By Electronic Medical Services, LLC
Medical foster care providers across the country— and especially in states with strong post-accident rehabilitation mandates, such as Michigan—are facing an ever-growing challenge: caring for residents whose medical, behavioral, or quadriplegic conditions far exceed what traditional “general supervision” models can safely support. For these populations, Attendant Care is not a luxury; it is an urgent clinical requirement rooted in medical necessity, statutory protections, and widely accepted standards of care.
Why Attendant Care Is Urgent for High-Acuity Residents:
Residents who are quadriplegic, medically unstable, or severely behaviorally impaired cannot rely on the generalized observation typical of basic adult foster care. Their conditions create continuous vulnerability, including:
- Compromised mobility leading to pressure injuries, contractures, and impaired pulmonary function.
- Complex medical regimens involving ventilator care, tracheostomy maintenance, feeding tubes, seizure precautions, or wound management.
- Cognitive and behavioral impairments resulting in elopement risk, self-injurious actions, aggression, or refusal of essential treatments.
The U.S. Agency for Healthcare Research and Quality (AHRQ) identifies immobility, cognitive decline, and neurological injury as major predictors of “never-events” such as pressure sores, preventable infections, and medication complications. For these risks, intermittent supervision is ineffective. Only dedicated Attendant Care staffing, present solely for the resident’s medical and safety needs, can deliver the vigilance required to prevent decline. How is that not reasonable and necessary?
General Supervision Is Not Enough:
General supervision in adult foster care settings is intended for residents who are largely independent with Activities of Daily Living and who can direct their own care. But state foster care regulations consistently clarify that homes serving residents with high medical or behavioral needs must operate above this threshold.
For example, the Michigan Adult Foster Care Licensing Act (PA 218 of 1979) requires providers to ensure the “protection, supervision, and daily care” necessary for each resident’s assessed needs. A home that provides hands-on turning, wound care support, trach monitoring, behavioral redirection, or seizure precautions is already delivering labor-intensive Attendant Care—whether it is billed or not.
Billing Adjustments Are Often Necessary:
Many residential programs have provided these specialized services for months or years without claiming proper reimbursement. As regulators and insurers more strictly review care plans, homes may need to revise their billing procedures to accurately reflect the complexity of the populations they serve. This includes separating general roomand-board functions from Attendant Care, which is medically necessary, one-to-one, or near-continuous care.
Hospitals and Nursing Homes Already Bill This Way:
Attendant Care in medical foster care mirrors how hospitals and nursing homes are financed. Medicare pays facilities under the Prospective Payment System for:
- Room and Board – the standardized cost of housing, meals, utilities, and facility operation.
- Special Staffing – including “constant observers” or “sitters,” paid separately or within the acuityadjusted rate when risk of falls, behavioral events, or elopement is present.
Similar models exist in the Medicare Benefit Policy Manual, Chapter 8, which notes that additional staffing is justified when patient safety could be compromised without devoted personnel present. Medical foster care providers are simply applying this same standard in a community-based environment.
How Attendant Care Prevents Medical Decline:
Without dedicated staffing, risks multiply dramatically:
- Wounds and Pressure Injuries: Turning schedules are missed, and deep tissue injuries form within hours.
- Infections: Foley care, trach care, and G-tube management require precise technique and timing.
- Behavioral Crises: Unmanaged agitation or cognitive dysregulation can lead to injuries, assaults, or property destruction.
- Medication Complications: Many residents require cueing, monitoring, or specialized administration.
Attendant Care is, therefore, a clinically supported harm-reduction strategy.
Judicial Review: Points Providers Should Raise:
While this article does not purport to give legal advice, it is worth noting that when insurers or agencies such as the Michigan Department of Insurance and Financial Services (DIFS) fail to recognize the value or necessity of Attendant Care, providers seeking judicial review should emphasize:
1. Statutory Rights Under Michigan No-Fault (MCL 500.3107 & 500.3157):
- Allowable expenses include “reasonably necessary products, services, and accommodations for an injured person’s care, recovery, or rehabilitation.”
- Services should reflect the individual’s needs, not averaged assumptions about level of care.
2. Medical Documentation of Necessity:
Physician, PM&R, neuropsychology, wound care, and behavioral health notes emphasizing the need for frequent observation or intervention. You have one person on duty providing general supervision while three residents require turning every 20 minutes as this offloading is physician ordered, 2 need catheter adjustments and urine drainage bag emptying, 2 are convinced they need to escape and are rolling toward an exit constantly and this is going to all be responsibly managed among quadriplegics and the brain injured with behavioral challenges with one, (1) person on duty? The very premise is ridiculous, dangerous and medically irresponsible.
3. Comparison to Medicare-Recognized Practices:
- If hospitals and SNFs receive additional pay for sitters and special staffing, community-based programs providing the same intensity should also be recognized.
4. Geographic Price Reductions Must Be Transparent:
Many insurers reduce rates citing “geographic averages” without defining:
- the precise geographic area, the radius used, the dataset or the methodology.
Under administrative law principles and Michigan No-Fault’s requirement for reasonableness, a payer cannot impose reductions based on undisclosed or unverifiable benchmarks. Providers should request the exact geographic boundaries, cost-source data, publication year, and statistical method (mean, median, blended index). Imagine a market survey comparing the daily charge of a provider for a person who can walk, talk, and express need with a quadriplegic elsewhere who cannot communicate, express need, or ambulate independently. Perhaps this is why courts frequently view undisclosed pricing criteria as arbitrary.
To Summarize and Conclude…
Residents with profound physical and behavioral challenges depend on Attendant Care for survival, safety, and quality of life. Residential providers must not shrink from asserting the medical legitimacy of this staffing model, nor from billing accurately for what is already required by law, clinical standards, and common sense. Insurers may challenge, but the statutes, medical data, and established healthcare payment structures all support the necessity of Attendant Care in medical foster care environments.
Another Blog Post by Direct Care Training & Resource Center, Inc. Photos used are designed to complement the written content. They do not imply a relationship with or endorsement by any individual nor entity and may belong to their respective copyright holders.
| Follow us in the Social Stratosphere… | ||||
|
