Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Suggested Changes to Improve the Medicaid-Funded Residential Care System


Respondents views on needed changes focused on quality of care and rights issues, as well as the need to help counties determine appropriate service rates.

  • Two things are needed. One is a specific bill of rights for residents of assisted living and the second may be a requirement for a licensing of administrators of assisted living to have a minimum skill set or knowledge base for dealing with this vulnerable population.

    Consumers living in their home, whether its their own home or a congregate residence considered as a home, have fewer rights than residents of nursing homes. There are substantial federal requirements for rights in nursing homes for non-discrimination. The home care bill of rights is much more limited.

  • There are specific problems with the landlord / tenant contract where we will need to plug holes--assisted living is in the gray area so that the rights of the resident are not clear. The rights of the resident versus the rights of the landlord. I would like to see a specific bill of rights for residents of assisted living facilities.

  • Because the regulatory scheme was built on a home care model we do need to do some thinking in three areas:

    1. We need to come up with a universal bill of rights for long term care. The current one does not provide an appeal process or due process prior to termination.

    2. The current assisted living regulations are poorly written in terms of supervision--consumers think that monitoring means 24 hour availability of a nurse. The state needs to 'clean up' supervision and to clarify communication with the consumer so individuals clearly understand what they are getting. Someone should be available 24 hours a day. The current requirement: they have to have someone in the building with no specificity as to ratio, sleep or awake, who this person is. This is the case under Assisted Living Plus as well--with no ratio required. "Present and aware" but no requirement to be awake.

    3. The number and training of staff needs to be addressed. The little training that assistants receive is not directed toward the type of residents they will be taking care of. Resident assistants are not required to complete a nursing aide course.

  • We need to give county health departments tools with which to determine the hours of service needed for a particular level of care. To have better model procedures that the state can provide to the counties as to what they can do before a person can be placed in a particular setting. The state needs to give the county some model language and enforcement language if quality is not adequate. In addition to licensing, the county needs to have a greater role to ensure that waiver clients are actually getting their needs safely met over time.

  • In Minnesota we have folks on Medicaid who are elderly who need to be in a managed care situation--it is still being developed in some counties--the PMAP program--it's supposed to provide all benefits, but if someone is eligible for the waiver they refer them to the county. If you're at risk for institutionalization and meet income guidelines you get moved to the waiver--otherwise you get PMAP (and Medicaid state plan services).

    This creates an incentive for PMAP to move people to the waiver but they should keep them and use Medicaid Home Health. Once they move to the waiver, care coordination is lost.

    You have these perverse incentives and you have these two programs that go back and forth--we would get more bang for our bucks if we could coordinate both acute and long term care for this population. Minnesota's managed care program should be giving 90 days post acute care, but it's not working. There was a desire to move the waiver patients to PMAP but counties did not want that because they wanted to hold on to the case management dollars but can only do that if they manage Elderly Waiver. There are reasons to think about a more integrated model--if political and financial realities could be overcome then another more integrated model would be possible and would have a positive effect on assisted living services.

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