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PART I:
THE PLACES
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Chapter 1
What Is a Residential Care Facility?
Given the widespread lack of interest in residential care facilities, it is not surprising that many but infrequently asked questions arise. Following is a list of such questions (IAQs).
INFREQUENTLY ASKED QUESTIONS
Q. What is a residential care facility?
A. A residential care facility is a privately owned facility that functions to provide unlocked shelter, three meals a day, and supervision of medication to psychiatric patients.
Q. What is a residential care psychiatrist?
A. A residential care psychiatrist is a psychiatrist who makes routine on-site visits to residential care facilities for the purpose of treating the residents of this facility. In California residential care facilities are statistically divided into two categories, residential care facilities for the elderly (RCFEs) and adult residential facilities (ARFs).
Q. How do adult residential facilities (ARFs) differ from residential care facilities (RCFs)?
A. The adult residential facility is another name for the residential care facility. Residential care facilities also have other names in other states. Residential care facilities are also known as board-and-care homes, adult residential facilities, adult foster homes, adult homes, community care homes, supervisory care homes, sheltered care facilities, continuing care facilities, transitional living facilities, group homes, domiciliary care homes, personal care homes, family care homes, and rest homes. Although California officially uses the term adult residential facilities (ARFs) to describe residential care facilities for the nonelderly, I donât like the term because of its inherent vagueness insofar as it is possible to use the term to describe the situation of people living in retirement homes or hotels. Also ARFs inevitably invoke the inappropriate image of the balloons that come out of the head of barking dogs in comic strips. The reasons for the California preference for this term is a long story and is described in Appendix A.
Q. How do residential care facilities differ from nursing homes?
A. Residential care facilities differ from nursing homes in that the purpose of a residential care facility is to provide nonmedical personal care with the exception of the supervision of medication. Nursing homes, on the other hand, provide essential nursing care at a certain level. A licensed practical nurse must be available twenty-four hours per day. In addition, a registered nurse must be available for eight hours per day.
Q. Are nursing homes the same as skilled nursing facilities?
A. Not exactly. Not all nursing homes are qualified as skilled nursing facilities although most are. Skilled nursing facilities are specialized nursing facilities that can provide a level of care almost equivalent to that of hospitals.
Q. Are residential care facilities the same as residential treatment facilities?
A. No, they are not.
Q. What is the difference?
A. In residential care facilities, the treatment, with the exception of the visiting psychiatrist (if one exists) and the administration of medication, is done off the premises. Residential treatment facilities, on the other hand, provide treatment on the premises and are known as acute diversion units, halfway houses, three-quarter way houses, and possibly other fractional equivalents. Residential treatment facilities are richly endowed with mental heath professionals who live or work on site compared to residential care facilities where professional help is generally referred to an outside source. The principal exception to this is the on-site services rendered by a visiting residential care psychiatrist and visiting social worker.
Q. What about psychiatrists who treat residential care patients in their offices? Arenât they residential care psychiatrists?
A. Such psychiatrists are practicing standard office psychiatry in the treatment of patients who are residents of residential care facilities. This is fine except that it is not an efficient way to treat this population as a whole, although it may be the preferable treatment for an individual patient.
Q. Why is it not the most efficient way to treat this population as a whole?
A. There is no quick answer to that question. That is what this book is about.
Q. Is there a subspecialization called âresidential care psychiatryâ?
A. If there is such a specialization, sub or otherwise, I have not been able to find it via Internet searches. Also, I am not aware of any university psychiatric residency program that offers a rotation in residential care psychiatry or any of its synonyms. Therefore the answer is no, but in my opinion there should be such a specialization.
Q. Why?
A. Again, that is what this book is about.
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Chapter 2
The Problem of the Problem
As stated in the Introduction and elsewhere, residential care facilities are known by different names in different states. Generally speaking, all these facilities provide room and board, supervised medication, and assistance with the activities of daily living to chronic mental patients or individuals who are developmentally disabled.
No clear information is available on how many mentally ill residents are serviced nationwide in residential care facilities. There is a dearth of literature on this subject and a surprising lack of reliable statistics. This presents a problem in that the diversity of names prevents adequate national statistical categorizations. Without reliable statistics, it is difficult to identify a constituency. This has contributed to the legislative neglect of this population when compared to the legislative mandates affecting nursing homes. Where no identifiable constituencies exist, there are no lobbies militating for legislative oversights. However, regardless of what they are called, all these facilities share the essential characteristic of being the domiciles of mentally ill patients in their adult years, some of whom may be considered borderline geriatric patients.
In a sense these facilities are long-term care facilities. For many people long-term care necessarily connotes a facility for the elderly, but in fact many chronic psychotic patients spend much of their young and middle years in facilities designed for the nongeriatric. Many chronic schizophrenic patients spend most of their lives in a residential care facility, and in that sense the long-term care provided by these facilities is probably longer in duration than the long-term care provided by facilities for geriatric patients.
Chronic psychotic patients get older and eventually qualify for placement in the geriatric long-term care facility. However, although much has been written about the treatment of geriatric patientsâboth psychiatric and nonpsychiatricâin long-term care facilities, very little has been written about the treatment of the nongeriatric psychiatric patients in the other types of long-term care facilities.
Because of the multiplicity of names, it is difficult to determine how many chronic psychotic patients are living in nongeriatric long-term care facilities on a nationwide basis. Perhaps the least ambiguous descriptive name to define the function of these residential care facilities is âlong-term care facilities for the nongeriatric mentally ill,â but this term is somewhat cumbersome and does not lend itself to easily articulated acronyms that trip off the tongue. Besides, some of the older patients in their middle years gradually become geriatric and if they are in reasonably good physical health, they tend to remain in the residential care facility rather than be transferred to a selectively geriatric facility. To make matters even more confusing, many nonpsychotic developmentally disabled residents also live in these facilities.
The problems of terminology are even more complicated than just suggested, and it is for this reason that I have previously referred the reader to Appendix A. However, because there is no agreement regarding terminology, I have decided to use the term residential care facilities because it appears to enjoy the widest usage in California.
Proposals to conduct national surveys have failed because of the high costs of data collection and the difficulty of reliably identifying residential care facilities. Improvement in the quality of information pertaining to residential care facilities is important because of the need to increase the number of residential care facilities while improving the quality of care received by the residents. This information is particularly important with respect to mentally ill residents because of the increasing tendency by psychiatric hospitals to make quick discharges to community facilities in response to the tendency of thirdparty payers to decertify payment. Because of this, it is easy to see how economic trends will cause residential care facilities to proliferate. The decennial census should be the primary source of national statistics on residential care facilities, but unfortunately the rules addressing the classification of living arrangements have created insurmountable barriers to accumulating meaningful information regarding the numbers of residential care facilities or the characteristics of their occupants.
THE PROBLEM OF DATA COLLECTION
One of the problems of data collection is that a continuum of facilities provides varying degrees of care and protective oversight to a variable number of residents. Some of these facilities are institutions, but it can be difficult from the statistical point of view to distinguish noninstitutional residential care facilities from institutions, especially since the number of residents alone is an insufficient basis for differentiation. The problem is compounded by the fact that states have different licensing laws and in some states the distinction between nursing homes and residential care facilities is not clearly delineated.
In 1987 a national survey of state licensing agencies was conducted by the National Association of Residential Care Facilities, which represents residential care facility owners and operators. The survey reported a total of 41,381 homes with 562,837 beds. Of this total, approximately 10,000 homes with about 264,000 beds were identified as primarily geriatric, with the rest servicing the developmentally disabled or the mentally ill.1
The association stated that its estimates were incomplete due to the wide variety of definitions included in licensing as well as the fact that some states were just beginning to license some homes. Confusion about the size of this population is not new. During congressional hearings in 1981, the Department of Health and Human Services estimated that boarding home population was between 500,000 and 1.5 million, but that it was unclear as to how many of these residents lived in homes that could be defined as board-and-care homes.2 There was an insufficient breakdown of residents into separate geriatric, developmentally disabled, and mentally ill categories. Also it was acknowledged that the bottom line estimate of 500,000 was necessarily an undercount because of the lack of information on the number of unlicensed facilities. Some facilities were unlicensed because the state criteria excluded them from licensing requirements. Other homes were able to meet criteria but remained unlicensed due to lack of enforcement efforts. Thus, unfortunately, there is no nationwide information on the number of unlicensed homes. No clear nationwide information exists on the number of licensed homes.
However, in California the statistics are somewhat clearer in that we have statistics regarding licensed residential care facilities statewide, and a breakdown as to how these homes are divided among the aged, the mentally ill, and the developmentally disabled. In California in 2000, there were 4,639 licensed nongeriatric residential care facilities with a bed capacity of 37,985.3 These facilities are categorized as residential care facilities by the Department of Social Services and are occupied by the mentally ill and the developmentally disabled. Of the RCF beds, 26,590 (70 percent) were occupied by residents diagnosed as developmentally disabled and 11,395 (30 percent) RCF beds were occupied by patients with mental illness.
In September 2000 in California the total number of nursing home patients (NH) was estimated at 107,084.4 We already know that mentally ill residential care facility occupants totaled 11,395. We now have a RCF/NH ratio for California (11,395/107,084 or 10.6 percent). If we label the 10.6 percent as the California ratio, it is possible to use this ratio to estimate the nationwide population of mentally ill residential care facility occupants as follows: According to the HCFA Online Certification and Reporting statistics the national number of nursing home beds for this time period was calculated at 1,490,155.5 We can now compute an estimate of the nationwide number of residential care facility beds by multiplying the nationwide nursing home beds by the California ratio of 10.6 percent. This produces an estimate of 157,956 as the number of residential care facility beds nationally.
It can be argued that such an extrapolation is unwarranted because California is not a typical state because it has a higher incidence of mental illness than the rest of the country. Although this inference may appear to be true by observing the pedestrian traffic at certain intersections in San Francisco, it is not true of the state as a whole. There may be no way to prove that California is typical of the rest of the country but the fact that California accounts for oneeighth of the national population makes it extremely unlikely that California-derived statistics would be seriously unrepresentative.
However, life is not that simple. It is probable that many more mentally ill patients occupy residential care facility beds than the 157,856 beds estimated from the California ratio,
First, the California statistics for the residential care facility population are based on licensed homes. The number of residents in unlicensed facilities is still unknown. Second, and even more important, many mentally ill residents, when they attain geriatric status at age sixty, are frequently transferred to residential care facilities for the elderly. These patients continue to be mentally ill, but they no longer occupy recognized mentally ill beds. From the statistical point of view they have literally disappeared.
This problem is increasing in importance because more schizophrenic patients are attaining geriatric status and are thus in danger of disappearing statistically. Schizophrenic patients are now living longer because many of them are being effectively treated for concurrent medical diseases such as arthritis, diabetes, heart disease, hypertension, hypercholesterolemia and the various forms of chronic obstructive pulmonary diseasesâto name only a few. To make matters somewhat more complicated, many geriatric patients have no prior history of mental illness and develop psychopathology during their residency in the facilities for the elderly. When these factors are considered it is highly probable that many more than the 157,956 nationwide residential care facility beds exist for the mentally ill than indicated by simple extrapolative methods based on the California statistics.
This is not to say that 157,956 patients are residing in licensed residential care facilities nationwide. Some states may not have residential care facilities or their equivalents. Some states have substituted other facilities such as specialized hotels to subserve the functions that would otherwise have been delegated to residential care facilities. Yet this gives some indication of the scope of the population that is in need of the services of these facilities whether they exist or not.
In addition to this population, another population of geriatric schizophrenic patients are too disabled to reside in residential care facilities for the elderly and currently occupy beds in nursing homes. In many instances the nursing home has replaced the state hospital as the repository for the severely disabled geriatric schizophrenic patient. In fact, the statistics for nursing homes are much more accurate with respect to mental illness than are the statistics for the residential care facilities for the elderly. Thus, in 1999 it was estimated that the psychiatric (mostly schizophrenic) population of nursing homes comprised 14.5 percentâor 216,072âof the total nursing home population of 1,490,155.6 If we add this to the number of psychotic patients living in residential care facilities or their equivalent (157,956), we get a total in excess of 370,000 mentally ill patients living in either nursing homes or residential care facilities. This is an estimate of the number of occupants, but does not give us information about the number of mentally ill patients who can benefit from placement in such facilities but are unable to utilize them because the number of facilities is inadequate. I am talking about the mentally ill homeless.
The mentally...
