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Assisted Living and Residential Care in the States in 2010

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Assisted Living and Residential Care in the States in 2010 INSIGHT on the Issues INSIGHT AARP Public Policy Institute Assisted Living and Residential Care in the States in 2010 Robert Mollica Consultant Ari Houser Kathleen Ujvari AARP Public Policy Institute Produced by the AARP Public Policy Institute with support from The SCAN Foundation and The Commonwealth Fund Assisted living and other residential settings represent a critical component of the long-term services and supports (LTSS) system for older adults who cannot live alone, but do not require the skilled care provided by nursing homes. In 2010, states reported a total of 51,367 licensed residential care settings with a total capacity of 1,233,690 beds—a dramatic increase from an estimated 1,046,631 beds in 2007. States use many different terms for In 2010, to collect data on the supply of residential settings: boarding homes, alternatives to nursing homes for the rest homes, adult care homes, Scorecard, the AARP Public Policy domiciliary care homes, personal care Institute, funded by The Commonwealth homes, community based residential Fund and The SCAN Foundation, facilities, assisted living, and adult surveyed state licensing agencies to foster care (AFC). Until the mid-1990s, determine the number of settings and the most frequently used term was capacity for residential care. board and care. Today all types of group residential care are commonly All states and the District of Columbia referred to as assisted living. reported 51,367 residential settings with a total capacity of 1,233,690 beds.2 This Results from Raising Expectations: total includes facilities that, at a A State LTSS Scorecard minimum, provided assistance with activities of daily living (ADLs) and Ensuring an adequate supply of assisted room and board, primarily to older adults living options and residential care and individuals with physical disabilities. capacity was included as an indicator in It does not include nursing facilities.3 the 2011 scorecard, Raising Expectations: A State Scorecard on Long-Term Services This is a dramatic increase in licensed and Supports for Older Adults, People capacity within the last three years. In with Physical Disabilities, and Family 2007, states reported 38,373 assisted Caregivers (hereafter, the Scorecard) in living facilities with 974,585 beds (in most states, this count did not include the dimension of Choice of Setting and 4 Provider.1 AFC). A 2009 study found 18,901 homes licensed/certified as AFC Assisted Living and Residential Care in the States in 2010 with a capacity to serve 64,189 people.5 Assisted Living Federation of America A composite of these results provides an defines assisted living as a long-term approximate baseline of 53,774 facilities care option that combines housing, and 1,046,631 beds in 200.6 support services, and health care, as needed. Assisted living is designed for There is an approximately sixfold individuals who require assistance with difference in capacity between the highest everyday activities such as meals, and lowest states (see Table 1 for medication management or assistance, capacity for all states). The average bathing, dressing, and transportation. capacity in the five highest-performing states was 62 units per 1,000 people age The National Center for Assisted Living 65 or older in the state, compared with (NCAL), which also represents providers, just 11 units per 1,000 people age 65 or describes assisted living as residences older in the bottom five states.7 The that offer a multifaceted residential national average is 31 per 1,000. Redfoot setting that provides personal care and Houser (2010) considered the services, 24-hour supervision and expansion of residential settings as one assistance, activities, and health-related factor in the declining use of nursing services designed to minimize the need to homes.8 relocate; accommodate individual residents’ changing needs and Three of the top five states in capacity— preferences; maximize residents’ dignity, Minnesota, Oregon, and Washington— autonomy, privacy, independence, choice, ranked in the top five states for the and safety; and encourage family and percentage of Medicaid LTSS spending community involvement. going to home and community-based services (HCBS), and also ranked as the The physical structure of older top three states in overall LTSS residential care facilities may be performance. institutional, sometimes with two or more residents sharing a bedroom, and Assisted Living and Residential as many as eight to ten residents sharing Care Definitions a bathroom. Market forces and preferences for private apartment-style There is no standard definition of units have affected the supply over time. assisted living. States licensing assisted Only about 3 percent of units were living and other residential care options occupied by two unrelated individuals in do not use the same definitions and 2009.9 State policy has also changed. In standards, and even within states and the late 1980s, policymakers in licensure category, the characteristics of Oregon—and later in other states— facilities vary greatly (see Table 2 for developed a separate licensing category supply by state and licensure category). called assisted living. Assisted living embraced a philosophy of care that Assisted living is generally defined as emphasized privacy and greater control offering or providing assistance with over daily activities such as sleeping, ADLs and instrumental activities of eating, and bathing. Today, nearly all daily living such as meals, and states use the term “assisted living” to assistance with medications and related license residential facilities. However, services in a residential setting to most states that use the term do not residents who are not related to the require apartment-style units. owner of the facility. Associations that represent providers have similar Many states license smaller facilities as definitions of assisted living. The adult foster care. In general, AFC 2 Assisted Living and Residential Care in the States in 2010 typically serves five or fewer residents in providers, individuals with whom to a provider’s home, although several interact, and daily life activities.” states use a lower threshold. A 2009 report by the AARP Public Policy “A setting is not integrated in the Institute found that 29 states have community if it is located in a building regulations to license or certify AFC, that is also a publicly or privately 6 states have regulations or standards for operated facility that provides inpatient AFC to participate in Medicaid, and institutional treatment or custodial care; 17 states cover AFC through assisted in a building on the grounds of, or living regulations.10 immediately adjacent to, a public institution; or a housing complex Many AFC providers are registered nurses, designed expressly around an licensed practical nurses, or certified individual’s diagnosis or disability, as nursing assistants. Some providers cared determined by the Secretary; or has for a spouse or relative and decided to use qualities of an institutional setting, as these skills to earn a living by caring for determined by the Secretary.”11 others in their own home. The proposed regulations described the Recent Changes in State and conditions for assisted living that must Federal Assisted Living Policy be met for serving older adults in community settings: On April 15, 2011, the Centers for Medicare and Medicaid Services (CMS) ■ Individual has a lease (resident issued proposed regulations that would agreements or contracts may be define “community settings” where permitted); Medicaid beneficiaries could receive ■ Setting is an apartment with services that are covered by §1915 (c) individual living, sleeping, bathing, HCBS waiver programs. The current and cooking areas and individuals waiver guidelines describe assisted can choose whether or not to share a living services as follows: “Personal care living arrangement and with whom; and supportive services (homemaker, chore, attendant services, meal ■ Individuals have lockable access to preparation) that are furnished to waiver and egress from their own participants who reside in a homelike, apartments; non-institutional setting that includes 24- ■ Individuals are free to receive visitors hour on-site response capability to meet and leave the setting at times and for scheduled or unpredictable resident durations of their own choosing; needs and to provide supervision, safety ■ Aging in place must be a common and security. Services also include social practice; and recreational programming, and medication assistance ….” ■ Leases may not reserve the right to assign and change apartment States have the flexibility to propose assignments; other definitions. The proposed regulation would require that waiver ■ Access to the greater community is services be provided only in “settings easily facilitated based on the that are home and community-based, individual’s needs and preferences; and integrated in the community, provide ■ Individuals’ compliance with their meaningful access to the community and person-centered care plan is not in community activities, and choice about and of itself a condition of the lease.12 3 Assisted Living and Residential Care in the States in 2010 CMS continues to review more than facilities were excluded because they did 1,200 comments on this and other not meet the inclusion criteria, most provisions of the proposed regulation, often because they exclusively served a and changes are anticipated. Defining different population, such as adults with
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