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Chapter 8

Long Term Care

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CHAPTER OBJECTIVES

• Define long-term care

• Review major factors in the history and development of the long-term care industry

• Identify and define types of long-term care providers

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Care Needs of the Life Span

• Birth to death, needs may vary in intensity and duration– Level of support required for optimal

functioning may vary over time– Service locations vary with type and intensity of

needs– Services range from intense medical to social

support; combinations

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Long Term Care Definition

• Service Continuum: infants to older adults, meeting diverse needs

• Formal (institutionally based or operated)

• Informal (family/friends); often a combination

• Older adults are predominant users

• Coordination is key for an “ideal” system

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Changing Socio-demographics Impact Need

• Lifespan increasing: more chronic conditions

• Lifestyle, family changes limit availability of informal caregivers

• 65+, 19% of total population by 2030

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FIGURE 8-1 Projected Number of Persons 65 Years of Age or Older by 2030.

Source: U.S. Bureau of the Census.

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FIGURE 8-2 Projected Population,

Age 65 Years and

Older, 2000–2050.

Source: U.S. Bureau of the Census.

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Development of Long-Term Care Services (1)

• Colonial era: almshouses started by European colonists

• 19th-early 20th century: city, county-operated homes & infirmaries

• Great Depression: private citizens boarded older adults for financial benefit; serious quality of care issues

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Development of Long-term Care Services (2)

• Social Security (1935): enabled older adults and those with certain disabilities to purchase long-term care services

• 1950s: government loans aided not-for-profit nursing home development

• 1965: Medicare, Medicaid stimulated for-profit long-term care businesses

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Abuses

• 1970s public exposes’: Congressional hearings on inhumane treatment, e.g.– Untrained, inadequate staff– Hazardous, unsanitary conditions– Over, under-medication– Discrimination against minorities– Thefts of belongings

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Reforms

• State nursing home & home care licensing

• Medicare and Medicaid certification

• Laws for elder abuse reporting

• Regulations on restraints

• Ombudsman programs

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Current Long-term Care Businesses

• Stand alone, or parts of nursing home or assisted living corporate entities:

• for-profit

• not-for-profit

• government

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FIGURE 8-3 Percent Distribution of Nursing Homes, According to Type of Ownership: United States, 2004.

Source: CDC/NCHS, National Nursing Home Survey, 2004.

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Modes of Long-term Care Delivery

• Skilled nursing facilities• Assisted living facilities• Home care• Hospice• Respite• Adult day care• Innovations

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Skilled Nursing Facilities (SNFs) (1)

• Institution-based, “hands-on” nursing; predominant mode

• 1.5 million Americans reside in 16,100 SNFs• Federal certification required for Medicare,

Medicaid reimbursement; state licensing of facilities, administrators

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Skilled Nursing Facilities (SNFs) (2)

• Costs– 2009: $13849 B; double cost of home care– Private room = $ 79,935/year– Medicare, Medicaid pay ~ 62%; 38% private,

out-of-pocket, long-term care insurance

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Skilled Nursing Facilities (SNFs) (3)

• Staffing– Administrator– Medical Director– Registered Nurses and Licensed Practical Nurses– Certified Nurse Assistants– Social workers– Nutrition & Dietary Staff– Rehabilitation (PT & OT)– Recreational/ Activities– Housekeeping/Plant & Facilities

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Assisted Living (1)

• “Combination of housing, personalized supportive services and health care designed to meet both scheduled & unscheduled needs of those needing help with activities of daily living.”

Assisted Living Federation of America

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Assisted Living (2)

• Single homes to multi-unit apartments; no “hands-on” nursing; supportive assistance

• 20,000 facilities house 1 million+; growth projected to 2 M+ by 2025.

• Primarily personal payment; varying costs; average monthly cost = $3,131

• State licensing requirements are evolving.

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FIGURE 8-4 Projected Growth of Assisted Living Beds Based on Population Growth for

Those 75 Years and Older.

Source: National Center for Assisted Living, reprinted with permission.

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Home Care Services (1)

• Origin in 1900s as social welfare response to immigrants in industrialized cities– Aegis of government public health departments

and private agencies, e.g. Visiting Nurses Association

• Services at client residence

• Short term during convalescence; long term for chronic conditions

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Home Care Services (2)

• Formal home care: local health departments and private agencies; 9,000 certified agencies serving 3 million; 65%+ for-profit; Medicare predominant payer

• Informal home care: delivered by family members, friends; 65 million caregivers (66% women) valued at $ 354 B/year; 2x cost of nursing home & formal home care combined

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Informal Home Care Recognition

• Family Medical Leave Act (1993): important first step; 12 months unpaid leave makes unworkable for many

• 2002: CA workers using FMLA to care for family members eligible for disability payments

• 15 states enacted paid leave for private company employees; 40 states for government workers

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Home Care Regulation

• State licensing for Medicare & Medicaid certification; requirements:

1. Skilled nursing, physical, occupational, speech therapies; medical social services

2. Client confined to home

3. Physician orders for care

4. Agency meets all Medicare certification requirements

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1990s Home Care Reforms

• Federal investigations of rising costs & quality concerns prompted:– Operation Restore Trust (ORT) targeted Medicare

billing practices– BBA of 1997 stiffened requirements for Medicare

certification– Outcomes & Assessment Information Set (OASIS):

reporting of patient condition, satisfaction

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2006 CMS “Post Acute Care Reform”

• Consumer-centered approach– More choice by patient, family, caregivers– High quality care in most appropriate settings– Measures to drive quality– Seamless care continuum through coordination of

post-acute – long-term care transitions

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Hospice-History

• Roots in medieval Europe

• Modern model (1960s): London, U.K.; Dr. Cicely Saunders

• First U.S. hospice 1974 in CT; all volunteer

• Now, not-for-profit & for-profit

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FIGURE 8-5 Tax Status of Hospice

Agencies.

Source: The National Hospice and Palliative Care Organization, reprintedwith permission.

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Hospice Services (1)

• A philosophy of care for terminally ill– Palliative care for physical & emotional

symptoms; not cure-directed

• Low-tech: pain control, quality of remaining life

• Settings: home, dedicated hospice facilities, hospitals, SNFs

• Costs: Highly cost-effective; ~ 2.5% total Medicare spending

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Hospice Services (2)

• Medicare reimbursement (1982) freed from sole reliance on volunteers & charitable support; 73-fold increase in agencies, 1984-1998.

• 4,800 hospices serve 1.4 M/year with staff and 550,000 volunteers

• 2008: 39% U.S. deaths in hospice care

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FIGURE 8-6 Total Hospice Providers by Year.

Source: National Hospice and Palliative Care Organization, reprinted withpermission.

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FIGURE 8-7 Total Hospice Patients Served by Year.

Source: National Hospice and Palliative Care Organization, reprinted with permission.

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Hospices Services (3)

• Staff: Physician director, physicians, nurses, social workers, counselors, supportive staff, volunteers

• Provide drugs, medical appliances, supplies

• Bereavement services for survivors and general community

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Respite Care

• Temporary, surrogate care for a patient in primary care giver(s) absence

• 1970s origin: deinstitutionalization of developmentally disabled and mentally ill

• Short-term service gives “respite” to at-home caregivers

• Purpose: forestall placement in institutional setting

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Respite Services

• Duration: short-term & intermittent• Settings: homes, day care centers, hospitals, nursing

homes• Staff: professionals and trained laypersons• Medicare: no reimbursement• Medicaid: stringent requirements• Not-for-profit organizations: grants help to fund

services

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Respite Models

• Alzheimer’s disease inpatient care for several weeks

• Community-based adult day care settings

• In-home nurse aids

• Temporary furloughs to hospitals or nursing homes at regular intervals

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Respite Care Legislation• Lifespan Respite Care Act (2006): $ 289 M, 5

years; state grants for community-based respite program development “for family caregivers of children & adults with special needs.”

• Older Americans Act of 2006: AOA pilot demonstrations on cost-effectiveness & consumer acceptability of programs for independent living

• 2010 AoA budget: $ 7 M increase for home, community-based services

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Adult Day Care (1)

• Origin: Lionel Cousins (1960s) to prepare institutionalized mental health patients for discharge into the community

• Supervised social activities (social model)

• Supervised medical, rehabilitative activities (medical model)

• Temporary relief to caregivers; therapeutic social contacts for care recipients

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Adult Day Care (2)

• Staff: variable for social & medical models

• 4,000 licensed, unlicensed centers– 80% not-for-profit organizations– Quality & Accreditation (1999): Commission on

Accreditation of Rehabilitation Facilities & National Adult Day Services Assn. issue standards

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Innovations in Long-term Care: Aging in Place

• Program of All-inclusive care for the Elderly

(PACE)

• Continuing Care and Life Care Communities

• Naturally Occurring Retirement Communities

(NORCs)

• High Technology Home Care

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On Lok Senior Health Services Model (PACE)

• San Francisco (1972): Medicare demonstration project: “peaceful & happy abode.” – Frail older Americans remain at home with

interdisciplinary support services

• Outcomes: lower hospitalization & nursing home placements

• BBA (1997): PACE approved as permanent Medicare benefit

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Continuing Care Retirement and Life Care Communities (1)

• CCRCs: Older Americans desiring secure, assisted environment– 2,200 CCRCs accommodate 725,000 residents– Comprehensive dietary, social, recreational

services – Ownership: 80% not-for profit;50% faith-based

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Continuing Care Retirement and Life Care Communities (2)

• Continuing Life Care Community: insurance model, prepaid lifetime services– Independent living to skilled nursing – Regulated by state insurance departments & health

care regulators– Extensive service options available on continuum

of needs

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NORCs

• Coined by Dr. Michael Hunt (U of Wisconsin), 1980s; apartment residents 60+ years. – Apartment building residents, neighborhoods,

community sections harboring aging residents– AOA demonstration grants programs underway:

case management, nursing, social, recreation, nutrition

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High Technology Home Care

• Advanced technology for intravenous infusions, ventilation, dialysis, parenteral nutrition, chemotherapy available in the home– Specialist home care personnel (nurses,

pharmacists, respiratory therapists, etc.) – Cost effective– Preferred by patients

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Long Term Care Insurance

• Fastest growing type of health insurance• Many employers now offer as benefit

– Federal government offers tax deductions for employer contributions; many states offer tax incentives to individual purchasers

• Broad spectrum of benefit options & costs• Increases choices & avoids public dependency

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The Future of Long Term Care (1)

• Increased diversification & specialization to meet wide range of needs, e.g. dementia

• Managed care integrated provider networks bundle hospitalization and post-hospital care into one “episode.”

• More demand for home care: cost-effectiveness, client preferences prompt legislation favoring community-based services, e.g. NORC demonstration projects

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The Future of Long Term Care (2)

• Staffing shortages– Private philanthropic, government initiatives

seeking solutions– Reimbursement allowing competitive wages

• Support for informal caregivers– Legislation for paid family leave