Academic journal article Social Work

Licensure of Sheltered-Care Facilities: Does It Assure Quality?

Academic journal article Social Work

Licensure of Sheltered-Care Facilities: Does It Assure Quality?

Article excerpt

During the past 35 years, the decentralization of responsibility for services to the mentally ill population has been the major guideline of mental health policy. Hospital units were decentralized geographically, and state responsibility was decentralized to county departments and later to catchment areas within counties (Mechanic, 1989). Furthermore, responsibility for the care and maintenance of individuals was decentralized to the nursing home system and the sheltered-care facility system; both systems now have provided for the care of more patients than mental hospitals ever did (Goldman, Gattozzi, & Taube, 1981). Although coordination of decentralized organizations has always been a problem, neither coordination nor quality-control issues have been given much attention in the literature. State legislatures, however, have used facility licensure to assure quality of care in decentralized systems.

This article looks at the effort to license sheltered-care facilities as an attempt to achieve quality control in a decentralized system. Sheltered-care facilities--including board- and-care homes, family care homes, halfway houses, and psychosocial rehabilitation facilities--are now the placement of choice for seriously mentally ill individuals who need supervised care. Therefore, it is necessary to guarantee that such care is quality care.

Two questions about quality of care were raised for study: (1) What characteristics distinguish facilities that become licensed from those that do not? (2) Although we cannot attribute direct causation to licensure, what are the consequent differences between licensed and unlicensed facilities? In the summer of 1973, Segal and Aviram (1977, 1978) completed a survey of 214 sheltered-care facilities, a representative sample of all such facilities in California that served mentally ill adults ages 18 to 65. Also in 1973 the State of California passed a licensing law for such facilities, the California Residential Care Facilities Licensing Act. Because the law did not go into effect until January 1974, the data from the Segal and Aviram sample were gathered before licensure was a possibility. Between 1983 and 1985 the Mental Health and Social Welfare Research Group of the University of California, Berkeley, reinterviewed or otherwise determined the status of each facility in the original study.

The California law required licensure of all 24-hour residential- care facilities that were not licensed as hospitals and that provided supervised living arrangements to mentally ill adults. However, facilities could avoid the licensure requirement by disavowing their claim to providing a supervised setting for the disabled population and by representing themselves as boarding houses.

The authors looked at several quality-of-care indicators that could influence licensure, including operational characteristics of a facility, its resident population, and its community environment. The most important operational characteristics include a facility's cost to clients and the character of its environment; the latter was thought to be the main reason for licensing a facility.

We assumed that the higher-priced facilities would be more likely to become licensed, because they could afford to comply with regulations that favored the development of intrafacility programming and that often required expensive physical plant modifications. We further hypothesized that the facilities would become more institutional in character, moving away from a traditional family atmosphere to a more structured social environment, because the structured environment would make it easier to comply with licensing laws. We also believed that the professional orientation of treatment facilities would make licensure more attractive to owners and managers. In looking at the resident population of a facility, we expected that those facilities serving an increasingly disabled sample and those likely to serve mentally ill people as their major target group would be more likely to become licensed. …

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