ALFA policymaking moves ahead: interview with Tom Grape and Janet Forlini.

"In late April the Assisted Living Workgroup, at the behest of the U.S. Senate Special Committee on Aging, put forward its long-awaited recommendations for enhancing quality of care in assisted living. The creation of the Workgroup and its final report provided the Assisted Living Federation of America (ALFA) an opportunity to express, in a supplemental report, its long-held beliefs that viable assisted living regulations should be consumer-oriented and centered on state-based laws. Why did ALFA take this approach to this momentous initiative in the development of recommendations for the federal government? Why, shortly thereafter, did ALFA hire a key aide from the staff of powerful Sen. John Breaux (D-La.)--Janet Forlini--as its direct liaison with Congress? And how does all this work with ALFA's recent emphasis on the word "Federation" in its name? Recently, ALFA Chairman Tom Grape and Ms. Forlini fielded questions on these issues and others from Nursing Homes/ Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: Why didn't ALFA sign on with the Assisted Living Workgroup's report and instead file its own supplemental report to the Senate Special Committee on Aging?

Grape: ALFA applauded the Special Committee's initiative in forming the Workgroup. To clear tap any misconceptions about the supplemental report, there are numerous Work group recommendations that ALFA voted to support--measures that are consistent with ALFA's philosophy that regulations should foster both state flexibility and consumer choice. By offering supplemental positions on other recommendations, ALFA was afforded the opportunity to articulate this philosophy.

Peck: Was the reason behind this that the Workgroup's recommendations tended to be relatively prescriptive compared with ALFA's stance favoring consumer-directed assisted living?

Grape: There were specific recommendations that ALFA felt removed states' opportunity to determine their own regulatory paths and restricted consumer choice in assisted living. We felt it was important to express our long-held views on this.

Peck: Let me play devil's advocate and advance some of the arguments made for more federal involvement in assisted living and get your responses. What about the argument, for example, that federal standards make more sense from the multistate operational standpoint than differing state-specific regulations, because they are administratively easier to understand and cope with?

Grape: ALFA has long recognized the differing needs among consumers and states. We have noted over the years a lot of creative models of assisted living being generated in various states and think that this is a stronger approach from the consumer standpoint.

Forlini: The needs and wishes of a person in a rural, Midwestern small town are likely to differ from those of someone living in a large city. This closer-to-the-grassroots approach allows for that sort of accommodation.

Grape: We have also noted that uniform requirements of assisted living operators may not work well for--in fact, may be a detriment to--smaller operators, who have neither the need nor the money to implement all of them.

Peck: As a multistate operator yourself--as president/ CEO of Benchmark Assisted Living--have you found keeping up with various state regulatory programs to be impractical or a burden?

Grape: Not really. Sure, it's an inconvenience at times, but we have people on the ground keeping track of things in all the states we're involved in; it's a fact of business life, and not a big problem.

Peck: What about the argument that with strong regulation, society knows where it stands with providers--either they're compliant or they're not--whereas with consumer-directed assisted living, it's difficult to determine what consumer satisfaction means or what to do if consumers are dissatisfied?

Grape: The development of consumer-based outcomes measurement, the way we would like to see it done, will be the subject of discussion and research for some years to come. But consumers already have a means of registering their satisfaction or dissatisfaction: They move in and they move out. More refined measurements of satisfaction are important but will take more time.

Peck: Some observers have noted that industries such as nursing homes, for example, seem to have more political power at the state level than at the federal level, and that big government, paradoxically enough, is on the side of the "little guy." What about that argument against leaving assisted living regulation to the states?

Forlini: That seems to be missing the point. The question is, in which venue will consumers be served better? Our view is that the states are closer to the action.

Peck: Janet, as a former aide to a high-ranking senator, what is your sense of Congress's sentiment regarding OBRA-style regulation? I sometimes get the impression that there's a fairly large consensus against it.

Forlini: Without disparaging OBRA in general, there seems to be a sentiment across a broad political spectrum that some misregulation of nursing homes is occurring. An example is the denial of funding for nurse aide training for facilities at a certain level of deficiency, which seems to be the exact opposite of what these facilities need. There is pretty widespread recognition that assisted living is a different model of care, requiring a different approach.

Peck: Is there any particular view of assisted living that prevails on Capitol Hill?

Forlini: There is a growing understanding among members that with the baby boomers becoming seniors, long-term care needs attention. The dialogue is changing, and people are using different terminology--for example, "continuum of care." There are also a number of people in Congress who have a personal involvement in long term care through family members, and of course that makes it more prominent in everyone's eyes. Specific interest in assisted living itself varies from person to person but, in general, long-term care is becoming a priority.

Peck: What about your former boss, Senator Breaux? How does he look at long-term care these days?

Forlini: He's one of those who are changing the dialogue and, in general, he's very optimistic. He's focusing on the continuum of options in long-term care and on the development of private long-term care insurance, and he's excited about the growth of those industries. He senses, as I mentioned earlier, that the momentum is turning in favor of long-term care issues.

Peck: What are ALFA's legislative priorities now?

Grape: We will continue to communicate and foster dialogue with other Assisted Living Workgroup organizations and update our legislative agenda more specifically after Janet has had a chance to settle in.

Peck: What about the word that ALFA is going to focus more on developing its federation structure?

Grape: A lot has already happened in that direction--for example, state representatives are involved in a lot of ALFA activities, elect some board members, and continue to be deeply involved in public-policy conversations. We, as an organization, are committed to working with assisted living at the state level, so continued empowerment of our state affiliates is a real priority.

Tom Grape is chairman, and Janet Forlini is senior vice-president/ director of public policy, Assisted Living Federation of America. For further information, contact ALFA at [e-mail] or visit www.alfa.org. Visit www.alworkgroup.org to read the Workgroup's report. To comment on this article, please send e-mail to [e-mail].