Assisted Living in Rhode Island

Assisted living residences (ALRs) are an important part of the spectrum of long-term care for older adults. They serve as an intermediary option for individuals who can no longer live independently at home but do not need round-the-clock nursing home care.¹ ALRs provide a wide range of services to residents and offer 24-hour security and staff availability in case of emergency. Typical services include housekeeping, laundry, and meals; assistance with activities of daily living such as bathing, dressing, and grooming; medication management; social and recreational activities; health and exercise programs; and transportation services.²

In Rhode Island,^(a) there are approximately 76 licensed ALRs.³ Our research explores the landscape of assisted living in the state and shares perspectives from administrators, staff members, and residents at five ALRs. We conducted semi-structured interviews with four ALR administrators, three focus groups with staff, and four focus groups with residents. For the purposes of this report, we analyzed data on the 60 ALRs that are members of the Rhode Island Assisted Living Association (RIALA).

The Landscape of Assisted Living in Rhode Island

The 60 ALRs that are members of RIALA provide long-term housing and services to approximately 4,419 Rhode Islanders. These facilities range in size from small establishments with a handful of beds to much larger, apartment-style residences with space for more than a hundred older adults. Thirty eight (63%) of the ALRs in RIALA have a capacity of between 26 and 100 residents, while fourteen (23%) can accommodate more than a hundred residents. In addition to older adults, ALRs can serve specific population groups, including individuals with chronic mental health conditions and HIV/AIDS. The vast majority (96%) of ALRs in Rhode Island, however, focus on caring for older adults (age 65+).

ALRs vary widely in the level of care they provide. The majority offer long-term care, housing, and custodial care services. A number of ALRs in Rhode Island have the capacity to provide more intensive care and health services to residents.^(b) Fourteen (23%) of the residences in RIALA offer skilled nursing services and 10 (17%) have a Limited Health Services (LHS) license, which allows them to provide basic medical services that include pressure ulcer treatments, simple wound care, ostomy care, and urinary catheter care.

Thirty (50%) of the ALRs in RIALA are licensed to care for individuals with Alzheimer’s, dementia, and other memory issues, with a section or entire floor of the community designated for memory care services.^(c) A large share (85%) of ALRs in Rhode Island are also licensed to provide respite care, which is short-term care for people with physical or cognitive needs that is designed to provide temporary relief for their regular caregivers.

Paying for Assisted Living

In 2017, the median monthly cost for ALR care in Rhode Island was $5,155 ($171.83 per day).⁴ Many ALRs charge extra for certain services such as medication administration and personal care, which can increase the cost to $7,000 or more per month. Most residents pay for ALR housing and care services out of pocket. Four out of the five ALRs we focused on in this study were primarily funded by such private payments. However, some ALRs also accept government-subsidized general income support waivers and other benefits that may be used to pay for some or all of the ALR services.

Long-term care subsidies from the federal government that can be used to pay for ALRs include Veteran’s Affairs (VA) benefits for military veterans and Supplemental Security Income (SSI) benefits for older adults and disabled individuals with little to no income and financial resources. The VA benefit amount may differ based on the length and type of a person’s military service. SSI benefits for eligible Rhode Islanders living in ALRs equate to $1,082 per month to pay for all services and room and board, as well as a Personal Needs Allowances (PNA) of $55 per month.⁵ While fifty-one (85%) of RIALA’s ALR members accept VA benefits, only six (1%) accept the SSI benefit alone to cover all board and care expenses. The vast majority of ALRs do not accept the SSI benefit alone because it does not cover all service and room and board costs, and the individuals that qualify for this benefit typically do not have additional resources to cover the remaining costs.

More recently, states have also been attempting to subsidize ALR care for low-income adults. Based on our interviews, we learned that Rhode Island has attempted to collapse all existing waivers for long-term care, such as those from Medicaid and the Department of Elderly Affairs (DEA), into a single “Global Waiver.” This pilot program is designed to help individuals obtain care so they can “maximize their independence and remain in the least restrictive environment for as long as possible.”⁶

The Rhode Island DEA typically manages waivers for eligible individuals who are 65 or older. To be eligible for the Global Waiver, individuals must qualify for Medicaid long-term care, have a monthly income of under $2,205, have assets below $4,000, and have a determined level of care according to new Level of Care procedures. The program is only available to NHPRI (Neighborhood Health Plan of Rhode Island) Medicaid clients, not FFS (Fee-For-Service) Medicaid clients. A case management team from either the DEA’s Office of Community Programs or Regional Case Management network conducts comprehensive assessments and care plans for those who qualify. According to data from RIALA, twenty-five (42%) ALRs in Rhode Island accept the Global Waiver, and one of the goals of the pilot program is to reach providers that currently do not accept the waiver.

The Preference for Private Pay Clients

While a range of government subsidies can be used to pay for ALR care, our research shows that many ALRs in Rhode Island do not accept these subsidies. In our interviews, administrators of ALRs that are primarily private pay reported that, even if they accept certain waivers and benefits, they only allocate a very limited number of beds for individuals paying through these government-subsidized programs. These beds are often reserved for residents who have already paid privately to live in the ALR for years and have spent down their assets to the point where they now qualify for government assistance.

The reason many ALRs are unwilling to accept government subsidies is simple: cost. Administrators we interviewed said that accepting too many individuals on Medicaid waivers, for example, could put their ALR at a fiscal disadvantage because of the significant difference in government reimbursement rates and what they charge private pay residents. While ALRs that cater to specific sub-populations, including veterans and low-income individuals with mental health conditions, are more likely to accept VA and SSI benefits, our research suggests that there may not be enough of these facilities to meet demand.

The preference for private pay clients limits access to assisted living to more affluent individuals who do not need government subsidies. In our focus groups with low-income residents of an ALR that does accept SSI payments, people reported that there were very few other options available to them and that most ALRs in Rhode Island that once accepted government subsidies are now closed. Many seniors expressed a fear of ending up in a nursing home because there are no less restrictive options. In our focus groups with staff, we found that many direct care staff enjoy their work but believe it is unlikely they will be able to live in an ALR once they get older because of the high cost of care.

Making Community-Based Care an Option for All Older Adults

In recent years, community advocates, lawmakers, and researchers have promoted a shift in how long-term care for older adults is provided, moving away from more institutional environments toward care offered in home and community-based settings (HCBS) whenever possible. Our findings suggest that Rhode Island’s ALRs are equipped to support this shift, since many of them are able to provide more advanced care to those who need it, including skilled nursing services, hospice care, and care for individuals with dementia and other memory challenges. Additionally, the temporary respite care that a significant majority of ALRs offer can serve as an important resource for families caring for their loved ones at home.

Per our interviews, the most pressing challenge is not ALR capabilities but reimbursement rates. Many stakeholders have advocated for a rebalancing of state and federal support for formal long-term care services, with more funds going toward HCBS, including ALRs. Most individuals in need of formal care services prefer ALRs over nursing homes.⁸ Yet our research indicates that ALRs are unlikely to accept residents who qualify for government waiver and benefit programs.

If policymakers want more long-term care funding to flow to HCBS, they need to address the difference in government reimbursement rates and the private pay rates influenced by the market. Recent increases in Global Waiver reimbursement rates may incentivize more ALRs to accept residents that qualify for this benefit. Policymakers could also consider providing other types of incentives, such as tax credits or small-business loans, to encourage ALR providers to cater to underserved populations and to develop new ALRs in lower-income areas.

Finding ways to incentivize ALR providers to serve lower-income seniors is critical. The range of licensed services that ALRs in Rhode Island currently provide (i.e., memory care, respite services, skilled nursing, etc.) may make it possible for more residents to stay despite increased frailty, but only if they can afford ALR services. The combination of being able to provide more complex care services in ALRs, avoiding unnecessary hospitalizations, and delaying premature nursing home placements may potentially lead to overall cost savings to the state.

In the past three decades, ALRs in Rhode Island have become a mainstream long-term housing option for individuals in need of formal care services. As aging and disabled populations increase, it is important to find ways to cost-effectively care for some of the state’s most vulnerable individuals. By broadening the long-term care options available and meeting residents’ shifting care needs in the community, institutionalization may be postponed or even prevented.