Transcript Long Term Care Defined - EPID 600

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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 82 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.
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Untrained, inadequate staff
Hazardous, unsanitary conditions
Over, under-medication
Discrimination against minorities
Thefts of belongings
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Reforms
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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
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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
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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
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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
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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
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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, reprinted
with 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, 19841998.
• 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 with
permission.
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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
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