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


A number of respondents made specific suggestions for improving the system:

  • The state should allow family supplementation for private or larger rooms for Medicaid residents in AFHs and RCFs. Washington state allows families to contribute the difference in cost between a studio and a one bedroom.

  • Get away from prescriptive regulations. Tell facilities that if they kick Medicaid folks out too early they won't get any more residents. Give providers incentives to keep people as long as possible. Give them enough money--the amounts in the past were sufficient, but recently have not kept pace with inflation, especially the increases in insurance.

  • What I would do is move to a standardized assessment tool for providers and develop quality indicators for this tool. You can't track quality without it. The current assessment is not a facility tool. It is used to determine Medicaid eligibility.

  • We need a quality assurance system that moves to the culture of patient safety--where you identify problems and then try to fix them.

  • Other than getting higher service rates--rates that accurately reflect costs--I would like the program to have a chronic disease management focus to save money on both the acute and long term care side. The length of stay in nursing homes and hospitals are so short, we have more people in the community with significant health issues. We need to look at the provision of health services in the community. There is a lack of health care in the service component. We need to know what are good outcomes. What level of falls are acceptable in the community. We can't have the same expectations as in nursing homes--that no one will ever fall or develop a decubiti. I'd also like to address the polypharmacy issue. There are too many people on 8 or more medications. I'd also like to replace physicians with nurse practitioners in all settings. The physicians do not understand the setting. They think they can call a nurse and have something done like in a hospital.

  • We need research on systems for assuring quality in community settings. We need information on best practices. How to teach unlicensed personnel about disease management? How to manage the non-compliant diabetic? How to provide palliative care? How to provide care to the anxious COPD patient with air hunger? All when you don't have nurses available on a 24 hour basis. We need special training for medication administration. We spend a lot of money on training using a train the trainer approach. But reimbursement needs to recognize the need for substitute staff when the regular staff are out of the facility to obtain training.

  • We need a career ladder for direct care workers.

One respondent noted that one of the reasons the number of assisted living facilities grew so fast was because the state had a financing mechanism through the housing agency, but the state should have placed requirements on the providers who received these loans.

  • Loans were made with general obligation bonds. About 25-30 percent of assisted living facilities a few years ago were all financed with these bonds. If the state gives a provider a low interest loan, the provider should be required to take a certain proportion of Medicaid clients until the loan is paid off.

One respondent said that consumers needed more information about the quality of services in each facility. Even though the state has a website, this respondent felt it did not provide sufficient information for consumers to make an informed choice.

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