is that they experience considerable social isolation. Several studies found that 83 to 85 percent were unmarried, and one-quarter of the residents had no living children (Fralich et al., 1997; Hawes et al., 1995a, b, c; Phillips et al., 2000). In one study conducted in the mid-1990s, the research found that one-third of 3,200 residents in 10 states reported they had not left the facility in the preceding 14 days; 19 percent reported no visits with family or friends in the preceding 30 days; and 24 percent had visited with friends or family only one or two times in the preceding 30 days (Hawes et al., 1995b). Similarly, in a 1998 survey of a national probability sample of residents in assisted living facilities that offered high services or high privacy, 9 percent reported no visit with family or friends in last 30 days, and 27 percent had visited with friends or family only once or twice in the last 30 days (Hawes et al., 2000). Thus, many residents lacked close family or friends who could be their advocates. In addition, ombudsmen programs that help fill this gap in nursing homes are largely absent in RCF settings, their activities mainly limited to complaint investigation (Phillips et al., 1994). Also, one study interviewed staff and residents and found that most residents and staff were ignorant of the ombudsman program (Hawes et al., 1995a).

Third, many RCF residents have additional characteristics that have been associated with disparities between services and unmet health care needs. Many of these have been identified as risk factors for abuse or neglect in other settings. Although estimates vary across states and types of residential care facilities, an estimated one-third of residents are poor— their care paid for by a combination of Supplemental Security Income (SSI), state supplemental payments, and Medicaid (Hawes et al., 1995a, b, c; Fralich et al., 1997). The majority of residents in traditional RCFs (outside of higher-priced assisted living facilities) would be classified as poor or near-poor (i.e., income less than 200 percent of poverty). Furthermore, about one-third of all residents have mental retardation, developmental disabilities, or persistent, severe mental illness (Fralich et al., 1997; Hawes et al., 1995a, b, c; Mor et al., 1986). As an example of disparities associated with these characteristics, one 10-state study14 that included a random sample of residents found that residents with SSI as a payor were twice as likely as other residents to have unmet need for assistive devices (Hawes et al., 1995c).


The 10 states were selected based on whether they had extensive or limited regulatory systems. Facilities were selected on a stratified, random basis, and residents were randomly selected within the study facilities.

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