CLEVELAND, Ohio — To work as an aide in an assisted-living center in Ohio requires empathy, compassion and very little training.
About 20 hours, to be exact.
In Kansas, it’s much different. Aides there must take a 90-hour class and pass a test. North Carolina requires aides to take 80 hours of instruction. But there are other states, such as Montana, that say training is needed, but don’t specify how much.
The number of assisted-living centers in the United States has jumped more than 150 percent in the past 20 years, fueled by an increase of residents with cognitive issues, a willingness of facilities to take more frail patients, and families who wish to avoid nursing homes.
But while the centers’ clientele has changed dramatically, there have been few efforts to systemically re-evaluate staffing or training guidelines necessary to properly serve residents. This has led some advocates of the elderly to renew the call for federal oversight of the facilities, much like nursing homes.
For instance, nearly half of the nation’s states lack extensive training programs for the facilities’ employees, with most requiring some form of a job orientation and less than a dozen hours of instruction.
When it comes to staffing, the differences are even more stark. Thirty-eight states leave the amount of personnel needed to care for residents up to individual facility owners.
In Ohio, facility owners must make sure “sufficient numbers of staff” are present to meet residents’ needs. That’s different than in South Carolina, where one aide or staff member must be present for every eight residents during the day.
"This is an enormous problem,” said Kristine Sundberg, the president of Elder Voice Family Advocates in Minneapolis. “[Federal oversight] would be better, of course. It would provide for greater consistency.”
But the nation’s leading voice for assisted-living centers disagrees, fearing federal oversight would push “paperwork over patients.”
“We believe that states are better equipped to help assisted-living centers adapt and customize the care needed,” said Rachel Reeves, a spokeswoman for the National Center for Assisted Living in Washington, D.C. "The states offer greater flexibility. They can see what is best for residents and deal with those issues.”
Industry officials also see a potential cost to federal oversight: The expense of hiring more staff could be passed on to residents.
Medicaid’s role in assisted living
Nursing homes rely on Medicaid, in most cases, to pay for the services for residents. In large part, that’s why the federal government oversees the facilities.
Assisted-living centers, meanwhile, are mostly private pay. But Medicaid provides waivers for a small, but growing fraction of residents in 42 states. In Ohio, the waivers pay a facility about $1,500 to $2,100 a month per resident for care and services, such as monitoring, medication assistance and transportation. Residents must pay for room and board.
Medicaid spent $47.8 million for Ohio residents using the waiver in fiscal year 2016, according to the most recent figures available from the Ohio Department of Medicaid. Currently, about 5,500 residents receive the waiver.
In May, Jean Thompson, the executive director of the Ohio Assisted Living Association, went to the state capital, seeking a boost to the Medicaid reimbursement facilities receive, saying it is needed to pay for staffing levels and services.
She testified before the House Finance Committee, saying that some assisted-living centers may leave the waiver program if the reimbursement isn’t raised. At the time, the House proposed a 2.7% increase in reimbursements for the state budget. The Senate has increased that to 5.1%. Gov. Mike DeWine must sign the budget by the end of the month.
But because Medicaid’s role is increasing in assisted living, advocates for the elderly say the U.S. Centers for Medicaid and Medicare Services, which oversees nursing homes, should also monitor assisted-living facilities.
Toby Edelman, the senior policy attorney for the Center for Medicare Advocacy in Washington, D.C., said the increased role of Medicaid, as well as the uneven way states oversee assisted living, indicates that federal oversight is needed.
“It’s time – it’s past time – for federal oversight in assisted living,” Edelman said. “The federal government shouldn’t just give money away with no strings attached.”
But Sheryl Zimmerman, the director of aging studies at the University of North Carolina’s School of Social Work, and others said they aren’t sure federal scrutiny is the answer.
“We have to be realistic,” Zimmerman said. “By and large, the people who run the facilities know the [staffing and training] that is needed there.”
Differences in staffing, training
Paula Carder, a professor at the Institute on Aging at Portland State University, said states have different admission policies that can affect staffing and training requirements.
Take Alabama and Colorado. Assisted-living facilities there, like in many states, do not admit residents if they have health conditions that require extensive care, such as paralysis or feeding tubes.
Because of the admission policies, the states can avoid stricter staffing and training requirements.
Other states, however, continue to push strict standards.
Missouri and Mississippi are among the strictest with staffing ratios for assisted living, with each requiring one aide or staff member per 15 residents during the day.
“We believe the more staffing, the better the quality of care," said Tracy Bowen, the long-term care ombudsman for Mississippi. The ombudsman office in each state offers help to families navigating long-term care. Often, the office fields complaints and deals with legislators on issues involving the elderly.
Some critics said that the ratios don’t necessarily guarantee better care. They stressed that nursing homes have had ratios for years, but the ratios have not prevented abuse or neglect.
A former official at two Northeast Ohio assisted-living centers said staffing, however, is a key issue in a resident’s stay, as older, more frail residents with mental-health needs live at the facilities.
“There is a great stigma to put[ting] Mom and Dad in a nursing home," the former official said. “Families will do anything to keep their parents and loved ones away from that."
Genevieve Gipson, the executive director of the National Network of Nursing Assistants, agreed.
“We have people in assisted living who can’t take care of themselves,” said Gipson, of Akron. “They can’t move."
As far as training, states such as Kansas, North Carolina, Washington and Massachusetts lead the nation, offering demanding course work. Aides also must receive annual training.
Employees who work with residents who have cognitive impairments receive additional, specialized training.
“We certainly think that training matters," said Barbara Hickert, the long-term care ombudsman in Kansas. “A well-trained work force is probably the most important part of quality care."
In Ohio, aides must have first-aid certification, complete a general training and orientation program and take two hours of initial instruction. Eight hours of continuing training are required each year.
All told, that’s about 20 hours total in the employee’s first year.
Beverley Laubert, the long-term care ombudsman for Ohio, said the state has stressed providing the training that meets the specific needs of an individual facility and of its residents.
For instance, she said one facility might specialize in cognitive issues, while another might have more residents who are quite independent. A one-size, fits-all training program would not meet the specific needs of facilities, she said.
Others aren’t so sure. They said more training can never hurt.
“Care is based on the abundance of qualified care," said Brian Lee, the executive director of Families for Better Care, a national advocacy group. “There is a changing world of long-term care. The first option for a family will be assisted living. It is more home-like. But many assisted-living centers are quasi-nursing homes."
And that leads some to consider the advantages of federal oversight.
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Amid growth of assisted living, some renew calls for federal oversight