State Assisted Living Policy Trends

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State Assisted Living Policy Trends

• Robert Mollica
• June 2003

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Assisted living - what is it?

• A niche?
• A model?
• A generic term?
• Overlap with housing and supportive services?
• Future convergence with nursing homes?

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What is assisted living?

• AARP study - supports for ADLs and IADLs
• Assisted living work group
• Provider associations, advocates, regulators
  (AHFSA, NARA), state associations, professional
  associations, federal agencies
• State definitions wide variations

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Assisted living work group

• A state regulated and monitored residential long
  term care option.provides or coordinates
  oversight and services to meet the residents
  individualized scheduled needs, based on the
  residents assessments and service plans and
  their unscheduled needs as they arise

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ALW . Services

• 24 hour awake staff
• Provision oversight of personal and supportive
  services
• Health related services
• Social Services
• Recreational activities
• Meals
• Housekeeping and laundry
• Transportation

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Other factors

• Private units shared by choice
• At least two levels of care
• Based on types and severity of physical and
  mental conditions
• Staffing levels qualifications,
• Special care or services
• Participation by health care professionals
• Fire safety

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Core principles

• Residential promotes quality of life, privacy,
  choice, dignity and independence
• Offer quality supportive services, individualized
  for resident
• Provide resident-centered services emphasizing
  needs of individual and lifestyle
• Support residents decision-making to extent
  possible

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Core principles

• Social climate fosters relationships in the ALR
  and community
• Full consumer disclosure including services
  offered and cost before move in
• Minimize need to move
• Foster culture of quality environment for
  residents, staff, family, volunteers

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Who should regulate?

• States
• National standards -- set by ?????
• Accreditation
• Model standards
• Assisted living work group
• NAIC model
• Senate Aging Committee Medicaid role

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Variations

• Size thresholds
• 13 states do not specify a threshold
• Range 1-7 units, often vary by category, type of
  resident
• Philosophy
• Services provided or arranged
• Relation to owner
• Entity (profit, not-for-profit)
• Setting (congregate, residential)

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Do states regulate assisted living - yes, but....

• All states have licensing rules that cover
  assisted living, but..
• Assisted living facilities may not always be
  licensed
• 34 states use the term assisted living
• 2 pending (NH, DC)
• General rules apply in 26 states

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Trends

• Philosophy of assisted living
• Creating new or updating existing categories,
  levels of care
• Rules for special care units
• Expanding or clarifying admission/retention
  criteria
• Changing rules on medication

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What works well?

• State actions, placement of monitor
• Range of remedies
• Fines
• Increased monitoring for poorer facilities, use
  of contract RN
• Clear enforcement procedures, consistent
  application
• Clear internal communication

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Philosophy and indicators

• 28 states have a philosophy statement
• 7 require apartments, five mixed
• 16 allow shared units only by choice
• 18 use a shared risk process
• 13 require training in the assisted living
  philosophy
• Texas requires training of surveyors

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Resident agreements

• Services package - 46
• Cost of services - 41
• Additional services available - 25
• Cost of additional services - 22
• Notice of changes - 17

• Refund policy - 23
• Grievance process - 12
• Resident rights - 19
• Admission/retention - 22
• Terms of occupancy - 7
• Termination - 14

Usually also required by other provisions 2
State license service agency 2 do not require
agreements
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Medication policy

• Trained aides administer 64
• Assist but not administer 98
• Problems with RX
• Frequent or very often 48
• Sometimes 24
• Rarely/occasionally 28

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Related staffing

• 92 require assessment prior to or within
  specified period of admission
• 92 of assessments include a health component
• 67 require completion by an RN
• 42 require an RN on staff/consultant
• 34 require pharmacy consultant
• RN oversight sometimes a substitute

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Alzheimers policy

• Special provisions (37 states)
• Disclosure requirements (18)
• Staffing patterns training (28)
• Activities (16)
• Environmental provisions
• Admission/retention criteria

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Disclosure - how is it special?

• Philosophy
• Admission/ discharge criteria
• Process
• Services

• Care planning
• Activities
• Environment
• Cost
• Role of families

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Assisted Living
Levels of care
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Approaches

• General criteria
• Levels of care
• List of conditions, triggers
• Waivers
• Combinations

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States with levels of care

• Arizona
• Arkansas
• Idaho
• Florida
• Maine

• Maryland
• Mississippi
• Missouri
• Montana
• Utah
• Vermont

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States with permissive criteria

• Minnesota
• Nebraska
• New Jersey
• Oklahoma
• Oregon
• Vermont (draft)

• Arizona
• Hawaii
• Kansas
• Maine
• Maryland

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Florida - ECC may not serve

• Need 24 hour nursing supervision
• Bedridden gt 14 days
• Stage 3/4 pressure sores
• Medically unstable
• Danger to self/others
• Cant make simple decisions (dropped)

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New Jersey - may serve

• 24 hour nursing supervision
• Bedridden gt 14 days
• Stage 3 or 4 pressure sores, multiple 2
• Medically unstable condition
• Danger to self/others
• Cant make simple decisions
• Totally dependent 4 ADLs

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Staff training

• Area Initial Ongoing
• Topics only 29 4
• Hours/topics 9 14
• Course 7 NA
• Other 2 6
• Not specified 3 26
• Other Plan on file or general

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Special care units training

• AZ 12 of 75 hours initial training 4
  hours/year
• FL 8 hours 4 hours/year
• ME 8 hr classroom 8 clinical
• TX 4 hours 16 hours OJT supervision12 hours
  annual in-service
• Topics general or specific

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Medicaid Coverage Perspectives

• Lenders/investors
• Developer/manager
• State licensing agency
• State Medicaid
• Consumers/family/advocates
• Local service delivery system

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The Perfect Storm?

• Target population light care
• Continuous or intermittent nursing care
  requirement
• Is Medicaid rate adequate, reliable?
• State Medicaid nursing home alternative, cost
  effective
• Consumer expectations Aging-in-place and
  Olmstead decision

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Medicaid considerations

• State plan or waiver coverage
• Waiver level of care criteria
• Assisted living or broader waiver
• Room and board cap?
• Rate methodology
• Service only or service and room and board

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Medicaid coverage for assisted living
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Source of coverage Medicaid and state revenues
WaiverAK IL OR AZ KS PAAR MD RICO MN
SDCT MS TXDE MT UTFL NE VTGA NV WAHI NH WI
IA NJ WYID NM WYIN ND
State Plan AR MIID
MOFL NYME NCMA SC
VT
State Funds CT MD
ND SD
Multiple sources
CT under pilot program
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Making the case

• Reduce Medicaid NF growth trend line

NF reliance

Broad menu
Time
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Public subsidy issues/options

• SSI
• Room and board only, or
• Room and board and personal care services
• Medicaid service options
• Regular Medicaid state plan
• 1915 (a) state plan amendment
• Waiver approaches
• HCBS Waiver - 1915 (c)
• Managed care - 1115

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Medicaid state plan coverage

• Cannot cover room and board
• States cannot readily control spending
• Entitlement program but may control provider type
  (FL, SC plan amendment)
• Eligibility is based on need for a service
• Available statewide - amount, scope, duration

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Medicaid waiver coverage

• Cannot pay for room and board
• No entitlement - can control spending
• Can serve residents with income lt 1,635/month
  (19,620 annual)
• Services include meal preparation and serving
  costs
• Must meet nursing home level of care
• Waive amount, scope, duration

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Rate issues

• Some states include room and board paid by the
  resident in the rate
• May be limited to SSI beneficiaries
• Most cover Medicaid services only
• RB for SSI beneficiaries set by state policy
• State SSI supplements may cover some personal
  care

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Family supplementation

• Allowed in 19 states
• Prohibited in 7 states
• Considered unearned income for SSI
• Should be paid to facility rather than
  beneficiary
• Federal SSI benefit reduced one-third

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Cover RB under Medicaid?

• Requires change in statute
• Basis in nursing home reimbursement
• Weakens non-institutional preference
• Shifts costs from Federal SSI to states
• SSI benefit personal needs allowance only
• Likelihood of raising rates????

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Future issues....

• Quality assurance and outcome approaches
• National or state standards
• Aging in place challenge
• Adequacy of Medicaid rates
• Affordability and access
• Housing subsidy and Medicaid linkages