Health Services Research & Development

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Evaluation of the Assisted Living Pilot Program

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 over time.
  • Veterans, caregivers, ALPP providers, and VA staff were very satisfied with ALPP services.
  • 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 Veterans Affairs.3

    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.

    1. Hedrick SC, et al. Resident Outcomes of Medicaidfunded Community Residential Care. Gerontologist 2003; 43(4), 473-82.
    2. Hedrick SC, et al. Characteristics of Residents and Providers in the Assisted Living Pilot Program. Gerontologist 2007; 47(3), 365-77.
    3. Principi AJ. Letter to Arlen Specter, Chairman, Committee on Veterans' Affairs, United States Senate, November 23, 2004.