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Correspondence: Address correspondence to Susan Hedrick, PhD, Health Services Research and Development, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101. E-mail: susan.hedrick{at}med.va.gov
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Abstract |
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Key Words: Assisted living facilities • Group homes • Long-term care • Department of Veterans Affairs
The increased availability of these services has created new opportunities, but also new demands and new risks for clients, providers, and administrators. Hawes (2001) cited the public's and policy makers' "largely uncritical enthusiasm" for assisted living (p. 4). Concerns remain about quality of care, especially given rising acuity levels (Hawes, 2001; R. Kane & Wilson, 2001), lack of accurate information to guide consumer choice (U.S. General Accounting Office, 1999), the financial effects of expanding these services in the face of increasingly strained budgets, and lack of information about program performance and outcomes. There are questions about how to achieve the best match between need for care and the type of facility, provider qualifications and training, certification and inspection standards, quality assurance, and payment systems; and, more generally, how to balance access, cost, and quality of care (O'Keefe et al., 2003). There is a critical need for systematic information about these programs.
Assisted living has only recently been a topic for serious research. Researchers have completed significantly fewer studies of assisted living programs than of other long-term-care programs, and the results of several large recent longitudinal studies have just started to become available (Frytak, Kane, Finch, Kane, & Maude-Griffin, 2001; Hawes, Phillips, Rose, Holan, & Sherman, 2003; Hedrick et al., 2003; Zimmerman et al., 2001).
The U.S. Department of Veterans Affairs (VA) is another possible funding source to extend these services to moderate- and low-income individuals. VA, long known as a leader in providing an extensive continuum of long-term-care services, was authorized to provide this level of care for the first time on a pilot basis in Public Law 106–117, the Veterans Millennium Health Care and Benefits Act (2001). This act allowed VA to establish a pilot demonstration program and an evaluation to determine the "feasibility and practicability of enabling veterans to secure needed assisted living services as an alternative to nursing home care." (Section 103). The language about feasibility and practicability indicates that this program was seen as difficult and perhaps even risky to establish within a large federal health care system. It represented potential benefits for residents and their families, and potential cost savings, but also a new and costly entitlement with potential quality-of-care and safety issues. The Act designed the pilot as a demonstration program whereby VA Medical Centers (VAMCs) would contract with existing community facilities to provide care rather than establish their own programs. The potentially high cost of providing these services was addressed by developing a new model whereby assisted living would be provided as a transitional benefit designed to facilitate residents' moving on to other sources of funding (such as private pay or Medicaid) at the end of the VA payment period. A competitive process resulted in the demonstration being awarded to a group of VAMCs in the Northwest VA region, which proposed the Assisted Living Pilot Program (ALPP).
None of the VA stakeholders had a history with such programs. This lack of experience, combined with concerns about the limited payment period and need to transition to other funds, were potential major barriers to participation in the program. There were also no models for such programs within an organized health care system, which meant that VA needed to develop its own procedures for inspections, admission criteria, staffing, required services, contracting procedures, payment systems, coordination with medical care providers and pharmacy, and so on. The pool of potential community facilities included some providers with preconceived attitudes toward VA and its patient population that could have reduced their interest in the program. Negotiating a federal contract was expected to be challenging for all, especially for the adult family home providers, many of whom did not speak English as a first language. In this article, we focus on program feasibility by describing the number of participating residents and providers, how they differed across the three types of facilities enrolled, and how they compared to those in similar programs and other types of long-term care. These issues should be of interest outside VA as states struggle with the feasibility of their own decisions on what type of facilities and residents to enroll in Medicaid-waiver/state-funded community residential care programs and private insurance companies explore these options as well.
Program Description
ALPP was implemented between January 2002 and December 2004 in the following seven VAMCs in four states in the Northwest region: Anchorage, AK; Boise, ID; Portland, OR; Roseburg, OR; Spokane, WA; Puget Sound Health Care System (Seattle and American Lake, WA); and White City, OR.
Definition of Services in ALPP
Legislation described the scope of ALPP as providing up to 6 months of assisted living, defined as "services in a facility that provides room and board and personal care for and supervision of residents as necessary for the health, safety, and welfare of residents." (Veterans Millennium Health Care and Benefits Act, 2001, Section 103.). Although the legislation used the term assisted living, ALPP decided to contract with the types of facilities in each state that were licensed by the state and eligible under the Medicaid Home- and Community-Based Waiver programs as community residential care programs. The reason for this decision was to address the wide variation in terminology and services across states, to help make ALPP consistent with the usual practices in each state, to provide the widest opportunity to match residents' needs with available services, and to promote transition of residents to Medicaid funding at the end of the VA payment period. Washington State and Oregon, especially, have long histories of providing Medicaid-funded community-residential care that the ALPP managers wanted to capitalize on.
The three types of facilities were termed adult family homes, residential care facilities, and assisted living, although all four states differed somewhat in their terminology and licensing requirements for these types of facilities. Table 1 presents information on these facilities as described by the four states in ALPP. The most basic differentiations were by number of residents and type of accommodation. An adult family home refers to a room within a family dwelling and is limited to no more than 5 or 6 residents. A residential care facility is a larger facility, often with shared rooms. Assisted living facilities are unique in that they provide private apartments with a private bath and may include a kitchen or kitchenette. The types of facilities in these states cannot be easily distinguished by differences in the types of services available; all three types of facilities were licensed to provide assistance with activities of daily living (ADLs) and other services. ALPP's decision to include these three types of facilities was an important one, and this evaluation focuses explicitly on differences among these three types of facilities to better understand their characteristics, the care provided, and the types of residents admitted.
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In keeping with their understanding of what kinds of people could benefit from a community-based residential program, ALPP managers targeted a heterogeneous group for enrollment in ALPP. These included frail, functionally dependent elders as well as younger individuals with mental health diagnoses and/or cognitive limitations who needed supported living due to difficulties with decision making or performing instrumental ADLs (IADLs). Potential residents needed to meet at least one of the four admission criteria in Table 2. Other factors affecting enrollment included the person's ability and willingness either to enroll in Medicaid or to assume the cost of care after the end of the VA payment period (usually 2 months).
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A number of factors were considered in the recruitment of ALPP facilities, including provider interest, licensing/inspection data, community reputation, perceptions about quality of care, willingness to accept Medicaid, geographic location (proximity to VAMCs and residences of most prospective residents), and cost. The decision about which facility type the person was placed in was based on that person's needs as determined by the GEC as well as a discussion between the ALPP case manager and the facility as to whether the facility was capable of providing appropriate care (as verified by state licensing criteria and VA inspection information). Most often, prospective residents visited more than one type of facility prior to placement. Other factors affecting placement included income and/or Medicaid eligibility and the facility's own assessment of the appropriateness of the placement. The ALPP contract specified that the vendors provide a room, meals, health monitoring, medication oversight, personal care, laundry, social and recreational services, and assurance of transportation with attendant care as needed.
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Data Collection and Measures
The GEC was the source of most of the demographic and health status items analyzed in this study. The ADL items ask about requiring help or supervision in the past 7 days to perform the following activities: bathing, dressing, eating, using the toilet, moving around in bed, and transferring. The IADL items ask about expressed difficulty with preparing meals, doing housework, shopping, using transportation, using the phone, managing medications, and managing finances. The behaviors and symptoms items ask if the person has exhibited a list of behaviors in the past 7 days, including wandering, verbal abuse, physical abuse, and resisting care. The GEC was also the source for an extensive list of items on health conditions and care needs.
ALPP case managers also completed an abbreviated version of the Resident Assessment Instrument for Assisted Living, an instrument that is compatible in core functional items with the Minimum Data Set (Hawes, Phillips, & Kimbell, 2004; Phillips, Hawes, Greene, & Wood, 1995). This form was the source of the items on self-rated health, psychotropic medication use, and diagnoses and was completed within 14 days of placement. Self-rated health was the resident's perception of his or her health status: excellent, very good, good, fair, or poor. Use of psychotropic medications referred to the use of a drug for a mental, emotional, or mental condition during the past 7 days. Diagnoses were defined as those that were documented in the electronic medical record and related to current status, treatment, and/or medications. Case managers received in-person training on these instruments and ongoing technical assistance.
We collected data on the ALPP providers through telephone surveys conducted with the administrator or owner of each facility that had at least one ALPP resident placed. We supplemented this information with data routinely collected as part of the VA contracting and inspection process. We developed the provider survey questionnaire based on items used in previous studies (Curtis, Kiyak, & Hedrick, 2000; Hawes et al., 2003; Hedrick et al., 2003; R. A. Kane, Kane, Illston, Nyman, & Finch, 1991) and on the Multiphasic Environmental Assessment Protocol, a measure developed for use across multiple residential care environments (Moos & Lemke, 1994). We also developed additional survey items based on feedback obtained from focus groups conducted with potential ALPP providers.
We obtained information on staffing as a listing of the key positions and full time employee equivalent of providers hired directly; we did not include those staff who were contracted to provide certain services (e.g., dietary and nursing). We assessed the restrictiveness of the facilities' admission policies through a series of 36 items that assessed whether the facility was willing to admit a person with a health or behavior characteristic and whether someone who developed the characteristic after admission would be retained. Items included medical problems (e.g., wound care), functional disabilities (e.g., need for two-person transfer), and behavioral problems (e.g., physical or verbal aggression). We grouped these problems into the following categories: (a) functional disability (7 items), (b) need for skilled medical care (16 items), (c) psychological/behavioral (9 items), and (d) incontinence (4 items). We summed the number of problems within each category that a provider was willing to admit and computed a mean percent (e.g., 4 accepted/16 possible = 25%). We then computed a mean for each category by facility type.
Data Analysis
To assess resident differences across facility type (adult family home, assisted living facility, and residential care facility), we examined each resident characteristic variable using separate regression models. In each model, the variable was the dependent variable and the type of setting was the independent variable (adult family home was the reference setting). To control for correlations within an individual facility where the person was placed, we used Huber/White robust standard error estimators. To adjust for potential geographic differences, we kept the specific VAMCs as covariates in each model. We performed linear regressions, logistic regressions, and multinomial logistic regressions on continuous, dichotomized, and categorical baseline variables, respectively.
We used Bonferroni correction to adjust for multiple comparisons. We present the results both with and without this correction.
For provider comparisons, we performed analyses of variance to compare differences in means by facility type. We did post hoc comparisons using Scheffé's test for pairwise comparisons in order to identify the significant differences between facility types. It was not possible to do the same type of nested comparisons that we had done for the resident data because the sample size for the provider data (N = 70) was too small. Also, the facility characteristics we compared were more likely to vary by facility type than by VAMC.
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Resident Characteristics
Demographics
The average ALPP resident was a 70-year-old unmarried White man who was referred from an inpatient hospital and was living in a private residence prior to ALPP placement (Table 3). The youngest resident placed was 28, and the oldest was 96; 7% were older than 85 (not shown).
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There were few statistically significant differences in resident demographic characteristics by type of facility, and even these differences were not significant after we applied the Bonferroni correction for multiple comparisons. Looking at the uncorrected differences, residents in both assisted living and residential care facilities appeared to be less likely to be married when compared to those in adult family homes. Residents of assisted living facilities were least likely of any participants to be living in another type of congregate setting (domiciliary, homeless shelter, other group residential care setting) at enrollment. There were no major differences in the type of informal caregiver support received by residents across type of facility (not shown).
Functional Status
Table 3 also presents information on one measure of the residents' functional status: their use of assistance with ADLs at the time of referral. Assistance with selected ADLs was one of the admission criteria for ALPP placement, as noted in the table notes. The largest percentage of residents required assistance with bathing (60.6%), and the smallest percentage with moving around in bed (8.2%). This pattern of disability is common in the chronically ill population.
Residents showed a wide range of disability, requiring assistance with between zero and all six ADLs (bathing, dressing, toileting, transferring, eating, and moving around in bed), with an average of 1.7 overall. Overall, 35% required no assistance with ADLs; 21% percent required assistance with 4 to 6 ADLs, a level of disability commonly associated with nursing home eligibility (not shown).
The major difference across type of facility was in assistance required with ADLs. Residents in assisted living and residential care facilities were significantly less likely than those in adult family homes to require assistance with many activities, and the average number of activities for which they required assistance was significantly less (1.6 vs 2.5; p <.05). Looking at the individual ADLs, 79.7% of respondents in adult family homes required assistance with bathing compared to 55.1% and 58.6% of those in assisted living and residential care facilities, respectively. This difference in bathing between residents of assisted living facilities and adult family homes was the only significant difference after we applied the Bonferroni correction (p <.05).
Almost all residents reported having difficulty with major IADLs such as preparing meals (96%), doing housework (94%), and managing medications (84%), with almost no differences across type of facility (not shown).
Diagnoses
Table 4 shows the common medical diagnoses as reported in the Resident Assessment Instrument. The pattern appeared to be that commonly found in the older veteran population, including large percentages of individuals with hypertension (40.6%), diabetes (26.4%), and arthritis (20.9%). These residents also had a significant burden of mental health disorders: 30.6% with depression or other mood disorder, 15.5% with schizophrenia or other psychotic disorder, and 7.9% with substance abuse. There were no significant differences in diagnosis by type of facility.
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There was a pattern of differences across type of facility in physical health conditions and care needs, with residents in assisted living and residential care being less likely to have these conditions and care needs than those in adult family homes. Without the Bonferroni correction, there were differences in the percentages of residents who had limited life expectancy; were homebound; needed physical, speech, or occupational therapies; and used wheelchairs. There may have been some evidence of a pattern of differences in psychological or behavioral conditions in which residential care facilities had a larger percentage of individuals with those conditions, although only the variable on hallucinations was statistically significantly different and only without the Bonferroni correction.
Comparisons to Other Settings
A comparison of ALPP residents with those in other settings may be useful in putting these results in a larger context (Table 5). We first compared ALPP residents to those in VA nursing home care units in the same geographic areas based on 2002/2003 Resident Assessment Instrument data. ALPP residents had lower levels of education and were less likely to be married. They were considerably less dependent in ADLs. Whereas 36% of ALPP residents required help in dressing, 69% of nursing home residents did, and we found similar results for the other ADLs. ALPP residents were also much less dependent in these activities than were residents in non-VA nursing homes in national surveys, where the rates are as follows: dressing, 87%; eating, 45%; transferring, 24%; and toileting, 58% (Dey, 1997).
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We also compared ALPP residents to participants in recent studies of assisted living. Golant (2004) reviewed the findings of 6 national studies assessing the physical disabilities of assisted living residents (American Seniors Housing Association, 2001; Assisted Living Federation of America, 2001; Hawes, Rose, & Phillips, 1999; National Center for Assisted Living, 2001; National Investment Conference, 1998; U.S. General Accounting Office, 1999). Golant reported that this was the first systematic comparison of the results of national studies reporting resident health status data. He noted that only one study (Hawes et al., 2003) had published any data in the peer-reviewed literature; that the studies had had different funders, including professional organizations representing providers; and that the studies had used diverse methodological approaches and different criteria to define assisted living facilities. Some of these studies had not included adult family homes, as several of them had excluded small facilities (fewer than 7 or 10 beds) or had only sampled members of assisted living professional organizations (small homes have their own professional organizations). Although the studies used different data collection procedures, they all assessed resident characteristics by asking the providers for estimates rather than assessing individual residents, as had been done in the ALPP and Washington State (Hedrick et al., 2003) studies. The sample sizes of facilities had ranged from 39 to more than 1,200, and the response rates had varied from 10% to 81%. Golant's review is useful, however, as it represents the first attempt to pull together this diverse literature and provide a national comparison base.
In columns 5 through 8 of Table 5, we compare the physical health status of residents as reported in the Golant (2004) review for four studies (Assisted Living Federation of America, 2001; National Center for Assisted Living, 2001; National Investment Conference, 1998; U.S. General Accounting Office, 1999). We compare the percentage of residents who required assistance with ADLs, rounded for ease of comparison. The percentage of residents who required assistance with bathing ranged from 53 to 72, compared to 61% in the ALPP study. When we compared each of the other ADL items, we observed the same pattern, with the ALPP percentages between the extremes of the other studies.
In the next to last column of Table 5, we add data on demographics and ADLs from the Hawes study that Golant (2004) did not report (Hawes, Phillips, & Rose, 2000). These data were for assisted living facilities that Hawes and colleagues categorized as providing high levels of either service or of privacy. Comparisons with ALPP demonstrated again the larger number of men in ALPP and the similar educational levels and race. A comparison of the ADLs demonstrated that ALPP residents appeared to be considerably more dependent in all ADLs assessed. For example, 36% of ALPP residents required help with dressing, whereas 19% of the Hawes residents had.
Finally, the last column in Table 5 presents data from a comprehensive multistate study of assisted living led by Zimmerman and Sloane (Morgan, Gruber-Baldini, & Magaziner, 2001). The results in that column show the range of values for the three types of assisted living compared in that study. The ALPP residents were again similar demographically to the participants in Zimmerman and Sloane's study, with the exception of gender. ALPP residents were most similar to individuals in the most disabled group studied in Morgan and colleagues (i.e., those with fewer than 16 beds).
Provider Characteristics
ALPP recruited a total of 160 facilities: 58 adult family homes, 56 assisted living facilities, and 46 residential care facilities. Table 6 presents information on selected characteristics of providers from a telephone survey of those facilities with at least one ALPP resident placed (N = 70). The survey respondents represented a total of 118 facilities, 74% of facilities that had at least one ALPP placement. We interviewed administrators with multisite responsibilities only once because pilot interviews revealed that admission and retention policies were determined by corporate headquarters and there was little or no variability between sites within the chain. The vast majority of potential respondents not interviewed indicated that they lacked sufficient experience with ALPP upon which to base their opinion of the program (e.g., only one ALPP placement, contract just approved).
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As expected, the average number of direct care staff ranged from 3.1 in adult family homes to 22 in assisted living facilities (p <.0001). The ratio of direct care staff to residents, a more meaningful statistic, was 0.49 overall, with little variability between facility type (ns).
ALPP inspection data indicated that registered nurses were available at 60% of adult family homes, almost 100% of assisted living facilities, and 72% of residential care facilities (not shown). Assisted living facilities were most likely of all the facilities to have nurses, activity directors, social workers, and dieticians on staff. It is important to note that residents at the other smaller types of facilities may have had access to these staff through contractual arrangements or other programs.
The contract required that certain core services be provided, and there was not much variability between different types of facilities in the availability of this set of services. Most facilities provided laundry, meals, housekeeping, and personal care. Some sites provided transportation, whereas others arranged it.
About one third of adult family home owner/operators were immigrants whose first language was not English (p =.001). For non-native English speakers, the most common languages spoken were Romanian (55%), followed by Filipino (33%), Mandarin (6%), and Russian (6%; not shown).
Table 7 presents data on provider admission policies by facility type. In general, ALPP providers indicated a willingness to accept residents who needed a wide range of care. Our results indicated that providers varied in their willingness or ability to manage residents with certain kinds of problems. Adult family homes reported being significantly more willing to accept patients with functional disabilities (p =.003) than assisted living facilities and more willing than either assisted living facilities or residential care to accept residents who needed skilled nursing care (p =.0001). Residential care facilities were the most willing to accept residents with behavior/psychological problems. We observed no significant differences by facility type with respect to incontinence.
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The average ALPP resident was a 70-year-old unmarried White man referred from an inpatient hospital, who lived in a private home at referral and was dependent in 1.7 out of 6 ADLs. Residents were less likely to be married, had lower educational levels, and were considerably less dependent in the ADLs on average than those in VA nursing home care units in the same geographic region. They were generally comparable in demographics to residents in other studies of assisted living, except, as expected for this veteran population, they were more likely to be men. They were extremely similar in level of dependency in ADLs to Medicaid-funded residents in a study of the same type of settings in the same geographic area (Hedrick et al., 2003), which indicates that the VA program may be able to recruit similar types of residents and providers to ongoing state programs. ALPP residents were in the middle of the range of ADL dependency reported in the unpublished surveys sponsored by provider organizations and the U.S. General Accounting Office as reviewed by Golant (2004), indicating that ALPP is able to recruit and serve a population that is generally comparable to those in national facilities despite program differences. ALPP residents were, however, more dependent than residents in the high-service/high-privacy settings in the Hawes and colleagues national survey (Hawes et al., 2000). This may be because that study explicitly targeted assisted living facilities, eliminating those that were smaller than 10 beds or where more than three residents shared a room. ALPP residents, in comparison with the residents in the Zimmerman and colleagues study (Morgan et al., 2001), were similar to the most dependent group in that study, those in the smallest facilities with fewer than 16 beds.
These comparisons support our finding that the smallest facilities in our study, the adult family homes, enrolled residents who required greater levels of assistance with ADLs, as they were dependent in an average of 2.5 of 6 ADLs compared to 1.6 for both assisted living and adult residential care facility residents. Adult family home residents also had the highest levels of skilled care needs: had limited life expectancy; were homebound; needed physical, speech, or occupational therapies; and used wheelchairs. The recent study of Medicaid-funded assisted living in Washington State (Hedrick et al., 2003) found these same patterns of differences. These findings support the ALPP managers' decision to contract with the full range of types of facilities in each state, not just assisted living facilities. This policy allows enrollment of residents with high levels of disability and those who are at most at risk for nursing home placement, and allows for the best matching of residents' needs with available services.
The finding that the most impaired residents were in adult family homes, the smallest and most home-like facilities with the fewest staff with professional health training, is of great interest for the field. We can speculate that this is influenced by some combination of differences in size and layout of the facility, ability to observe residents for potential problems, availability of trained staff for personal care rather than administration and health promotion, level of financial sophistication of the owner/managers, number and economic implications of unfilled beds, and finally goals and cultural traditions of the adult family home providers.
Potential benefits to a resident in an adult family home may include living in a more home-like environment in a family atmosphere with potentially greater individual attention to personal care needs and care preferences such as food choices; the potentially lower costs are a benefit to the system and may allow for greater expansion of the programs. Others (Davis et al., 2000; Golant, 2003; Polivka, 2003) have addressed the potential benefits of these smaller adult family homes for this population and the difficult challenges in helping "Mom-and-Pop" facilities survive in an increasingly complex and regulated environment. It is clear, however, that experts should continue to pay attention 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 very vulnerable population. The provision of such supports is especially challenging given the small size and geographic dispersal of these settings, and the fact that for many owners/managers, English is not their first language. This whole area is an extremely important topic for future research.
ALPP's objective when recruiting facilities was to identify a large enough number of providers that were capable of caring for individuals with heterogeneous needs. ALPP recruited a large number of facilities with a good mix of the types of community residential programs licensed under state Medicaid-waiver programs. ALPP was able to recruit both for-profit and non-profit providers of varying sizes and physical environments in rural, urban, and suburban settings. Although most facilities served an older population, ALPP also recruited a number of facilities that provided specialized care, including care for individuals with functional and cognitive impairments, ventilator dependency, need for end-of-life and hospice care, as well as psychological and/or behavioral problems. About half of the beds in the ALPP facilities were funded by Medicaid, even within assisted living facilities. This is important, because it indicates that ALPP was successful in recruiting facilities that accepted Medicaid and therefore could facilitate the resident's transfer to alternative funding at the end of the VA funding. Most facilities reported participating in nurse delegation programs, which may enable providers to care for specific health needs, potentially supporting the individual's ability to age-in-place.
Placing and maintaining individuals with a wide range of disabilities and health conditions into a type of care totally unfamiliar to them and to potential referring staff is a challenging task and supports the importance of the role of the ALPP case managers. Case managers also needed to teach ALPP providers how to navigate the VA system and acted as liaisons between them and the resident's health care providers to ensure continuity and quality of care. This evaluation within a health care system presents a unique opportunity to assess the integration of health care with long-term care.
Providers' admissions policies indicated that they were willing to accept residents with a wide range of care needs. The kinds of care that providers were least willing to provide represented structural problems (e.g., need for a locked facility), staffing (e.g., need for two-person transfer), as well as potential areas for additional training and/or support (e.g., skilled nursing care, bowel incontinence, and/or behavioral/psychological problems). In some cases, they represented a source of potential (and growing) concern that states have attempted to address through licensing, namely the increasingly complex problems that older individuals hoping to avoid nursing home placement bring to assisted living. The patterns we observed with regard to providers' willingness to admit residents with certain problems are similar to those found by others (Golant, 2004). Golant used the results from three studies to rank order conditions according to provider willingness to admit residents with those conditions. He found that problems like mild confusion and self-managed incontinence were more acceptable to providers (98.2 and 93% weighted averages), and being bedfast or having certain skilled care needs (intravenous tube, tube feeding, and ventilator care) were least acceptable to providers (4.8–9.2% weighted averages). Our findings indicate that assistance with bathing and assistance with incontinence were most acceptable to ALPP providers (97–99%); behavioral problems, especially aggression, were least acceptable (9%). Certain conditions, especially those that required skilled nursing care (e.g., wound care, intravenous medication, ventilator care) or were related to staffing (e.g., wandering, assistance with eating), were problematic for providers in all of the studies.
This study and others (Golant, 2004; Hawes et al., 2003; Hedrick et al., 2003; Zimmerman et al., 2003) support the need for additional training in assisting providers to deal with cognitive and behavioral problems in particular. The intensive efforts needed by case managers to train providers who may not be experienced with conditions frequently encountered in the VA population are important in this regard.
ALPP was conducted in seven VAMCs in four states, which was very helpful in assessing the differences in challenges to program implementation and operation in VAMCs that varied widely in size, academic affiliation, size of catchment area, number and type of potential contracting providers, and state Medicaid policies. The Northwest region may, however, have been an especially advantageous setting for implementation of ALPP, as Oregon and Washington, especially, are national leaders in the development and Medicaid funding of community-based long-term-care alternatives. However, the more developed infrastructure in the Northwest region may mean that VA's ability to implement ALPP in other geographic locations may require additional effort.
This ongoing evaluation is following all ALPP participants for 12 months after enrollment, assessing their health status, satisfaction with care, and use and cost of ALPP services and other VA and non-VA care. Informal caregiver, ALPP, and VA staff satisfaction with ALPP are also being assessed. These results should be of interest both in and outside VA. First, the results here should be generalizeable more broadly, as the program involved existing community providers and ALPP residents were generally similar in demographics and functional status to participants in other studies. This study thus presents a further picture of what the new, growing, and evolving community residential care sector and its residents are like. Second, if Congress were to authorize VA to support the provision of assisted living for veterans, then this could represent a major expansion of access to individuals with lower incomes and increase demand for this care nationwide. Finally, ALPP is a prospective study that provides individual-level outcome data. This evaluation should thus be useful both in VA and nationwide in guiding the growth and development of these programs and designing an optimal system of residential care services.
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1 Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System, Seattle, WA.
2 Midwest Center for Health Services and Policy Research, Edward Hines, Jr., VA Hospital, Hines, IL.
Decision Editor: William D. Spector, PhD
Received for publication November 12, 2004. Accepted for publication October 7, 2005.
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