The following are ideas the Demonstrations Work Group regarding what we might expect to learn from the proposed affordable assisted living demonstrations proposed by Howard Young Health Care in Woodruff and Avanti Health Care in Ashland, Hurley and Superior. These ideas come from a brainstorming session at the Work Group’s first meeting on July 24, 2001.

1. Service Provision. Demonstrate non-traditional ways of providing service in an RCAC. Most RCACs provide services with in-house staff. As we understand it, these RCACs in the 2001 demonstrations plan to rely largely on a third-party contracts with existing hospitals, nursing homes, home health agencies, and EMS providers located on adjacent properties within which the developers have an ownership interest. What will the duties of the on-site manager be; will it be a different role than just a real estate manager? It is unclear how this will work and we need to speak directly to the owner/developer to clarify this.
   
   
2. Synergies. What are some creative ways of coordinating service provision with other related businesses to reduce cost? For example, these projects will share maintenance staff and food purchase and preparation with adjacent health care facilities.
   
   
3. Funding for Services. Make use of funding sources that have not, to date, played a large role in paying for services to assisted living residents.
   • How to make effective use of the Medicaid (MA) card to pay for assisted living services.
   • How to use Food Stamps to pay for meals and in-house convenience store purchases in an assisted living setting.
     
     
4. Regulatory Compliance. How can a RCAC make maximum use of services from home health and other outside agencies and still meet minimum regulatory requirements? Particular attention is needed to compliance with regulatory requirements in the following areas:
• Ability to meet unscheduled care needs of the residents (e.g., toileting)
• 24-hour coverage
• Access to emergency care
  
  
5. Target Population. What is the feasibility of serving a largely or entirely low-income population? 100% of the units in the proposed demonstrations are set aside for tenants who meet the criteria for low-income housing tax credits. While all must meet the tax credit criteria, most will probably not yet be eligible for MA card or the MA waiver. For tax credit purposes, they must meet an income test, but there is no limitation on assets. (This interest earned is added to income.) Only over time, when assets dwindle, may they become MA eligible.
   
   [For any tax credit development, a market study is required and reviewed by WHEDA for market feasibility. This is one of the first things that is checked in order to receive the tax credit. The market study must incorporate the elements in an assisted living development that are different from independent living apartments (high turnover, shorter tenancy).]
   
   
6. Case Mix. Can a RCAC successfully serve both high functioning tenants and residents with high care needs at the same time? The building is expected to attract tenants who are still active and have few service needs, while the services and potential for MA and MA Waiver funding are expected to attract people with high needs. To be eligible for the MA Waiver, participants must have care needs that would qualify them for MA funded nursing home care.
   
   
7. Level of Care. What level of care can be supported with this approach?
   
   
8. Aging in Place. Will the RCAC be able to support aging in place? What will happen as tenants who are in good health when they enter the RCAC grow older and develop care needs? It may take a number of years to really see how this shakes out.
   
   
9. Building Design. What effect will the physical plant have on the RCAC’s resident population, particularly on the level of care needs of incoming tenants? These projects are similar to independent living apartments in many respects. They include large one- and two bedroom units with amenities not generally included RCACs (full size kitchens, dishwashers, washer/dryer, heated underground parking). They also have generous amounts of common space (dining room, activity room, 3 season porches, and "county store") more commonly featured in high quality assisted living environments.
   
   
10. Financing. How does financing impact the RCAC’s feasibility, performance and cost to tenants? What does each of the financing sources used (low-income housing tax credit and HOME, etc.) have to offer and what strings are attached to each?
    
    
11. Access to Information. Will we be able to get cost information on services provided through third party contracts?
    
    
12. RCAC Size. How can assisted living work in small RCAC? One of the four proposed demonstrations (Ashland) has only 12 units.
    
    
13. Appropriate Level of Regulation. It may be that the proposed approach would work better in a non-regulated setting, where the RCAC is neither registered nor certified as an RCAC and tenants arrange their own services from outside providers. If this proves to be the case, how and to what extent can assisted living type services be made available to tenants without crossing the line to where regulations would apply?