Regulation of Assisted Living Facilities: State Policy Trends

By Mollica, Robert L. | Generations, Winter 1998 | Go to article overview

Regulation of Assisted Living Facilities: State Policy Trends


Mollica, Robert L., Generations


Growth in the private market has prompted officials in many states to develop public policy governing the regulation, licensing, and reimbursement of assisted living. In 1996, thirty states had implemented an assisted living policy, and twelve others instituted a process to study the issue (Mollica and Snow, 1996). In 1995 and 1996, Arizona, Hawaii, Iowa, Kansas, Kentucky, Maryland, North Carolina, and Tennessee all passed laws related to assisted living facilities. Legislation amending previous law passed in Florida and Maine. In 1997, twenty-two states were examining policy options or reviewing existing policy, and by mid-year, legislation had passed in Louisiana and Oklahoma. Increasingly, assisted living is covered as a Medicaid benefit.

CONSUMER FOCUS

The 1996 study (Mollica and Snow) found a number of trends among states. State regulators reported that initiatives to establish public policy on assisted living were emerging from state policy leaders themselves, from consumers interested in new and stronger consumer-based options, and from segments of the long-term-care industry. There are, however, diverging opinions within "stakeholder" groups, and some industry leaders opposed new regulations or preferred that new policies mirror the evolving practice among providers.

State regulators reported being more responsive to consumer preferences for autonomy and for residential, as opposed to institutional, environments and, based on the experience and limitations of regulating nursing facilities, less driven to create safe but institutional environments at the expense of autonomy and consumer preference. During interviews, state policy-makers spoke about the limits of regulations to ensure safety and quality of care and their intention to create a balance between residential, homelike settings, consumer decision-making, and safety.

As new states develop their approach to assisted living, it is unlikely that a uniform definition or approach to assisted living will emerge. The process for developing policy encourages the participation of diverse groups, each with different priorities and influence. Policy development varies by state and reflects the unique blend of the interests and preferences of consumers and advocates, of associations and providers representing assisted living facilities, nursing homes, and home health agencies, and of legislators and state officials. Despite significant differences among states, there are also many similarities. For example, policies in fourteen states include a statement of philosophy that describes assisted living as a model that emphasizes consumer or resident independence, autonomy, dignity, privacy, and decision-making. Oregon was the first state to include a statement describing the philosophy of this new model, and other states have used the Oregon rules as a starting point.

KEY POLICY QUESTIONS

Developing assisted living regulatory policy requires that state leaders must answer several key questions:

For regulatory purposes, how will assisted living be defined?

Who will be served?

What services will be provided?

Will subsidies be available for lowincome residents?

How will the new policy differ from current practice? Is a new licensure category needed?

What approach to regulation will be taken?

DEFINING ASSISTED LIVING

There is no common definition of assisted living for regulators to use, although state rules generally include a reference to the philosophy of the program, its residential nature, the availability of services to meet scheduled and unscheduled needs, and the ability for residents to age in place. Single occupancy apartments or studios with a kitchenette, broader admission and retention policies, and more intense service capacity tend to differentiate assisted living rules from board-andcare rules.

Private or shared occupancy is one controversial policy area. …

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