Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Admission and Retention Requirements, and Aging in Place


One noted that the aging in place philosophy is not so easy to implement.

  • Aging in place policy is a conundrum. There will always be people who need to be in a nursing home and so we need a different model of care at the nursing home level--that's the ultimate goal to work towards: resident-centered models of care that can provide skilled care without the institutional and warehousing look and feel.

Some felt that while retention requirements needed fine-tuning, it was not a good idea to have rigid requirements as in nursing homes.

  • Discharge and transfer policy needs more work. I believe discharge regulations need to be more flexible than in nursing homes where they have rigid distinctions between an ICF and a SNF level of care. Some homes want only the frail and some market to those with more acute needs. It's important to remember that some facilities with a specific area of expertise want to market to a particular group. It's a private business. The advocacy groups and ombudsman want to rigidly define discharge requirements but I will oppose this. The variety and ability to be creative has made our assisted living good.

  • Many facilities have not bought into aging in place. To protect the public and families--we need to move away from the idea that everyone can age in place. You need full disclosure when someone enters a facility so there are no surprises down the road. There are limitations on tenancy. People have to choose a facility knowing that they many not be able to stay there forever. They just have to enjoy it as long as they can.

One felt that while flexibility is desirable, parameters are needed.

  • The assisted living umbrella is too big. The state needs to tighten up admission and retention requirements but not so much that consumers don't have choices. You need different types of licensing. The public is not served well--they have no idea what the umbrella term of assisted living covers. You want flexibility so people have choices, but you need parameters.

    At the assisted living level, there is considerably more variation than at the nursing home level. There are very tight definitions of services at the independent living level and in nursing homes with most of the variation in the level of care at the assisted living level. They are given so much leeway. Some homes say they can do much more than they deliver. Some don't want residents to be too dependent, some will accept people with multiple needs, yet they are all licensed under the same standard. Mental health issues are major.

Many of the respondents expressed a wide range of concerns about the ability of adult care homes to meet the needs of its residents. Most concerns related to homes keeping people beyond the point where they should be discharged.

  • As the requirements for SNFs and ICFs have become more stringent, and nursing homes have become more focused on subacute residents, a lot of people wind up staying in lower levels of care far beyond the capability of those levels to provide the care that is needed. These places don't provide adequate staff training and don't have required coverage ratios. But they keep the residents in order to keep the beds filled and because it's difficult to find a nursing home bed for a Medicaid beneficiary. Nursing homes are under a Certificate of Need program--so nursing home growth has been constrained. So the situation is affected by two things--lack of beds and higher acuity hospital discharges.

  • The State does not have a good system in place to assess residents of Adult Care Homes to be sure their needs continue to be met as they age.

  • Adult care homes tend not to take people with certain disabilities. They want people they can manage with limited assistance and oversight. But as they age, their needs increase, and some homes do try to accommodate them to the best of their ability. But others take whoever they can get--and the residents get minimal custodial care.

  • I am particularly concerned about inappropriate placement of persons with SMI. Residents with serious psychiatric problems are retained because it is very difficult to get people into the geriatric wards in the state psychiatric hospitals. The state needs to conduct a study to determine the extent of inappropriate placement of people with SMI, particularly in response to Olmstead.

  • In some states the nursing home occupancy rate has been dramatically reduced but not here--we still don't have enough beds. The easiest way to get into a nursing home is from a hospital--paperwork is done--Medicare will pay. When we tried to place folks from home, like an Adult Protective Services case, it was very difficult--even if they had a bed--too difficult to admit. Coming from the hospital, they know what medications the person is on and whether they have a catheter. Nursing homes don't want to accept the unknown--maybe because they have had very difficult residents or very heavy care folks placed by county folks with no forewarning. It could have made them reluctant to trust the information provided on cases seeking admission from the community.

  • The adult care home client is basically the old ICF nursing home client. We have people in adult care homes in North Carolina that would be in nursing homes in other states.

  • Prior to 2000, assisted living residents did not have some of the same rights and protections that nursing home residents have. If you were a resident of assisted living, you could be discharged with no notice for no reason. A bill enacted in 2000 gave assisted living residents the same rights as nursing home residents: they can't be discharged without 30 days notice. Basically, the bill applied existing North Carolina law regarding nursing homes to assisted living residents. However, implementation has been problematic. The regulatory body has issued regulations and there has been a lot of discussion about changes in the level of care. Facilities are saying that when there is a change in the level of care designation by the MD on the eligibility assessment form, then it's immediate jeopardy and the 30 day notice doesn't apply.

  • Residents may desire to stay because it's a familiar setting. Most homes are for-profit businesses so occupancy rates play into this. If they have 100 percent then they look to skim the cream.

One made a distinction between the need for protections for residents with and without families.

  • Many discount the intelligence of family and residents but they are better regulators than the state. But residents without families who live in adult care homes need different standards.

Some expressed concerns about the level of nursing care needed by residents in adult care homes.

  • If Catherine Hawes' 1991 study was repeated today, it would find that people need two hours of care a day not one hour.

  • There are people in adult care homes who need nursing care and it is provided either through the Medicare or Medicaid Home Health benefit. However, providing nursing care through these benefits one-on-one is very expensive. But if you allow these homes to provide health care, then you will have unlicensed, substandard nursing homes. There is a lot of money in the system but it is not focused on getting needs met in the right way.

  • Many of the current residents of adult care homes in the past would have been in ICF nursing facilities. The old ICF nursing homes had LPNs and there was LPN supervision of aides, and nursing care was provided. Although Adult Care Homes are not licensed to provide nursing care, there is probably no difference in the type of residents they serve. People in private pay assisted living facilities may also be inappropriately placed from the perspective that they meet the nursing home level of care criteria. However, people in these places can pay for as much care as they can afford.

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