Monday, March 28, 2011

Assisted Living Regulations

NCAL's 2011 Assisted Living State Regulatory Review

Published in March 2011, this report offers a state-by-state summary of assisted living regulations covering 21 categories; provides contact information for state agencies that oversee assisted living activities; and includes each agency’s Web site address. A summary of regulatory changes in 2010 and state-by-state highlights can be downloaded here.

Even though most states were preoccupied by budget issues in 2010, state policymakers continued developing and refining assisted living/residential care regulations.

  • At least 18 states reported making statutory, regulatory, or policy changes in 2010 and January 2011 impacting assisted living/residential care communities. At least six states made major changes including Idaho, Kentucky, Oregon, Pennsylvania, South Carolina, and Texas.
  • Focal points of state assisted living policy development include life safety, disclosure of information, Alzheimer’s/dementia standards, medication management, background checks, and regulatory enforcement. Other areas of change include move-in/move-out requirements, resident assessment, protection from exploitation, staff training, and tuberculosis testing standards.
  • Pursuant to legislation enacted in 2007, Pennsylvania implemented new assisted living regulations on January 18, 2011, thereby creating a second level of licensure alongside personal care homes. Oregon developed new rules for the endorsement of Memory Care Communities. Endorsement rules focus on person-centered care, consumer protection, staff training specific to caring for people with dementia, and enhanced physical plant and environmental requirements. Rhode Island passed legislation that, once implemented, will expand the types of assisted living residents that may receive skilled nursing care or therapy and the length of time they may receive such services.
  • Washington state clarified that boarding homes must fully disclose to residents a facility’s policy on accepting Medicaid as a payment source. New Jersey passed legislation requiring an assisted living residence or comprehensive personal care home that surrenders its license and promised not to discharge Medicaid residents to escrow funds to pay for care in an alternate facility.

To obtain a printed copy of the 2011 edition, call (202) 898-2855, or send an e-mail to myates@ncal.org. Be sure to include your name, address, and phone number. Past editions of the report can be found below.

(See List Here)

Why Don’t Employers Hire and Retain Workers with Disabilities?

Abstract
Introduction Despite persistently low employment rates among working-age adults with disabilities, prior research on employer practices and attitudes toward workers with disabilities paints a generally rosy picture of successfully accommodated workers in a welcoming environment. Findings from previous studies might have been biased because of either employer self-selection or social desirability, yielding non-representative or artificially positive conclusions. Methods In this study, a novel approach was used to survey human resource professionals and supervisors working for employers known or reputed to be resistant to complying with the ADA’s employment provisions. Attendees of employer-requested ADA training sessions were asked to assess various possible reasons that employers in general might not hire, retain, or accommodate workers with disabilities and to rate strategies and policy changes that might make it more likely for employers to do so. Results As cited by respondents, the principal barriers to employing workers with disabilities are lack of awareness of disability and accommodation issues, concern over costs, and fear of legal liability. With regard to strategies employers might use to increase hiring and retention, respondents identified increased training and centralized disability and accommodation expertise and mechanisms. Public policy approaches preferred by respondents include no-cost external problem-solving, subsidized accommodations, tax breaks, and mediation in lieu of formal complaints or lawsuits. Conclusions Findings suggest straightforward approaches that employers might use to facilitate hiring and retention of workers with disabilities, as well as new public programs or policy changes that could increase labor force participation among working-age adults who have disabilities.

Keywords People with disabilities – Employment – Americans with Disabilities Act – Employer attitudes – Discrimination


Introduction

Decisions made by employers are critical to improving employment rates among working-age adults with disabilities. During the more than two decades since the Americans with Disabilities Act (ADA) was first proposed in the late 1980s, many researchers have surveyed employers about their attitudes toward hiring and retaining workers with disabilities and their experiences with accommodating such workers. The picture that has emerged is generally rather rosy, reflecting “a veneer of employer acceptance of workers with disabilities” [1]. Answers to general questions about workers with disabilities reflect particularly favorable attitudes. For example, two early studies of Fortune 500 corporations indicated favorable attitudes toward hiring people with intellectual and other significant disabilities, benefitting both the worker and the employer [2, 3], and positive views of the job performance of workers with disabilities generally [4]. More recently, human resource and other high-level managers responding to one survey indicated generally favorable attitudes toward workers with disabilities [5]; respondents to that and a second survey expressed a moderate level of commitment to hiring workers with disabilities [5, 6].

A similar picture emerges when employers are asked about their experiences with accommodating workers with disabilities. In a 1998–1999 survey of private businesses and Federal agencies, a majority of human resource professionals from both types of organizations reported that they had accommodated workers with disabilities in each of the following ways: made their facilities more accessible, created flexible human resources policies, restructured jobs, modified the work environment, provided written job instructions, provided transportation accommodations, and modified equipment [79]. Additional accommodations available from a majority of employers, according to a 2010 survey, include flexible work schedules, telecommuting, and ergonomic redesign of workstations [10].

Employers report that accommodations provided to workers with disabilities typically cost little or nothing [1115], but are generally effective [13] and “worth the investment” [6] in terms of retaining experienced workers and increasing productivity [12, 16], as well as improving organizational culture and climate [16]. In several general employer surveys, only a small minority cited concerns over the cost of accommodations as a reason for not hiring workers with disabilities [6, 7, 10, 11]. Another potential financial concern is fear of litigation under the ADA or other non-discrimination laws, but employers rarely cite this as a barrier to hiring workers with disabilities. In one study, 4% of employers cited fear of litigation as a principal barrier [11], and, in another, this concern appeared fairly low on the list of most-often cited barrier to hiring workers with disabilities [17].

Notwithstanding a few other studies revealing somewhat negative attitudes, especially those asking employers about more stigmatized types of disability [1820], most employer surveys appear to paint a picture of successfully accommodated workers in a more or less welcoming environment. If we were to accept such findings at face value, we would be left wondering why the employment situation for working-age adults with disabilities remains dismal a full two decades after the enactment of the ADA [21, 22]. Workers and job seekers with disabilities, for their part, often cite employer attitudes and workplace discrimination as barriers to acquiring or keeping a job (see, e.g., [2327]).

One explanation is that true employer attitudes and experiences are not being obtained from employer surveys, either because employers are not being completely honest or because only employers with positive attitudes and experiences are responding to the surveys. The former could be the result of social desirability bias [28], in which respondents essentially report what they think the interviewer wants to hear rather than expressing their true attitudes, which are socially unacceptable and may run counter to legal requirements [1, 2931]. The latter explanation, that employers with negative attitudes are not part of the survey samples, might come about because such employers either decline to participate or, in surveys whose sample is selected from businesses expressing interest in hiring or accommodating people with disabilities (e.g., [12, 15]), are not part of the sampling frame. Studies focusing on employers with a history of successful accommodation are unlikely to detect negative attitudes toward or unfavorable experiences with workers with disabilities.

The present study attempts to address both limitations. To reduce social desirability bias, we asked human resource professionals and managers why they thought other employers might not hire or retain people with disabilities. And to compensate for selection or non-response biases in other studies, we purposely sought employers known or reputed to be reluctant to complying with disability non-discrimination laws. Our results directly contradict many prior findings, and offer participants’ perspectives on strategies that could help improve hiring and retention of workers with disabilities.


Methods

We began with the hypothesis that our study would yield distinctly different results from prior studies if we were able to collect data from a set of “ADA-recalcitrant” employers—businesses and government entities known or reputed to be reluctant to hire and accommodate workers with disabilities. We identified such employers from among those who were referred to or otherwise known by the DBTAC–Pacific ADA Center, one of ten regional Disability and Business Technical Assistance Centers (DBTAC) offering information and guidance on complying with the ADA and other disability laws to businesses, government entities, workers, and other consumers; the DBTAC maintains partnerships with local organizations throughout Federal Region IX, and these affiliates also identified candidate employers. Employers were considered ADA-recalcitrant if they had directly expressed resistance to complying with the ADA to DBTAC or affiliate staff; had established such a reputation among DBTAC staff, its local affiliates, or the disability community; or had been referred to the DBTAC because of an actual or threatened legal action or complaint against them or as part of a settlement of a lawsuit or complaint.

Early attempts to question a few such employers directly about their attitudes and experiences were not successful, with participants becoming defensive and answering disingenuously, according to the interviewers’ perceptions. Rethinking our strategy, we decided instead to use indirect or structured projective questioning, a technique suggested in the literature and found to be effective in reducing social desirability bias [3234]. Instead of asking about the participants’ own attitudes and experiences, we ask them to speculate as to the attitudes and behaviors of employers in general, not necessarily their own business or government entity. In a pilot test, this indirect method proved much more effective in engaging the participants to consider the reasons that employers might be reluctant to hire or retain workers with disabilities.

We developed a pair of paper-and-pencil questionnaires, the first on barriers to hiring and retaining workers with disabilities and the second on practical and policy strategies to improve hiring and retention. The first questionnaire contained two sets of statements asserting reasons that employers might be reluctant to hire (for the first set) or retain (for the second set) workers with disabilities, with each set beginning with the instruction, “Thinking about employers in general, and not necessarily the organization you work for, please give us your opinion about the following statements.” The statements were prefaced by the question, “Why don’t some employers hire people with disabilities?” or “…retain workers with disabilities?”

The statements that followed were of the form, “Some employers don’t hire people with disabilities because…” followed by a reason and response choices of “Strongly agree,” “Agree,” “Disagree,” and “Strongly disagree,” along with “Don’t know.” The section on reasons for not hiring people with disabilities contained 14 statements, beginning with the most innocuous (“…they rarely see people with disabilities applying for jobs”) and ending with the least innocuous (“…they discriminate against job applicants with disabilities”). Similarly, the section on reasons for not retaining workers with disabilities presented 12 statements, e.g., “…they believe that workers with disabilities can no longer do the basic functions of their jobs.”

These statements were developed by the project team based on our review of the literature, our own prior research, and the experienced garnered through frequent interactions with employers on ADA and other disability non-discrimination issues; they were then refined and augmented after a pilot test. Following each list of statements, space was provided for respondents to add additional reasons and offer comments.

The second questionnaire, which asked respondents to rate the helpfulness of suggested practical or policy strategies in improving hiring and retention of people with disabilities, followed a similar format. Following another instruction to think “of employers in general, and not necessarily the organization you work for,” statements were of the form, “Employers would be more likely to hire and retain workers with disabilities if they had…” or “if there were….” Eight statements focused on practical approaches, such as “a written company policy of non-discrimination that includes disability,” and another eight on policy strategies, such as “tax breaks for hiring and retaining workers with disabilities.” Response categories were “Very helpful,” “Helpful,” “Not very helpful,” and “Not helpful at all,” plus “Don’t know.” Again, space was provided for additional strategies and comments.

Questionnaires were distributed to human resources professionals and managers working at ADA-recalcitrant organizations who attended ADA or other disability-related trainings provided by DBTAC—Pacific ADA Center and its affiliates. An introduction to the first questionnaire, required for human subjects approval, emphasized the voluntary nature of the survey and its confidentiality. Some 463 respondents, each attending one of 38 trainings, completed and returned questionnaires. Few attendees refused to participate entirely, although many declined to provide a response to one or more statements. To maximize anonymity, no information about the individual or the employer was collected on the questionnaires or provided to the researchers.

Item non-response (includes missing, ambiguous, or otherwise invalid) averaged about 3% for the first questionnaire and 2% for the second; “don’t know” averaged about 8% for the first questionnaire and 5% for the second. Both missing and “don’t know” responses have been excluded from the analysis; i.e., the percentages reported are of known responses.


Results
Reasons for Not Hiring or Retaining Workers with Disabilities

Affordable Care Act Supports States in Strengthening Community Living

Nationally, $4.3 Billion in New Funds Announced to Help Establish and Expand Community-based Alternatives to Institutional Long Term Care

States will see significant new federal support in their efforts to help move Medicaid beneficiaries out of institutions and into their own homes or other community settings now and in the near future, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today.

The Affordable Care Act provides additional funding for two programs supporting that goal, the Money Follows the Person (MFP) demonstration program and the Community First Choice Option program. Today, Secretary Sebelius announced thirteen States would together receive more than $45 million in MFP grants to start that program in their States, with a total of $621 million committed through 2016. In addition, HHS has proposed rules to allow all States to access a potential of $3.7 billion in increased federal funding to provide long-term services and supports through the Community First Choice Option program.

“Our country recognized in the Americans with Disabilities Act that everyone who can live at home or community-based setting should be allowed to do so,” Secretary Sebelius said. “The Affordable Care Act provides States critical new dollars toward achieving that goal.”

Thirteen States Receive Money Follows the Person Program Grants

The Money Follows the Person (MFP) demonstration program, which was set to expire in fiscal year 2011, is extended through the Affordable Care Act for an additional five years. The 13 States receiving awards today (see list and award amounts below) join the 29 States and the District of Columbia already operating MFP programs. Together, these States will receive more than $45 million in the first year of the program, and more than $621 million through 2016.

The MFP program provides individuals living in a nursing home or other institution new opportunities to live in the community with the services and supports they need. Groups benefiting from these home-and-community based programs include the elderly, persons with intellectual, developmental and/or physical disabilities, mental illness or those diagnosed with several of these conditions. To date, these programs have helped 12,000 individuals move out of institutions and back into their communities. Today’s grants are expected to help an additional 13,000 people.

“The Money Follows the Person program is hugely important to improving the lives of Medicaid beneficiaries,” said Donald Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services (CMS), which will implement the demonstration program. “This helps bring everyone, even those who in the past may have had no choice but to live in an institution, into the community where they can become full participants in the activities most of us take for granted.”

New Community First Choice Option Available to States

Many of the same goals under the MFP demonstration are shared and supported by the Community First Choice (CFC) Option, created by the Affordable Care Act. Today, nursing homes and institutions are too often the first or only choice for people with Medicaid who need long term care. The goal of this new option is to give States additional resources to make community living a first choice, and leave nursing homes and institutions as a fall back option.

Starting in October, this option will allow States to receive a six percent increase in federal matching funds for providing community-based attendant services and supports to people with Medicaid. Over the next three years—through 2014—States could see a total of $3.7 billion in new funds to provide these services. States currently receive Federal Medicaid matching funds for these activities at the State’s normal matching rate.

Services and supports that can be provided under CFC include, but are not limited to, attendant services and supports that help individuals with activities of daily living such as bathing and eating, and health-related tasks through hands-on assistance or supervision. States may also cover costs related to moving individuals from an institution to the community, such as security and utility deposits, first month’s rent, and purchasing basic household supplies.

To qualify for the increased Federal funds, States must develop “person-centered plans” that allow the individual to determine how services are provided to achieve or maintain independence. States must also establish implementation councils with a majority membership consisting of persons with disabilities, elderly individuals and their representatives to advise in the design and implementation of Community First Choice option. The proposed rule, posted today, describes the details of this program and solicits public comment. The rule can be found at:http://www.ofr.gov/OFRUpload/OFRData/2011-03946_PI.pdf.

“There is more evidence than ever that people who need long-term care prefer to live in their own homes and communities whenever possible,” said Dr. Berwick. “To restrict these individuals to institutions where even the simplest decisions of the day such as when to get up, what to eat and when to sleep are made by someone else must no longer be the norm. This new Federal funding will make a difference in people’s lives.”

MONEY FOLLOWS THE PERSON DEMONSTRATION GRANTS

See below for the list of States receiving MFP grants today.

Money Follows the Person Grant Awardees
StateGrantee1st YR. AwardFunds committed through 2016

Colorado

Colorado Department of Health Care Policy & Financing

$2,000,000

$22,189,486

Florida

Florida Agency for Health Care Administration, Medicaid

$4,203,999

$35,748,853

Idaho

Idaho Department of Health and Welfare, Division of Medicaid

$695,206

$6,456,560

Maine

Maine Department of Health and Human Services

$699,970

$7,151,735

Massachusetts

Massachusetts Executive Office of Health & Human Services, Office of Medicaid

$13,486,888

$110,000,000

Minnesota

Department of Human Services

$13,421,736

$187,412,620

Mississippi

Mississippi Division of Medicaid, Office of Health Services

$1,341,394

$37,076,814

Nevada

Nevada Department of Health & Human Services, Division of Health Care Financing & Policy

$800,000

$7,276,402

New Mexico

New Mexico Human Services Department, Medical Assistance Division, Long Term Services & Supports Bureau

$595,839

$23,724,360

Rhode Island

Rhode Island Department of Human Services, Division of Health Care Quality, Financing & Purchasing / Medicaid Division

$2,503,021

$24,570,450

Tennessee

Tennessee Bureau of TennCare

$2,357,733

$119,624,597

Vermont

Department of Disabilities, Aging and Independent Living

$2,123,975

$17,963,059

West Virginia

West Virginia Department of Health & Human Resources, Bureau for Medical Services

$1,267,373

$22,220,423

TOTAL

$45,497,134

$621,415,359


Analysis: Job quality endangers long-term care industry

BRONX, NY – The poor quality of direct-care workers’ jobs endangers the country’s caregiving infrastructure, according to PHI, a national nonprofit organization advocating for the direct-care workforce in home and residential settings.

PHI’s analysis of the March Supplement of the Current Population Survey, a nationally representative sample issued by the U.S. Census Bureau and the Bureau of Labor Statistics, determined that the nation’s fastest-growing workforce faces challenges that undermine the long-term care industry’s ability to care for the elderly and disabled.

According to the analysis:

  • Direct-care workers are so underpaid that many live in poverty.
  • Hourly wages for home health aides and personal care assistants are under $8.
  • 45 percent of direct-care workers live in households earning below 200 percent of the federal poverty income level and 46 percent depend on public assistance such a food stamps, Medicaid and child care, housing or energy assistance.
  • In 2009, an estimated 900,000 direct-care workers didn’t have healthcare coverage and only 47 percent of direct-care workers had employer-sponsored healthcare coverage.

“The problematic quality of direct-care jobs continues to undermine America’s capacity to produce a caregiving workforce that can deliver the basic hands-on services and supports demanded by millions of elders and persons with disabilities needing assistance with basic daily activities and tasks,” said Dorie Seavey, PhD, PHI’s director of policy research, in a statement.

Direct-care workers provide 70 percent to 80 percent of paid, hands-on, long-term care and personal assistance for elders and people living with disabilities, said PHI. There were more than 3.2 million direct-care workers – nursing assistants, home health aides and personal assistance aides – in 2008. More than 4.3 million are projected by 2018.

[See related story: Healthcare share of employment reaches all-time high]

“The historic proportions of this workforce are truly astounding,” Seavey said. “With demand for over a million new positions expected in the next few years, policymakers and providers have an unprecedented opportunity to improve the quality of these jobs. The fabric of our country’s caregiving infrastructure depends on it.”

Celebrating Health Reform

March 23 marks the first anniversary of the passage of the health reform law.

The Patient Protection and Affordable Care Act (PPACA) and its companion legislation, the Health Care and Education Act of 2010, have already begun to make health coverage more accessible and change how health care is delivered in the United States.

Dozens of organizations throughout the nation, including the National Council on Aging, National Partnership for Women and Families, and Small Business Majority, are sponsoring events to celebrate the anniversary. The events will highlight the many protections afforded under health reform to people with low incomes, women, children, the elderly, people with pre-existing health conditions, and small businesses.

The “Moving Forward” events will be organized around the following themes:

  • March 21: Protecting Small Business’s Care
  • March 22: Protecting Seniors’ Care
  • March 23: Protecting Patients’ Rights
  • March 24: Protecting Women’s Care
  • March 25: Protecting Young Adults’ Care

Details of the events will be released before each day. Contact Carol Regan, PHI director of government affairs and the Health Care for Health Care Workers campaign, for event information.

Health Reform and Direct-Care Workers

While the health reform law contains many general provisions that benefit direct-care workers, some of the items specifically address community-based long-term care services and support the direct-care workforce, including:

Health Reform Law Resources

Visit the PHI Health Reform Resource Center and Health Care for Health Care Workers websites for more information about the law, including the Health Reform Fact Sheet series and a complete PHIsummary of direct-care workforce and long-term care provisions (pdf).

– by Deane Beebe

House GOP questions CLASS Act startup funds

By Jason Millman - 03/17/11 02:32 PM ET

House Republicans on Thursday questioned why the White House is requesting millions of dollars to implement a long-term health insurance program that the administration admits is unsustainable.

The Department of Health and Human Services (HHS) is seeking $120 million in the 2012 budget to ramp up implementation of the Community Living Assistance Services and Support (CLASS) Act, a voluntary program included in the healthcare reform law enacted nearly a year ago.

But Republicans on the House Energy and Commerce Committee's Health subpanel want to know why HHS is moving forward on a program that HHS Secretary Kathleen Sebelius acknowledges is deeply flawed. They are particularly agitated that more than three-quarters of the funding would go toward an education and outreach campaign for a program the department is in the midst of transforming.

“If we have a program that everyone acknowledges is broken, why do we want to waste money educating people on something that might not work in its present form?” asked Rep. Bob Latta (R-Ohio) during a hearing on the program.

Concerns about the sustainability of the CLASS Act surfaced during the healthcare reform debate, but the program has been under heightened scrutiny since President Obama’s fiscal commission recommended repealing or reforming it.

Sebelius said last month the department, which has generous flexibility under the law to make tweaks to the program, will consider premium bumps over time and tightening eligibility standards to ensure the program’s sustainability.

"It would be irresponsible to ignore the concerns about the CLASS program's long-term sustainability in its current form, and we haven't done that," Sebeliustold senior advocates last month.

On Thursday, Administration on Aging Secretary Kathy Greenlee testified the program wouldn’t get off the ground until HHS can ensure it is fiscally sound.

“The program will not start unless we can absolutely certain it can be solvent and self-sustaining in the future,” Greenlee said.

The CLASS Act is an employer-based program meant to take the place of private long-term care insurance, which few people currently have. Employers must choose to enroll in the program, and employees can opt out if they wish.

Conservatives raised concerns that the program faces severe funding challenges if healthier individuals decide to opt out, leaving only sick individuals who are the most expensive to cover.

“We are absolutely committed to the solvency of the program, and the key to solvency is broad participation,” Greenlee said.

The program is expected to start collecting premiums by late 2012 or 2013. Employees generally must pay in five years of premiums before they can collect payments if they become disabled.

Greenlee said department actuaries are in the process of reviewing models that will support the program, and it will publish a regulation in the fall with the department’s assessment of three plan offerings. Greenlee said she was unsure whether the rule would include specific pricing.

After the hearing, Greenlee told The Hill that the pricing structure would place an emphasis on age.

“There’s no underwriting of the program, so age clearly is something that we will use and need to use as we look to market to younger individuals,” she said.

Rep. Michael Burgess (R-Texas), who chairs the GOP Congressional Health Care Caucus, said he was concerned the public will mistakenly believe the program is a new automatic entitlement.

“I fear this CLASS Act gives people the false impression the government will pick up the expense,” Burgess said.

Democrats, who said they are committed to making the program solvent, accused Republicans of holding the hearing as part of their strategy to peel back parts of the healthcare reform law.

“I’m getting very frustrated because almost every hearing is an effort … to defund or debunk something that’s in the Affordable Care Act,” said Rep. Frank Pallone (D-N.J.).