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


Most respondents suggested changes to address the specific issues and barriers they had identified.

  • The overriding issue is that more people need services than services are available, so we need to generate revenue to make it possible to serve more people. We also need to downsize nursing home capacity.

  • We need more affordable facilities that provide good care. We need the non-profit and religious-based mission sector to develop affordable assisted living.

  • Mandate that only RCACs can call themselves assisted living. This would reduce the current confusion among consumers.

  • Make qualitative evaluations of facilities available to consumers. This would be very useful. We need to make it easy for consumers to get information from regulatory agencies about facilities. Some facilities feel enforcement activities do not reflect quality of care. But with folks making decisions in a brief time in a crisis situation, they must have information.

  • Lift restrictions around hours of care in CBRFs and RCACs. Nursing homes are the most regulated industry and they have the worst care.

  • Use more process measures built on outcomes -- not regulations about the length of the blanket and the food pyramid. This is what Family Care does. Does the person live with whom they want to live with? Do they engage in desired activities? Do they choose what they want to eat?

  • Allow oversight by Ombudsman Program in RCACs. The Ombudsman can really help with quality assurance. They can't issue fines but they can report things. They can get involved in areas that the state regulatory body can't get into, e.g., they can consult with a facility about quality. At a minimum, the Ombudsman program should have the ability to investigate complaints in RCACs. I'm not for over regulation -- but residents of RCACs need some independent advocacy entity to call if they can't get a grievance addressed.

  • Make sure assisted living is part of a coordinated service package under Family Care or Partnership throughout the state, and develop a state plan for assisted living development (distribution) -- address over bedding.

  • Develop more public housing models with a service component.

  • Address the staffing problems by funding the community college system to train workers and create a career ladder; institute more requirements for staff who work in assisted living -- training and standards to measure the quality of work; give them more money and benefits.

  • Give more power to the counties in running the long term care system because they are accountable to local residents.

  • There is a correlation between oversight and care. I'd move all oversight to the local level, to the people who pay for services. That will improve quality. The closer the money is to the local level, the better will be the quality assurance. Quality assurance needs to be tied to reimbursement. If a county pays millions of dollars it has the ability to demand quality. One county asked the state to de-license a facility that it felt was providing poor quality but the state said there were not enough technical violations. However, the county terminated its contract with the facility. When a Family Care client enters a nursing home, the R.N./ Social Worker team monitors care and will pull clients out of nursing homes if the care plan isn't met.

  • Fix the room and board issue. People on Medicaid should be able to live in RCACs.

  • The whole home and community care system needs to be better funded. In many cases people need congregate care because there is insufficient home care.

  • Increase funding and staff to enforce regulations and increase the sanctions against the bad operators. Most of the industry is not in the business to make a profit -- rather, they want to provide a service. We need to get to the point to trust the caregivers and facilities -- get rid of the people not doing a good job -- enforce what's there and don't reinvent the wheel every few years.

  • Develop more residential care options by expanding the supply of adult foster homes. Oregon has a lot and I wish Wisconsin had more. We have some counties that make a lot of use of them; they have a staff person who recruits them.

With very few exceptions, the respondents cited the state's pilot Family Care Program as the solution to many of the current issues regarding accessibility and believe that the program should be expanded statewide. However, most recognized that expansion was unlikely due primarily to the state's budget crisis, but also because many counties do not yet have the capability of implementing the program.

  • The Family Care program should be expanded throughout the state -- it has eliminated waiting lists in the five pilot counties (bringing the statewide list from 11,000 to 9,000) and it gives people choices. However, in the current budget climate, nothing remotely like that would happen.

A few respondents expressed concern that the cost of expanding Family Care statewide would "bankrupt" the state because it treats home and community services as an entitlement.

  • As a taxpayer I do not want to see Family Care go forward. If Family Care was universal there would be no need to purchase private long term care insurance in Wisconsin. People could take a year's worth of long term care insurance premiums, hire an estate planning lawyer and create a trust that will make them eligible for Family Care when they need long term care.

Others felt that the fear was unwarranted or could be dealt with.

  • There is a fear that the cost of expanding Family Care statewide will bankrupt the state. But you could tighten up the eligibility criteria if needed.

  • Reducing the waiting list by 9000 folks would make Family Care expensive to implement. It's an entitlement now -- though it didn't start that way. In the current system, the nursing home is an entitlement -- but people may not need to be there. The state does not believe in a strict continuum of care. Family Care looks at what people need and tries to find where they can best be served and folks with severe disabilities can be served in homes. Family Care operates according to the assumption that people should have the choice to live in the community. It's difficult to know if expanding Family Care statewide would be more expensive.

Several respondents expressed more general concerns about the ability of the publicly funded long term care system to meet the needs of the Baby Boom cohort, and made suggestions to address this concern.

  • To reduce the number of people on Medicaid, the state has to stop the divestiture of assets that is going on by tightening loopholes. There are a set of older people who don't' see Medicaid as welfare, and a lot of people divest assets. There is a lot of estate planning -- a seminar every day. Older people think they need to leave a legacy to their children. They don't understand the difference between Medicare and Medicaid. They paid into Medicare when they were working and they think it covers Medicaid and that they are entitled to it.

  • Something needs to be done other than the very small tax break for long term care insurance to get people to start planning for and funding their future long term care needs.

  • More financial planning is needed for folks thinking about entering an RCAC. They need to understand how to financially plan for it -- deal with the spend down issue.

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