subsidized elderly housing sites which register as multiunit assisted housing with services settings will be eligible for both programs.
States designing policies to facilitate aging-in-place must recognize the importance of meeting unscheduled needs for personal care, especially during the night, holidays, and weekends. In terms of capacity to serve frail residents, these are key variables. Whether services are provided directly by the building management or through a contract to serve all residents with a community agency (certified home health agency, licensed home care agency) is less significant than the availability of 24-hour staffing capacity and the ability to meet unscheduled needs for assistance with activities of daily living. Issues of cost are also significant. A certified home health agency may have a higher cost structure in order to maintain its Medicare certification which adds to the cost of delivering services. Home health agencies which have created home care subsidiaries can deliver a similar level of care with lower costs.