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


A number of respondents expressed concerns about admission practices and the need to assure that people can age in place.

  • Fire and safety regulations have made it possible for facilities to deny residence to individuals in wheelchairs. One provider claimed he couldn't admit people in wheelchairs, because they would "knock down" other residents, especially in an emergency.

  • Some ALFs might be creaming the lesser impaired because they don't want to take care of people with higher levels of care needs.

  • Some providers are willing to take clients who need higher levels of care, but they don't want to deal with more accountability standards.

  • Providers are required to make an assessment decision within 72 hours, which is too short a time. Facility managers and staff want to meet a prospective client in person to make decisions, which is difficult to arrange within 72 hours, especially if the client lives in another area. Another problem is that facilities are pressured to take clients that "don't fit" with the current facility population or that have heavier care needs than is desirable for a particular facility at a particular point in time. For example, one facility was pressured to take a 350 pound man prone to falls who also had a very large service dog.

    The CBA waiver contract managers recognize that some clients have particularly difficult needs or problem behaviors, but the CBA waiver requirements--not licensing and regulation--require their admittance. I admit, though, that if the requirements were not there, and providers had full choice in admittance decisions, discrimination would likely occur.

With regard to discharge policy, one respondent reported that it was hard to discharge people from assisted living facilities, but noted that the state was getting better about supporting facilities who had really difficult cases.

  • There is a need for regulatory support for aging in place. I strongly promote the chance for individuals to age in place, but I also recognize that facilities who serve individuals needing higher levels of care are required to pay more attention to fire and safety standards.

  • CBA waiver clients with Alzheimer's are most at risk for not being able to age in place in assisted living facilities due to extreme problem behaviors and the inability for Medicaid to pay for full-time private sitters that some of the private pay clients have. Caring for these people is so expensive that most facilities don't want them and they wind up in nursing homes.

Respondents felt that the issues related to aging in place were far from settled, with some providers liking the concept and others not. Most supported the concept but had concerns about its implementation.

  • The state recently instituted new regulations that will allow more people to age in place by allowing short term nursing services to be provided (24 hour skilled nursing is not provided normally). Aging in place is a relatively new concept and providers are still learning the consequences and benefits.

  • I have concerns that some providers might not have the capacity to really support aging in place.

  • There have been a few cases of residents inappropriately kept in an ALF, although these were mostly small providers that might not have had a full understanding of how to safely maintain clients.

  • It's easier to age in place in an ALF that is part of a continuing care retirement community.

  • CBA waiver case managers fairly often pressure facilities to retain a client even though the client's behaviors or conditions allow the facility to remove that individual under current licensing and regulations.

  • Several respondents remarked that some providers felt that their facilities would be stigmatized by accepting CBA waiver clients. One has spoken with providers not involved in the program who cited "red tape", financial risks, and fear that the facilities will be known as the "Medicaid house" as reasons for not accepting waiver clients.

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