The state does not subscribe to a continuum of care model, where those with the most severe impairments are cared for only in nursing homes. There is a strong belief that unless a person needs 24-hour medical/nursing oversight, they should be able to be served in the their home or the community if that is their choice. While the state's goal is to serve people with a high level of need in residential care facilities, some felt that this goal is met more by AFHs, and RCFs than ALFs.
Oregon's experience is the same as Washington's--the AFHs take care of sicker and more impaired folks. Why? In general, assisted living is run by large corporations. They're good at creaming; they don't want to be in the position of taking care of very impaired people, don't want to hire the staff, and don't want to be exposed to the risk of fines and bad publicity.
A lot of providers try to skim; they try to get rid of the high level folks. Regulations are too permissive--they only require disclosure about discharge. I don't know if there is a regulatory solution. The goal of aging in place is problematic given the insurance and lawsuit issues. Oregon's idea was to do a nursing home replacement model with a better living environment. If assisted living is a replacement model, then assisted living should do all it can to care for residents until they need 24 hour nursing oversight. Aging in place used to be a key factor, but now the state is getting away it.
If providers are going to get Medicaid money, they should be prepared to provide as much care as possible. Small facilities with 30 beds can't do three person lifts. But there needs to be a commitment to keep people as long as possible.
Oregon is not like New Jersey and Florida--saying that when you reach a particular level of need you have to go to a nursing home. Admission is not an issue, but retention and discharge requirements are--determining when people in assisted living have become impaired or have greater medical needs and need to be moved to a higher level of care.
Some providers have difficulty finding a higher care setting that will take a particular resident. Some people in assisted living do not want to move. A facility may be able to take care of one or two people with greater needs but not five or six.