Paper #2

Chapter 10 Long-Term Care Learning Objectives • To comprehend the concept of long-term care and its main features. • To get an overview of LTC services. • To discover who needs long-term care and why. • To become familiar with the large variety of home- and community-based long-term care services, and who pays for these services. To learn about long-term care institutions and the levels of services they provide. Learning Objectives • To get an overview of specialized long-term care facilities and continuing care retirement communities • To explore institutional trends, utilization, and costs • To get a perspective on private long-term care insurance • To understand application of the Affordable Care Act to long-term care Introduction • A complex subsystem that escapes a simple definition • Numerous services and sources of financing • Regular health insurance generally does not cover LTC; private LTC insurance has made limited headway Introduction • LTC is not confined to the elderly; 37% of the clients are under the age of 65 • Growing nonwhite elderly population is in poorer health, and is likely to have a greater need for LTC services • About 70% of older Americans will eventually need LTC; most will get it in their own homes • Community-based services have grown more rapidly than institutional services Introduction • The LTC system must interface with the rest of the health care system • LTC is associated with functional deficits caused by – Multiple chronic conditions – Serious illness or injury – Cognitive impairments • Functional limitations are assessed by ADLs and IADLs Introduction • An estimated 22% of elderly Americans need LTC • The number of LTC recipients is likely to rise from 9 million to 12 million by 2020 • 15.4% of those using LTC are in nursing homes • ⅔ of total LTC spending is paid by Medicaid; hence, the financial burden falls on taxpayers • Other developed countries also face LTC-related challenges The Nature of Long-Term Care • LTC is multidimensional • Variety of services • Individualized services • Well-coordinated total care • Maintenance of residual function • Extended period of care • Holistic care • Quality of life • Use of current technology • Use of evidence-based practices Nature of Long-Term Care • Variety of services – People’s needs vary and they change over time • Individualized services – Comprehensive assessment–individualized plan of care–customized interventions • Well-coordinated total care – LTC providers take responsibility for obtaining needed non-LTC services Nature of Long-Term Care • Maintenance of residual function – Goals: (1) maintain function (2) prevent further decline – By letting the person do as much as possible for himself/herself • Extended period of care – Irreversible functional decline – Short-term rehabilitation – Indefinite institutional care Nature of Long-Term Care • Holistic care – Physical, mental, social, and spiritual needs must be met • Quality of life – It is significant because of a loss of self worth, and because – Patients remain in LTC for long durations Quality of Life • A multifaceted concept 1. Lifestyle pursuits 2. Living environment 3. Clinical palliation 4. Human factors 5. Personal choices Nature of Long-Term Care • Use of current technology – To promote safety and quality of care • Use of evidence-based practices – Best practices are evaluated through clinical research – Clinical practice guidelines provide directions and treatment protocols Long-Term Care Services • Medical care, nursing, and rehabilitation - Postacute continuity of care - Management of chronic illness and comorbidity - Restoration or maintenance of physical function - Transfer to a hospital for acute episodes Long-Term Care Services • Mental health services and dementia care - Mental illness is prevalent among 25% of elderly - Comorbid with other chronic illnesses - Diagnosing mental illness among elderly is challenging Dementia • Progressive and irreversible decline in cognition, thinking, and memory • 15% of people age 70 and over have dementia • Alzheimer’s disease is the most common – affects 5 million elderly in the United States • 40% of those with dementia need institutional care Long-Term Care Services • Social support - Coping with changing life events that create emotional imbalances - Adaptation to new surroundings - Help deal with conflict - Coordination of total care Long-Term Care Services • Preventative and Therapeutic LTC - Main goal of preventive LTC is to prevent or delay institutionalization - Various community-based LTC services have a preventive function - Therapeutic services include nursing care, rehabilitation, and therapeutic diets Long-Term Care Services • Informal and formal care – Informal: Nonreimbursed care by family and friends – Most LTC in the US is informal – Insufficient informal care is associated with higher all-cause mortality, hospitalization, and institutionalization – Issue • Shrinking pool of informal caregivers Long-Term Care Services • Respite care – Family caregivers often face numerous physical, emotional, social, and financial issues – Respite care relieves stress and burnout – It includes any type of LTC service that allows caregivers some free time Long-Term Care Services • Community-based • Home- and community-based services (HCBS) have a four-fold objective • Economical and least restrictive setting • Supplement or substitute informal caregiving • Temporary respite for informal caregivers • Delay or prevent institutionalization Long-Term Care Services • Institutional Services • Institutionalization: short or long duration • 3+ ADLs deficits dramatically raise the probability of institutionalization • Main goals 1. Deliver therapeutic services 2. ADL help 3. Prevent functional decline 4. Coordinate total care Long-Term Care Services • Housing – Noninstitutional housing other than one’s home – May or may not have support services: meals, housekeeping, transportation, recreational activities, etc. – Home health care meets occasional LTC needs – Private or public housing Private Housing • Upscale retirement centers • Entrance fee + monthly rental • Some support services may be included Public Housing • Government-assisted, subsidized housing • HUD programs - Federal aid to local housing agencies to offer lower rents to qualified low-income people - Vouchers that can be used for housing of one’s choice - Public housing operated by the government (less common) - Federal funds may be provided to nonprofit sponsors to construct rental housing Long-Term Care Services • End-of-Life Care - Prevent needless pain and distress for the terminally ill - Dignity and comfort - Care provided by institutional staff or hospice services Clients of LTC • Older adults • Children and adolescents • Young adults • People with HIV/AIDS Clients of LTC • Older adults - 85+ age group is the fastest growing segment. - Demographic trends have serious implications for financing and delivery of LTC; 20% of the population will be age 65+ by 2030. - Elderly in the lowest socioeconomic status are at the greatest risk of need for LTC and are the least able to pay for such services. Clients of LTC • Children and adolescents – Birth-related disorders (cerebral palsy, autism, etc.) – Developmental disabilities (DD) – Mental retardation (MR), now referred to as ID (intellectual disability): Down syndrome is the most common ID in America – Specialized facilities are equipped to care for those with severe ID or DD Clients of LTC • Young Adults – Neurological malfunctions, degenerative conditions, traumatic injury (auto, sports, and industrial), surgical complications – Sometimes need ventilator care and total assistance with ADLs – Adults with MR/DD (or IDD) – 1999 US Supreme Court ruling in Olmstead v. L.C. : states must provide community-based services for MR/DD patients when appropriate Clients of LTC • People with HIV/AIDS – Now a chronic condition thanks to highly-active antiretroviral therapy – HIV has increased, including among the elderly – People with AIDS are subject to comorbidities and cognitive impairment – Lack of informal support – High need for LTC and care coordination Level of Care Continuum • Personal care—basic ADL assistance (e.g., bathing) • Custodial care—nonmedical care to maintain function and prevent decline • Restorative care—help regain or improve function; professional therapies • Skilled nursing care—clinical care provided by licensed nurses under the direction of a physician • Subacute care—postacute, technically complex services HCBS • Both private and public financing • Older Americans Act, 1965 provides federal funds to states - Overseen by the federal Administration on Aging • Section 1915(c) waivers (to the Social Security Act) enable states to provide community-based LTC under Medicaid HCBS • Title XX Social Services Block Grants are also used for community-based LTC • Medicaid Personal Care Services Program (limited) • Issues – Needs go unmet; inadequate workforce; transportation barriers; limited supportive housing Types of Community-Based LTC Services • Home health care • Adult day care • Adult foster care • Senior centers • Home-delivered and congregate meals • Homemaker services • Continuing Care at Home • Case management Home Health Care • Community or hospital-based agency • Services must be approved by a physician • Skilled nursing care is the most common service provided • Medicare is the single largest payer; Medicaid is second • Mean length of service is higher among the nonelderly • Diabetes and heart disease are the most common health conditions Adult Day Care (ADC) • Clients stay with family/friends, but cannot be left alone during the day • Provides partial respite to families • ADC centers have increased across the country • ADCs are highly focused on prevention and health maintenance, but they also incorporate nursing care, psychosocial therapies, and rehabilitation • Nearly half of the clients have dementia; 50% of ADCs offer specialized services for dementia • Financing : Medicaid; private sources; Medicare for rehabilitation services, but not for ADC services Adult Foster Care (AFC) • Family environment in small community-based dwellings • Services primarily focus on room and board, supervision, and light ADL assistance • Program differs widely from state to state • Financing : Medicaid; private sources; Medicare may pay for rehabilitation services Senior Centers • Local community centers • Socializing • Many offer one or more meals • Wellness programs, education, counseling, recreation, health screenings, etc. • Financing : Some public funding; United Way; private donations Home-Delivered and Congregate Meals • Elderly nutrition program • Hot noon meal, 5 days per week • People age 60+ and their spouses qualify • Area Agencies on Aging do contracting • Home delivery (meals-on-wheels), senior centers, and other congregate settings • The program has successfully targeted at-risk people • Financing : Older Americans Act; Title XX block grants; 1915(c) waivers; private donations Homemaker Services • Shopping • Light cleaning • Errands • Minor home repairs, etc. • Financing : Medicaid; title XX block grants; Older Americans Act; private funds Continuing Care at Home (CCAH) • A new model • Extension of the CCRC model (continuum of housing and institutional LTC on one campus) into home health • Initial lump-sum fee + monthly fee • Future LTC care is guaranteed • Services typically include care coordination, home maintenance, home health care, transportation, meals, and social and wellness programs • Future institutional needs are met Case Management • Functions • Evaluating needs • Plan to address the needs • Identifying appropriate services • Determining eligibility and financing • Making referrals • Coordinating the delivery of services • Reevaluating needs Case Management Models • Brokerage model—Case managers are freestanding agents who assess client needs and make referrals; minimal coordination and monitoring. – Medicaid Preadmission Screening and Resident Review (PASRR) • Managed care model—Services are delivered through a social managed care plan. All services are received through the MCO. – Have been shown to postpone institutionalization – But, only 4 such programs participate in Medicare Case Management Models • Integrated care model—PACE—focused on frail elderly already certified for nursing home placement under Medicare and/or Medicaid The ACA and Community-Based LTC • Limited financial incentives for states to enhance HCBS • Options for states – Enhance existing HCBS – Offer “attendant services and supports” under Community First Choice – Undertake structural reforms to increase services – Use the existing Money Follows the Person program The ACA and Community-Based LTC • Balancing Incentives Payment Program – Greatest amount of financing to states that currently rely more on nursing homes than on HCBS, but states must meet certain criteria Institutional LTC Continuum • Residential and personal care facilities • Assisted living facilities • Skilled nursing facilities • Subacute care facilities Residential and Personal Care Facilities – Physically supportive dwelling – Monitoring and/or assistance with medications, oversight, and personal or custodial care – No nursing care or medical services – Advanced services are arranged with a home health agency – Private-pay; SSI payment and other government assistance – Services generally include meals, housekeeping, laundry, and recreational activities Assisted Living Facilities (ALFs) • Personal care services; 24-hour supervision; social services, recreational activities, and some nursing and rehabilitation services • Increasingly, ALFs are providing dementia care • Generally, private rather than shared accommodations • All states require ALFs to be licensed • No federal oversight • 86% of the residents pay privately Skilled Nursing Facilities • All facilities are licensed by state – Federal certification is optional – Certification required for Medicare and/or Medicaid • Compliance with the federal Requirements of Participation – Noncertified : No federal or state funding; only privately funded patients – Federal certifications (Nursing Home Reform Act, 1987) • For Title 18 (Medicare)—SNF, freestanding or distinct part • For Title 19 (Medicaid)—NF • Dual certification—SNF and NF Skilled Nursing Facilities • Level of care has become more complex • Most common conditions: bladder incontinence, depression, Alzheimer’s, bowel incontinence • Depression and psychiatric diagnoses have risen • Quality of care has improved • Direct care nursing time has increased • “Culture change” has been underway to create vibrant living environments ACA Requirements for Nursing Homes • The administrator of a SNF or NF must provide written notice at least 60 days prior to closure • The administrator must also provide a plan for relocating residents • SNFs and NFs must institute effective compliance and ethics programs Subacute Care Facilities • Three types of institutions – LTCHs (certified as acute care hospitals) – Transitional care units in hospitals: SNF certification – Skilled care nursing homes: SNF certification • Costs vary; LTCHs are the most expensive • Medicare reimbursement – Severity-based DRGs (MS-LTC-DRGs) for LTCHs – RUGs for SNFs Specialized Care Facilities • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) • Separate federal certification • Financed by Medicaid • Patients often have other disorders, such as seizures, behavioral problems, mental illness, visual or hearing impairment, etc. • The facility engages in “active treatment” Specialized Facilities • Alzheimer’s facilities – Small-group living arrangements – Lighting, color, pleasant surroundings, protected pathways for wandering, and special programming – The objective is to minimize agitation, anxiety, and disruptive/combative behavior Continuing Care Retirement Communities (CCRCs) • Integrates and coordinates independent living with other institutional services, all located on one campus - Independent living cottages or apartments - Personal care and assisted living - SNF—Medicare certification Continuing Care Retirement Communities (CCRCs) • Care for future higher-level services are guaranteed • People generally enter when they are still healthy • Three types of contracts - Life care or extended care - Modified contract - Fee-for-service contract Institutional Trends, Utilization, and Costs • Table 10 − 1 • Nursing homes and beds have decreased with the rise of HCBS and aging in place, but a recent slight upturn • Nursing home beds per 1,000 population has dropped for 11 years in a row • Occupancy and ALOS show a declining trend • Hospitals have drastically cut back on SNFs • ALFs have been the fastest growing institution • Nursing home costs have increased, but share of personal care expenditures has decreased Institutional Trends, Utilization, and Costs • Most nursing home care is financed by Medicaid, but the share of Medicaid spending for LTC has decreased • Vast disparity between Medicaid and private-pay nursing home costs, but private financing has been declining • Medicare spending for nursing home care has risen sharply Private LTC Insurance • Wide range of choices on duration of care and services covered; prices vary accordingly • Coverage includes nursing home care and various community-based services • Paid 9% of national nursing home expenditures in 2010 • Private long-term care insurance has seen slow growth. Main issues: affordability; too many options can be confusing; many mistakenly think that Medicare will pay for LTC; few public policy incentives