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


No one interviewed raised issues about admission requirements, but many had concerns about retention requirements. Some were concerned about their affect on the ability to age in place.

  • A key complaint about RCACs is premature and/or involuntary discharge. The average time spent in RCACs is fairly short -- approximately 18 months -- and fifty three percent of those leaving RCACs do so because they need more care.

  • The CBRF limit of three hours of nursing care is unrealistic -- there is some confusion as well about the definition of nursing care.

  • The hourly limits are ridiculous. People should have to move from their homes only once and they should get the care they need in the new setting. What difference should the setting make? The nursing homes pushed this -- they want people to think nursing homes are the only place to get skilled nursing care. We have paid for people that nursing homes won't admit -- those needing tube feeding and on ventilators. We pay more than $42 a day on some folks. You spend what it takes to support the care plan.

  • I advocated for the hour restrictions, but I feel that if CBRFs and RCACs can demonstrate their ability to care for people then they should be able to keep them, even if they need a half hour more care than is permitted by regulation. This would promote the notion of aging in place.

  • The concept of aging in place in place is one thing. The reality is a disappointment. But I think it's doable to a greater extent than it is currently being done. We still try to fit people into facilities rather than get the facility to match the person's needs. We say, here's a package of service -- if it meets your needs OK. If not, you have to go somewhere else.

Several raised the issue of inadequate guidance in the RCAC regulations regarding the retention of people who develop cognitive impairment and dementia while in an RCAC. One commented that the state needs to expand the options for people with dementia, and noted that the general public does not know what to do about family members with dementia.

One provider stated that the hours of care needed is not the only indicator of the amount of care needed.

  • Even if a person needs only three hours of care a day, if they need a two-person transfer or one-on-one feeding, we can not serve them because we do not have the staff. Transfer and feeding issues cause people to leave long before they need 28 hours of care. The average number of hours of care people get is about 16 per week. Dementia is also not an hours issue, but a safety issue. Is the person safe behind a locked door? If a family can pay for a one-on-one companion, then they can stay. We don't have the staff to be with someone every moment.

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