1 INFORMATION BRIEF Minnesota House of Representatives Research Department 600 State Office Building St. Paul, MN February 2001 Randall Chun, Legislative Analyst Assisted Living/Housing with Services in Minnesota Assisted living, also referred to as housing with services in Minnesota, is an increasingly popular housing option for elderly individuals. This information brief describes the regulation of assisted living in Minnesota and provides information about the persons receiving assisted living, the services provided, quality assurance, and costs. Contents Page What is Assisted Living?...2 Housing with Services Minnesota s Version of Assisted Living...3 Characteristics of Persons Receiving Assisted Living Services...5 Services Provided...7 Quality of Care...10 Cost of Assisted Living...12 This publication can be made available in alternative formats upon request. Please call (voice); or the Minnesota State Relay Service at (TTY) for assistance. Many House Research Department publications are also available on the Internet at:
2 Assisted Living/Housing with Services Page 2 A. What is Assisted Living? Assisted living usually refers to the provision of supportive and health-related services to consumers in a variety of homelike or community settings. The promotion and encouragement of consumer choice and control is also generally part of the formal or informal definition of assisted living. There is, however, no standard definition of the term. Several definitions of assisted living are listed below. The National Center for Assisted Living defines an assisted living setting as a congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health-related services. The setting must be designed to minimize the need to move... accommodate the individual resident s changing needs and preferences... maximize residents dignity, autonomy, privacy, independence, choice and safety... (and)... encourage family and community involvement. 1 The American Association of Retired Persons defines assisted living as a residential setting that provides or coordinates personal care services, 24-hour supervision, scheduled and unscheduled assistance, social activities, and some health-related services. Assisted living provides a homelike atmosphere and is designed to accommodate residents changing care needs and preferences. 2 For purposes of the alternative care program, the Minnesota Department of Human Services defines assisted living services as a group of services provided by or arranged for by the management of a housing with services establishment or a residential center or contracted for by the county with a class A home care agency. Services provided or arranged for by the assisted living provider may include supervision, supportive services, individualized home care aide tasks, and individualized home management tasks. 3 Assisted living is referred to by many other terms, including board and care, residential care, and adult congregate care. In Minnesota, the vast majority of assisted living settings are registered as housing with services establishments with services regulated under home care licensure requirements. 1 Key Concepts of Assisted Living, National Center for Assisted Living web site, August 28, Citro, Assisted Living in the US, American Association of Retired Persons web site, August 28, Alternative Care Program: Program Services, Provider Definition and Standards, Department of Human Services, February 2000.
3 Assisted Living/Housing with Services Page 3 B. Housing with Services Minnesota s Version of Assisted Living Minnesota does not regulate a specific category of facilities called assisted living. Instead, the state separately regulates assisted living services and the facilities in which assisted living services are furnished. In most cases, an umbrella requirement of housing with services registration is superimposed over this separate regulation of services and facilities. Most assisted living services in Minnesota are provided in facilities registered as housing with services establishments. (A small number of elderly persons receive assisted living-type services in family adult foster homes, which are exempt from housing with services registration.) Housing with services registration. Minnesota requires facilities that provide two or more supportive services or one or more health-related services to residents who are primarily elderly (i.e., at least 80 percent of residents are age 55 or older) to register with the Minnesota Department of Health (MDH) as housing with services establishments. As of October 2, 2000, 643 housing with services establishments were registered with MDH. Nursing homes, family adult foster care homes, 4 certain board and lodging establishments, and other specified facilities are exempt from housing with services registration. Minnesota law defines a housing with services establishment as... an establishment providing sleeping accommodations to one or more adult residents, at least 80 percent of which are 55 years of age or older, and offering or providing, for a fee, one or more regularly scheduled healthrelated services or two or more regularly scheduled supportive services, whether offered or provided directly by the establishment or by another entity arranged for by the establishment. (Minn. Stat. 144D.01, subd. 4) Health-related services include professional nursing services, home health aide tasks, home care aide tasks, and the central storage of medication for residents. (Minn. Stat. 144D.01, subd. 6) Supportive services are defined as help with personal laundry, handling or assisting with personal funds, or arranging for medical services, health-related services, social services, or transportation to medical or social service appointments. (Minn. Stat. 144D.01, subd. 5) Housing with services registration does not exempt a facility from any other applicable facility licensure requirements (e.g., board and lodging, adult foster care). If health-related services are provided, the facility, or home care provider if the facility contracts for services, must also have the appropriate home care license from MDH. Facility licensure requirement. Most housing with services establishments are apartment buildings, corporate adult foster care facilities, or board and lodging facilities that provide 4 A family adult foster care home provides sleeping accommodations and services to up to four adults (five if all residents are elderly and other criteria are met). The home must be licensed by DHS and be the primary residence of the license holder, and the license holder must be the primary caregiver. (M.S. 144D.01, subd. 7)
4 Assisted Living/Housing with Services Page 4 supportive or health supervision services. Corporate adult foster care facilities and board and lodging facilities must obtain the appropriate facility license, in addition to being registered as housing with services establishments. Apartment buildings must comply with local building codes but do not need to obtain a specific facility license. A corporate adult foster care home provides sleeping accommodations and services to up to four adults (five if all residents are age 60 or older and do not have a serious and persistent mental illness or a developmental disability) and must be licensed by DHS. Unlike a family adult foster care home, a corporate adult foster care home is not the primary residence of the license holder and the license holder is not the primary caregiver. Instead, corporate adult foster care homes usually employ shift staff. A board and lodging establishment provides sleeping accommodations and food to five or more adults for a period of one week or more. Board and lodging establishments must be licensed by the Commissioner of Health under chapter 157. If a board and lodging establishment provides supportive services or health supervision services and is not registered with the commissioner as a housing with services establishment, it must register with the commissioner as a board and lodging facility with special services. The pie chart provides information on the distribution of housing with services units across different facility types, as of May As of that date, 626 housing with services establishments were registered with the Commissioner of Health. These establishments had a total of 27,142 units. Number of Housing with Services Units by Facility Type 5 Corporate Foster Care (2,000) 7.4% Housing With Services Only (apartments) (1,699) 66.2% Board and Lodging (5,484) 20.2% Foster Care and Board and Lodging (1,699) 6.2% Source: Long-Term Care Task Force, Long-term Care Data Book, May 2000, and discussions with DHS staff. 5 The number of units reported under the Foster Care and Board and Lodging category may not accurately reflect the number of facilities dually licensed. Adult foster care licensure is limited to facilities that care for no more than five elderly persons, while board and lodging licensure is limited to facilities serving five or more individuals. Since only facilities with five individuals could potentially have dual licensure under state licensure standards, the reported number of 1,699 units may be an overestimate due to reporting errors or may reflect local licensing requirements.
5 Assisted Living/Housing with Services Page 5 Home care license requirement. A housing with services establishment that provides one or more regularly scheduled health-related services must obtain the appropriate home care provider license from MDH. If the facility contracts or arranges for these services, the entity providing the services under contract must obtain the appropriate home care provider license. The most common licenses for housing with services establishments are the Class A home care provider license, the Class E assisted living license, and the Assisted Living Home Care Provider license. A provider with a Class A, or professional home care agency license, can provide all home care services in a place of residence, including a residential center. 6 These services include nursing, physical therapy, speech therapy, respiratory therapy, occupational therapy, nutritional services, medical social services, home health aide tasks, or the provision of medical supplies and equipment when accompanied by the provision of a home care service. (Minn. Rules, part , subpart 3, item A) A provider with a Class E, or assisted living program license, can provide assisted living services only to residents of a residential center. For purposes of a Class E license, assisted living services means individualized home care aide tasks or home management tasks. (Minn. Rules, part , subpart 3) A provider with an assisted living home care provider license can provide assisted living home care services to residents of housing with services establishments. Assisted living home care service means a nursing service, delegated nursing service, or other service performed by an unlicensed person (such as home health aide and home care aide tasks), or the central storage of medications. (Minn. Rules, part , subpart 2c) Table 3 on page 11 provides information on the total number of home care licenses issued by MDH, and the number of home care provider surveys conducted by MDH. C. Characteristics of Persons Receiving Assisted Living Services There is little demographic and statistical information available for individuals paying out-ofpocket for assisted living services in Minnesota. Some information is available on the health care needs (as measured by case-mix score) of individuals receiving assisted living services under the elderly waiver or the alternative care program. National data on the characteristics of individuals receiving assisted living services is also available. 6 A residential center is a building or complex of contiguous or adjacent buildings in which clients rent or own distinct living units. (Minn. Rules, part , subpart 35)
6 Assisted Living/Housing with Services Page 6 Average case-mix scores. All recipients of elderly waiver and alternative care program 7 services are screened by county screening teams and assigned one of 11 case-mix classifications (designated A through K ), based upon the severity of their disabilities and their care needs. Case-mix classification A represents the lowest level of care, and case-mix classification K represents the highest level of care. Each case-mix classification is associated with a numerical weight that is used in setting reimbursement rates. These weights range from 1.00 for case-mix classification A to 4.12 for case mix classification K. A comparison of case-mix classifications shows that individuals receiving assisted living services under the elderly waiver or alternative care programs have on average a lower level of disability, and lower care needs, than individuals receiving nursing facility services. The average case-mix classification for individuals receiving assisted living services ranges varies between case-mix category A to case-mix category D, depending upon the service package (see Table 1 below). For three of the four assisted living service packages, over 60 percent of recipients had case-mix classifications of A or B. In contrast, individuals residing in nursing facilities have an average case-mix classification of G. 8 Table 1 Case Mix Classifications for Assisted Living Service Package Average Case-mix Elderly Waiver Recipient % of Elderly Waiver Recipients, Case-mix A or B Average Case-mix Alternative Care Recipient % of Alternative Care Recipients, Case-mix A or B Assisted living plus C 62 C 68 Assisted living B 78 A 80 Foster care D 32 D 39 Residential care C 69 C 74 Note: Service packages are described on pages 9 to The elderly waiver provides Medical Assistance (MA) funding for home and community-based services provided to persons age 65 and older who require the level of care provided in a nursing home but who reside in the community. In order to qualify for MA, individuals must meet income and asset standards and satisfy other eligibility criteria. The alternative care program provides home and community-based services to persons age 65 who are not eligible for MA, but who would become eligible for MA within 180 days of entering a nursing home. 8 Case-mix classifications are assigned based upon an evaluation of an individual s dependencies in activities of daily living (ADLs), special nursing requirements, neuromuscular conditions, and behavioral conditions. For example, an individual with a case-mix classification of B is dependent in three of fewer ADLs, does not need special nursing, but does have a behavioral condition. An individual with a case-mix classification of G is dependent in seven or eight ADLs, does not need special nursing or have a behavioral condition, and has a dependency related to eating that is below a specified threshold.
7 Assisted Living/Housing with Services Page 7 National data on assisted living residents. A 1998 national survey conducted by the National Center for Assisted Living provides the following information on assisted living residents: 9 The average assisted living resident is 83 years old. 74 percent of assisted living residents are female and 26 percent male. 26 percent of residents need no help with activities of daily living. On average, residents need help with 1.7 activities of daily living. Most residents (58 percent) move to an assisted living facility from their own homes, while nearly equal percentages moved from nursing facilities (13 percent), another assisted living residence (12 percent), and hospitals (12 percent). The most common reason for leaving an assisted living facility is to enter a nursing home (43 percent), followed by death (22 percent) and returning to one s own home (13 percent). The average length of stay in an assisted living facility is almost three years. D. Services Provided Services provided by assisted living facilities can vary considerably. There is no standard package of services offered to persons paying for assisted living services out-of-pocket. A survey of housing with services establishments conducted by the Minnesota Health and Housing Alliance (MHHA) has identified commonly offered services. The elderly waiver and alternative care programs pay for several defined packages of assisted living services. MHHA survey. A survey of housing with services establishments conducted by the MHHA in 1999 found that the services most commonly offered by facilities were housekeeping, meals, personal laundry, recreational activities, blood pressure checks, grooming, and 24-hour emergency response. Some facilities offered these services as part of their base rent or without charge, while others provided the services for an additional charge above base rent. Table 2 provides more detailed information on services offered. 9 National Center for Assisted Living s 1998 nationwide survey of the assisted living industry, as summarized on that organization s web site (http://www.ncal.org).
8 Assisted Living/Housing with Services Page 8 Table 2 Services Most Commonly Provided by Housing with Services Establishments Service % of facilities providing service without charge or as part of base rent % of facilities providing service for an additional charge Housekeeping Meals Recreational activities 43 4 Personal laundry Blood pressure checks hour emergency response 38 8 Grooming Arranging health-related or other services Nursing services Meal tray delivery Scheduled transportation Linen service hour on-site staffing 28 6 Wellness program 25 5 Central storage of medication Social services 18 6 Memory loss program Assistance with personal funds 14 3 Source: Minnesota Health and Housing Alliance. The percentages in the table are calculated based upon the total number of facilities (N=334) responding to the MHHA survey during August The number of facilities responding to the specific questions on provision of services was not available from MHHA at the time this table was prepared. If this number is less than the overall facility response rate, the figures above will be an underestimate of the percentage of facilities that provide each service. Additional survey information can be found in Minnesota Health and Housing Alliance, Housing-with-Services in Minnesota: A Profile Summary, October 1999.
9 Assisted Living/Housing with Services Page 9 Elderly waiver and alternative care program services. The elderly waiver and the alternative care programs 10 pay for five packages of assisted living services assisted living plus, assisted living, corporate and family adult foster care, and residential care. Payments are limited to services that meet chronic needs, and which are provided in a facility under contract with county to serve elderly waiver or alternative care clients. A separate payment rate is established for each individual, based upon that individual s need for services. Assisted Living Plus Services 24-hour supervision Supportive services. These services include socialization (if the service is part of the care plan and other requirements are met), assisting clients in setting up meetings and appointments, and arranging for or providing transportation. Individualized home care aide tasks. These services include preparing modified diets, reminding residents to take medications or perform exercises, performing household chores in specified circumstances, and assisting with dressing, oral hygiene, hair care, grooming, and bathing, if the resident is ambulatory and has no serious acute illness or infectious disease. Home health aide tasks. These services include the administration of medications, performing routine delegated medical or nursing or therapy procedures, assisting with body positioning and transfers, feeding clients at risk of choking, assistance with bowel and bladder control, assistance with therapeutic and range of motion exercises, providing skin care, and, during episodes of serious disease or acute illness, providing assistance with hygiene, nutrition, and mobility. Central storage of medication Incidental nursing services (restricted to medication set-up and drawing of insulin) Central storage of medication, incidental nursing services, and home health aide tasks can be performed only if allowed under the home health care provider s license. Assisted Living Services Allowed services are the same as under assisted living plus, except that 24-hour supervision is not required. 10 These programs are briefly described in footnote 7, on page 6.
10 Assisted Living/Housing with Services Page 10 Adult Foster Care Services (Corporate and Family) Supervision Household services Personal care Medication assistance Caregiving Homemaking Transportation Residential Care Services Supportive services. Includes the provision of up to 24-hour supervision, meal preparation, individualized home management tasks, socialization (if the service is part of the care plan and other requirements are met), assisting clients in setting up medical and social services, and arranging for or providing transportation. Health related services. Limited to minimal assistance with dressing, grooming, and bathing, providing reminders to take self-administered medication, and providing storage for medications. E. Quality of Care The regulation and monitoring of quality in housing with services establishments is more decentralized and more reliant on consumer initiative than is quality regulation and monitoring in nursing facilities. The quality of care in housing with services establishments is regulated and monitored in four main ways. First, the housing with services law requires establishments to provide each resident with a legally enforceable contract and specifies items that must be addressed in the contract. Second, the provision of health-related services in a housing with services establishment is regulated through the applicable home care licensure requirements. Third, those establishments that are required to obtain a facility license are subject to the applicable facility licensure requirements. Finally, residents of housing with services establishments can file complaints about care with the Office of Health Facility Complaints and can also seek the assistance of the Ombudsman for Older Minnesotans. Housing with services contracts. Housing with services establishments are required to provide residents with a contract that addresses 17 items. (Minn. Stat. 144D.04, subd. 2) This contract is legally enforceable and gives residents the option of redress through the courts, or through informal negotiations with management. Items addressed by the contract include: a description of the registration and licensure status of the establishment and any provider providing health-related or supportive services under an arrangement with the establishment;
11 Assisted Living/Housing with Services Page 11 a description of services to be provided to residents as part of the base rate; a description of any additional services available for an additional fee from the establishment directly or through arrangements with the establishment; fee schedules outlining the cost of any additional services; a description of the establishment s complaint resolution process; the establishment s referral procedures if the contract is terminated; criteria used by the establishment to determine who may continue to reside in the establishment; a statement regarding the ability of residents to receive services from service providers with whom the establishment does not have an arrangement; a statement regarding the availability of public funds for payment for residence or services in the establishment. Home care licensure requirements. The quality of health-related services provided in housing with services establishments is monitored and enforced through MDH surveys of home health care providers. Home health care provider surveys involve on-site interviews of individuals receiving care, observations of the care provided, and reviews of patient charts and records. The number of surveys and inspections conducted depends on the amount of funding MDH receives from home care provider licensure fees. Table 3 below provides information on number of home care license holders and the number of surveys conducted. License Type Table 3 Home Care Licenses and Number of Surveys Number of licenses as of Number surveyed, to Class A, Medicare certified Class A, not Medicare certified Class E 14 4 Assisted Living Home Care Provider Notes: Some, but not all, Class A license holders provide services in housing with services establishments. Assisted living home care provider license holders serve only housing with services establishments, but can provide services at more than one establishment. Source: Minnesota Department of Health, Licensing and Certification Program, Facility and Provider Compliance Division.
12 Assisted Living/Housing with Services Page 12 Facility licensure requirements. Housing with services establishments that are licensed as corporate adult foster care facilities or board and lodging facilities must meet the applicable structural and physical plant requirements in state law and rule. Adult foster care facilities must be inspected by county human services licensing staff at least once every two years. The inspection involves an assessment of whether the services provided meet adult foster care program requirements, as well as an assessment of whether the facility meets structural and physical plant requirements. Board and lodging facilities must be inspected by MDH or local public health board staff at least once every two years for compliance with structural and physical plant requirements. Housing with services establishments not required to have a facility license (e.g., apartments) are subject to local building code requirements. Filing of complaints; Office of Ombudsman. Residents of housing with services establishments who receive services from a licensed home care provider are covered under the home care bill of rights (Minn. Stat. 144A.44) and the vulnerable adults act (Minn. Stat ). Residents can file complaints about the services provided through a housing with services facility with the Office of Health Facility Complaints within MDH ( ). Residents can also seek the assistance of the Ombudsman for Older Minnesotans within the Minnesota Board on Aging ( ). F. Cost of Assisted Living Little information is available on the cost of assisted living services. The MHHA 1999 survey did collect information on assisted living base rents. While a specific estimate is not available, it is thought that most assisted living residents in Minnesota pay for assisted living services out-ofpocket. For the nation as a whole, the National Center for Assisted Living 1998 survey found that 81 percent of assisted living residents paid for assisted living services using their own funds. The elderly waiver and alternative care programs set payment rates for different packages of assisted living services that vary with the case-mix rating of the individual receiving the service. Group residential housing is a potential payment source for the room and board component of assisted living. MHHA survey of base rent. The MHHA 1999 survey of housing with services establishments collected information on average monthly base rents. The base rents reported did not include the cost of services or amenities that are billed separately from the base rental rate. Facilities differed in the type and amount of services included as part of the base rate. The survey found that average monthly base rents vary widely. For example, base rents for nonfederally subsidized facilities ranged from $834/month for a studio in a continuing care retirement community to $2,406/month for single occupancy adult foster care (see Table 4 below). This variation is likely due to differences in the type and amount of services included in the base rate and differences in facility type and the care needs of persons served.
13 Assisted Living/Housing with Services Page 13 Since base rents do not include the cost of health services or amenities billed separately from the base rate, base rents understate, in many cases, the total cost of residing in a housing with services facility. For example, MDH staff who survey assisted living facilities have found that total monthly charges in housing with services establishments (the cost of base rent plus charges for additional services) can range from $2,000 to $4,000 a month. Total charges in housing with services facilities serving dementia clients with health care needs are commonly in the $3,000 to $4,000 per month range. These ranges are considerably higher than the base rent averages reported in the MHHA survey. (It should be noted that these estimates of total charges are based on the observations of MDH staff and not on systematically collected survey data; collecting data on rates is not one of the regulatory functions of MDH.) Table 4 Average Monthly Base Rents Charged by Housing with Services Establishments Building Type Market Rate Apartments Average Monthly Base Rent (Note: Base rent does not include that costs of services and amenities billed separately; facilities differ in the type and amount of services included in the base rental charge.) Studio $1,171 1 bedroom $1,091 2 bedroom $1,253 Federally Subsidized Apartments Studio $222 1 bedroom $400 2 bedroom $363 Board and lodging Single occupancy $1,580 Double occupancy $1,819 Foster Care Single occupancy $2,406 Double occupancy $1,452 Continuing Care Retirement Communities Studio $834 1 bedroom $1,450 2 bedroom $1,956 Source: Minnesota Health and Housing Alliance, Housing-with-Services in Minnesota: A Profile Summary, October 1999.
14 Assisted Living/Housing with Services Page 14 Elderly waiver (EW) and alternative care (AC) program payment rates for services. The elderly waiver and the alternative care program pay for different packages of assisted living services. Payment rates are negotiated with county human services agencies, subject to program maximums. 11 Rates vary by the type of service package, the health care needs of the recipient as measured by the individual s case-mix classification, and, in the case of the assisted living and residential care service packages, by geographic location of the facility based upon the three geographic regions used to set nursing facility rates. Table 5 provides average monthly cost per recipient and other information for different packages of assisted living services. The average monthly cost figure includes only the cost of providing assisted living services. It does not include the cost of other services provided to the recipient that are not part of the assisted living service package. 11 Elderly waiver and alternative care program rate maximums for assisted living services are listed in the following Department of Human Services bulletins Assisted Living Plus Service Available for Qualified Housing with Services Establishments and Assisted Living Service Name Expands to Additional Settings # , April 25, 2000, and Service Cost Limits for AC/EW and Rate Limits for Assisted Living Plus or Foster Care, Assisted Living or Residential Care Service for FY 2001 # , July 25, 2000.
15 Assisted Living/Housing with Services Page 15 Table 5 Rate and Other Information for Assisted Living Service Packages Service Package Licensure and Other Requirements Setting Average monthly cost per recipient (CY 2000) Assisted Living Plus Housing with Services (HWS) 12 and Class A or Assisted Living Home Care Provider (ALHCP) license. Must include 24-hour supervision. Adult foster care, board and lodge, or apartments EW $1,437 AC $1,127 Assisted Living HWS and Class A or ALHCP license. Must not include 24- hour supervision. Adult foster care, board and lodge, or apartments EW $753 AC $776 HWS and Class E license. May include 24-hour supervision. Apartments Not registered as HWS. Class A or Class E license. May include 24-hour supervision. Adult foster care, board and lodge, or apartments if Class A license. Apartments if Class E. Family Foster Care Foster care license under Rule 203 or county certification. (Family foster care is exempt from HWS and home care licensure requirements.) Family foster care residence EW $1,420 AC $1,212 Corporate Foster Care Foster care license under Rule 203 and facility is not required to register as HWS (if registration required, service is assisted living or assisted living plus). Corporate foster care residence EW $1,420 AC $1,212 Residential Care Services Source: DHS Bulletin # , April 25, Board and lodge registered to provide special services (if registration as HWS is required, service is assisted living or assisted living plus). Board and lodge EW $850 AC $ A facility must register as a housing with services establishment if at least 80 percent of residents are age 55 or older and it offers or arranges for one or more health-related and two or more supportive services. Nursing homes, family adult foster care settings, certain board and lodging establishments, and other specified facilities are exempt from registration.
16 Assisted Living/Housing with Services Page 16 GRH payments for room and board. Low-income elderly can have their room and board costs paid for through the Group Residential Housing (GRH) program, if they meet program eligibility criteria 13 and reside in a facility registered as a housing with services establishment that provides three meals a day or a facility licensed as a family or corporate adult foster home. The GRH basic room and board rate is $633/month for the fiscal year ending June 30, In addition, individuals residing in foster care facilities may receive an additional payment for room and board or supplementary service costs of up to $426.37/month. 13 The GRH asset standard for elderly individuals is that used by the Supplemental Security Income program ($2,000 for a single person and $3,000 for a married couple, with various exemptions). In order to qualify for GRH, an individual s income, after specified deductions, must not exceed the GRH provider s monthly rate. GRH recipients are required to contribute much of their income towards the cost of their care.
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