When a North Carolina assisted-living facility accepts a resident, the home has the legal responsibility to look after the person or to find a safe alternative placement.
But a bill making its way through the state House would shift that responsibility to county social services departments, which don't want the responsibility of dealing with early-morning phone calls demanding the care of a person with a disability such as dementia.
The bill also would allow facilities to escape state sanctions after making an unsuccessful attempt to find a new place for a resident.
Some advocates for older people say the bill could result in some of the most dependent residents being released to homelessness.
The assisted-living industry says the ultimate authority shouldn't rest with the businesses. Once a resident becomes too ill or disruptive, he or she could endanger the safety of others, said Lou Wilson, a lobbyist for an assisted-living trade association.
"I don't think facilities should be let off of the hook of a safe and orderly discharge, or even helping that person find a place," Wilson said. "But to say to the facility that it is totally your responsibility, that is wrong."
Introduced by Rep. David Lewis, a Dunn Republican, the bill has been referred to the House health and human services committee, but it was not on the committee's calendar as of late last week. Lewis could not immediately be reached for comment.
The bill has sparked discussion about the duty and ability of state-licensed homes, which earn higher reimbursement for caring for residents with dementia, to continue caring for them when their situations take a turn for the worse.
The number of beds dedicated to secure care in North Carolina has increased 240 percent since 2003, according to state figures. The surge reflects marked increase in dementia patients.
"Securing a subsequent placement is the most essential piece of a safe and orderly discharge," said Annaliese Dolph, director of public policy for Disability Rights North Carolina. "By shifting this responsibility to already overburdened county DSS offices, the adult care homes could discharge adults to homelessness without bearing any responsibility."
Some advocates for older people say they'd be willing to accept a negotiated compromise with more shared responsibility for finding spots for difficult residents.
Under the current arrangement, advocates say, the businesses are happy to take residents, including those with dementia, when they are more manageable. But the businesses want to be able to discharge them if they become too difficult to handle.
"The bill calls for the county to have placement responsibility for residents that the facilities are unable to look after," said Gail Holden, director of adult services for Wake County Human Services. "It could be residents in Alzheimer's special care units or younger residents with mental illness that have exhibited aggressive behaviors."
A contract signed
As head of Triangle J Area Agency on Aging, which coordinates aging services in seven central North Carolina counties, Joan Pelletier works with regional ombudsmen who respond to resident and family complaints. The ombudsmen often wind up trying to mediate between an assisted-living home and a family who placed an aging mother or father there because their best efforts to keep the parent at home weren't good enough.
"I am not without empathy for these facilities," Pelletier said. "But that's the responsibility that's built into the expectations of their work.
"Are there not ways that they can address these individuals, such as increasing staffing, or better screening at intake?"
The state's 178 special care units strive to advertise that they're qualified to take residents with dementia. But to accept such residents, the facilities must tell guardians or relatives how they will respond to changes in a resident's condition. They also have to spell out how they will deal with changes specific to dementia, such as wandering, ingesting nonfood items, falling and behaving aggressively.
"The facilities are the ones that made the decision to accept the individual, and they signed a contract" agreeing to look after the person, Holden said.
Advocates say that residents who start showing clearer signs of dementia are sometimes discharged, particularly from settings withmany other residents, even though it's known that people with Alzheimer's get worse as time goes on. Patients with worsening physical conditions, or those who can't pay, can also be told to leave.
"We have people in our facilities who may be dangerous, and there might be someone who is a brittle diabetic and that facility might say, 'I can't handle that person,'" said Wilson, with the assisted-living association.
("Brittle" diabetes refers to patients with frequent marked swings in blood glucose levels.)
Missing dialogue
Mary Bethel, a lobbyist for AARP, said the issue would have been better addressed by first gathering owners, state regulators and advocacy organizations for discussions.
"One of the big issues is that we need to assure that there's an appropriate evaluation of people upfront" so that residents don't move into centers that can't handle their needs, Bethel said.
Susan McCracken, director of social services for Lincoln County, learned about the bill in her role as committee chair for aging services for the state association of social services directors.
"It's that opportunity for a dialogue: How are these people that might be on the streets, what's going to happen to them?" McCracken said. "We are talking about people that have no ability to look after themselves. They could wind up back in jail, back on the streets, back wherever."
Wilson, a longstanding advocate for higher reimbursements for assisted-living homes, said higher levels of staffing would make it possible for some troublesome residents to get needed support. It's unfair for the state to accept nursing-home levels of care from centers where reimbursement is lower, staffing is skimpier and training is lighter, she said.
Mixed populations of frail elderly residents and younger people with mental illness require more skilled staff and also contribute to frictions that could lead administrators to turn residents out, Bethel said. "It's a big issue for families," she said. "And then you do have situations where there are no families to help out."
