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BOARD AND CARE HOMES

Board and care homes are a communitybased residential option for older adults requiring care and services. As part of the continuum of care from home to nursing home, they assist primarily those not needing nursing or medical care but unable to live independently due to physical or cognitive impairments. Homes range in size and in extent to which the environment is institutional, from very small, family-style, residential settings in communities of single-family homes to larger, multiroom, more "institutional" facilities (Morgan et al., 1995). Regardless of size, board and care facilities offer residents shelter (room), meals (board), twenty-four-hour supervision, and a range of services, often for a minimal cost.

Defining board and care

The legal definition of what constitutes a board and care home depends on local, state, and national statutes, and is related to the health and welfare agencies that monitor homes. Nomenclature varies widely. As noted by Robert Rubinstein, the middle range of care settings includes such alternatives as sheltered housing, domiciliary care, adult foster care, small congregate homes, and assisted living. The same name may be used for different types of settings in different states, making it hard to distinguish board and care facilities (McCoy and Conley). However, the term "board and care" is often used to describe the range of non-nursing home care arrangements, including many of those listed above.

Distinctions between board and care and "assisted living" are blurred. Assisted living is the name given to a consumer-focused residential model emphasizing privacy, independence, decision making, and autonomy. Moreover, the label "assisted living" has been used to differentiate this type of housing from conventional board and care housing and the negative connotations that some people associate with it (GAO, 1992; Kane et al.). In many states considerable overlap exists between board and care and assisted living, and the terms may be used interchangeably (Mollica).

Size is often a distinguishing feature in board and care settings. In particular, small board and care homes are often distinguished from larger, multiunit, purpose-built facilities. Both size and coresidence of the operator differentiate small, family-type homes from larger, more institutional, staffed homes. Studies of small board and care homes have found them to be much like extended family settings in single-family homes. The majority of small home operators are middle-aged women, many of whom have limited education (Morgan et al., 1995). Living spaces and meals are often shared in these small homes, which are believed to serve a more vulnerable adult population who are poor, have inadequate kin and other support, and suffer from long-term disabilities, mental illness, mental retardation, and chronic physical conditions (Eckert and Lyon).

Estimated numbers of beds

The number of board and care facilities is difficult to establish, since there is no generally accepted definition of what constitutes such a facility or any systematic way to count them. With the emergence of purpose-built facilities offering assisted living services during the 1990s, the numbers of older adults being served in nonmedical care settings has increased substantially. Prior to the boom in assisted living, a 1987 industry survey identified about 563,000 board and care beds in 41,000 licensed homes nationally. A 1992 GAO study found some 75,000 licensed and unlicensed homes serving a million people, including half a million disabled older adults. A 1999 GAO report on assisted living that includes board and care facilities, estimates the number of beds in the United States at between 800,000 and 1.5 million. The report notes that consumer demand is expected to grow significantly as the projected number of elderly Americans in need of long-term care doubles between 2000 and 2020.

Resident characteristics

Studies of home residents find that most of them are older, frequently widowed, and lacking proximate kin (Morgan et al., 1995). Some homes accept younger physically or mentally disabled adults as well as elderly residents. In the mid-1980s it was estimated that older people constitute 40 to 60 percent of the board and care population, with the largest category of residents being older, functionally impaired women (Dobkin).

Most home residents have multiple health problems or cognitive problems that make it risky or impractical to live independently (Dittmar and Smith; Morgan et al., 1995). In many cases the number of limitations in Activities of Daily Living among residents in board and care homes approaches that found among nursing home residents (Morgan et al., 1995; Morgan et al., 2001).

In small homes, a high percentage of residents are economically disadvantaged, receiving support from Supplemental Security Income or state programs to provide for their care (Morgan et al., 1995). Fees that residents pay for care and housing come from state-funded programs, personal savings, Social Security or other retirement benefits, family contributions, or private insurance. Since fees range from a few hundred dollars to several thousand dollars per month, board and care has met a need to provide an alternative for low-income elderly persons, who would be unable to afford the newer assisted-living facilities on meager private resources.

Services

The goal of board and care facilities is to provide housing and supportive services to individuals who are sufficiently impaired to require regular assistance with or supervision of daily tasks but are not in need of medical intervention (i.e., nursing care) on a regular basis. As with many older adults, needs at these midlevel facilities are for assistance with personal care, mobility, and supportive services, such as meals, laundry, medication management, and housekeeping.

The services provided in board and care homes, while variable across facilities, focus on helping with the daily tasks and personal care needs of residents, rather than with health care services. The range of services provided to residents is quite broad, responding both to their diverse needs (driven by both physical and cognitive impairments) and to variations among the facilities in terms of size, willingness to deal with more difficult or advanced care needs, and the fees paid for care (Morgan et al., 1995). Some homes offer a substantial range of services, while others provide a limited set at lower cost. In general, however, basic services to residents include meals, room, twenty-four-hour oversight, assistance in personal care (bathing, dressing, etc.), homemaking services, and assistance with mobility and with taking medications (Morgan et al., 1995). In addition, recreation, transportation, beautician/barber, and laundry services may be included. To the extent that homes attempt to keep residents from relocating to nursing homes, more advanced care may also be arranged, including assistance with feeding, toileting, mobility, and orientation, and even some nursing services. These services, enabling homes to keep residents and permit them to "age in place" as health declines, may be provided outside the home or by outside service providers delivering care within the board and care home.

Funding and regulation

The topics of funding and regulation are typically discussed together, since they are related. For much of its history, board and care has operated as a "grassroots" option, out of view of public funding and regulation (Morgan et al., 1993; Nolin and Mollica, 2001). While public sources of funding have been unavailable throughout most of this history, board and care homes have also, until recently, been largely unregulated, especially if they are small (Morgan et al., 1995). Given that public funding has focused on medical needs of older adults via Medicare, and nursing homes via Medicaid, the nonmedical housing and support provided by board and care homes has been privately paid by most residents or their families. In some cases, state programs have provided support to the poorest elders living in board and care homes (Dobkin, 1989).

That situation has been changed by the utilization of Medicaid waiver monies and funds to support community-based care, thus providing public monies to support the care of older adults residing in board and care homes in some states. This change has been motivated by the generally lower costs for board and care than for nursing homes, with the expectation that public costs overall would remain lower for individuals able to remain in board and care facilities rather than nursing homes (Nolin and Mollica, 2001).

At the same time that funding is beginning to flow from federal sources, states are moving rapidly in the direction of regulating smaller, non-nursing home facilities, driven both by the boom in assisted living and by the earlier reports of poor care in board and care homes (GAO, 1992). State regulations include size requirements, staffing, services, whether units may be shared, transfer policy, and resident rights (see Mollica, 2001). It is unclear whether board and care will flourish, change, or disappear under the dual thrusts of state regulation and the growth in private-pay assisted living facilities.

J. KEVIN ECKERT LESLIE A. MORGAN

See also ASSISTED LIVING; HOUSING; LONG-TERM CARE.

BIBLIOGRAPHY

DITTMAR, N., and SMITH, G. P. Evaluation of Board and Care Homes: Summary of Survey Procedures and Findings. Denver, Colo.: Denver Research Institute, 1983.

DOBKIN, L. The Board and Care System: A Regulatory Jungle. Washington, D.C.: American Association of Retired Persons, 1989.

ECKERT, J. K., and LYON, S. "Regulation of Board and Care Homes: Research to Guide Public Policy." Journal of Aging and Social Policy 3, no. 3/4 (1991): 147–162.

General Accounting Office (GAO). Board and Care Homes: Elderly at Risk from Mishandled Medications. House Select Committee on Aging, HRD 92-45. Washington D.C.: U.S. Government Printing Office, 1992.

General Accounting Office (GAO). Assisted Living: Quality-of-Care and Consumer Protection Issues in Four States. GAO/HEHS-99-27. Washington, D.C.: U.S. Government Printing Office, 1999.

KANE, R.; WILSON, K. B.; and CLEMMER, E. Assisted Living in the United States: A New Paradigm for Residential Care for Frail Older Persons. Washington, D.C.: American Association of Retired Persons, 1993.

MCCOY, J., and CONLEY, R. "Surveying Board and Care Homes: Issues and Data Collection Problems." The Gerontologist 30 (1990): 147–153.

MOLLICA, R. L. "State Policy and Regulations." In Assisted Living: Residential Care in Transition. Edited by Sheryl I. Zimmerman, Philip D. Sloane, and J. Kevin Eckert. Baltimore: Johns Hopkins University Press, 2001.

MORGAN, L. A.; ECKERT, J. K.; and LYON, S. M. "Social Marginality: The Case of Small Board and Care Homes." Journal of Aging Studies 7, no. 4 (1993): 383–394.

MORGAN, L. A.; ECKERT, K. J.; and LYON, S. M. Small Board-and-Care Homes: Residential Care in Transition. Baltimore: Johns Hopkins University Press, 1995.

MORGAN, L. A.; GRUBER-BALDINI, A. L.; and MAGAZINER, J. "Resident Characteristics." In Assisted Living: Residential Care in Transition. Edited by Sheryl I. Zimmerman, Philip D. Sloane, and J. Kevin Eckert. Baltimore: Johns Hopkins University Press, 2001.

NOLIN, M., and MOLLICA, R. In Assisted Living: Residential Care in Transition. Edited by Sheryl I. Zimmerman, Philip D. Sloan, and J. Kevin Eckert. Baltimore: Johns Hopkins University Press, In press.

NOLIN, M. A., and MOLLICA, R. L. "Residential Care/Assisted Living in the Changing Health Care Environment." In Assisted Living: Needs, Policies in Residential Care for the Elderly. Edited by Sheryl Zimmerman, Philip D. Sloane, and J. Kevin Ekert. Baltimore: John Hopkins University Press, 2001.

RUBINSTEIN, R. L. "Long Term Care in Special Community Settings." In Long Term Care. Edited by Z. Harel and R. Dunkle. New York: Springer, 1995.