The boundaries between the new model of assisted living and old forms of residential care are very squishy. How do you regulate a philosophy? What Keren Brown Wilson did in Oregon when she was a hands-on manager is one thing. But when it goes beyond mission driven entrepreneurs into the market place it turns into something else. North Carolina has played it out and we haven't done it well. The Keyes amendment is the only way the feds can weigh in.
North Carolina provides a good example of what not to do. Don't put people who should be in nursing homes into assisted living settings that can't meet their needs.
The big issue states have to think about is that we don't' know how to care for very impaired people without a professional component. We don't know how to regulate the settings that provide this care. We don't know what to replace the current regulations with.
In looking at what the states are doing in residential care with Medicaid you have to realize that states are starting from very different places. Oregon was very serious about deinstitutionalization, but its very important to remember that because of the nursing home moratorium, North Carolina had a very low nursing home supply--maybe 35 beds per 1000 people age 65 and older. When Oregonstarted, they had more than the average--approximately 50 per 1000. When Oregon started to change their system, they had less than 5000 domiciliary care beds; at the same time, North Carolina had 30,000.
North Carolina had already bifurcated the population--the people in nursing homes were very impaired, and the ones in rest homes--while they may have started out less impaired--were getting more and more impaired. So in effect, North Carolina already had the situation that Oregon was aiming for. North Carolina had difficulty discharging folks from hospitals due to lack of nursing home beds. But people in North Carolina and consumers--older people with family looking for nursing home care--they have not been in favor of decreasing nursing home beds--so consumers said: give us something besides nursing homes--if the occupancy rates are so low--how low can you go and still give consumers a choice. We had virtually 100 percent occupancy. No consumer choice. The nursing homes were going to take some heavy needs patients but not that many. So for a heavy needs person to get placed, someone else had to expire or be transferred. The only place where there was movement was on the adult care home side.
Theoretically, people who meet the nursing home level of care criteria should not be in domiciliary care. There are big issues to consider on the health care side. Moving to a lower level of care shouldn't mean abandonment of health care standards. You need to keep costs manageable, but you also need to assure that people receive the health care and medication management that they need. North Carolina provides a good example of what happens when you serve a lot of folks in a lower level of care than the nursing home. You might have a private room, but if you don't pay enough for services, then people will not get good quality care. Other states should understand all these things before they move forward.