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One respondent stated that in the absence of a budget crisis Oregon would probably want to expand and improve the current HCBS system, noting that the state is pretty close to a balanced system. Another said that the state's program has changed since its inception and it will continue to change, noting that it is important for the state to continu

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.

A few noted that because Oregon set a cap on room and board rates for Medicaid eligibles--particularly for ALFS, which provide private apartments--the state has to pay enough for services to attract providers. In general, most felt that ALF rates were high relative to rates for ACHs and RCFs. Setting the initial assisted living rate at 80 pe

Only a few respondents had views on this topic. Generally, in assisted living, the concept of managed risk is incorporated into specialized service planning. Specific risk factors are addressed as part of a person's service plan. There is new language in the assisted living regulations stating that incompetent residents can't enter risk agre

The state does not subscribe to a continuum of care model, where those with the most severe impairments are cared for only in nursing homes. There is a strong belief that unless a person needs 24-hour medical/nursing oversight, they should be able to be served in the their home or the community if that is their choice. While the state's goal is to

Most felt that Oregon's standards were good, even if they needed fine tuning in a few areas. One noted that it was highly unlikely that Oregon, or any other state, would adopt national standards, because states do not like to use other's rules. One noted a need for standards and said that good ideas are always welcome but strongly opposed the mand

One respondent stated that overall, the regulations for dementia care are "pretty good," and that the state has an overlay of rules for RCFs and ALFs for dementia clients, but they are not applicable to AFHs because they serve such a small number of residents. Providers have to have a higher ratio of caregivers to residents. Adult foster hom

Most concerns about quality related to staffing issues, particularly that fact the providers may not have sufficient staff to care for their residents due to problems with recruitment and retention.

A number of respondents mentioned that the state needs to do a better job assuring sufficient nursing consultation, noting that most providers are keeping residents longer even though the state does not require aging in place. Several felt that some regulatory changes were needed to address the increased acuity levels of residents in residential c

Two respondents expressed a desire for more outcome based measures of quality. The types of things needed to really assure quality, such as performance based outcomes, would be better put into the Medicaid provider contracts than in licensing and regulatory requirements.

Very few felt that licensing and regulatory requirements posed a major obstacle to affordable assisted living in Oregon. There were varying views on whether the licensing requirements and regulations assured quality. Most acknowledged that quality problems had been a major issue in the program's early years.

Everyone interviewed agreed that Oregon's primary goals in using Medicaid in residential care settings were (1) to reduce nursing home utilization, and in so doing, save money, and (2) to increase community alternatives to nursing homes, thereby providing consumers with more choice. In particular, respondents felt that the program's success lay in

Most felt that people in Oregon who need long term care have a wide choice of community residential options, depending on their preferences. If you like bed and breakfasts, you'll probably prefer an adult foster home. If you like hotels, you'll prefer assisted living. Several noted that because ALFs offered private apartments and were

We consulted with three state staff and policy makers regarding the technical details of the state's programs and interviewed two of them. In addition, we interviewed the founding director and a former director of Oregon's Senior and Disabled Services Division (SDSD) (since renamed Seniors and People with Disabilities (SPD). These two respondents

The state does not regulate admissions. Consequently, facilities have total discretion over who they will admit. admissions. Facilities may care for residents for whom they are able to provide appropriate services; there are no other limitations. The facility determines whether a potential resident meets its admission requirements. Prior to the

Oregon assesses ALF residents and assigns a payment level based upon the individual's need for assistance with ADLs. Effective September 2003, the rates are: Level 1   651.69  Level 2   887.16  Level 3   1,173.56  Level 4   1,534.74  Level 5   1,894.75

ALFs are required to offer three meals, laundry and housekeeping services, assistance with ADLs and personal needs, and a program of social and recreational activities. Required health services include providing a licensed registered nurse to conduct health assessments and periodic monitoring, assigning the basic tasks of nurse delegation, and

The state limits the amount that providers can charge Medicaid eligible residents for room and board to $449.70. This amount is equal to the combined SSI/SSP payment of $553.70 minus $104 for a personal needs allowance. 22

ALFs have six or more single occupancy apartments that are fully accessible with a lockable door, private bathroom, and kitchenette facilities. Units must provide 220 square feet of space, not including a private bathroom. Units in pre-existing structures may provide 160 square feet, not including the bathroom. To assure personal choice,

The only distinction between assisted living facilities (ALFs) and other models of residential care in Oregon is that ALFs have private apartments. Other settings have both private and shared rooms and private and shared baths.