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Resident Outcomes of Medicaid-Funded Community Residential Care

Correspondence: Address correspondence to Susan C. Hedrick, PhD, HSR&D (152) VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108. E-mail: susan.hedrick{at}med.va.gov

	Abstract

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Purpose:Washington State's initiatives to increase the availability and quality of community residential care presented an opportunity to describe clients entering adult family homes, adult residential care, and assisted living and to identify outcomes of care. Design and Methods:We enrolled 349 residents, 243 informal caregivers, and 299 providers in 219 settings. We conducted interviews at enrollment and 12 months later, and we collected data from state databases.Results:The average resident was a 78yearold woman reporting dependence in two of six activities of daily living. Residents in adult family homes demonstrated significantly more disability. Seventy-eight percent of residents survived at the 12-month follow-up. In analyses that controlled for differences at enrollment, residents in the three types of settings were very similar in health outcomes at follow-up.Implications:State policies should reflect the wide range of needs of residents seeking care in these settings. Choices among type of setting can be based on the match of needs to individual preferences.

Key Words: Long-term care • Assisted living • Health status

The AFH are residential homes licensed to provide room, board, and assistance with personal care tasks for two to six residents not related to the owner or operator. Published payment rates statewide during the 1998 fiscal year were $39.95 per day under the Medicaid waiver.

The ARC or enhanced ARC (EARC) settings provide room, board, and personal care services in licensed boarding homes. ARC services are provided under Medicaid personal care or state funds. Some boarding homes that contract to provide Medicaid waiver services, known as EARC requirements, include limited nursing care and also require that no more than two people share a room. Published payment rates statewide were $23.24 for ARC services; EARC rates were $37.80 per day. The settings in our study had from 12 to 105 licensed beds.

The AL settings are the most recently developed type of service, with a stated philosophy of maximizing the independence and self-esteem of clients, who play an active role in developing a negotiated service agreement. AL settings must meet physical plant requirements, including the provision of an individual private apartment with a full private bathroom, a lockable door, and a mini-kitchen. Published payment rates statewide varied from $49.93 to $69.41 per day, depending on the geographic location of the setting and the extent of client care needs. The settings in our study had from 12 to 206 licensed beds.

In 1983, the state of Washington's Medicaid waiver program was approved, allowing nursing home eligible clients to be served in home and community residential settings. The state has taken a series of actions since then to increase availability and improve the quality of community residential care and to reduce nursing home caseload. Washington is first among all states in the percentage of long-term care dollars going to community long-term care rather than nursing homes (Murtaugh et al., 1999). State actions included increased payment rates to compete with private pay rates; enhanced case management in hospitals and nursing homes; increased client participation in paying for care; changes in the reimbursement structure for nursing home care; improved quality assurance, including training for care of persons with dementia and mental illness; and amendments to the Nurse Practice Act to permit delegation of nursing tasks to community residential care providers. During the period of this study, the state-supported nursing home caseload was reduced from 14,646 to 13,672 and the state pledged to reduce that number to 12,000 by the year 2002, even in the face of the rapid aging of the population. At the time of the study, approximately 3,100 AFH, 1,300 ARC, and 2,050 AL residents were supported on state funds.

State case managers complete a Comprehensive Assessment to determine eligibility, payment level, and a care plan. Medicaid waiver eligible clients can choose to enter an AL, ARC, or AFH setting. Those who do not meet Medicaid waiver criteria but do meet the lower level state-only–Medicaid personal care funding qualifications (minimal assistance with one activity of daily living or need room and board and supervision) may choose an ARC or AFH. State case managers may recommend a type of setting, but the final choice is left up to the client or the family or guardian.

The movement to place state-funded clients in community residential care has created new opportunities but also new risks for residents, providers, and administrators. Hawes (Hawes, 2001) cites the public's and policymakers' "largely uncritical enthusiasm" for AL (p. 4). Concerns remain about quality of care, especially given rising acuity levels (Hawes, 2001; Kane & Wilson, 2001), lack of accurate information to guide consumer choice (U. S. Congress General Accounting Office, 1999), concern about the financial effects of expanding these services in the face of increasingly strained state budgets, and lack of information about program performance. Washington State's new initiatives presented an opportunity to evaluate these important service alternatives and provide guidance for the future role of each type of setting in the long-term care continuum. Persons who differ widely in demographics and health status were entering into three types of settings that differ in size, physical plant, amenities, services, and cost. In this paper we (a) describe the characteristics of clients entering or newly receiving state funding in one of three types of community residential care, that is, AFH, ARC, and AL, and (b) describe outcomes of care, including location, survival, and health status for all residents 12 months after enrollment.

	Methods

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Design and Setting
The study used a prospective cohort design in which we targeted for enrollment all persons entering an AFH, ARC, or AL setting in a three-county area between April and December of 1998 on Medicaid or state funding. Study residents were those placed by the state Aging and Adult Services Administration Home and Community Services Division and do not include residents with developmental disabilities or mental illness placed by other state agencies.

The University of Washington and State of Washington Human Subjects Review Committees approved a complex enrollment procedure. Figure 1 presents the number of residents at each step in this process. Contact information for all new state-funded residents was sent by regional office staff to a staff person in the state headquarters. This person mailed a letter and brochure describing the study to each of these potentially eligible residents or legal guardian and the provider. The letter gave the residents an 800 number to call if they did not want to be contacted by the study. If the state staff person received no reply within 10 days, she referred the residents to the study. Our staff then contacted them to obtain informed consent.

Our goal, on the advice of our Advisory Board, was to conduct the baseline interview at 3 months after the residents' entry into the community residential program to allow for them to settle into their new setting. We found that, by that time, some residents were no longer eligible for the study because they had died, moved home or to a nursing home, or could not be located. There were no significant differences across setting type in the proportion of residents who could not enroll for any of these reasons.

We enrolled 349 residents: 204 in AFH, 51 in ARC, and 94 in AL settings. This represents 86% of the 404 residents who were eligible for and contacted by the study. We also enrolled 243 informal caregivers for these residents (family or friends), 184 administrative providers (owners or managers) for the settings in which the residents were placed, and 115 direct care providers identified as the person in the setting who provided the most hands-on care to the resident. We obtained information on a total of 219 settings. These settings admitted between 1 and 17 study residents during the study period.

Data Collection
Data collection included extraction of data from state and Medicaid databases; in-person interviews with residents, providers, and informal caregivers at study enrollment and 12 months later; and a questionnaire completed by the administrative providers.

Interviews
For the in-person interview, our goal was to interview the resident 3 months after notification of placement, and 80% of the interviews were conducted within this time frame. Interview data were available for 325 residents at enrollment. Fifty-six percent of these interviews took place with the residents and 44% with proxy respondents when the residents were too impaired to complete the interview. At follow-up, our goal was to conduct interviews 12 months after the study enrollment date, allowing for a 1-month window on either side: 89% were completed within this time frame. Only 18 residents refused or were lost to follow-up. Twenty-two percent died by the end of the follow-up period. We also conducted bimonthly telephone contacts, primarily with providers or informal caregivers, to determine resident location and reasons for change in residence.

Comprehensive Assessment
We obtained the Comprehensive Assessment state database, which contains the detailed assessment completed by the state case managers at enrollment and periodically thereafter to assess the resident's demographics, health conditions, functional status, and psychological and cognitive status. These data were available for all 349 residents at enrollment. The Comprehensive Assessment is intended to be completed annually or whenever a change in status occurs. The actual time between the first and later assessments varied widely. In the analysis of Comprehensive Assessment database information at follow-up, we included any resident who had an assessment completed between 10 and 14 months after his or her first assessment (n = 166).

Main Variables
Demographics
We describe residents by age, gender, educational level, marital status, and race.

Resident Decision to Move
The residents' perception of the amount of control they had over the decision to move to the setting was measured on a 3-point scale (1 = complete or almost complete; 2 = some; 3 = little or none), using questions from Kane, Illston, Kane, and Nyman (1989).

Resident Satisfaction
Resident satisfaction was assessed by using measures from Hawes and colleagues (Hawes et al., 1999). Residents were asked to rate the overall quality of staff, room or apartment, meals, and overall setting by using a scale with possible responses ranging from 0 (the worst) to 10 (the best).

Activities of Daily Living (ADLs)
We report data from the in-person interview with the resident or proxy and the Comprehensive Assessment database on the resident's performance of six ADLs: bathing, dressing, locomotion, transfer, toileting, and eating. Possible scores range from 0 to 6 and represent the number of ADLs on which the resident received supervision or more help. The in-person interview ADL items were based on the Minimum Data Set items assessing the person's performance over the past 7 days (Morris et al., 1990).

Instrumental Activities of Daily Living (IADLs)
The performance of four IADLs was assessed: shopping, making telephone calls, managing money, and getting around outside the setting. Residents or proxies reported if the resident received assistance, did not receive assistance, or the activity did not occur in the past week (Zimmerman, & Sloane, 1999). We report only data from the in-person interview, as the Comprehensive Assessment used a different set of items.

Health Status
The Short Form-12 [SF-12] was used to assess global health status. The SF-12 is a norm-based score with a mean of 50 and SD of 10 for the general population (Ware, Kosinski, & Keller, 1996). We report both the physical and mental health component scores; higher scores indicate better health.

Memory and Behavior Problems
The Revised Memory and Behavior Problem Checklist (RMBPC) frequency scale is a measure of observable behavior problems reported by the provider. A total of 24 behaviors are assessed, and scores range from 0, for behavior never occurred, to 4, for behavior occurs daily or more often (Teri et al., 1992). The total score is a mean of the scores for the 24 behaviors assessed.

Cognitive Status
The Short Blessed Test, a six-item instrument, was used to evaluate cognitive status. This measure includes questions pertaining to resident orientation, memory, and concentration (Katzman et al., 1983). Possible scores range from 0 to 28, with a score of 8 or higher indicating cognitive impairment.

Setting Characteristics
Although this paper focuses on resident characteristics, in the analyses reported here we included several measures of setting characteristics that could potentially influence the resident's likelihood of entering a particular type of setting. These variables could then be used as potential observed confounders in the analyses of health outcomes. The variables that were analyzed for this purpose included staffing, occupancy rates, the study interviewer's assessment of overall pleasantness and attractiveness of the setting, the administrator's assessment of the restrictiveness of admission to the setting (number of health or behavior conditions that would lead to nonadmittal of the resident), regulations (number of behaviors encouraged or allowed by the facility out of 18 items measured) and services (number of services offered or arranged by the facility out of 20 possible items).

Data Analysis
We first characterize residents descriptively at study enrollment. We assessed differences across type of setting (AFH, ARC, or AL setting) at study enrollment by using an analysis of variance for continuous variables, the chi-square statistic for categorical variables, and the Scheffé test for post hoc multiple comparisons.

To analyze differences in resident outcomes at the 12-month follow-up period, we constructed two cohorts from the sample. The first cohort included all 349 enrolled residents for the survival analysis, as we were able to ascertain survival for all residents at the 12-month follow-up period. The second cohort included only those residents who were alive at follow-up for the outcomes analyses. There were missing data on those variables obtained from in-person interviews because of patients who could not be interviewed and who had no proxy or because of items that could not be assessed with a proxy (e.g., satisfaction with care or cognitive status). We imputed data by using a multiple imputation technique proposed by Rubin (1987) and implemented with SOLAS (Statistical Solutions Ltd., 2001).

We adjusted for self-selection bias caused by observed confounders in order to compare outcomes across type of setting (AFH, ARC, and AL). We first identified potential confounders by assessing differences in resident, provider, and setting characteristics at enrollment across type of setting from the descriptive baseline analysis described herein. We then controlled for the characteristics that varied significantly across type of setting in the outcomes analyses. We used a Cox proportional hazard regression model for survival analysis, a linear regression model for continuous scale outcomes, and a logistic regression for binary outcomes.

	Results

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Resident Characteristics at Enrollment
Overall, 68% of the residents were women (Table 1). ARC settings had a significantly lower proportion of women than AL settings. Most residents had at least a high school degree, though ARC settings had significantly fewer high school graduates than AFH settings. Few residents were currently married. The majority of residents were White. The average resident was 78 years old, but these settings served residents between 25 and 102 years old. There were significant differences in age, with AL settings serving the oldest population and ARC settings serving the youngest. ARC settings generally seem to serve a population with higher proportions of younger, less educated men.

Health and Cognitive Status
Residents or proxy respondents reported on assistance received with six ADLs: bathing, dressing, toileting, transfer, locomotion, and eating (Morris et al., 1990). Residents in AFH settings reported requiring significantly more help in every ADL than residents in other setting types (Table 2). The number of ADLs with which residents reported receiving help ranged from 0 to 6 and averaged 1.95; AFH residents reported significantly more disability. ADLs as reported by case managers on the Comprehensive Assessment demonstrated considerably higher levels of disability on every activity and averaged 4.78 of 6. AFH residents again demonstrated significantly more disability. The differences in scores between the in-person interview and Comprehensive Assessment is striking, and we found that the two measures had surprisingly little relationship (as indicated by the kappa statistic of.023). The differences between the interview and the Comprehensive Assessment may be due to differences in timing, differences in item wording, the tendency for older respondents to report lower levels of disability than their caregivers report for them, inconsistent case manager training, and the use of the Comprehensive Assessment data to determine program eligibility. These differences support our use of both measures in the data analyses reported here.

Decision to Move to Community Residential Care Setting
More than half (58%) of residents reported complete or almost complete control over the decision to move to this setting. This was not significantly different across type of setting. Residents reported a wide range of factors as being important to them in making their decision, including clean and pleasant surroundings, quality of care or staff, location, availability of personal assistance, homelike character, compatibility or familiarity with setting, and privacy.

Satisfaction With Community Residential Care
The vast majority (92%) of residents reported that moving to the setting was a good decision. They reported very high levels of satisfaction; for example, 75% of residents reported that staff members always treat them with respect. ARC residents were significantly less likely to report satisfaction with the decision to move, the setting overall, the food, and respectful treatment from staff. AL residents were significantly more satisfied with respectful treatment from staff and with their apartment or room. Half of the residents reported that their settings were very homelike, with AFH settings reported to be significantly more homelike than ARC settings.

Resident Characteristics at Follow-Up
Resident characteristics analyzed at follow-up included location, ADL from the in-person interview, ADL from the Comprehensive Assessment database, SF-12 Physical Component, SF-12 Mental Component, the Short Blessed Test, the RMBPC Checklist, and survival. Potential confounders used in the regression analyses included resident characteristics at enrollment presented herein (age, ADL from the in-person interview, ADL from the Comprehensive Assessment database, and RMBPC frequency score) and three setting variables that were significantly different across setting type.

Location at Follow-Up
Of the 349 residents, 61% (214) stayed or died in their original settings during the 12-month follow-up period. Fifty-eight percent (118) of AFH residents, 53% (27) of ARC residents, and 73% (69) of AL residents stayed or died in their original settings. There was a nonsignificant difference across type of setting in the logistic regression analysis, when potential confounders for the binary outcomes of staying in or leaving the original setting were adjusted for.

Health Status at Follow-Up
The results of the linear regression analyses on health outcome measures at follow-up are shown in Table 5. Of the six assessed health outcome measures, only one outcome was significantly different across type of setting after potential confounders were adjusted for. ARC residents appeared to have significantly lower ADL scores than AFH residents as measured on the Comprehensive Assessment database, indicating better function at follow-up.

	Discussion

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The average resident is a 78-year-old unmarried White woman, similar to residents in other reports on this type of setting (Ball et al., 2000; Kane, Kane, Illston, Nyman, & Finch, 1991; Mitchell & Kemp, 2000; Mor, Sherwood, & Gutkin, 1986; Morgan, Gruber-Baldini, & Magaziner, 2001; Quinn, Johnson, Andress, McGinnis, & Ramesh, 1999; Spector, Reschovsky, & Cohen, 1996). Residents are dependent on assistance with an average of almost five of six basic ADLs, based on state case manager assessment data, or two out of six based on an in-person interview with the resident or proxy.

Persons in community residential care are similar to those receiving home care, and they are much less functionally impaired than those in nursing homes, in a comparison of study participants to national home care (Dey, 1996) and nursing home (Dey, 1997) populations. Sixty-five percent of persons in these community residential care settings report (according to in-person interview data) being dependent in bathing, compared with 54% of home care recipients and 96% of nursing home residents. Similarly, 28% of those in community residential care report dependence in toileting compared with 24% of those in home care and 58% of those in nursing homes. Finally, 12% of those in community residential care report dependence in eating compared with 9% in home care and 45% in nursing homes. We also found that most residents in this study came from private homes, though 7% did reside in a nursing home before enrollment.

The general health status of persons in community residential care is below that of the general population aged 75 or older, and 47% have evidence of cognitive impairment. AFH residents demonstrate significantly more disability, behavior problems, and cognitive impairment. These averages obscure the finding that a wide variety of persons enter these settings. These programs serve, for example, residents from the age of 25 to 102 who report being dependent in between none and all six of the ADLs. State policies and programs should reflect the variety of needs of residents seeking state-funded care in these settings.

Residents on the whole were very satisfied with their care in these settings. The vast majority (92%) of residents reported that moving to the setting was a good decision, and they reported very high levels of satisfaction with each aspect of care.

Residents in the three types of settings, in analyses that controlled for differences at enrollment, were remarkably similar at the 12-month follow-up period. There was only one significant difference across the six health status outcomes or time to survival across the three types of settings. There is thus no strong pattern of evidence from the outcomes in this study for health status advantages or disadvantages from placement in a particular type of setting. Choices among type of setting could be based on the match of needs to individual preferences for the setting characteristics such as location, size, amenities such as private rooms, or homelike character.

AFH settings are noteworthy in serving a population with remarkably higher care needs at lower published payment rates than AL facilities. The only significant difference in our analyses of health outcomes at follow-up was a higher score on one of the two ADL measures, that from the Comprehensive Assessment database completed by the state case manager, for the AFH compared with the ARC setting, indicating lower function. In contrast, AFH residents reported marginally better SF-12 scores at follow-up than ARC residents (p<.08). There are many possible interpretations of these findings. It is clear, however, that attention should continue to be paid to the effect of payment rates on staff quality and turnover, as well as supports such as training and consultation that may be needed for these settings to provide good-quality care to this vulnerable population. The provision of such supports is especially challenging given the small size and geographic dispersal of these settings with many owners or managers for whom English is not their first language.

ARC settings serve somewhat younger, less educated men, with less cognitive impairment and less need for basic ADL assistance, some of whom have histories of homelessness and substance abuse. ARC residents were significantly less likely to report satisfaction with the decision to move, the setting overall, the food, and respectful treatment from staff. This, combined with the lower levels of published state payment rates, deserves further attention.

The role of AL settings is especially interesting. AL settings served the oldest residents in the study, with significantly lower need for ADL assistance and fewer behavior problems than AFH residents. They were also the most likely to be in the original residence at follow-up, possibly indicating higher levels of satisfaction or lower levels of need to move to a higher level of services. AL settings nationwide serve primarily a private pay population. Published statewide payment rates in this study were also higher for AL, and the physical plant requirements of private rooms and kitchenettes distinguish these settings, with possible benefits of higher levels of privacy and autonomy. AL residents were significantly more satisfied with respectful treatment from staff and with their apartment or room, possibly indicating the influence of the stated AL philosophy of autonomy and privacy, and the required physical layout of separate apartments with lockable doors, kitchenettes, and the like. Zimmerman and colleagues (2001b) support the importance of states continuing to try and find "effective low cost models" (p. 322) of AL services that can be funded through Medicaid to avoid a two-tiered, income-based system of long-term care.

Study limitations include the difficulties in comparing resident outcomes across type of setting when residents and settings differ on many factors that potentially influence the residents' likelihood of entering a particular type of setting. Given the ethical and practical obstacles to conducting a study in which individuals in need of care are randomly assigned to type of setting, these limitations are probably inevitable. We attempted to control for selection bias caused by observed confounders, but there is undoubtedly uncontrolled bias remaining caused by unmeasured confounders. There are also limitations on generalizability from a study of a limited number of residents and settings who agreed to participation conducted in a three-county area of one state. Small sample sizes for some outcomes for some types of settings and the need to impute data for some outcomes are additional limitations.

Future papers will present information on care received, settings, and providers in this study. Promising directions for future work include a meta analysis of findings across the recent high-quality studies of similar settings (Hawes et al., 1999; Kane et al., 2001; Zimmerman, Sloane, & Eckert, 2001a), building on the use of standardized measures across many of these studies, to add to our ability to understand the extent to which findings can be generalized across multiple states and types of settings. Studies of training, access to consultants, and other interventions designed to help give providers access to tools for managing the wide range of health needs and behaviors encountered would be useful. There is also a need for development and evaluation of support services to help potential residents and their families find a setting that best meets their needs and personal preferences.

We hope this study can assist in moving toward the long-term goal of designing the optimal system of residential care services that provides persons with chronic illnesses or disabilities a choice of high-quality programs that best meet their unique needs while making the best use of finite resources.

View larger version (21K): [in this window] [in a new window]   Figure 1. Resident recruitment

	Footnotes

¹ Health Services Research and Development Center of Excellence (152), VA Puget Sound Health Care System, Seattle, WA.

² Department of Health Services, University of Washington, Seattle.

³ School of Pharmacy, University of Washington, Seattle.

⁴ Epidemiology and Evaluation Section, Maternal and Child Health Branch, California Department of Health Services, Sacramento, CA.

Decision Editor: Laurence G. Branch, PhD

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