Old Rules Don’t Match Up with New Healthcare Reform Initiatives for Assisted Living

America’s health system is increasingly moving toward a managed care model that emphasizes cost-effective, quality care and plenty of choice for older adults’ living options, including community-based settings.

But some states’ assisted living regulations can be restrictive, worrying providers in those areas about their ability to participate in various healthcare reform initiatives, such as care partnerships through Accountable Care Organizations (ACOs) or reducing unnecessary hospitalizations.

In Rhode Island, for example, assisted living providers–even those with on-staff registered nurses and licensed practical nurses–aren’t allowed to perform basic first-aid acts like putting Band-Aids on residents. The state of New York, on the other hand, recognizes assisted living as an “integral part of the continuum of long-term care.”


Unlike the nursing home industry, assisted living is not federally regulated, so rules can vary from state to state. While some states have progressive rules in line with healthcare reform, others still need some tweaking so they can be more in line with the new direction healthcare is heading, say those in the industry.

Alabama has its own challenges for assisted living providers, although not quite to Rhode Island’s level. Basic first aid care is allowed, and non-licensed staff can apply Band-Aids to residents, if necessary. But anything beyond that is off-limits, says Frank Holden, the president of the Alabama Assisted Living Association (the state’s ALFA affiliate).

“Anything that could be defined as skilled care is pretty restricted [in an assisted living setting], even if a nurse is present,” he says, adding that while communities aren’t required to have nurses, ones that do still can’t provide certain services.


“This is really where the Alabama rules are going to be sorely tested,” says Holden regarding the ability of his state’s assisted living providers to participate in Affordable Care Act initiatives.

Assisted living residents recovering from an injury or operation in Alabama can contract to hire licensed home health aides and hospice workers for skilled care. But that is regulated, too: these services can only be administered in an assisted living setting for a couple of weeks, regardless of whether the resident has fully recovered.

The state’s assisted living industry has been negotiating with the state Department of Public Health to change the rules of what’s considered “skilled care” and what can be safely provided in assisted living in recent years, says Holden, who says the process will be painful—but ultimately successful.

“The pressure from the physician community [seeking to avoid penalties for rehospitalizations] is going to make it impossible to maintain this outdated notion,” he says. “Change will happen; it’s just a question of when.”

Some state rules do potentially limit providers from participating in healthcare reform, agrees Ginger Lynch Landy, principal at N.Y.-based lobbying firm Hodes & Landy–ALFA’s N.Y. Chapter lobbyist. “We used to be one of those states,” she says.

There is hope for states with outdated regulations, though. In recent years, New York has evolved from regulations that were “behind the times,” according to Landy, to “embracing aging in place and giving seniors more options,” including a licensed “enhanced” assisted living category.

It wasn’t easy to change the state’s assisted living views and regulations, she says, but residents can now stay through hospice as long as they, their physician, and the community agree the community can meet the senior’s needs.

In establishing that statute, Landy’s firm worked with organizations whose interests exceeded assisted living to recognize the need for more senior living choices, including the New York AARP chapter.

“Governmental policy is definitely moving in that direction from the federal level on down. Aging in place is the model, and there’s definitely room for others to come on board,” she says.

Reducing hospital readmissions is an area where assisted living can contribute “significantly” in keeping older adults out of the hospital, according to Landy, because part of what senior living providers do is closely manage care and work to prevent hospitalization in the first place.

Looking into the future and the healthcare changes it holds, assisted living residents are getting older and have much higher clinical acuity levels compared to 5-10 years ago, says Rita Vann, Brookdale Senior Living’s director of clinical services.

“They continue to age in place,” she says. “In certain states, it’s going to become increasingly difficult to provide those services with some of the state’s regulations the way they are.”

Seniors who call an assisted living community their home deserve the right to stay there as long as they safely can, says Lara Williams, executive director of ALFA’s South Carolina chapter.

She and other organizations are lobbying the state to allow for aging in place—a notion that’s currently restricted in favor of transitioning people to nursing homes—and has submitted legislation to that end.

The healthcare reform law has driven a “collision of philosophy,” says Holden, adding that he has “no doubt” the Department of Public Health in his state—and others—will follow.

While the possibility of new rules is still pending in South Carolina, the industry as a whole has been moving toward a managed care, aging-in-place model even prior to the Affordable Care Act, many agree.

“I’m not a proponent of federal intervention,” says Vann. “We have to monitor this and be actively involved in our professional organizations that represent assisted living to help educate our lawmakers and those putting these regulations out there, that the needs of our seniors are changing and some of the regulations might be quite antiquated.”

Written by Alyssa Gerace

This article is sponsored by the Assisted Living Federation of America (ALFA) as part of its efforts to advance excellence and explore topics impacting the future of senior living. For more information about ALFA, visit www.alfa.org.

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