UCSF School of Nursing - UCSF - University of California, San ...

It is important to recognize
that the population
in licensed housing is
nearly as large as that
in nursing homes.
Virtually all states permit residents to
receive short-term or intermittent skilled
nursing care from a home health agency.
Some states permit those in RCFs to receive
extended periods of skilled nursing
care, and to remain in these facilities even
if they become non-ambulatory. Other
states, such as Oregon, allow residents
with extended skilled nursing needs to
remain on a negotiated shared-risk basis
involving the resident, the facility and the
state. For many, assisted living is seen as a
substitute for nursing homes.
The Size of the RCF
Population Nationally
At least 800,000 Americans live in licensed
supportive housing. An equal
number are thought to live in unlicensed
boarding and other group homes (Hawes,
Wildfire, & Lux, 1993). Based on some
estimates, the population in licensed
housing is growing rapidly (Bedney,
Carrillo, Studer, et al., 1996). However, it
is unclear whether the so called “growth”
in this sector is coming from new construction
versus moves of existing unlicensed
housing into licensed status, or the
result of changes in state (or provider)
housing definitions, or new construction
replacing older facilities. Published estimates
of licensed RCF bed supply from
the late 1980s, for example, place the supply
of licensed housing at about one million
beds (Newcomer & Grant, 1989).
Based on these estimates the actual supply
of licensed housing may not have
changed at all over the decade. Nevertheless,
it is important to recognize that the
population in licensed housing is nearly
as large as that in nursing homes. Further,
the perception of growth, whether it is actually
occurring or not, has moved the political
discussion of “Assisted Living” into
the continuum of long-term care. Until the
mid-1990s residential care was a quiet
giant in long-term care.
Policy Transition
The residential care and nursing home
industries are in transition, attempting to
adapt to unprecedented changes in
health and long-term care. Industry
changes include shorter hospital stays,
an increased emphasis on home-based
care, and expanded definitions of the
“home.” Adaptation to these changes
has implications across and among the
various levels of care, including residential
care itself, home care, nursing
homes, primary health care, and hospitals.
Among the responses to these
changing times is that states have begun
to permit higher levels of physical and
cognitive frailty among those living in
licensed and unlicensed residential settings
(Mollica, 2000).
These policy changes and state innovations
have been largely unstudied
with respect to their effectiveness,
resident outcomes, or the effects on
access to care, staff turnover, and operational
performance. In short, the
“emerging” roles of residential care
are essentially an untested and fastevolving
social experiment. The federal
government, with the exception of
a few General Accounting Office Studies
(US GAO, 1997, 1999), and two
projects funded by the Assistant Secretary
for Planning and Evaluation
(Hawes, Mor, Wildfire, et al., 1995;
Hawes, Rose, Phillips, 1999), has had
virtually no involvement with this industry.
Even major national surveys,
such as the National Health Interview
Survey, and the American Housing
Survey, expressly exclude the population
living in group housing – including
most of the residential care facilities
in the US.
Proponents for an expanded role and
scope of services for residential settings
argue the presumed operational cost savings
of a “non-medical” approach to care,
the necessity of “normalizing” the living
situation for the disabled older person
(including many who may qualify for admission
to nursing homes), and a reduction
or replacement of time as a nursing
home resident. Critics of expanded levels
of care in RCFs raise concerns with resident
safety and the adequacy of care in
such settings. They fear that RCF settings
may become less well staffed versions of
nursing homes, with the result that health
conditions may deteriorate even further.