Reprinted from Aging Today, July-August 1998
Assisted Living
NOT (YET) AFFORDABLE FOR ALL
By PAUL KLEYMAN
Despite "phenomenal growth" in the assisted living industry, "there continues to be a great need for affordable assisted living models, " according to a recent publication from the American Association of Homes and Services for the Aging. The 24-page technical assistance paper, titled "Affordable Assisted Living: Options for Converting or Expanding Housing to Assisted Living," describes four projects that have effectively managed to juggle state and federal funds, mainly from the Department of Housing and Urban Development and Medicaid, to open their doors to low-income elders. (For information on ordering the report, see "Key Sources" in this "In Focus" section.)
The Catholic-run MI Residential Community in Lawrence, Mass., seeing the average age of its residents reach 80, expanded its services to take advantage of a new state program, Group Adult Foster Care, which aids those in the Medicaid population deemed ineligible for nursing homes because they are not yet frail enough. A dozen years ago Allied Jewish Apartments, Denver, Colo., converted 25 of its 400 high-rise HUD-subsidized units for low-income elders to assisted living apartments. The facility relied on several resources, among them funds under one of the few Medicaid waivers then approved by the federal government for pooling the program's funds with dollars from other sources.
Elsewhere, Northhaven II, a freestanding 40-unit assisted living building in Seattle, Wash., was added to the nonprofit Northhaven Retirement campus in 1992, and the Amherst H. Wilder Foundation in St. Paul, Minn., worked with the local housing agency to bring contracted assisted living services, such as meals and homecare, to residents from ages 48 to 99.
EXPERIMENTS IN ILLINOIS
Clearly, such creative efforts are not the first attempts to serve increasingly frail elders who are not yet ready for nursing home placement. Yet the rapid growth of assisted living developments, especially in the private, for-profit sector, is not quickly yielding widespread accessibility to this new form of intermediate aid. (See "Federal Study Reveals Trends, Development Barriers" elsewhere in this section. ) The crafting of comprehensive models for affordable assisted living, rather than innovations by single institutions within a fragmented system, is now underway state by state.
One experiment being watched around the country is in Illinois. Donna Munroe, research director at the Life Services Network's Center for Eldercare Choices (CEC), Hinsdale, Ill., described a catch-22 situation challenging providers around the country. Existing long-term care models require older people to live in particular settings, such as nursing homes, before they can receive assistance, she said, but "the driving force for where people choose to live tends to be what they can afford. Therefore, a model that prescribes both services and setting runs the risk of standardizing environmental design features that are unacceptable and/or unaffordable to older persons."
Under Illinois' Nursing Home Care Act (1992) the state regulates any facility that provides personal care, sheltered care or nursing for three or more persons not related to the applicant or owner by blood or marriage. Munroe described how assisted living providers have devised ways to avoid this law's regulatory constraints. One method is for residents in congregate housing apartments that usually offer no assistance to contract independently for support and nursing services with community-based agencies. However, she said, the statute's array of requirements for coordinating services can be problematic. She stressed, "This coordination function can be the difference between maintaining a seamless community-based system of care and major care gaps that drain caregiver resources and culminate in hospitalization or nursing facility placement of residents."
Furthermore, she said, individual service contracts bring strangers in and out of buildings, which raises security concerns. Also worrisome is the accountability of individual workers and the quality of the service they provide. Frequently, she went on, residents must contract for more help than they need, because many providers require private parties to order minimum units of service. Some residents refuse services, because they cannot afford to pay for more than they need.
QUAGMIRE
Munroe described initiatives in Illinois to address the "assisted living quagmire." In 1994 and 1995 CEC and the Illinois Department on Aging (IDOA) held statewide summit meetings aimed at developing consensus on this issue among key aging network professionals, legislators, government agencies and providers, although this process is yet to result in comprehensive new legislation.
In addition, the Illinois Department of Public Aid initiated a Medicaid-waiver program this year. Yet numerous residents in low-income housing fail to meet financial limitations for Medicaid or do not wish to spend down their assets to meet the financial requirements for eligibility, she noted.
Especially promising, Munroe said, is the Community Based Residential Facilities program, a three-year project being conducted by IDOA. It exempts a participating organization from the Nursing Home Care Act and allows it to provide both housing and services. This public-private initiative involves IDOA, the CEC, and the Midwest Center for Health Services and Policy Research at Hines Veteran's Administration Hospital.
Funded by the Retirement Research Foundation and the Chicago Community Trust, the project will compare six projects. Three senior housing facilities specially permitted for this demonstration to employ their own assisted living staff will be compared to three housing facilities that have developed a managed-care-style preferred provider contract with a local community-based care agency. Activity in all of these sites will be compared to traditional service delivery.
Munroe explained that participating organizations expect the demonstration program to yield cost savings that will show the models can work for moderate- and low-income seniors. Additionally, the project will test ways to monitor service quality "that may emerge as alternatives to bureaucratic regulation of assisted living." Also, she said, the project will contrast resident outcomes in the project settings with those in existing models.
Monroe commented, "The challenge to those of us who claim to be advocates of accessibility and choice for consumers of aging services is to have the courage to promote the creativity and flexibility required to develop such models for assisted living."
For more information contact Donna Munroe, director of research, Life Services Network, 911 N. Elm St., Suite 228, Hinsdale, IL 60521; (630) 325-6170; fax (630) 325-0749.
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