The need for and provision of nursing care in residential care settings was a major issue that nearly all respondents commented on. Respondents in every state had concerns that providers were keeping residents longer and that regulatory changes were needed to address the increased nursing needs and acuity levels of residents in residential care settings.
Many noted that the average age of residents was the early to mid-eighties, and that this age group has more medical needs. They also noted that with shorter hospital and nursing home stays, residents were returning to residential care settings with higher acuity needs. In several states, respondents felt that residential care settings are, to a large extent, serving the population that used to be served in intermediate care facilities (ICFs); however, they noted that in contrast with the ICFs, residential care settings do not have licensed practical nurses (LPNs) on staff providing direct nursing care, supervision, and oversight.
The problem was seen as particularly acute in North Carolina, where adult care homes are not licensed to provide nursing care; but many felt that there is no difference in the type of residents served by these homes and those that used to be served in ICFs. If a resident needs nursing care, the facility arranges for it through Medicare or Medicaid Home Health. However, one person noted that providing nursing care in this one-on-one manner was not only very expensive but was insufficient because the visit lasts a half hour and there is no registered nurse (RN) or LPN oversight the rest of the day. However, another respondent said that having nurses on staff in these homes was not the solution, because if the state allowed these homes to provide health care, they would become "unlicensed substandard nursing homes."
In Oregon, several people noted that assisted living residents need and want more health and medical services from an RN or certified nursing assistant (CNA), but ALFs are not required to hire CNAs. Several acknowledged that when the state began paying for waiver services in residential care settings, it focused on ADL needs to the exclusion of chronic illness management. Now there is recognition that more nursing is needed in these settings, but they believe a nursing teaching and consultation model should be used, not a nursing services model.
While many states have nurse delegation provisions, Oregon is unique in its extensive use of nurse delegation and nurse consultation services in its HCBS system, and most said that this nursing model was an essential prerequisite for expanding its system. But several in Oregon acknowledged that questions remain about how nursing should be provided in residential care settings, and that if the state was going to require more nursing, it would have to increase reimbursement rates.
In Florida, there were differences of opinion about whether residential care settings that provided nursing care should have higher licensure standards. One respondent expressed concern that facilities licensed under extended congregate care, which enabled residential care settings to admit waiver clients and provide nursing care, were moving toward a medical model and becoming too much like nursing homes.