Over the past two years, dozens of unlicensed residential facilities offering elder care have opened in neighborhoods around Hawaii, embracing a new model that its proponents herald as safe, effective and the wave of the future.
But critics contend the homes flout state law and circumvent oversight designed to protect vulnerable seniors.
The debate over these businesses, called “aging in place” facilities, is expected to be taken to lawmakers in the upcoming state legislative session and likely will trigger broader discussions about the state’s ability — some say inability — to effectively oversee an industry that needs to grow substantially to care for Hawaii’s mushrooming elder population.
Even as the state Department of Health pursues legal steps to try to close some of these new facilities, others are popping up.
One of the aging-in-place model’s chief proponents estimated that more than 100 and possibly even 200-plus have opened within the past several years, and she said she gets at least two calls a week from people interested in opening others. Many callers already run licensed care or adult foster homes but want to convert to the AIP model.
“It’s taken off like wildfire,” said Maile Harada, a registered nurse and case manager who has assisted operators in opening facilities. Last week, she registered with the state a nonprofit called the Aging in Place Association, an advocacy group that plans to adopt membership standards designed to maintain good quality care.
What has attracted operators to the AIP model also has attracted the scrutiny of regulators and the wrath of licensed care home operators.
A new model for care
Proponents said these facilities can provide good care to seniors without having to be subjected to what they describe as an onerous, inefficient and inconsistent state licensing and inspection process. They are able to do that, supporters maintain, by treating the residents as renters.
Under the model pushed by Harada and the association, residents sign a boarding agreement with the homeowner, setting the monthly rent. They sign a separate agreement with a home health care company, specifying a set rate each month for care that can be as basic as getting help with daily living activities or as complex as nursing-home- level services.
Sometimes, the home and care company are owned by the same person.
The care is overseen by independent nurses, referred to as case managers, who monitor their clients to ensure their needs are being met.
Harada said AIP facilities are not care homes, which require state licenses, but are rental homes in which the residents get health care. She said three lawyers have reviewed the model and concluded that it complied with Hawaii law.
What’s more, Harada noted, the state can’t dictate where someone rents a home or whether the person is able to get care in that home.
“We think this is a good model that will provide a really good service to Hawaii,” Harada said, adding that the owners are not “trying to get around the Department of Health.”
Questions of legality
But Keith Ridley, chief of the agency’s Office of Health Care Assurance, which oversees state-licensed facilities in Hawaii, told the Honolulu Star-Advertiser that he believes the AIP operators are trying to skirt the intent and spirit of state law. Hawaii statutes require caregivers to have a state license to provide care in a home to a non-relative for a fee.
“They seem to be trying to get around that,” Ridley said.
Following up on complaints, he said his agency has investigated several facilities and is pursuing legal measures to force them to cease operating.
Harada said none of the homes using the association’s model have been shut down.
While the legality of the AIP homes ultimately may have to be decided in the courts, the state is pursuing a legislative fix as well.
Ridley said his agency is working with a legislator on a bill that would make it easier for the state to shut down unlicensed operations. The measure is expected to be considered in the upcoming legislative session.
Ramon Sumibcay, a licensed care home owner and president of the Alliance of Residential Care Administrators, said allowing AIP facilities to operate without state oversight is unfair to all the licensed facilities that must comply with state regulations.
The state, for instance, inspects the latter typically once or twice a year; checks to ensure that the care, building safety, environmental, training and other standards are met; and posts inspection results online so the public can get easy access. The state provides no such oversight to unlicensed places.
If 1,700-plus licensed elder care facilities have to abide by such regulations, the AIP homes should have to as well, otherwise everyone should be free of regulatory oversight, Sumibcay and others argue.
“It’s not fair that we are subjected to all those regulations and yet you’re letting 200 (unlicensed) homes operate,” Sumibcay said in an interview. “That’s not right.”
John McDermott, the state’s long-term care ombudsman, expressed similar concerns.
“The aging-in-place model is not licensed and doesn’t allow for these safeguards,” McDermott wrote in an article for the December edition of Generations Magazine. “And until they do, they should be shut down.”
Continuum of care
But Harada, AIP operators, and some residents and their loved ones defended the AIP model.
They said case managers ensure that the AIP residents get the services they need. And unlike with care homes, the AIP facility can provide a full continuum of care, including hospice, so the residents can remain in one place the rest of their lives, according to proponents.
“The quality of care and service is just amazing,” said Allen Kaanana, whose 93-year-old mother, Helen Kaanana, has been in a Salt Lake AIP home since January.
The home, which has eight residents, was opened three years ago by Helen Ferrer, who previously ran a licensed adult foster home. She opened her AIP facility after waiting about a year to get a care home license, which she eventually stopped pursuing.
“I could not wait anymore,” said Ferrer, who added that she can provide better care as an AIP operator because she is not as pressured in dealing with inspections and other state regulations.
Jeanne Shibuya, 92, one of the eight residents in Ferrer’s home, said she enjoys living there. “The people are really nice, the food is really nice,” she said.
Fight over oversight
Harada said the AIP movement in Hawaii was born out of frustration from people waiting months or even years to get licenses approved by the Health Department or being adversely affected by inconsistent, subjective inspections.
The AIP proponents said a state license does not necessarily mean the care at that facility is high quality, noting that inspections are too infrequent to ensure that.
“To me, it’s only looking at paperwork and making sure they’re dotting the i’s and crossing the t’s,” said Harada, who has clients in licensed facilities. “The results of the inspections are not improving safety.”
Harada said she and other AIP proponents have been trying to meet with those who have expressed concerns about this model, but no one is returning their calls. While she said she would like to see a resolution reached through compromise, Harada vowed not to back down from a court fight.
Because the AIP homes aren’t licensed or certified by the state, they are not able to accept patients covered by government-funded Medicaid. That limits their market to private-pay clients only.
Costs can be similar to licensed facilities. Skilled nursing care, for instance, can run around $5,000 to $6,000 a month, according to AIP operators.
Cullen Hayashida, a gerontologist and former Kapiolani Community College professor, says he would tend to steer people away from facilities that are not licensed.
At the same time, however, Hayashida said that if the AIP model has merit, it should be evaluated, perhaps through a waiver of Health Department rules and the monitoring of a sufficient sample of residents and other data over several years.
“If this is in fact innovative, let’s document the evidence so that we can improve our overall system of caring,” he wrote in an email. “Let’s not stifle innovation if it is in fact innovation and not just the circumvention of the rules.”
