Testimony to
The Commission on Affordable Housing and Health Facility
Needs for Seniors in the 21st Century
November 7, 2001
by
William L. (Larry) Minnix, D.Min.

Madame Co-chairs and Commissioners, it is an honor for me to appear before you today to discuss the future of senior housing and health care and the changes that must be made in the current system to better serve future generations of older Americans. On behalf of the American Association of Homes and Services for the Aging (AAHSA), I particularly appreciate your vision to hold this field hearing during AAHSA's annual meeting here in San Diego. This joint event gives AAHSA members and other experts with extensive experience serving older Americans in various settings the opportunity to participate and share their views and recommendations with the commission.

It is especially appropriate that many AAHSA members participate in this hearing because of our unique perspective as the only professional national association to represent the entire continuum of housing, health care, and community services that are available for the elderly. While AAHSA began forty years ago as an organization primarily of nursing homes, our members now provide the full continuum of services including senior housing, home and community-based services, and assisted living. Our continuing care retirement community (CCRC) members provide all of these services in one location; other members increasingly serve seniors in a variety of settings. Because of the increasingly diverse ways in which our members serve seniors, the word "services" was added to our name a few years ago to reflect the dynamic, evolution, rather than static ways in which our members adapt to consumer preferences.

Furthermore, AAHSA members bring the not-for-profit difference to the table. Of our more than 5,600 members serving over 1,000,000 individuals daily, approximately seventy-five percent are affiliated with religious organizations; the others are sponsored by private foundations, fraternal organizations, government agencies, and community groups. The freedom from accountability to stockholders and the strong commitment to their mission of high-quality care and services have enabled AAHSA members to continue leading the field in developing best practices for housing, long-term care and services.

Need for Change

Unfortunately, our nation's long-term care system is highly fragmented as a result of having developed in a haphazard manner, under various laws enacted over several decades, with different eligibility criteria and other rules, and a bewildering array of financing mechanisms. Most seniors obtain services in the settings under which costs can be covered by government programs, rather than according to what would best meet their needs. This lack of coordination and integration results in enormous inefficiency in the use of economic and social resources and in severe dissatisfaction among the elderly as to the choices that are realistically available to them. If we were to provide services according to what seniors and their families or caregivers want and need, rather than according to what can be paid for under existing government programs, the system would be far different from the way it is today.

Clearly, the time for reform is now. The fundamental problems in the current system will only worsen over time as the demographic tidal wave of aging Baby Boomers approaches. Government and providers must come together as partners, before lack of access to quality and affordable long-term care reaches crisis proportions. We must develop a responsive and bold long-term care policy for both the short term and the long term for America's frail, elderly and disabled and the men and women who care for them, day in and day out.

Support for the Commission

It was in recognition of this need to develop a more rational system of housing, long-term care and services that Congress created the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century (Seniors Commission). AAHSA actively advocated for the establishment of this Commission as a means to examine the present housing and health care system for the elderly. We strongly support the work that you are doing to obtain a wide range of views on the future of senior housing, long-term care, and services in order to make recommendations to Congress on restructuring the system.

Your commission's work is especially important given the social and economic pressures on the senior housing, health and long-term care systems, which will only increase in the coming decades with the aging of the baby boom generation. Whereas there are now 35 million people aged 65 and older, the age cohort born between 1946 and 1964 (the baby-boomers) numbers approximately 77 million. Two out of every three nursing home residents now have their care covered by the Medicaid program, and long-term care takes a disproportionate share of total Medicaid spending. If the elderly population more than doubles over the next decades, it is difficult to see how governmental programs will be able to continue paying a major share of the cost of seniors' long-term care.

It is time to reassess how public and private funds are being used to assist the ever-increasing numbers of older persons. As much as government programs now spend on long-term care and senior services, even more is provided on an informal, unpaid basis by spouses, children, and friends. A recent study estimated that two-thirds of all long-term care is provided by these informal caregivers. Many families already face serious difficulties in caring for a member with chronic care needs, and stress on the informal caregiving system will only get worse due to smaller family size, families living farther apart and two-wage earner families. If government programs fall short in covering long-term care needs, most families are not going to be able to pick up the slack on their own.

Continuum of Care

I want to clarify that in using the term "continuum of care" I am referring to the full range of housing, services, and chronic or long-term health care with which seniors may need assistance. These include housing adapted to the "aging-in-place" needs of residents, supportive services that enable people to live independently in the community, home health and nursing home care.

Housing is one of the most basic of life services, and needs to be recognized as an integral part of the continuum of care for the elderly. Housing needs to be recognized as the "where" in long-term care. Within the continuum of care, a safe, decent, suitable and affordable home is the foundation that allows the provision of all other services such as meals, health and personal care. Older persons in most income groups struggle to find affordable and suitable housing near their family caregivers, near health and other services, near transportation, and so on. Federally assisted senior housing plays a critical role in our nation's safety net for our increasingly aged population. Primarily, federally assisted housing offers affordable shelter to low and moderate income people who are not able to compete in the marketplace. In addition, the investment in senior housing also offers a critical venue for services to be delivered in flexible, cost-effective ways. Senior housing can be an effective community focal point and platform for the delivery of services to both facility residents and to elders in the surrounding community. AAHSA supports meeting the needs of low and moderate income seniors through an expansion of successful housing programs, preservation of precious existing units, provision of supportive services, and coordination with services agencies to bring health and personal care to residents.

In my statement here today, I will discuss some of the major issues now facing the housing, long-term care and services system. As suggested by the Commission, I will discuss what's working; what's not; and make some recommendations to make programs more responsive to present and future needs of elderly Americans. In discussing the development of a healthy, safe, and affordable continuum of care, I would recommend that the Commission support the "Eight Pillars of Long-Term Care Reform" proposed by Citizens for Long-Term Care, our member coalition that strives to achieve long-term care reform in America through education and advocacy. This coalition has attracted many diverse groups, including the Service Employees International Union, AARP and the Alzheimer's Association, as well as AAHSA and the American Health Care Association. The eight pillars are:

1. Every American must be assured access to needed long-term care services.



2. A wholly new, stand-alone, comprehensive financing system for long-term care is neither practical nor likely at this time; hence, long-term care financing reform should be initiated on existing structures.



3. The social commitment to long-term care must be in the form of a public/private system built on the principles of social insurance and private insurance.



4. Eligibility for the social insurance benefit should be based on functional limitations as an entitlement benefit.



5. Private and public policies should be developed to educate and encourage individuals and families to plan for the financing of care prior to the onset of disability.



6. Professionals, paraprofessionals and direct support professionals are critical to quality care and must be recognized and valued by the system.



7. Public assistance must be maintained and improved to provide a full range of services and supports to those who are not otherwise covered.



8. The financing system must support choices across the continuum of care and help maximize personal independence, self-determination, dignity and fulfillment.

Needs and Challenges with the Long-term Care Continuum

There are four primary ways in which the long-term care community must change in order to meet the needs of current and future senior populations:

1. Need to focus on the entire continuum of care system as a whole to ensure that it focuses on the needs of individuals in their local communities. The system currently is not centered on the needs and preferences of individuals to have their needs met across time, place and provider.
2. Need to ensure sufficient and well trained staff to assist older persons and their caregivers
3. Need to ensure sufficient program funding and that the financing system is cost effective and administratively productive
4. Need to ensure quality and effective regulation.

1. Need for an Integrated Long-Term Care Continuum that focuses on the Needs of older persons

The present long-term care system is not centered on the needs and preferences of individuals to have their needs met across time, place and provider. Funding for the continuum of long-term care services is fragmented and often not in adequate amounts to meet demand. Eligibility requirements vary from program to program, and services usually are administered by a variety of federal and state agencies which makes it difficult and confusing for consumers to obtain what they need.

Health and home- and community based care

Medicaid and Medicare provide the major source of funds for long-term health care services. Studies vary, but generally about two or three times as much is paid for institutional care as is paid for home and community-based care. Other public programs, many of which target funds specifically for home and community-based services and supports, include state programs, the Administration on Aging/Older Americans Act (OAA), the Social Services Block Grant (SSBG-Title XX) and the Veterans Administration. In addition, some public funding for services is available for public housing residents through the Department Housing and Urban Development (HUD), including the Congregate Housing Services Program (CHSP). Private financing includes private insurance, philanthropy and out-of-pocket payments by individuals and families in need of care. Out-of-pocket payments comprise almost 40 percent of all funding for services delivered in home and community-based settings.

Senior Housing

Most older persons live in their own homes; the rest are renters in a variety of public and private settings. Only 1.5 million older persons live in federally assisted housing, coincidentally about the same number that reside in nursing homes. More than 7.4 million elderly households pay more than they can afford for their housing, including 1.4 million households with worst case housing needs. A majority of these households are on fixed incomes and receives no housing assistance. Unfortunately, low income elderly people seeking housing are faced with multi-year waiting lists exacerbated by the shrinking supply of suitable, affordable housing as some owners convert existing units to market rate housing. According to a recent AARP study, there were nine people over 62 years old waiting for every Section 202 unit in 1999. Given the demographics, loss of existing supply of affordable housing, and limited new developments over the past few years, that number has undoubtedly grown since then.

The dynamic of fixed incomes, high housing costs and limited supply of affordable housing options is compounded by an ever increasing aging population needing a range of supportive and health care services. This need for supportive services, appropriate community space, and service coordination applies to the frail elderly who currently live in federally-subsidized housing, as well as to those in need of housing assistance. Additionally, many elderly housing facilities have "aged" and need modernization and/or retrofitting and refinancing in order to better accommodate supportive services to aging residents, assure quality of life, accessibility and marketability. It is essential that adequate funds be made available for adjustments to project operating costs to accommodate such increases, which also include those for utilities, insurance, and staffing.

Emerging Role of Senior Housing in Long-Term Care Strategies

AAHSA believes that one of the most important contributions that the Commission can make to address future housing and health care needs of older persons is to examine existing barriers between senior housing, supportive services, and health care; and to make recommendations to develop a more integrated and affordable continuum of care. AAHSA would recommend that the Commission seek solutions to the existing fragmented administrative systems, to make them more seamless in bringing services together at the local community level where older persons live. In many ways, AAHSA believes that the Commission may need to have bold, creative solutions to "shake-up" the existing fragmented system and bureaucratic silos.

While it will not be an easy task, we believe that the timing is ripe and that there are many opportunities and incentives to make these dramatic policy changes, including: consumer preferences, aging baby-boomers and caregivers, skyrocketing health care costs, bureaucratic overload, taxpayers' demands for cost-effectiveness, the Supreme Court's recent Olmstead decision, recent initiatives by HUD and HHS and just plain compassion and concern for the quality of life for each older person and preparation for an ever-aging society. There are many components to developing a more streamlined continuum of care with housing, services and health care, including: the role of service coordinators, affordable assisted living, PACE and other health care reforms, and effective collaboration strategies such as the co-location of elderly housing with an array of services and health care.

Service Coordinators

Programs that bridge the gaps between housing, supportive services and health care are necessary to facilitate a seamless continuum of care. The service coordinator program is such a lynchpin that AAHSA has long advocated for its expansion. This program enables frail elderly people to live independently with dignity in their own homes, and often defer or delay their need to move to a higher, more costly level of care. AAHSA urged passage of the recent legislation that significantly increased the funding for service coordinators and gave them flexibility to serve older persons in both the elderly housing facility and the surrounding area.

Increase Alternative Supportive Housing Options

Just as some seniors living in their own homes need better information on or access to services, a need which may in part be met by the expanded role of service coordinators, some seniors need better information on or access to available or innovative housing options. Home-sharing concepts are successful in many localities, relying heavily on local provider knowledge and integrity in recruiting, screening and matching house-rich and sometimes income-poor or even home-bound seniors with families or individuals who need a stable living environment and can provide supportive assistance to all participants in various ways. Home resale efforts encouraging seniors to take advantage of communal supportive housing settings can also assist in making housing available to others entering the housing market or looking to move up as their income allows. Similarly, home equity programs enable older homeowners to tap into the equity of their homes to pay for home and community-based services and health care.

Co-location to promote collaboration

One approach for promoting collaboration among a host of public and private organizations involved with housing, services and health care at the local community level is through co-location. Through this approach, a multi-service senior center, which might be owned and/or operated by the local government or the private sector, would be co-located next to senior housing. The senior center can provide the space (rented, condo, or donated) to a host of community agencies, such as an Older Americans Act-funded nutrition site, child or adult day care, or health clinic, which would provide services both to residents in the senior housing, as well as to older persons in the surrounding neighborhood. Similarly, an assisted living and/or nursing facility may be co-located on the same site, adjacent to or as a wing to the housing facility and/or senior center. Another example for collaborating health care with senior housing would be the co-location of a PACE (Program for All-inclusive Care for the Elderly) site (often an adult day or home-health site) with senior housing.

Funding, staffing, licensing and other administrative issues would be the responsibility of the respective organizations. While each of these providers would remain separate organizations, they would have the mutual benefit of sharing space and administrative costs, as well as the ability to reach increased numbers of older persons. A number of communities are beginning to develop this modular approach to supportive senior housing as a community focal point in facilitating an affordable continuum of care for the elderly.

Affordable Assisted Living

The term "assisted living" describes a number of residential settings offering a variety of services. Assisted living residences may be stand-alone, part of a continuing care retirement community, attached to a nursing home, part of a housing complex, or part of a larger campus. The American Association of Homes and Services for the Aging (AAHSA) defines assisted living as a program that provides and/or arranges for the provision of daily meals, personal and other supportive services, health care and 24-hour oversight to persons residing in a group residential facility who need assistance with activities of daily living (ADLs).

Services provided within assisted living residences range from meals and housekeeping to medication assistance, incontinence care, and limited nursing services. Assisted living facilities are residential and "home-like" in nature, often configured as a private apartment that includes a private bathroom and kitchenette. Facilities may range in size from fewer than sixteen units to well over 100 units. While an exact number has not been calculated, experts estimate that there are approximately 30,000 assisted living facilities in the United States. More than 1,280 AAHSA members provide assisted living. The cost of assisted living ranges from several hundred dollars a month to more than three thousand dollars a month depending on region, size of the accommodations, services available and amenities

One of the biggest current gaps in achieving a continuum of healthy, affordable and ethical care for seniors is the lack of affordable assisted living for low-income seniors. To address this need, AAHSA supports expanding the assisted living conversion and development programs. Last year, a number of legislative changes were made that will help address the needs for affordable assisted living units; including the conversion of federally assisted elderly housing units into assisted living and the use of Section 8 vouchers with assisted living. This past year, HUD awarded grants to 13 projects funded under the Section 202 program to make physical changes to their existing facility to enable personal care and other services of a licensed assisted living program. It is anticipated that HUD will announce shortly the awardees for this year's funding under the program that has been expanded to include other federally assisted elderly housing. Unfortunately, Congress has not yet provided development funds, as AAHSA has advocated, for financing affordable assisted living facilities.

AAHSA also supported the expansion of the use of Section 8 tenant-based housing vouchers to pay for the shelter portion of assisted living. This is a significant step toward making assisted living more affordable; however, there are a few concerns with both the availability and use of these vouchers. In addition to the scarcity of Section 8 vouchers, HUD guidance implementing these vouchers (HUD Notice PIH 00-41) does not readily facilitate the use of vouchers in assisted living facilities and contains provisions that make assisted living providers resistant to the concept. The Commission could promote the concept by asking Congress to direct HUD's Office of Public and Indian Housing to eliminate the provision stating that, "Nonpayment of fees for meals and services is not grounds for termination of housing choice voucher assistance or for eviction from the housing." Assisted living is designed with specific meal and service packages as up-front components of their program. Making participation in any or all of these elements optional or allowing voucher-assisted residents to renege on their requirement to pay for them is counter-intuitive to the success and rationale for selecting assisted living in the first place.

Other steps necessary to facilitate use of vouchers in assisted living include directing development of a coordinated effort by PHAs and willing local assisted living providers to reach out to current and future voucher holders advising them of the right to use vouchers in assisted living settings. Current implementation simply informs PHAs that vouchers may be used in assisted living settings, but it does nothing to require or even urge PHAs to make the information known.

In addition, while the recently appropriated grants enable physical changes to be made to elderly housing facilities, including restructuring of units and/or additions, these funds may not be used to finance any of the accompanying personal care and supportive services. The commitment of long-term funding of services, potentially through Medicaid, may be one of the most challenging aspects of the conversion of federally assisted housing to assisted living. AAHSA would recommend that the Commission examine means to ensure the long-term funding of services in affordable assisted living. One option that the Commission might want to explore is a program enacted this year by the state of Florida to enable a project-based Medicaid program for assisted living.

Olmstead Implementation

The Olmstead decision was decided by the Supreme Court in June 1999. It upheld Title II of the Americans with Disabilities Act (ADA) affirming the right of individuals to receive services in the least restrictive setting. The Court ruled that it is a violation of the ADA for states to discriminate against persons with disabilities by providing services in institutions when the individuals could be served more appropriately in the community. While the decision involved two women with developmental and mental disabilities, it has been interpreted more broadly to include people with physical and mental disabilities, to those in nursing homes and other institutional settings, and to those in the community who are at risk of institutionalization.

The implications for the provision of long-term services, not only for persons with disabilities who currently need services, but for the growing numbers of baby boomers who will need services in the future, are enormous. It is estimated that there are currently 1.8 million people in institutions, 1.6 million of these are in nursing homes. The number at risk of institutionalization, defined as needing considerable help from another person with two or more self-care activities, is estimated at 2.3 million. These numbers will grow substantially as the population ages.

The vast majority of states are in the process of planning or implementing strategies to meet their Olmstead obligations. In doing this they face substantial challenges. Some of these are barriers presented by fragmented systems and funding streams, inadequate Medicaid funds, and provision of the necessary community supports - such as transportation and housing. The lack of affordable, accessible housing is one of the major barriers to successful transitioning of nursing home residents to the community. In its review of eight state nursing home transition grant programs, the National Association of State Units on Aging (NASUA) noted that the lack of affordable, accessible housing was not only a major barrier to returning people to the community, but was also a contributing factor in many unnecessary nursing home placements.

AAHSA supports the Olmstead decision and efforts to implement it. AAHSA believes that long-term care services must be centered around the needs and preferences of individuals and that individuals have a right to have their needs met across time, place and provider. This means that a full range of services and supports have to be available. This must include a range of housing options.

As a part of strategies to address Olmstead and its requirements that communities develop nursing home transition grants and de-institutionalization of all willing and qualified persons with disabilities, the Commission should recommend to Congress that HUD develop a demonstration program setting aside a number of vouchers for use in assisted living facilities. This would allow local PHAs to respond to local community needs in this area by creating a priority assignment of a certain portion of their annual/available housing choice voucher allocation. It would also provide an opportunity to further explore the financial and social benefit ramifications of pairing rental assistance subsidies with medical assistance programs in stable environments. Further, the Commission could encourage the development of a joint HUD/HHS working group to pursue ways to educate assisted living providers of the authority to use vouchers in assisted living, the manner in which current assisted living residents could access rental assistance and models where assisted living providers and PHAs have established successful voucher use programs.

Systems Change Grants for Community Living

In response to the Olmstead decision, the Department of Health and Human Services (HHS) through its Center for Medicare and Medicaid Services (CMS -- recently renamed from the Health Care Financing Administration) established this year an initiative that could have a significant impact on the relationship of elderly housing with health care. Specifically, CMS will provide grants to States and others, in partnership with their disability and aging communities, to design and implement effective and enduring improvements in community long-term support systems. The funds will enable states to work with their disability and aging communities to expand the support and opportunities people with disabilities of all ages have to live in their own homes and communities. Grant funding may be directed towards improvements in quality assurance mechanisms, long-term service system reform and demonstration projects.

These "Systems Change for Community Living" grants support the Administration's New Freedom Initiative to assist state and local communities in responding to the Olmstead decision by removing barriers to equality for the 54 million Americans living with disabilities. As stated in the CMS proposal, these systemic changes are intended for persons of any age who have a disability or long term illness to: (a) live in the most integrated community setting appropriate to their individual support requirements and their preferences; (b) exercise meaningful choices about their living environment, the providers of services they receive, the types of supports they use and the manner by which services are provided; and (c) obtain quality services in a manner as consistent as possible with their community living preferences and priorities.

Last month HHS announced the grantees for three-year grants under several program, including: 1) Nursing Facility Transitions - to help states transition eligible individuals from nursing facilities to the community; 2) Community-integrated Personal Assistance Services and Supports - to support States' efforts to improve personal assistance services that are consumer-directed or offer maximum individual control to enable persons with a disability or long term illness to live in the community; and 3) Real Choice Systems Change - to help states design and implement effective and enduring improvements in community long term support systems to persons who have a disability or long term illness to live and participate in their communities.

AAHSA would urge that the Commission examine issues and opportunities through this Administration initiative to address the relationship between affordable housing and health care needs of older persons

Recommendations

Meeting the long-term care needs and preferences of aging, frail and disabled consumers, particularly home and community-based services and supports, can be difficult for several reasons. 1) Long-term care is often equated with and funding is tilted toward institutional care; 2) funding is fragmented and often inadequate to meet needs; 3) regulations and eligibility requirements vary from state to state and sometimes within states; and 4) in the majority of states, there are numerous entry points for obtaining services, causing confusion and decreasing the ability of consumers to make informed choices. We believe services must be centered around the needs and preferences of individuals and that individuals have a right to have their needs met across time, place and provider. There must be balance across the LTC continuum from home and community-based services to skilled nursing facility care to ensure that consumers receive the optimum of access, choice and protection, and that all providers are fairly reimbursed for the indispensable services that they provide.

AAHSA would urge the Commission to examine issues and make recommendations to support the following plans to address the fragmentation and inadequate funding for non-institutional long-term care services:

• Support adequate funding for home and community-based services (HCBS), specifically: a 10 percent increase for Older Americans Act programs; an increase in Social Services Block Grants funding to $2.38 billion while allowing states to transfer up to 10 percent of their Temporary Assistance to Needy Families (TANF) funds to support block grant programs; an increase in Medicaid funds targeted to HCBS, including funding for assisted living through the CMS 1915(c) waiver program; and elimination of the 15 percent reduction in Medicare funding of home health services called for in the Balanced Budget Act that, if allowed, would cause serious access and availability problems for Medicare beneficiaries. While funding for HCBS programs should be increased, such additional funding must not be achieved by arbitrarily reducing funding for institutional care. "Robbing Peter to pay Paul" is bad policy and jeopardizes the welfare of these providers and the residents they serve.
• Modify processes and regulations, including: streamline the home and community-based waiver process and investigate incentives to encourage states to incorporate waiver programs in their state plans; revise the current Medicare medical transportation laws to permit use of vehicles other than ambulances, when appropriate, for emergency medical transportation and reallocate savings to other non-emergency transportation services, such as transportation to adult day service centers; and provide reimbursement mechanisms to cover the additional costs of the reporting requirements of new regulations such as the Outcome Assessment Information Set (OASIS) and the Health Insurance Portability and Accountability Act (HIPAA).
• Increase choices and options for individuals and providers: support a Medicaid statutory change so that funding can follow consumers and give them more control over the services they receive; unbundle non-routine medical supplies to enable home health beneficiaries to have their choice of supplier; and develop incentives to encourage states to implement the rule change to increase eligibility for Medicaid, or make this mandatory for states.
• Encourage and support a continuum of services: promote effective collaboration among HHS, HUD and others to develop programs and services that help maintain older persons in their homes and communities, including co-location of services with elderly housing, flexible use of Medicaid and other funds and conversion of elderly housing to affordable assisted living, including project-based Medicaid; promote community-wide planning for housing, services and health care that has as a goal developing an affordable continuum of care for individuals.
• Support a demonstration program to enable local communities to be creative, "out of the box", in approaches to improving collaboration between housing, services, and health care for older persons. Under this proposed "Communities of Care" program, any HUD, HHS, or other regulations could be waived to enable the demonstration of new administrative approaches for bringing together at the local community and/or facility level diverse financing and administrative systems. For example, a non-profit sponsor might create a Community of Care Foundation for one or more facilities at which HUD, HHS, and other public and private funds could be commingled into a seamless program to provide affordable housing and services as needed by older persons with various income and service needs.

2. Workforce and Staffing Capacity and Training Needs

Nursing and assisted living facilities, home health agencies, and providers of home and community-based services and senior housing all require sufficient numbers of qualified staff to effectively serve elders. The staffing crisis in long-term care has developed and worsened over time, influenced by social, economic and demographic factors, often beyond providers' control.

Long-term care and service providers across the continuum are struggling to fill staffing positions due to a combination of factors. These include a still-competitive labor market, wage and benefit levels limited by current low Medicare and Medicaid rates, public misinformation and negative public perceptions of the profession and limited opportunities for career advancement.

Furthermore, there is even greater demand on long-term care staff as a result of increasing paperwork requirements and the overly adversarial and subjective nature of the regulatory system. Staffing needs will only become more acute as the aging population increases, the level of acuity of clients served in long-term care settings continues to rise and the labor pool decreases in coming years.

According to the Bureau of Labor Statistics, by 2008, nursing facility and personal care employment will expand by 25.6 percent, creating a need for about 451,000 more caregiving positions. This comes at a time when fewer and fewer professionals are entering the nursing profession and the average age of today's nurse is nearly 50 years old and climbing. Truly, this is an alarming trend.

Service Coordinators in Senior Housing

Service coordinators are an integral part of a strategy to provide a healthy, ethical and affordable continuum of care in elderly housing facilities. Their primary role is to link residents with home and community-based service providers that assist residents with supportive services needs. Coordinators facilitating access to services for residents who need them enable economies of scale for services and promote residents' independence. Last year Congress expanded the role of service coordinators to allow them to serve older members of the surrounding community as well as the residents of the senior housing facility. AAHSA supported this expanded role and recommends the timely implementation of this option. In addition, we would urge the development of training programs to enhance the skills of coordinators in community planning and mobilizing health and supportive services.

AAHSA has long maintained that funding for service coordinators should be through a predictable, regularized process. While it is our understanding that service coordinators may be funded as a part of a project's routine operating expenses, many elderly housing facilities are presently unable to use this procedure because this would exceed their cost limits under Section 8 rent subsidies.

AAHSA also encourages the Commission to recommend a more reliable and stable source of funding for service coordinators by assuring that service coordinators can be part of every facility's routine operating expense. Grant recipients should have the realistic option to build the cost of service coordinators into their operating budget upon the expiration of the grant, but we must also sustain separate funding options for those facilities where only a portion of the residents benefit from direct rental subsidies. AAHSA supports the establishment of a separate funding stream, apart from the Section 202 account, for service coordinators and CHSP contracts.

HUD Staffing

HUD's recent downsizing of staff has resulted in a lack of meaningful attention to many programs important to sound management of senior housing and the issues being examined by the Commission. These include the timely allocation of Section 202 funds (needed to expedite the funding pipeline), the new assisted living conversion program, implementation of new authority for Section 202 mixed finance for refinancing or development, administration and oversight of contract administrators, and other administrative functions. HUD staffing needs (number of staff and their training needs) influence every new and existing HUD program. AAHSA believes that increased and better-trained HUD staff are essential to accelerate Section 202 construction, lease units up, and sound management.

Recommendations

To ensure that sufficient levels of staff are available and trained to provide quality long-term care and services now and in future years, immediate funding increases are needed, fringe benefit packages must be created, new approaches to recruitment and retention must be developed and existing barriers to innovative staffing solutions must be removed.

AAHSA would urge that the Commission address the workforce crisis by supporting the following:

• Ensure sufficient Medicaid and Medicare funding to enable providers to offer competitive and livable wages
• Provide incentives to states to apply for waivers to expand their State-Children's Health Insurance Program (S-CHIP) to cover income-eligible parents, as was successfully done in Wisconsin.
• Where appropriate, certify certain geographic areas as "health care shortage areas," thereby triggering action by the Attorney General and Secretary of Labor to grant work visas for professional and paraprofessional foreign health care workers.
• Support legislation recently introduced in Congress designed to recruit and retain qualified professional and paraprofessional employees for employment in LTC. These bills are S. 706 and H.R. 1436, the Nursing Reinvestment Act, and S. 626 and H.R. 138, which would reauthorize the Worker Opportunity Tax Credit and Welfare-to-Work Tax Credit Program.
• Expand the service coordinator program until each senior development can benefit from service coordination. Financially restructured or refinanced federally assisted elderly housing facilities should have the ability to build the cost of funding a service coordinator into their operating budget through their project's rental assistance contract. The ost of a service coordinator should be exempted from the annual limits on expiring Section 8 contracts. And insured or assisted housing projects without project-based Section 8 rent subsidies should have existing service coordination funding continued through direct grant renewal funds.

3. Need for Streamlined and Cost Effective Financing of the Continuum

The financing system for long-term care and services, including housing, is severely flawed and headed for ruin with the demographic tidal wave of Baby Boomers.

Health care

Most people assume that their long-term care needs will be covered one way or another. The popular misconception is that Medicare will pick up the tab. That is simply not the case. Medicare does not pay for long-term care. Medicare pays in full for the first 20 days in a skilled nursing facility after a three-day hospital stay, then for a portion of days 21-100, with beneficiaries contributing a co-payment of about $100 a day, or about $8,000 total for a 100-day stay.

As soon as beneficiaries no longer need daily skilled care, they must resort to out-of-pocket payment or private insurance until they have "spent down" their assets to poverty level to qualify for Medicaid. Two out of three people in the United States resort to the latter, since an average cost for nursing home care is around $50,000 per year, which quickly drains one's savings. In fact, more than half of residents who begin paying for long-term care with private funds impoverish themselves within one year and become eligible for Medicaid.

Approximately 80 percent of nursing facility care is publicly financed through the Medicaid (67 percent) and Medicare (13 percent) programs. The nature of this system forces public officials to have budget policy drive health care policy. This is backwards. The system simply fails to provide a stable funding base for providers so they can plan for the future.

Another alarming statistic is that nearly half of all Americans will need some form of long-term care at some point in their lives, yet less than 10 percent take personal responsibility by purchasing private long-term care insurance.

Today, Medicaid covers an average of two-thirds of all nursing facility residents in this country. On average, Medicaid pays approximately $4 per hour for resident care. Government is demanding more quality care, yet providing scarce resources with which to provide it. For this minimal dollar amount, nursing facilities are expected to provide a room, three meals a day, linens, some therapies, assistance with daily activities and nursing services, among other services. Without question, Medicaid has become, by far, the largest payer of nursing facility care by default.

The Medicare skilled nursing benefit is very narrow, covering only post-acute, medical and rehabilitative needs. Medicare does not provide any payment for chronic or custodial care services in nursing facilities. The federal government has created incentives for citizens to divest assets to qualify for Medicaid payment of LTC. We have done little to educate and encourage our citizens to plan and pay for their future long-term care needs.

The utilization of the Medicaid system as the premiere payment source for nursing facility care has placed extreme pressure on state budgets. In fact, recent studies show that Medicaid spending is expected to double by 2004. The seriousness of this crisis cannot be understated. However, state governors' necessity to contain costs has caused chronic under funding of Medicaid programs across this nation. To compensate for escalating Medicaid obligations, states have had to resort either to arbitrary reimbursement cuts or to unorthodox mechanisms such as intergovernmental transfers and provider taxes to maximize federal financial participation.

Medicaid must be placed on a firmer financial footing in the short term. Failure to do so will threaten resident care while nursing staff will continue to leave the nursing facility profession. Under the current direction, nursing facility providers simply will not be able to maintain the delivery of quality care to Medicaid recipients for the amounts currently paid by many states.

With regard to Medicare, the 1997 Balanced Budget Act (BBA) reduced Medicare payments for skilled nursing facility care by nearly twice the $9.2 billion Congress intended, resulting in serious financial distress throughout the LTC profession. Approximately 15 percent of all nursing homes nationwide filed for bankruptcy. Congress and the Administration recognized this crisis and restored several billion dollars of Medicare funding for resident care in the Balance Budget Refinement Act of 1999 (BBRA) and the Medicare, Medicaid and S-CHIP Benefits Improvement and Protection Act of 2000 (BIPA).

However, several of the provisions adopted in these pieces of legislation have sunset provisions, which will result in significant payment reductions starting in 2002 (for FY 2003) and the threat of rampant bankruptcies and inability to access quality care in some areas. Furthermore, flaws in the current payment methodology have been discovered, including problems with the Centers for Medicare & Medicaid Services (CMS) database, design issues with the skilled nursing facility (SNF) market basket methodology and problems with the manner in which the present system accounts for acuity levels of residents.

AAHSA would urge that the Commission support actions to address immediate and long-term solutions to the long-term care financing crisis facing our nation:

Recommendations to correct states' chronic under funding of Medicaid include:

• Modifying or repealing the recent Medicaid Upper Payment Limit Regulation to address the loss of Medicaid revenue to states beginning on or about Oct. 1, 2002. Require states to spend restored funds only for health care purposes. Without such a remedy, states will have no choice but to cut the health care services that have been financed by intergovernmental transfers.
• Support legislation to provide federal Medicaid funding to make up all or a portion of historic and chronic under funding.
• Support legislation that would provide additional federal funding for dedicated purposes, such as employee recruitment and retention or physical plant rehabilitation.
• Require states to use any additional federal funding for the dedicated purpose or make them ineligible for the funds.
• Prohibit states from cutting existing funding levels in expectation of new federal resources.

Recommendations to preserve viable Medicare financing include:

• Secure permanency to the interim funding provided to nursing homes under the Benefits Improvement and Protection Act and the Balanced Budget Refinement Act-the so-called "fix the cliff" solution.
• Address the long-term issue of correcting the problems with the Medicare skilled nursing facility market basket.
• Ensure that any attempts to refine the Resource Utilization Group III (RUG-III) case mix system for nursing homes are developed appropriately by CMS.
• Eliminate the additional 15% cut in Medicare home health care spending that is scheduled to take place on October 1, 2001.

Senior housing

While there are a number of federal, state, and local government programs to develop affordable elderly housing, the most successful federally assisted elderly housing program often cited by the Administration and Congress to develop affordable housing is the Section 202 program. Yet, despite its strong bi-partisan support, this highly successful program has not received sufficient funds to prepare for future affordable housing and health care needs of the elderly. In recent years, the Section 202 funding trend has been downward from $1.2 billion in FY95 to $679 million last year. In FY2000, more than 50% of applications for funding of new affordable housing under the Section 202 program were denied, simply for lack of funds available to the program. This limited funding for development has contributed to multi-year waiting lists in many communities.

In light of the projected elderly housing population and the increased role that elderly housing may have in long-term care strategies, AAHSA urges that the Commission support at least a doubling of existing funds for Section 202s with an index for increases in future years based upon projected population growth. We believe that legislative changes enacted over the last two years , as AAHSA urged, will provide new opportunities to expand the supply of affordable elderly housing by leveraging Section 202 funds to attract other public and private resources. Specifically, recent legislative changes will enable Section 202 funds to be used with tax credits and other financing tools once off-limits to Section 202 sponsors. However, many of the potential benefits of mixed-finance housing cannot be realized until HUD implements these new legislative changes. We are pleased that there are legislative provisions pending in the HUD FY2002 Appropriations bill (H.R. 2620) to expedite the implementation of these mixed-financing provisions.

With the new financing tools, nonprofit Section 202 sponsors, as the sole general partner of a limited partnership, can partner with for-profits so that low income housing tax credits and private activity bonds can be used for Section 202 projects. This type of mixed-finance housing offers opportunities to develop mixed incomes projects. Anecdotal evidence very strongly points to a need for housing that targets persons with incomes just above the low-income eligibility range. This will only be exacerbated as the elderly population with moderate income increases - this population is expected to be among the largest of the growing senior contingents. AAHSA supports a housing safety net for all income groups.

In addition to recommending increases for the Section 202 program, AAHSA also urges the Commission to support maintaining the Section 202 program's current administrative system and not to support the block-granting of the program to state housing finance agencies. While we recognize that there is always room for improvement, the Section 202 program "works". In a recent resident satisfaction survey, the Section 202 program received the highest score of all HUD administered housing programs. The program successfully achieves its multiple goals of: providing high quality affordable housing to low income older persons by involving nonprofit sponsors; building organizational capacity in small, local and grassroots organizations; encouraging financial partnerships in local communities; and distributing limited Section 202 funds fairly across the nation. Any major disturbance of the current distribution plan is unnecessary and potentially detrimental to the program. Applications in response to each year's notice of funding availability are reviewed at the field office level, where knowledge of local housing conditions is greatest. The local HUD offices then make recommendations to HUD headquarters on which applications to approve.

As is true for all housing and community development efforts, including those involved in the Section 202 program, the products and financing tools available through housing finance agencies (tax credits, bonds, HOME, CDBG, etc.) and other entities can be accessed if necessary, appropriate and sufficient resources are available. Currently, many Section 202 sponsors take advantage of financing tools like those administered by state housing finance agencies, other state and local government offices, and private sources simply because grant awards for Section 202 developments are inadequate. Last year's expansion of the types of financing that nonprofit sponsors can use is certainly beneficial; however, the administration of the Section 202 program by state housing finance agencies is not in any way a prerequisite to accessing these competitive funds.

We would also welcome an opportunity to work with the Commission and HUD to refine, for example, Section 202 grant application and selection requirements (market analyses, data collection) to ensure that award funds develop units in geographically diverse areas in need of such housing. If vacancies are ever an issue in some areas or projects, we would urge that the Commission support additional strategies to fill these vacancies, such as extending eligibility to near-poor elderly, and/or modifying the rent based upon unit type (i.e. cheaper rent for efficiencies), or other flexibility with admissions eligibility and rents.

Modernization and Retrofitting Needs of Existing Elderly Housing

Another important strategy to provide affordable housing to older persons is to preserve existing units by ensuring that they will be suitable for future affordable housing needs. Funds are desperately needed to maintain our nation's current investment in federally assisted elderly housing. AAHSA supports new funds to rehabilitate, modernize and retrofit older federally assisted nonprofit elderly housing facilities and to enhance access to (and delivery of) supportive services. As a nation we have a significant investment in all federally assisted housing. AAHSA strongly believes in maintaining the integrity of this investment and recognizes the needs present in many aging elderly housing facilities, including Section 236 properties.

We owe it to our existing investment to accommodate the modernization and retrofitting needs of aging buildings and buildings that need to be adapted to facilitate supportive services. Just as our residents are aging in place, our housing facilities are also aging and are in need of modernization. Legislation enacted last year gives Section 202 providers with Section 8 housing assistance payments greater access to their residual receipts and reserves for building modernization, retrofitting and up to 15% of service costs. Many other types of aging, nonprofit-owned elderly housing developments also need access to such funds and the time for this investment is now.

According to AARP's 1999 survey of Section 202 properties, projects built during the earliest round of 202 and the cost-containment years of the mid-to-late 1980s will have heavy demands for capital to modernize and retrofit in order to continue to meet the needs of the residents they serve. AARP found that 20% of the oldest facilities reported that their capital reserves are inadequate to meet current repair concerns and that 36% reported that reserves are inadequate to meet projected repair needs.

The Section 236 non-profit elderly developments appear to be the most in need of modernization funds. AASHA fears that ignoring these needs now will only increase affordable elderly housing needs in the near future as the health of these properties continues to deteriorate. While we can appreciate the current concern over constraints in the federal housing budget we believe it is imperative that a modernization program be established to meet the increasing needs for our aging residents within our aging facilities.

Preserve Affordable Housing Stock

The loss of federally assisted elderly housing units exacerbates the housing crisis in general, and the elderly housing crisis in particular. According to the 2001 State of the Nation's Housing report by the Joint Center for Housing Studies of Harvard University, more than 300,000 units affordable to households with low incomes were lost between 1997 and 1999 alone. Given the tremendous need for affordable housing, AAHSA believes that as many of these units as practical should be maintained. For this purpose, we support various tools to assist in preserving at-risk stock for the increasing numbers of elderly households in need of such units. The number of household heads over the age of 75 alone is expected to increase by roughly 1.3 million this decade.

AAHSA supports the enactment of a preservation matching grant program for states and localities that dedicate funds toward the preservation of federally assisted housing at risk of leaving the affordable housing inventory. In addition, we support efforts to relieve (via deferral or outright cancellation of the exit tax) current owners of tax burdens when they transfer their properties to nonprofits that agree to maintain the units as affordable to people with low incomes. AAHSA believes these tax burdens are preventing the transfer of properties to nonprofits, many of which are ready and willing to sustain ownership of this critical housing stock. State and local investment to preserve federally subsidized housing merits federal financial support. Programs like the preservation matching grant can greatly assist in preserving as many units as possible.

Financial Restructuring

One action that AAHSA would recommend for the preservation of the existing supply of affordable elderly housing would be forgiveness of the existing federal mortgages on Section 202s. A few years ago, AAHSA examined various means to develop long-term solution to the financial and administrative pressures on our older elderly housing stock. We addressed the resource needs of aging residents and aging buildings in light of changing government capacity and uncertainty over future funding. We determined that the most workable solution is to give sponsors of pre-1990 Section 202 projects the option to convert to the Section 202 Capital Advance with its accompanying Project Rental Assistance Contract (PRAC). Under this approach, HUD would forgive the mortgage and shift the source of operating assistance from Section 8 to a PRAC.

An explanation and justification for this conversion process is highlighted in an AAHSA white paper which we would like to include as part of our testimony to assist the Commission to examine this issue and our recommendation. In addition, the Commission might want to examine a HUD report that was sent to the House and Senate Appropriations Committees in May, 2000 that studied the budgetary impact of this option. HUD's study used two methods to analyze the budget impact: (1) a nominal cash flow analysis, and (2) an analysis of budget scoring implications of the current Credit Reform Act and rules pursuant to the Budget and Enforcement Act (BEA).

The report points out that the cost and benefits associated with forgiving the loans owed to HUD are affected by the current rules governing debt forgiveness. If actual cash flows are considered, any cost of debt forgiveness will be fully offset by the reduced need for future appropriations and the rescission of the current account balance. According to the report, "there is no inherent cost to the government of forgiving the outstanding Section 202 loans if all current score rules, under the BEA, are assumed not applicable." The report recognized that HUD would forego $19.3 billion in future principal and interest payments on the forgiven loans but, by the same token, HUD would save the cost of Section 8 subsidies that would otherwise go to make those principal and interest payments. The report notes, however, that if the analysis were made with current budget scoring rules, the budget would have to accommodate the present value of the foregone mortgage payments, of $3.2 billion in both budget authority and outlays. That full amount would be "scored" in the year in which the debt is forgiven - most of the resulting savings would not be shown until later years.

Furthermore, the actual scoring of the loan obligation or debt forgiveness would be dependent on which congressional committee takes action. As stated in the report, "Under the current budget scoring convention and pay-as-you-go (PAYGO) rules, if the Authorizing Committee acts on the modification, it would be considered on the mandatory side of the budget and the scoring will not impact the VA-HUD Appropriations Subcommittee. It will however, score as a PAYGO cost. If the Appropriations Committee acts on the modification, then the action would be considered discretionary spending and the amounts would be scored against the VA-HUD-IA Appropriations Subcommittee bill." In essence, the cost and benefits associated with forgiving the loan owed to HUD are different depending on the rules that govern the debt forgiveness. We believe that this HUD study helps make a compelling case for the feasibility and prudence of debt conversion.

In addition to Section 202s, AAHSA would recommend that the Commission examine the special needs of non-profit-sponsored Section 236 funded elderly housing that we developed during the five-year moratorium (1969-1974) of the Section 202 program. We would recommend that these projects also be included in any debt forgiveness strategy; and be recognized as if a Section 202 program.

AAHSA recommends that the Commission examine finance issues to preserve existing elderly housing and to expand the supply of affordable housing for older persons by supporting the following:

• Take actions to preserve the existing stock of federally assisted elderly housing, as well as to significantly expand the supply of affordable elderly housing. These actions are critical not only to solve the present critical shortage of affordable housing, but also in recognition of the emerging role that elderly housing can have with long-term care strategies
• Significantly expand funding for the Section 202 program, as well as to maximize Section 202 resources through market analyses and coordination with Consolidated Plan and other resources within application / selection process.
• Expedite use of other authorized resources (low income housing tax credits, tax exempt bonds, etc.) to enhance Section 202 developments and increase their ability to develop mixed-income and mixed-use facilities.
• Preserve viable and appropriate existing affordable elderly housing stock; including adequate federal funds for rehabilitation, modernization and retrofitting of older federally assisted housing facilities.
• Support the option for conversion of pre-1990 Section 202s to the revised capital grant and project rental assistance program (PRAC) by the forgiveness of their existing federal mortgage; as well as the option for non-profit sponsored elderly housing financed by Section 236s (during the 5 year mortgage of the Section 202 program) to be included in the program
• Improve the administration, distribution and awareness of rental assistance vouchers for assisted living.
• Create a national affordable housing trust fund to produce a significant number of new mixed-income, mixed financed rental housing units using dedicated funds. Funds would be distributed to states based on need and states would have incentives to bring their own matching funds to the table. The newly developed, preserved or rehabilitated housing would remain affordable for the lifetime of the project

4. Need for Quality Assurance and Regulatory Reform

Nursing homes

There is no definition of quality long-term care and no yardstick for adequately measuring long-term care quality that helps consumers, regulators and policymakers distinguish between good and bad providers, and which helps providers readily identify and solve quality problems.

There is general agreement that the definition and measurement of quality in long-term care is multi-dimensional and complex. In addition to positive clinical outcomes desirable in all of health care, long-term care frequently involves a residential component that can either contribute to or detract from an individual's quality of life. Quality of care, quality of end-of-life care and quality of life, though closely related, are distinct elements in long-term care.

One of the major problems impeding the development of systems to measure and ensure quality in long-term care has been the absence of a definition for quality in this setting derived from evidence-based research. There is no argument among providers, consumers, regulators and policymakers that quality of care, quality of end-of-life care and quality of life-not just delivery of services-must be integral to measuring outcomes for long-term care recipients. However, there has been little clear consensus on what this actually means for long-term care. Unlike patients in acute or subacute settings, individuals in long-term care are frequently being treated for multiple chronic conditions, have limited prognoses for healing or "cure," are experiencing the natural declines in status associated with aging and may be living in a residence other than their original homes. Thus, health outcome measures for this population must remain distinct from outcome measures generally applied to patients in acute or subacute care settings, where stays are short and clinical outcomes highly outweigh other measures. In long-term care settings, clinical as well as quality of life outcomes are equally important.

AAHSA recommends that the Commission encourage research to develop valid long-term care quality measures.

These measures must encompass a holistic view of quality covering a range of areas including: clinical quality outcomes (e.g., reductions in preventable pressure sores; incontinence care management, pain management, etc.); quality of life measures (for residents and employees); staff turnover and retention rates; workers compensation history; and measures of care coordination. Unlike the current "quality indicators" (more appropriately termed clinical markers), such indicators or measures must incorporate extensive risk adjustment mechanisms such as admission case-mix profiles, restricted denominators and appropriate designation of high/low risk groups that will allow them to provide meaningful comparative information for providers, consumers and regulators. The CMS project to develop quality of life measures shows promise for addressing some of the non-clinical areas; however, much remains to be done to develop adequate measures of clinical quality.

There are currently 24 so-called "quality indicators" (clinical markers) derived from the data collected through the Minimum Data Set (MDS) component of the Resident Assessment Instrument, mandated for use with all nursing home residents. CMS has acknowledged that MDS 2.0 contains data elements that require greater clarity and updating and is planning to address these issues in the next version of the instrument. CMS defines the "quality indicators" (clinical markers) not as definitive measures in and of themselves, but as "markers that indicate the need for additional review in a particular area." In addition, recent research sponsored by CMS has determined that more than half of the clinical markers currently in use should be dropped from future revisions to the reporting systems because of issues that significantly compromise their validity, such as low prevalence, inadequate risk adjustment, excessive interstate variation and instability over time. Researchers have recommended that none of the existing clinical markers be used in their current form, because additional risk adjustment is needed to make them appropriate for use in the regulatory process or for consumer information.

We support efforts to refine and improve indicators/markers and to develop measures of quality in long-term care, while recognizing that extreme caution must be exercised to ensure the validity and reliability of the information prior to implementation for a broad variety of users. We also advocate that CMS take steps to limit the ongoing release of misleading information to surveyors and the public through the existing "quality indicators" (clinical markers) until the necessary research is completed.

AAHSA recommends that the Commission support demonstration projects to define quality.

HHS should use its existing authority to conduct quality demonstration projects designed to define quality in long-term care through the development of clinical standards and to emphasize collaboration, consultation, education and continuous quality improvement as a means of developing alternatives to the current system.

Standards of practice such as clinical practice guidelines, critical pathways and other evidence-based approaches have become the norm in many acute and ambulatory care settings. Unfortunately, research in these areas for the long-term care population has been extremely limited. The ability to test these sorts of approaches in long-term care has been limited by an exclusive focus on regulation as the primary means to the end of quality improvement, a strategy which carries with it its own high price tag for both the federal and state governments. An investment in bringing the "state of the art" in health care quality to long-term care has promise as a more effective and efficient means of reaching the goal of continuous quality improvement of care by making tested and validated tools available to providers.

AAHSA recommends that the Commission support the use of advanced technology critical to the continuous improved development of a long-term care system for the future.

While there have been striking advances in technology to facilitate improved care and reduce unnecessary burdens on clinical staff (e.g., telemedicine, electronic medical records, computerized prescription and physician order entry, etc.), many of these technologies have not yet been widely adopted in long-term care settings. Some of the obstacles to wider proliferation include lack of affordability and inadequate approaches to reimbursement for their use, such as is illustrated in our earlier example regarding the use of telemedicine in lieu of hospitalization for necessary monitoring of a nursing home resident. Ways must be found to provide affordable access to these technologies for providers of long-term care, and existing payment and regulatory barriers to their implementa-tion must be eliminated if the field is to advance and to ensure continuous quality improvement.

Another concern affecting quality assurance in nursing homes is the subjective, ineffective survey, certification and enforcement system for long-term care does not recognize or improve quality care and provides inadequate information to consumers and providers.

CMS' ongoing efforts to achieve greater consistency in the interpretation and implementation of the long-term care survey and enforcement protocol are to be commended. However, few would dispute that the system is plagued with inconsistencies in survey results and the imposition of remedies. Standards for determining the existence of a deficiency, identifying if actual harm has occurred and designating scope and severity levels vary from region to region, state to state and even within some states.

Interpretations of CMS policy directives also vary, especially among CMS regions. These inconsistencies result in a lack of predictability that compromises the integrity of the entire process. They diminish the efficiency and potential usefulness of the survey process as a proxy for quality measurement and a basis for fair and effective enforcement.

The present regulatory system has developed into an adversarial process that pits surveyors against nursing facilities, intermediate care facilities for persons with mental retardation and developmental disabilities and home health agencies-rather than allowing all parties to work together to improve quality of resident care and services.

The process is based on the presumption of negative outcomes, distinguishing only between compliance and noncompliance, and never recognizing excellence. A perfect survey merely means the absence of observed violations or deficient practices. It says nothing about whatever positive actions the facility is taking for its residents or any innovative programs it may have put in place for residents and clients or staff. A deficiency-free survey is perceived less and less as a marker of good care. In fact, it is often viewed as an indication that the surveyor is not applying the appropriate level of scrutiny to the facility. The result is an environment in which it becomes almost impossible for a good surveyor and a good facility to coexist.

The increasingly negative climate surrounding the long-term care survey and enforcement process has repercussions beyond the statement of deficiencies and any remedies that may be imposed. The damage to employee morale emanating from such a system makes it far more difficult for long-term care providers to recruit and retain qualified staff at a time when they are already experiencing a staffing crisis at all levels.

A more reciprocal approach to surveys needs to be developed-one that allows surveyors and caregiving staff to work together, not only on promoting and achieving sustained compliance, but on meeting individual care needs and expectations to improve care. In the long-term, we must create a new system-one focused on outcomes and continuous quality improvement, rather than process. The focus of the survey and enforcement process should be on solving problems and offering expert guidance rather than on punishment.

In summary, we are not asking for less government. We are simply asking for smarter government-a system that recognizes, builds on and improves quality care.

AAHSA recommends that the Commission support the following immediate and long-range remedies to the survey, certification and enforcement system:

• Direct CMS, CMS regional offices and state survey agencies to abide by a policy that supports an environment of collaboration and cooperation among surveyors and providers to solve problems, disseminate best practices and optimize quality care and quality of life in nursing facilities.
• Direct CMS regional offices and state survey agencies to implement CMS' policies and directives in the same manner as promulgated by the CMS central office.
• Inject due process into the informal dispute resolution process by requiring face-to-face proceedings and by allowing providers to challenge scope and severity of and selection of remedies for deficiency citations and by requiring that those who preside at the proceedings be truly independent and have no part in the survey process.
• Direct that neither facilities nor surveyors have the authority to change a physician's order when they question the medical judgment. Provide guidance that in such cases, facilities have a responsibility to question or challenge the physician in the resident's best interest, and surveyors must determine if the facility's response to the order complies with Medicare and Medicaid requirements.
• Liberally grant waivers to states that would test alternative survey processes such as surveying facilities with good track records less frequently and facilities with poor track records more frequently.
• We ask that the Administration and Congress take actions to clarify the use of survey and other quality assurance documents at trial to create a fair playing field, based on state negligence law.

AAHSA recommends that the Commission support age-distinct senior housing

Over the past few years the shortage of affordable housing and confusion over regulations have contributed to the inappropriate mixing of frail elderly with non-elderly persons with mental and physical disabilities. While AAHSA members have a mission to serve the special housing needs of older persons, many of our members also have a mission to serve others with special housing needs, including non-elderly persons with disabilities. Their extensive experiences with serving each of these special populations underscores that the inappropriate mixing of these populations with different housing needs is a disservice to each. Yet, current confusing regulatory guidance about the right to operate age-distinct housing dissuades those who seek to maximize efficiencies of programming for groups with common needs and supportive services.

While the Fair Housing Act Amendments allows facilities to be classified as "housing for older persons" under some circumstances and allows them to restrict admissions to serving only older persons, the Department of Housing and Urban Development has refused to designate federally subsidized elderly housing as exempt from the familial status provisions of the FHAA. This simple designation would remove a major barrier in encouraging the efforts of senior housing providers to expand their efforts to meet the needs of the growing low-income senior population.

In addition Congress has clearly expressed its intent to afford providers the option of developing affordable housing targeted for specific populations, particularly with the distinctions provided in the 1990 Housing Act between the Section 202 Supportive Housing for the Elderly and the Section 811 Supportive Housing for Persons with Disabilities.

AAHSA recommends that the Commission support actions to:

• Clarify the option for age-distinct elderly housing; and direct HUD to designate its senior housing programs as exempt from the familial status requirements. Revise regulatory guidance to protect the right to operate age-distinct housing, and develop a process allowing existing HUD senior housing program providers to request and receive designations as providers of age-distinct housing.
• Ensure that stakeholders or enforcement agencies have a clear and comprehensive understanding of how the FHAA, Americans with Disabilities Act (ADA), and Section 504 regulations interact. Establish a stakeholder task force, including providers, architects, consumers (the public), and agency officials from the various Federal departments that have a role in regulatory interpretation and enforcement.
• Develop a series of educational materials and a national strategy for educating all parties involved, including those who are doing the enforcement to assure consistent application of agency investigation and enforcement guidelines and a solid understanding of the regulations that they are charged with enforcing.

Conclusion

In order to develop a healthy, affordable, and ethical system of long-term care, services, and housing for older Americans, we must integrate services into a seamless continuum that is adequately financed, appropriately staffed, and effectively monitored to ensure quality.

AAHSA's representation of the full long-term care continuum allows us to fully understand how each piece of the continuum is critical, serving a particular population and providing the least restrictive, lowest cost level of care necessary for each individual. There is a place for, and a value of, the entire continuum of care and AAHSA hopes that the Commission's recommendations will acknowledge the importance of the full range of services necessary to serve our aging population. As the continuum becomes more sophisticated, AAHSA anticipates seeing more flexibility and more access to the most appropriate care for individuals. This could mean, for example, that more nursing homes would also sponsor home care services, thus offering consumers a broad range of services, all of which they may or may not need. The result is that consumers have real choices, nursing homes facilitate lower levels of services than is traditional, and costs are kept down. AAHSA supports this kind of approach, where the continuum becomes seamless and a full range of senior needs is met by a strong range of services.

Once again, AAHSA appreciates the opportunity to testify before the Commission today. Our website, www.aahsa.org, contains additional background materials on these complex issues.