Reprinted from Aging Today, July-August 1998
Assisted Living
QUALITY CONCERNS MEET CONFLICTING GOALS?
By BILL ORIOL
How to deal with an assisted living facility resident who refuses to take prescribed medication? A regulatory agency may hold the facility responsible for not doing its job, while the resident may argue that the decision is personal. After all, the facility is "home," and home is sanctuary.
This medication question was one of several conundrums raised in a session on "The 'Real' Issues of Quality in Assisted Living" at the American Society on Aging's 44th Annual Meeting in San Francisco in March.
MUDDY ISSUES
Assisted living facilities continually must resolve "muddy" issues, according to Paula Hertel, vice president for operations, ARV Assisted Living, based in Costa Mesa, Calif. This circumstance has arisen as "our industry gets more complex, as our residents have more needs," ranging from medication concerns to mental health, she said.
She cited the recent example of a resident who said, "I don't want to take this medicine. I'm not paying for it, because I'm not going to take it." Although the heart medication was not absolutely necessary for sustaining the resident's health, and side effects caused her discomfort, the physician refused to take her off it because of liability concerns.
Hertel reported that the matter was finally resolved by a regulator who noted that the law's intent is to ensure that residents are not kept from needed medications. The regulator said the facility should "document that you've asked her every day, and she said no; then she doesn't have to buy her medication, and you don't have to set it up and throw it away." After seven months the resident was doing fine, Hertel said.
Hertel continued that central to assisted living facilities is the conflict between a resident's decision-making autonomy and worries over safety and liability. "We're having to open our minds and open our doors to work with other providers who would have some expertise," she commented. "If we can all work together to look at a balance between safety and resident choice, we'll get there." She worried that providers may become so focused on compliance with safety regulations that they will add unnecessarily to the cost of care, making facilities unaffordable for some.
POTENTIAL HEADLINES
The need for regulators and assisted living personnel to work things out was a recurring theme during the session. According to Robert Applebaum, professor and research fellow at the Scripps Gerontology Center at Miami University in Oxford, Ohio, "Every legislator I've ever talked to is worried about the headline, 'Mrs. Jones Falls in Shower/Lies for Six Hours/Water Leaks to Next Floor.'"
Applebaum is concerned that "in another 10 years assisted living could look a lot like nursing home care." He described efforts in Ohio to develop workable state regulations. One problem is that "in most states the people regulating assisted living are in health departments. They're the exact same people who are regulating nursing homes, and their thinking is dominated by safety considerations."
A different possibility was raised by Sharon Hermanson, senior analyst, American Association of Retired Persons (AARP) Public Policy Institute, Washington, D.C. She described efforts to develop quality indicators for assisted living, or "minimum standards outside the paradigm of some old-style regs." She said that AARP is working with consumers, providers and others to examine "what it actually costs to do specific services within the facility." One goal is to determine fair reimbursement rates for low-income residents under Medicaid.
Karen Wayne, president and chief executive office of the Assisted Living Federation of America (ALFA), noted that only 20% of the residents in ALFA's 5,400 member facilities receive any financial assistance. Concerned about the need for assisted living to be affordable to low-income people, the organization is conducting research on new practice and reimbursement models.
RESEARCH PROJECTS
For example, Wayne said, in the coming year ALFA plans to launch a Medicaid demonstration project in three or four states. Vouchers for care will be given not to institutions or organizations, but to potential clients who could use them to select care options as appropriate. Wayne explained that the vouchers "will be portable, so that the resident can use them along the continuum of care." The research will test the concern that providing payments to facilities tends to box consumers into one choice, such as a nursing home.
In some cases, the voucher demonstration program may rely strictly on Medicaid funds under a federally approved waiver secured by the state to allow flexible application of the money outside of the program's usual regulations. In other states, participating ALFA providers will form a partnership with a state Medicaid program by donating parts of facilities to test whether care can be offered affordably to lower-income elders. Wayne told Aging Today in an interview, "We are saying to state legislatures that we're willing to take the risk together" to come up with new reimbursement models that work for different population groups. She stressed that ALFA's proposals are all "budget neutral," and would not cost states additional funds.
Furthermore, Wayne said that ALFA is investing $1.2 million in a training program that "deals with best practices for our caregivers." This intensive series of books, videos and tests covers such topics as Alzheimer's care, sensitivity to the aging, activities of daily living, and care for the health and well-being of residents.
Whether to establish a program for accrediting assisted living facilities is another issue. In Wayne's view this approach may be too cumbersome for ALFA members. She suggested that the development of an award for meeting standards of quality, such as the seal given to roadside services by the Automobile Association of America, would "create a model that inspires providers to be the best they can be."
Applebaum observed that the voice of consumers is becoming increasingly important. He added, though, "We have this battle between what consumers want and what everybody else wants for them. If that battle gets won on the side of consumers, then we'll have reasonable sets of regulations for doing this, and if that battle doesn't get won by consumers, then I think we'll go the other way. I think the jury is still out on that."
Bill Oriol, a frequent contributor to Aging Today, is a writer based in Sedona, Ariz.
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