Board and Care Homes Vary in Services Offered, Need Stricter Regulation
From 1991 to 1994, researchers from Brown University Center for Gerontology and Health Care Research examined factors affecting the quality of health care in board and care homes.
Well publicized problems at these facilities—which provide room, board and other services but not medical care for chronically ill, disabled adults—have inspired tighter state regulations, which risk driving homes out of business or altering their residential character.
Specifically, the research team determined whether regulations promote interconnection between the homes and community health agencies, and whether those connections lead to better quality care for home residents.
- Residents received more health and social services in larger homes and those licensed by the state, but regulatory stringency did not seem to affect the services they received.
- There was widespread use of multiple prescriptions and over-the-counter medicines in the homes, and a lack of training among board and care staff administering medications, although the situation is somewhat better in states with strict regulations.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $93,349.
Between 500,000 and 1 million adults with disabilities reside in group settings that range from large complexes to four-person board and care homes. These settings provide room, board, some protective oversight, and, occasionally, personal care, but do not provide medical care or assure access to health or health related services.
Board and care homes tend to operate in institutional isolation; residents are often socially isolated and lack access to basic medical, rehabilitative, or social services, despite their need for community-based services. Some evidence suggests that the residents of board and care homes receive fewer supportive services from home and community-based programs than individuals who remain in their own homes.
Over the years, scandals surrounding fatal fires and exposes of mistreatment and abuse have periodically drawn attention to board and care homes. New regulations introduced over the past two decades in response to public outcry have focused on smaller providers. Many observers worry that increasingly stringent physical plant and program regulations may destroy the home-like atmosphere of smaller homes, and that some homes may stop accepting residents rather than meeting new requirements.
At the time of this grant, two major studies of board and care homes were underway. With funding from the American Association of Retired Persons (AARP), the Research Triangle Institute (RTI) had recently completed a survey of state and county officials concerning current board and care policies.
And in 1990, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the Department of Health and Human Services (HHS) commissioned a 10-state study to analyze the impact of state regulations on quality of care in board and care homes and to describe the characteristics of homes, their owner-operators, and residents. (Vince Mor, the grantee, was a subcontractor on the ASPE study, receiving $100,019 during the period of the RWJF project to develop and analyze a survey of board and care homes. He also received a grant of $25,000 from the Geriatric Drug Therapy Research Institute to process and analyze medication data on 6,400 home residents.)
The project's main objectives were to (1) build upon these prior data collection efforts to examine the extent to which the regulatory environment promotes interconnection between board and care homes and community health and social services and (2) to enhance a data collection effort funded by ASPE to assess the degree of community connectedness in 511 board and care homes serving the elderly in 10 states across the country.
The project conducted a supplement to the AARP study through a subcontract to RTI. It survey local agencies involved in the regulation of board and care homes in 50 states. Interviews were conducted with local case management agency staff in one county per state, usually the second most populous one.
The project also examined existing data collected from local agencies responsible for board and care homes and respondents to the ASPE survey were re-interviewed on the issue of the connections of board and care homes with community-based agencies. The responses were analyzed to determine the availability of community-based services to board and care home residents.
In addition, the researchers did a survey of inspectors of board and care homes in the same 10 states at the ASPE study. The study was the first to look at the interrelationship of inspection officers and case management staff with community-based service providers.
- Licensed homes and large homes provide the most services, regardless of whether they are provided directly by the home or arranged through an outside agency.
- Regulatory stringency did not appear to influence the number of services provided. This suggests that increased regulatory efforts may not lead to better care for elderly board and care home residents. Instead, efforts to facilitate connections of board and care homes, particularly small, unlicensed homes, with outside agencies may be a more fruitful approach to enhancing the quality of care.
- 82 percent of community service agency representatives surveyed said they had no agreement with board and care homes to serve their clients, although some stated they did have a mandate to monitor residents. Most operators of board and care homes, however, report that homes do have arrangements with outside agencies to provide services. This inconsistency suggests that many homes do secure outside services for residents who need them. However, structural linkages of community service agencies and board and care homes are rare.
- 51 percent of service agencies felt that a formal agreement to provide services for all residents of a board and care home would not help improve the quality of care in board and care homes, while only 21 percent thought it would. Almost all (97 percent) felt such an agreement could not substitute for inspections by a regulatory agency.
- Licensed homes tend to be smaller facilities with more direct care staff per resident than unlicensed homes. They provide slightly more health-related (2.22 services, vs. 1.78) and social services (3.87 vs. 3.50) to residents, and are more likely to have arrangements with outside agencies for resident services.
- Homes in states with strong regulations were more likely to serve an exclusively elderly clientele.
- Size of home does not appear to influence the number of health-related services provided directly by the home.
- Board and care staff who assist with drug administration typically have no medical training in drug management. Yet, most older residents of homes routinely take multiple prescriptions and over-the-counter drugs, and many take prescribed drugs considered inappropriate for the elderly. Psychoactive drug use rates are high. Drug management is somewhat better in licensed homes located in states with more stringent regulation of homes, but still far below what should be expected of licensed board and care homes.
- The project recommends regulatory intervention to ensure proper care for older residents of board and care homes. Pharmacists should be part of the care process, and states should review all board and care regulations regarding medication and mandate staff training programs in drug characteristics and management. However, states face a challenge in assuring drug safety while preserving homes' "noninstitutional" residential setting.
In the survey of local agencies, it was often difficult to determine, despite repeated questioning by RTI interviewers, whether respondents were providing information about the whole area covered by the agency or only about the county in question. Similarly, some respondents may have provided estimates for all elderly in the county rather than only for elderly board and care residents. Agencies typically could not provide information about the actual level of service provision for residents, but could provide information about the availability of services in their county.
A paper on suboptimal drug prescriptions has been published in the Journal of the American Geriatrics Society and one on the regulatory environment and psychotropic medicines in the Journal of Gerontology. A paper on drug management and use in board and care homes is under review at The Gerontologist. (See the Bibliography.)
There is no formal report on home quality, interconnection with service agencies, and state regulation. However, the researchers have cited some of the data gathered during this project in papers written for other projects. The ASPE survey data will be available as a public-use tape at the ICPSR.
AFTER THE GRANT
RTI is now conducting an ASPE-funded study of assisted living. The grantee continues to analyze the data sets in order to address the fundamental questions of this project. The grantee is also the principal investigator of a Foundation-funded study (ID# 030983) examining the linkages between nursing homes and managed care insurers.
GRANT DETAILS & CONTACT INFORMATION
Health Problems of Chronically Ill Adults in Board and Care Homes
Brown University Center for Gerontology and Health Care Research (Providence, RI)
Dates: June 1991 to March 1994
Vincent Mor, Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Spore, Diana, Ph.D., Mor, Vincent, Ph.D., La Liberty, Linda, J.D., Hawes, Catherine, Ph.D., Green, Rebecca, B.S., Larrat, Paul, Ph.D., Wildfire, Judith, Ph.D., and Hirrus, Jeffrey, M.A. "Drug Management and Use in Licensed Board and Care Homes: Issues and Implications for Insured Quality of Care for Older Residents." Currently under review at The Gerontologist.
Hawes, Catherine, Wildfire, Judith B. and Lux, Linda J. The Regulation of Board and Care Homes: Results of a 50 State Survey. A National Summary. A report to American Association of Retired Persons. Research Triangle Park, NC. Research Triangle Institute. December 31, 1991. (Final revisions in progress.)
Wildfire, Judith B., Hawes, Catherine and Lux, Linda J. The Regulation of Board and Care Homes: Results of a 50-State Survey. State Summaries. A report to American Association of Retired Persons. Research Triangle Park, NC. Research Triangle Institute. December 31, 1991. (Final revisions in progress.)
Hawes, Catherine, Wildfire, Judith B. and Lux, Linda J. the Regulation of Board and Care Homes: Results of a Survey in the 50 States and the District of Columbia. A National Summary. Washington: American Association of Retired Persons, 1993.
Wildfire, Judith B., Hawes, Catherine and Lux, Linda J. The Regulation of Board and Care Homes: Results of a Survey in the 50 States and the District of Columbia. State Summaries. Washington: American Association of Retired Persons, 1993.
Hawes, Catherine and Mor, Vincent. "Analysis of the Effect of Regulation on the Quality of Care in Board and Care Homes. " Submitted to the Gerontological Society of America for presentation (within a symposium entitled "Board and Care: Research Initiatives and Preliminary Results") at the 1992 annual meeting in Washington, November 1822, 1992.
Report prepared by: James Wood
Reviewed by: Robert Narus
Reviewed by: Marian Bass
Program Officer: Andrea S. Gerstenberger