Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Confusion About the Various Types of Residential Care


As noted in the beginning of this report, the term "assisted living" originated as a distinct type of residential care model for the private pay market as an alternative to nursing homes and traditional residential care settings such as board and care homes. The model was developed to provide what was perceived to be lacking in these other settings: a private room and bath or full apartment, autonomy, and the ability to tailor service packages as long term care needs increased or decreased, temporarily or permanently.

Respondents in several states noted that due to the popularity of the new model, many residential care settings were using the term "assisted living" in their marketing materials, even though some did not provide private rooms or the ability to age in place. Some states now use the term as an umbrella category for quite different types of residential care settings; some have amended regulations to rename traditional domiciliary care homes as assisted living. Minnesota uses the term to describe a package of services that can be delivered in a wide range of housing settings, some of which market themselves as assisted living.

Respondents in several states noted that use of the term "assisted living" for different types of residential care settings has led to considerable confusion among consumers. Several respondents noted that the residential care system was so confusing that it was difficult for consumers (and their families) to figure out what type of residential care setting would be able to meet their needs.

Oregon is the only state of the six that limits the use of the term to residential care settings that provide individual apartments. There was a consensus among the Oregon respondents that the state was right to limit the use of the term in this way. In marked contrast with other states, no one in Oregon mentioned public confusion about the different types of residential care as an issue.

Minnesota. In Minnesota, assisted living is viewed not as an architectural model but as a service package that can be provided in a wide variety of housing types. One respondent noted that families are surprised to learn that the assisted living model in Minnesota is licensed as a home care provider, that 24-hour supervision is not available in many settings, and that although a residence is licensed, it is not regulated.

North Carolina. According to several respondents, when North Carolina amended its statutory provisions governing domiciliary care, the industry lobbied the legislature to redefine adult care homes as assisted living, because it wanted to be able to market adult care homes as assisted living to compete with the newer, private-pay, high end facilities.

The state's new statutory definition of assisted living includes adult foster care, adult care homes, and a new category of senior housing that provides meals and housekeeping and social services only. Many respondents -- providers, consumer advocates, and state staff -- said that the generic use of the term "assisted living" in North Carolina's residential care system was confusing for the public. They noted that the public does not understand the differences between nursing homes, adult care homes, and assisted living.

Several noted that the situation is particularly confusing when adult care homes with few if any of the features of market rate private-pay assisted living facilities market themselves as such. To add to the confusion, facilities licensed under the same standards offer substantially different levels of care. Some facilities accept only those with few needs, while others accept those with multiple needs.

One respondent said that another source of confusion was the use of the term "assisted living" by adult care homes that did not serve a predominantly elderly population. In North Carolina, adult care homes are permitted to serve persons of varying ages with substantially different service needs in the same facility: young adults with serious mental illness or developmental disabilities and frail elderly persons. Several felt that this caused even more confusion for the public, which generally associates the term "assisted living" with the care of elderly persons.

One person noted that she has received calls from families looking for residential care, who were upset after visiting some of these homes, saying that they could not put their frail mother in an assisted living facility that also served young adults with serious mental illness. They were particularly concerned because these homes did not have private units with lockable doors.

Several respondents, both consumer advocates and providers, said it was impossible to assure that the service needs of different groups -- the seriously mentally ill, developmentally disabled, and frail elderly -- could be met using the same set of licensing and regulatory provisions.

Wisconsin. Wisconsin has a similar situation as North Carolina, having only one licensing standard for all community based residential facilities (CBRFs), which can serve a diverse population, including elderly persons, persons with serious mental illness, traumatic brain injuries, developmental disabilities, veterans, unwed mothers, and even corrections clients.19 As in North Carolina, a few respondents -- both consumer advocates and providers -- said it was not possible to assure that the service needs of such different populations could be met using the same licensing and regulatory provisions.

When Wisconsin created a new licensure category called assisted living and required facilities licensed under this name to provide private apartments, the residential care industry lobbied the state to permit CBRFs (which provide private and shared bedrooms and mostly shared baths) to also market themselves as assisted living. Wisconsin revised the statute to allow this, and due to concerns that the public would be confused if the new apartment model and CBRFs were both called assisted living, it renamed the licensing category of the apartment model from assisted living to Residential Care Apartment Complex (RCAC).

Consequently, the model that matches the assisted living philosophy is not called assisted living. According to several respondents, this has created considerable confusion among the public. Several respondents said that just about any type of setting could call itself assisted living, and that the operative condition in the state when looking for a residential care placement is "buyer beware."

One noted that the state had a website that did an excellent job explaining the differences between RCACs and CBRFs and adult foster care, but that access to the web is an issue. The average age of entry into residential care is the early to mid-eighties, and many older persons and their families do not have computers; those that have computers do not always know how to use them to get information. This same respondent noted that another issue is that many, if not most, residential care placements are made in a crisis situation, after a hospitalization or a nursing home stay, and under these conditions, decisions are often made based on what is convenient and available rather than what is needed and preferred.

Another source of confusion for the public is that while RCACs must provide services up to 28 hours a week, they are permitted to choose which services to offer above the minimum required personal, supportive, and nursing services. One RCAC could limit nursing services to health monitoring, medication management, and administration (i.e., the minimum), and another could offer additional nursing services. Several respondents stated that differences in the services offered made it difficult for people to identify a facility that would best meet their needs over time.

In sum, with the exception of Oregon, respondents in all states agreed that the term "assisted living" has become a generic term that is not helpful to consumers, and that some standard nomenclature is needed to help the public understand the residential care system. A few respondents (all providers) stated that they opposed limiting the term "assisted living" to a specific model. The remainder felt that the term should be used to define a distinct model, because its current generic usage to cover many different types of residential care settings is confusing to the public.

19. There are a few changes in the regulations for correctional clients, e.g., provisions related to residents' rights do not apply.

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