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A Way to Help Meet Federal Oversight Goals for Assisted Living

Partnering with private accreditors could shape national standards while improving the quality of care.

An assisted-living facility in Moorestown, N.J.
(TNS/Philadelphia Inquirer/Elizabeth Robertson)
Assisted-living services have blossomed over the past two decades as part of a larger movement toward individualized, person-centered care. Before the early 1980s, older adults and people with disabilities who needed long-term assistance had limited options, and the services available at that time were often institutional and fragmented.

Today, these services are far more numerous, integrated and personal, offering practical support to people who need help with basic daily needs but prefer to receive it in a home-like setting. But federal and state regulatory entities still seek a cohesive way to administer oversight and uphold the health and welfare of older adults receiving the growing number of service options.

The challenge in overcoming this fragmentation is building a system that standardizes accountability and quality expectations nationwide while allowing the dynamic, individualized nature of assisted-living services to continue flourishing.

A recent Government Accountability Office report found such a challenge in the administration of what are known as 1915(c) Medicaid waivers, which allow states to provide home- or community-based care to people who might otherwise not be eligible under the federal health-care program. According to the report, 26 of the 48 states that receive Medicaid dollars for assisted-living services were unable, due to a lack of adequate tracking systems, to report the number of critical incidents that occurred in assisted-living organizations offering Medicaid-funded services.

Clearly, the Centers for Medicare & Medicaid Services (CMS) requirements for tracking and reporting of deficiencies and critical incidents could benefit from clarification across the states. A single definition of assisted living, while taking state licensing variations into account, also would be useful. The current inconsistencies lead to provider confusion, incomplete and non-uniform reporting, and a lack of usable data to improve safety and quality of care.

A potential solution to these consistency challenges is to weave private-sector accreditation into CMS's requirements for 1915(c) waivers. Not only do accreditation standards already encompass requirements for identification, tracking and reporting of critical incidents, but they also focus on performance-improvement practices to mitigate the recurrence of critical incidents and ultimately improve the quality of care received by Medicaid beneficiaries.

There is plenty of precedent for this approach. U.S. federal and state authorities, as well as Canadian provincial authorities, frequently adopt private accreditation as part of licensure requirements and conditions of funding in many areas of health and human services.

For example, when the Substance Abuse and Mental Health Services Administration sought to improve quality of care in opioid treatment programs, it commissioned a study to examine the impact of accreditation as an oversight framework. That study, published in 2006, found that the shift to accreditation was beneficial for the field, particularly in ensuring more uniform standards across states.

Similarly, in 2013 the Association of Rehabilitation Nurses conducted a study, partly funded by the federal Agency for Healthcare Research and Quality, to examine the benefits of accreditation in nursing homes offering short-term rehabilitation. The study found that accredited nursing homes demonstrate better short-term-stay quality measures. It concluded that approaches beyond traditional regulation and governmental inspections, such as accreditation, are necessary to improve the quality of care.

CMS and state agencies should seriously consider implementing such an approach for assisted-living services receiving Medicaid dollars. Requiring organizations to submit their accreditation reports to the state, or to submit data they are required to collect as a condition of accreditation standards, would address many of the gaps brought up in the Governmental Accountability Office report.

Using national and international accreditation also would create a centralized definition of assisted living and other types of programs through which such services might be offered, such as home- and community-based health care services. And it would support the field in its primary goal of providing quality, accountable, person-centered care.

Each year, 330,000 people receive Medicaid benefits for assisted-living services. As the population of the United States continues to age, these living arrangements will remain a valuable service for those who require assistance with activities of daily living. As the nation's primary payer for long-term-care services, Medicaid is in a terrific position to leverage accreditation standards and support quality in the growing assisted-living field.

Managing director of public policy for CARF International
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