Long Term Care in Older Adults

Seki Balogun, MD, FACP

ObjectivesBy the end of this session, students will be able to: Recognize the two main types of long term care

Recognize the differences between the nursing homes and assisted living facilities.

Discuss the different patient characteristics of both institutions.

Relate to older adults who are in long term care.

Long Term Care

Nursing Homes

Assisted living facilities

• Focus of care is to achieve and maintain an optimal level of functioning

• Interdisciplinary care

LTC: Historical background

Twelfth century “Gerocomeia” in ancient GreeceEarly 1900 Europe: special care units for the

chronically ill elderly United States: chronically ill and

disabled Poorhouses

Historical background 1920s

• State licensure programs • Standards and oversight were minimal

Mid – 1900s• Social Security Act • Private nursing homes• Run by nurses• Custodial care

Post- world war II: modeled after hospitals

• Minimum standard of care

Historical background

1980s Nursing Home Reform Act (OBRA

’87) State regulations Quality of care for the cognitively

and functionally impaired

Nursing homes 1.5 million Americans (most aged 65

years and older) reside in 17,000 nursing facilities nationwide

43% of adults 65 years and older will stay in a nursing home at some time before they die

55% have a lifetime use of at least 1 year 21% have a total lifetime use of 5 years

or more

Nursing Homes Skilled nursing

care

Long term nursing care

Hospice care

Case 1. Mr. TB is a 90 year old man with

multiple medical problems, who was admitted to the hospital last week with community acquired pneumonia.

He is now ready for discharge He is deconditioned and is unable to

ambulate He lives with and is the caregiver for his

wife, who has advanced dementia

Nursing Homes

Skilled nursing care Typically for those discharged from an inpt

setting with functional deficits and often medically complex

Require one or more forms of therapy (PT, OT, speech)

High degree of nursing care: IV, wound care Length of stay usually less than 6 months (few

days to months) Paid for by Medicare

Case 2. Ms. TJ is an 85year old woman with paraplegia

from a spinal cord injury. She has severe neuropathic pain and is wheelchair dependent.

She lives alone, has no relatives in VA.

She had a paid caregiver, 6hrs/day, who helped her with self care (bathing, toileting) and her instrumental ADLs (cooking, cleaning and shopping).

She can no longer afford to pay her caregiver

Nursing Homes

Long term nursing care For those who can no longer

live independently• Require assistance for

self care and IADLs Significant functional,

cognitive or psychosocial deficits

Paid for: Private pay Long term care insurance Medicaid

Nursing Homes

Hospice care Terminal conditions with less than 6

months to live Usually in conjunction with an

independent hospice organization Team provides a network of services:

physicians, nurses, social workers, chaplain

Paid for by Medicare

So what should happen to seniors who need some help, but do not require 24 hr nursing care?

0%

0%

0%

0% 1. They should be admitted to the nursing home: better safe than sorry.

2. Their family should care for them: it is their responsibility

3. They could live in an assisted living facility

4. They should pay for a caregiver

Assisted Living facility Residents require some

supervision or physical assistance due to functional or cognitive deficits

Usually owned by private

organizations

Provision of individual care needs vary with facility

• Provides 3 meals and medication administration

• Costs about $2-4K/month

Paid for: Private pay Long term care

insurance

Assisted living facility Better received by

seniors• More home - like• Less institutionalized

setting

Rare “Auxiliary Grants” for low income people.

A few beds in our area at Mountainside in Crozet.

HealthCare Financing in LTC

Medicare

Medicaid

Long term care insurance

Private pay