Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Need for More Nursing Care


A number of respondents mentioned that the state needs to do a better job assuring sufficient nursing consultation, noting that most providers are keeping residents longer even though the state does not require aging in place. Several felt that some regulatory changes were needed to address the increased acuity levels of residents in residential care settings because the average age of residents in these facilities has increased to 85 and people at these ages have more medical needs, whether they are private pay or Medicaid eligible. One respondent disagreed, stating that acuity levels have not increased since the mid-eighties.

  • The current regulations assume that most ALF residents will self-direct their care, and the facility will assist them to do so. This works if the person has intact cognition and can make good decisions. But this is not always the case. Residents in these settings need and want more medical and health services from an RN or certified nursing assistant (CNAs). We do not currently require any of our residential care settings to hire CNAs. They can hire people off the street and train them.

  • We are seeing an increase in acuity in all residential care settings. In nursing homes, 80 percent of clients stay fewer than 90 days and 30 percent fewer than two weeks. Most are post acute. Many of the nursing home residents go from a 3.8 day hospital stay to a short stay in a nursing home and then back to a residential care facility or home.

  • When Oregon started paying for waiver services in residential care settings, the state did not understand chronic care management and focused on ADLs only. It's now obvious that there is a need for more nursing in these settings and it should have been brought in sooner. But it's not a nursing service model that's needed, it's a teaching nursing model.

One respondent noted that changing the regulations to increase the amount of nursing provided would necessitate an increase in the reimbursement level and finding the right balance would be difficult. Another noted that providers were worried the state will go too far with regulations, but stated "if they are going to do chronic care management, they need nursing." One stated that is was unclear how much nursing care should be provided in ALFs.

  • There are increased levels of medical acuity and complexity. Some people say there is not enough nursing in assisted living as care needs have escalated. The residents say they need more and there is expectation--regulators expect there to be more nursing care--but there are no additional rules regarding the provision of nursing care or increases in reimbursements to match this expectation.

    People also want more prevention to reduce hospital admissions from assisted living facilities. But many facilities don't have 24 hour nursing available. The staff may know how to take a blood pressure, but they do not know how to interpret it. If a person has a stroke he may want to go back as soon as possible after hospital or nursing home discharge to his assisted living facility, but the facility does not have the staff to do the monitoring needing three days post discharge; maybe seven days.

  • There are a lot of questions about how nursing should be provided in assisted living. There is an expectation that assisted living should be able to do certain things, but facilities do not have nurses available at all times. There are lots of questions. Who has access to what drugs and when? How actively should facilities be involved in assessing and monitoring changes in clients' condition? Currently, how often it happens depends on the facility--whether they have a lot of high or low acuity residents. Some facilities have a director of nursing services, some use RN consultants.

    Assisted living facilities are not required to do health assessments unless a resident has a nursing need. If they are diabetic and take oral hypoglycemics, they are considered to not need a health assessment; if they need daily glucose testing then they do need one.

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