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Assisted living and related community-residential
care programs such as adult family
homes are of growing importance. These
programs offer the promise of serving persons
needing long-term care in settings that
can meet their needs while maximizing autonomy
and privacy in a home-like setting.1
While assisted living primarily serves those
who can pay out-of-pocket, the majority of
states have moved to make some Medicaid
funds available to allow those with lower
incomes to access these programs.
VA is another possible funding source to
extend assisted living services to moderate
and low income individuals. Long known as
a leader in providing an extensive continuum
of long-term care services, VA was authorized
in Public Law 106-117 to provide these
services as part of a pilot demonstration
and evaluation to assess the "feasibility and
practicability of enabling veterans to secure
needed assisted living services as an alternative
to nursing home care."
The Northwest VISN, VISN 20, implemented
the Assisted Living Pilot Program
(ALPP) in seven Medical Centers in four
states: Anchorage, Alaska; Boise, Idaho;
Portland, Ore.; Roseburg, Ore.; Spokane,
Wash.; Puget Sound Health Care System
(Seattle and American Lake, Wash.); and
White City, Ore. Investigators from the
Northwest and Hines HSR&D Centers of
Excellence conducted the evaluation. ALPP
was designed to contract with existing community
facilities to serve the needs of the
VA patient population while reducing costs
to the system by transitioning residents to
private pay or Medicaid after an initial period
of VA payment.
The main findings from our evaluation of
the ALPP program follow.
ALPP was successfully implemented.
From January 29, 2002 through December 31,
2004, 789 veterans were placed in 142 ALPP
facilities, indicating that ALPP was able to
attract an impressive number of veterans and
is a feasible program based on this criterion.
Veterans were admitted as planned to all
types of community-based programs licensed
under state Medicaid-waiver programs: 56
percent to Assisted Living Facilities, 28 percent
to Residential Care Facilities, and 16
percent to Adult Family Homes.
The average ALPP veteran was a 70-
year-old, unmarried, white male who was
not service connected, was referred from an
inpatient hospital setting, and was living in a
private home at referral.2
ALPP veterans showed very little change
in health status over the 12 months after enrollment.
Health status typically deteriorates
over time in a population in need of residential
care; this finding suggests that ALPP
may have helped maintain veterans' health
Veterans, caregivers, ALPP providers,
and VA staff were very satisfied with ALPP
The mean ALPP cost per day was $84.89
and the mean length of stay paid for by VA
was 65.5 days. This finding, as well as the
next two, is based on the data for only those
participants who completed the informed
consent for use of their data in publications.
The total cost per veteran of all health
care paid for by VA during the 12-month
follow-up period was $29,812 which was
significantly higher by $11,533 than the cost
per comparison group veteran, controlling
for baseline differences. This difference was
the result of additional ALPP facility
($5,560) and case management ($2,830)
costs plus significantly higher primary care,
specialty care, emergency care, phone care,
and pharmacy costs for patients who participated
in ALPP. While the ALPP group had
significantly fewer nursing home days and
lower cost for nursing home care, the latter
was not statistically significant.
53 percent of veterans stayed in ALPP
facilities at the end of the VA payment period
and 50 percent of surviving veterans
were still in an ALPP facility at 12 months.
Our overall assessment was that ALPP
could fill an important niche in the continuum
of long-term care services at a time
when VA is facing a steep increase in the
number of chronically ill elderly who will
need increasing amounts of long-term care.
VA presented a report describing the results
of the pilot evaluation to Congress with an
accompanying letter from the Secretary of
This letter highlighted study findings and
stated that VA was "not seeking authority to
provide assisted living services believing that
this is primarily a housing function. VA is,
however, actively coordinating outpatient and
home-based medical services for veterans in
assisted living facilities in a variety of locations."
We hope this study can assist in moving toward
the long-term goal of designing the
optimal system of residential care services
that provides persons with chronic illnesses
or disabilities a choice of high quality programs
that best meet their unique needs
while making the best use of finite resources.
- Hedrick SC, et al. Resident Outcomes of Medicaidfunded
Community Residential Care. Gerontologist 2003;
- Hedrick SC, et al. Characteristics of Residents and
Providers in the Assisted Living Pilot Program.
Gerontologist 2007; 47(3), 365-77.
- Principi AJ. Letter to Arlen Specter, Chairman, Committee
on Veterans' Affairs, United States Senate,
November 23, 2004.