Rick Brose spends his days as short-order cook, entertainment director, nursing assistant, medication manager and companion to the five elderly residents who live with him and his wife in their Bend home.

As owners of two adult foster care facilities, the Broses said their weekdays are focused on meeting residents needs.

But that task has become increasingly difficult in recent years, as Medicaid reimbursement rates for the services have not kept pace with the actual costs of providing the care, Brose said. Medicaid is the combined federal and state program that covers health care for people with low incomes.

It is one reason Brose worries about his familys ability to continue in the business. He said other adult foster care owners in Central Oregon have closed or are limiting the number of Medicaid patients they will accept.

While the amount he receives per client remains low, Broses costs have increased. He said he has had to stop offering health benefits to his three employees.

And it is nearly impossible to get liability insurance for the business because of the high cost.

He and his wife are barely clearing $1,000 a month in wages to cover their own costs and debts.

”We haven’t had a pay raise in the last five years. You know how much expenses have gone up in recent years,” Brose, 56, said. ”If something doesn’t happen, before long, everything is going to dry up. It is not going to reduce the number of people that need care.”

Caring and committed

The issue of adult foster care reimbursement rates has come up repeatedly at the state level, said Julia Huddleston, of the Oregon Department of Human Services. She said she has heard that some facilities are going out of business, although the state doesn’t actively track that data. She and her colleagues have been discussing ways to help.

”We’re very concerned about that industry as a whole,” she said. ”I would love to somehow come up with more money, but that’s not in today’s cards and it’s not in my power.”

Pauline Clark, who has owned an adult foster care home in Bend since 1986, said many changes have taken place in the industry. In that time, she said, she has seen the number of homes grow from 29 to a peak of 85 in 1996. By 2003, the number had dropped to 67. As of May, she said, there were only 57 homes still operating in Deschutes, Jefferson and Crook counties.

The adult foster care homes are licensed for anywhere from one to five elderly or disabled younger adults who can’t live independently.

”Good foster homes give the best long-term care that is available. The most concentrated, the most tedious kind of care,” Clark said. ”We help (the residents) dress if they need it. We put their makeup on. We put their earrings on. They look like they are ladies and they smell like they are ladies and their rooms and their homes smell like a home. They feel loved. They feel good about themselves.”

At night, Brose and Clark both turn on monitor systems in their homes documenting every cough, toss and turn of their residents. They sometimes get up multiple times a night to check on people or help them to the bathroom.

It’s a physically demanding job and can be an emotional drain.

”I couldn’t tell you how many people we’ve been with when they passed away in this household,” Brose said. ”It’s been a number.”

Because of the demands of the job and the limited resources available to pay wages, Brose and Clark both said it is difficult to find employees to provide relief help.

”We’ve gone as long as seven months without any relief at a time because we won’t settle for just anybody,” Brose said. ”You are not going to leave people you care about in the hands of somebody you are not sure about.”

But at the same time, Clark said, the people who run foster homes well do it because it is their passion.

”I love what I do. I’m good at what I do,” Clark said. ”I feel that I give (the residents) a quality of life.”

It’s that quality of life the state of Oregon was hoping to encourage when, in 1981, it received a Medicaid waiver from the federal government allowing it to pay for long-term care services in settings other than nursing facilities. That waiver was the first of its kind, said Cindy Hannum, administrator of the Office of Licensing and Quality of Care for the Oregon Department of Human Services.

”That was a goal because people shouldn’t have to live in an institutional setting,” Hannum said. ”They should be able to live in a home.”

After the waiver went into effect, Hannum said the state began encouraging the development of alternatives to nursing homes, including adult foster homes, residential care facilities and assisted living facilities.

Foster homes are the smallest, with a maximum of five beds. Residential care facilities are similar in that people sometimes share rooms, but they often have as many as 20 beds. And assisted living facilities tend to be much larger buildings, with an average of 50 private apartments complete with living space and kitchenettes.

Some people prefer the more intimate setting that adult foster homes provide and Huddleston, of the human services department, said she believes the small homes remain an important option for seniors.

”In the foster home you get a much smaller environment. You get much more attention,” Huddleston said. ”People don’t have the opportunity to isolate themselves. Somebody is always watching.”

Bessie Lay, 91, said she likes living at the Broses’ foster home. It’s comfortable, she said, and she enjoys interacting with their dog and watching the colorful fish in a tank in the living room, where she spends time sitting in an easy chair near other residents.

Residents like Lay, who is one of 3,800 Medicaid recipients served by the state Seniors and People with Disabilities Program in Central Oregon, have a choice of where they want to live. But Brose worries that without an increase in payments, adult foster homes may have to stop taking Medicaid residents altogether.

From Brose’s perspective, the three categories of facilities provide essentially the same type of care. Staff members manage medications, help residents bathe and dress, and are available 24 hours a day for assistance.

But adult foster care and residential care facilities – which tend to have more staff members available per resident – are reimbursed by Medicaid at a lower rate than assisted living facilities.

A matter of money

The reimbursement rates per patient vary, depending on the severity of the person’s needs, but, in general, assisted living facilities receive about $300 to $400 a month more for Medicaid residents than adult foster homes and residential care facilities, according to the state.

That extra $300 to $400 a month per person could help, Brose said.

Between the food, rent, utility costs, wages, maintenance, automobile and licensing expenses, Brose estimated he spends about $6,300 a month to run one home. His income for the first quarter of this year was approximately $7,500 a month, and not all of his clients are currently on Medicaid.

Adult foster homes and residential care facilities can be reimbursed for Medicaid recipients from about $1,400 a month to about $2,100 a month depending on the severity of the patient’s needs, Hannum said. In comparison, assisted living facilities are reimbursed between about $1,700 and $2,500 a month for Medicaid residents.

The rate structure was initially set up differently for assisted living facilities because Hannum said the state was encouraging their development. Now, so many assisted living facilities have been built that a moratorium is in place limiting their construction until 2009.

”When Oregon started to develop the assisted living facility concept, people thought that, in the end, they would replace all kinds of other facilities,” Huddleston said. ”That has turned out not to be true.”

Only the Oregon Legislature can decide to change the rate structure. Given the budget constraints at the state level, Hannum said it would cost too much to bring reimbursement for adult foster care and residential care facilities up to the level that assisted living facilities receive.

”They would like to be paid like assisted living,” Hannum said. ”That all has a budget impact. It’s not small. It’s millions and millions and millions of dollars.”

James Carlson, executive director of the Oregon Health Care Association, a trade group that represents assisted living facilities, said he agrees that adult foster care and residential care facilities are reimbursed at an abysmal rate. But, he said, they can’t be compared on an apples-to-apples basis with assisted living facilities because the state has different requirements for them.

And although the reimbursement rate for Medicaid patients is better for assisted living facilities, Carlson said it is still inadequate compensation for care.

”I think, unfortunately, the state has been challenged on being able to provide adequate funding for people on Medicaid assistance,” he said. ”There are a lot of (facilities) who have opted out of Medicaid altogether.”

Private versus public

All of the clients living in Clark’s adult foster home currently are private pay customers, which means she can charge more than Medicaid would reimburse her for their care.

”Every year when we are relicensed, we can either sign a contract with the state to take Medicaid or we can refuse to,” Clark said. ”More and more foster homes are not signing with the state.”

She always continues her Medicaid contract, Clark said, so if one of her private pay clients ends up needing to go on the government program for financial reasons she will not have to ask that person to move.

”I give them a place to live that becomes their home,” Clark said. ”My hope is that this is their last home, that they don’t ever have to move again.”

When foster homes close due to financial issues or personal decisions, she said, the residents have to find another place to live.

Brose, his wife and his 72-year-old mother-in-law are co-owners of two adult foster homes in Bend. And none of them are getting any younger, he said.

But he is not sure he will ever be able to retire.

”My biggest concern is the number of years we’ve got left in this industry are limited,” he said.