Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Negotiated Risk Agreements


Only a few respondents had views on this topic.

  • Generally, in assisted living, the concept of managed risk is incorporated into specialized service planning. Specific risk factors are addressed as part of a person's service plan. There is new language in the assisted living regulations stating that incompetent residents can't enter risk agreements. Competence is determined by physicians or an assessment by facility staff and other health professionals. There is no standardized process for determining competency.

  • This is a big red herring. These risk agreements are not significant--very few clients have them. The regulations state that service plans shall include them if there is one. They are nothing but service planning around a problem. You don't need a risk agreement, you need a good service plan. A big problem is that consumer advocates want autonomy for elderly persons, but they also want to hold the facility responsible for negative consequences.

    We have lots of diabetics who want to cheat. What we want to do is have the facility and the resident agree on the times they will cheat so we can have a plan to test blood sugar and have sliding scale insulin coverage. But if they don't adhere to the planned time, then the facility is blamed for not identifying the onset of hypoglycemia.

  • I'm not a fan of negotiated risk agreements (NRAs). To do them right requires a great deal of skill--relying on the informed choice of a consumer. I believe that facilities are responsible for watching over their residents to be sure their needs are being met. Facilities shouldn't be able to relinquish this responsibility. With good providers I'm not as concerned. The norm is more of a "cookie cutter" approach.

    It's an easy way to release a facility from the responsibility to carefully work with the residents to help them maximize what they need to do to manage their own care. Oregon's licensing requirements state that a facility has to have ongoing active involvement to help residents manage if they are going to self manage. It's a challenge for facilities to deal with resident's wishes. I've seen these agreements end up as excuses for the facility not doing what they need to do.

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