Pennsylvania getting up to speed on assisted living care

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Timothy W. Coughlin is amused that Pennsylvania is recognizing "assisted living" as a new category of long-term care, considering his company and others believe they've been offering it since late last century.

On the other hand, he welcomes new state regulations and a plan for government funding that officially place assisted living as a new category between the long-established personal care home and nursing home industries, starting in 2011.

"In my personal opinion, assisted living in Pennsylvania is only new to Pennsylvania government," said Mr. Coughlin, president of Erie-based LifeServices Assisted Living, which operates in that city plus Titusville, Altoona, Johnstown, Washington, Pa., and the Cleveland area.

"Quite frankly," he added, "Ohio is 20 years ahead of Pennsylvania in understanding assisted living."

In fact, in the Verizon Yellow Pages for Greater Pittsburgh, some 50 listings already exist under the category of "Assisted Living Communities." The term had no official meaning, however, until the final approval June 3 of Department of Public Welfare regulations covering assisted living. That came three years after passage of legislation setting up the category, which itself followed years of debate and indecision among lawmakers and successive gubernatorial administrations.

Now that it's an official designation, the door is open for the state's 1,400 personal care homes to apply for assisted-living status, which carries higher standards in terms of larger living space, private bathrooms, kitchen appliances, resident independence and other aspects.

No facility is required to change to meet the requirements of the new category -- and it's impractical for most older and smaller homes to do so -- but if they don't, the door is closed to them to market themselves as "assisted living." They also will be shut out of new government funding that is supposed to cover facilities' cost of caring for a limited number of low-income, assisted-living residents sometime in 2011.

"If indeed the state starts funding assisted-living services, it will of course encourage more providers to get into it," said Ron Barth, president of PANPHA, a state trade group of nonprofit long-term care operators.

"Right now, personal care and what has been assisted living is essentially a private-pay market."

As any family experiencing a need for the first time knows, residential long-term care can be both expensive and confusing.

Personal care homes operating now cover a wide range. Smaller ones with four to eight beds in a converted private home might accept just $1,000 to $2,000 monthly from their residents to live like extended family. Large, modern facilities with a restaurant-style dining room and full menu of services and activities often charge $4,000 a month and up.

Either way, they've traditionally cared for people -- some 48,000 statewide, currently -- who need a modest amount of assistance in day-to-day living. People whose long-term health problems became serious were to be transferred to nursing homes -- which are even more expensive, though the state-federal Medical Assistance program covers costs of those who exhaust their assets.

The new regulations give flexibility to assisted-living facilities meeting some new staff training requirements to keep their residents as their status declines. People with complex needs, such as ventilators or feeding tubes, can only be retained with special approval from the state, but in general, facilities in the category and their residents have more options than before.

"There's recognition that aging in place is an important thing for this industry to embrace, and this is a vehicle for getting there," said Jennifer Burnett, deputy secretary for the state Office of Long-Term Living, which will oversee the new regulations and hire five inspectors initially to enforce them.

State officials believe, based on a survey, that about 150 of the existing personal care homes will apply for assisted-living status, though more than that meet most of the key criteria. Some will approach the new field cautiously, those in the industry said, considering it has higher licensing fees and other new requirements.

Facilities can obtain dual status to provide a personal care home in part of their building and assisted living elsewhere in it. That may be a prudent way for providers to test whether the change is worth it to them, said Anne Henry, chief operating officer of the Pennsylvania Health Care Association and Center for Assisted Living Management.

"Because this is all brand new and it will really take awhile for people to understand the difference," she said, "there's going to be a little confusion in the marketplace."

The biggest obstacle to many providers who might want to enter the new category is purely physical: assisted-living units must have at least 160 square feet of space within existing buildings and 225 square feet in any new construction, compared to an 80-square-foot minimum in personal care homes.

The living-space issue was the biggest point of contention in months of sometimes-heated discussion among state officials, consumer advocates and provider representatives. Advocates such as the AARP wanted plenty of footage to make the units feel like home, while operators were concerned about excessive costs.

Ultimately, most groups on both sides endorsed the regulations -- or at least did not oppose them -- although the Disability Rights Network of Pennsylvania was one objector, considering the needs of wheelchair-users among its constituency.

"I think that's going to be pretty cramped quarters," said Robert W. Meek, the group's managing attorney in Philadelphia. He said the network also objects to a provision that lets an operator dictate the outside agency that can provide therapies within the facility, instead of allowing full consumer choice.

Considering more than 2,000 comments were received on an initial regulatory proposal, with widely divergent views among them, the state's Ms. Burnett said, "We knew we would never come to consensus" on all issues with all groups.

The one universal point of agreement appears to be the value of helping to subsidize care in assisted living for low-to-moderate-income individuals, instead of restricting them to personal care homes that may be less appealing.

The details of that new funding remain to be worked out. The state plans to submit an application to the federal Centers for Medicare & Medicaid Services by fall to obtain a special Medical Assistance waiver for assisted-living funding, as 37 other states already have.

Once a waiver is in place, the state would set a certain number of slots per year through which it and the federal government would share in funding residents. Initially, those slots will number in the hundreds, rather than thousands.

"The last thing we want to do is open up the floodgates," considering the state's budget constraints, Ms. Burnett said.

Representatives in the industry said the biggest advantage to that may not be admitting new residents, but helping people already in the facilities remain if they have used up their money after months or years there.

Mr. Coughlin, who has been in the "assisted-living" field for 15 years and previously directed the Area Agency on Aging in Erie County, said when people run out of resources now, they often move into government-subsidized nursing home care even if they don't want to.

"We cannot carry residents in any kind of subsidy. We don't shift costs to other residents," he said.

His facilities charge residents an average of about $3,500 monthly. That means he doesn't accept individuals whose only form of payment is an existing state-federal personal care home supplement amounting to $1,028 monthly. Whether homes are willing to accept that level of payment is up to them, and about one-fifth of residents in the state fund their care that way.

"I wish I could [accept them] but I can't," Mr. Coughlin said. "That covers less than a third of the actual costs."

But for those with the ability to pay, he said, his idea of assisted living -- which he believes the state regulations also recognize -- focuses on the residents' dignity, privacy and independence.

"Personal care home and long-term care facilities historically in Pennsylvania have worked hard at taking care of older people. A true assisted-living provider doesn't so much take care of older people, as helps older people take care of themselves," he said.

It's a subtle difference, he acknowledged, but one more people may understand once implementation of the new regulations officially brings "assisted living" to Pennsylvania in January.


Gary Rotstein: grotstein@post-gazette.com or 412-263-1255.


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