CHAPTER TWO

Clients of the Continuum

Subsets of LTC Clients

Functional Status Need vs. Demand Static vs. Dynamic Short-Term LTC vs. Long-Term LTC Institutional vs. Community-Based Care

Functional Status

The primary consideration that makes an individual appropriate for LTC

Multiple Dimensions– physical– cognitive– emotional– social

Functional Status Activities of Daily Living (ADL)

– most commonly used measure of physical functioning; basic activities necessary for personal care

– bathing, dressing, toileting, transferring, continence control, and eating

– scale• 1 = totally independent• 2 = requiring mechanical assistance• 3 = requiring assistance from another person• 4 = unable to do the activity at all

Functional Status

Instrumental Activities of Daily Living– activities necessary to live independently in

the community– preparing meals, grocery shopping,

personal shopping, managing money, telephoning, housekeeping, and doing chores

Functional Status

Both ADLs and IADLs decline with advancing age– 65-70 y.o.

• 10% men; 11% women

– 75-84 y.o.• 18% men; 28% women

– 85+ y.o.• 46% men; 62% women

Need vs. Demand

Need– considered to be the result of a professional

judgment that a specific service or treatment should be provided to an individual in order to improve his condition

Demand– an individual’s overt request for a service or

treatment, presumably the result of a perceived deficit and a belief in the benefits of the requested service or treatment

Need vs. Demand

Not perfectly correlated– professional’s judgment vs. client’s needs

Distinction important in LTC because needs are multidimensional– difficult for providers to recognize need– clients may not want to admit a loss of

independence, demand may be weak

Dynamic vs. Static

Static perspective– no immediate needs; functionally independent,

have a well-established support network, and stable health conditions

– modest needs; relatively complicated problems that require more assistance than their informal networks can provide

– severe needs; more complicated ongoing problems or acute flare-ups of otherwise manageable problems

Dynamic vs. Static

Dynamic perspective– needs can range over time from no need, to

moderate need, to acute need--and back again

Short-Term vs. Long-Term LTC

Short-term LTC– clients whose complex problems are rapidly

changing and who require care for a short period of time but with greater coordination than the patient or family can expect to handle without formal or professional assistance

– in need of an integrated continuum of care due to functional disabilities

– use of formal services is finite

Short-Term vs. Long-Term LTC

Short-term LTC– clients are characterized by their rapidly changing

patterns of needs, by an expectation of recovery or rehabilitation, and by their shorter reliance on an integrated continuum

– etiologies of their present conditions are specific and of short duration (recent stroke, surgery, accident, or change of family situation that causes temporary dysfunctioning

Short-Term vs. Long-Term LTC

Long-term LTC– clients whose complex problems likely will require

multifaceted care over an extended or indefinite interval

– clients tend to have chronic, persistent, multiple problems with etiologies that are permanent

– clients functional abilities may vary of time, but tend to decline rather than improve

– the majority of clients that are able to stay in their own homes with specific types of assistance have worked out informal relationships with friends and families to provide the assistance they need

Short-Term vs. Long-Term LTC

Long-term LTC– some clients depend on the formal system and

pay out-of-pocket for help on a regular or intermittent basis

– a relatively small number of clients --about 5%-- have health conditions and/or functional disabilities too great or support systems so minimal that they cannot remain in their homes and reside in institutions (e.g., nursing homes, adult group homes)

Short-Term vs. Long-Term LTC

Providers may serve both short-term LTC and long-term LTC clients, as well as acute patients

Reasons for making distinctions include– staffing assignments– reimbursement policies– efforts to educate patient and family about self-

care

Institutional vs. Community-Based Setting Factors that determine setting include

– family support and social structure– marital status– home owner status– financial situation– state and federal regulations

Institutional vs. Community-Based Setting Long-term care services can be

provided to people regardless of their location of residence

30% of people admitted to nursing homes leave within 90 days; 50% leave within one year

Subsegments of LTC Clients

Older Adults People with Disabilities Mentally Impaired, Mentally Retarded,

Developmentally Disabled AIDS/ARC Acute Episode Patients

Older Adults Characterized by advanced age, particularly

age 75 and above Largest group of potential users

– numerous undiagnosed and diagnosed pathologies that impair independent functioning

– chronic illnesses– frailty of advanced age– acute episodes with long recovery periods

In 1997, 1.5 m persons 65+ were in nursing homes, representing 4% of the older population

Number of Persons 65+

0

10

20

30

40

50

60

70

1900 1920 1940 1960 1980 1990 2000 2010 2020 2030

Older Adults

Older population will continue to grow significantly in the future

By 2030, there will be about 70 million older persons, more than twice the number in 1998

People 65+ are projected to represent 13% of the population in the year 2000 but will be 20% by 2030

In the US, 21.5% of civilian, noninstitutionalized persons are 60+; 13% are 65+; 1.2% are 85 years and older

Older Adults

Elderly population is growing at a faster rate than the population as a whole

The population 85+ is growing faster than the elderly population as a whole– between 1960 and 1994, their numbers rose 274%– the elderly population in general rose 100%; the

entire US population grew only 45%

1/2 of the current elderly residents of nursing homes were 85+

Older Adults

During the 1990s, the number of centenarians nearly doubled– from about 37,000 counted at the start of the

decade, to more than an estimated 70,000 today

This per-decade doubling trend may continue– the centenarian population in the US could

possibly reach 834,000 by 2050

Older Adults Limitations on activities because chronic

conditions increase with age In 1996, over 1/3 (36.3%) of older adults

reported that they were limited by chronic conditions– Among all elderly, 10.5% were unable to carry on

a major activity In contrast, only 10.3% of the population

under 65 were limited in their activities– only 3.5% were unable to carry on a major activity

Top 10 Chronic Conditions Among Older Adults (1996)Chronic Condition 45-64 65+

Arthritis 240 483

Hypertension 214 364

Hearing Impairment 132 303

Heart Conditions 116 269

Cataracts 23 172

Orthopedic Impairment 178 158

Sinusitis 174 117

Diabetes 58 100

Tintinitus 60 88

Visual Impairment 48 84

Top 10 Chronic Conditions Among Older Adults (1996)

Chronic Condition 1987 1996Arthritis 480 483Hypertension 394 364Hearing Impairment 296 303Heart Conditions 277 269Cataracts 141 (7) 172Orthopedic Impairment 173 (5) 158Sinusitis 169 (6) 117Diabetes 98 (8) 100Tintinitus 85 (10) 88Visual Impairment 95 (9) 84

Older Adults

Accounted for 36% of all hospital stays and 49% of all days of care in hospitals in 1997

ALOS was 6.8 days for older people, compared to only 5.5 days for people under 65

Averaged more contacts with doctors in 1997 than did persons under 65 (11.7 contacts vs. 4.9 contacts)

Functional Disability In the US, 17.3% of persons 60+ and 49.8%

of those 85+ have a self-care or mobility limitation or both

1.2 million fewer older adults were disabled in 1994 than would have been expected based on disability rates observed in 1982– the number of older adults with functional

problems in 1994 stood at 7.1 million, not the 8.3 million who would have been impaired if health had not improved over the last few years

Functional Disability Many factors may be involved in the decline

in disability– public health measures and nutrition– higher levels of education– improved economic status– medical advances

In order to maintain and accelerate the decline, we need to pinpoint how each of these factors is contributing to the improved health of older adults

Functional Disability (1987)

Age Needs Help with1 ormore ADLs

Needs Help with 1or more IADLs

65-69 14.7 19.9

70-74 21.1 24.7

75-79 24.1 29.2

80-85 34.4 40.0

85+ 49.8 55.2

Functional Disability (1995)

Age % with AnyDisability

% with SevereDisability

65+ 52.5 33.4

15-64 18.7 8.7

0-14 9.1 1.1

Functional Disability In 1996, 27% of older adults assessed their

health status as fair or poor Over 4.4 million (14%) had difficulty in

carrying out ADLs and 6.5 million (21%) reported difficulties with IADLs

Percentages with disabilities increase sharply with age; race and gender are also factors– women more likely than men to be disabled– blacks more likely than whites to be disabled

People with Disabilities

Children or adults with permanent disabilities– neurological diseases– degenerative conditions– accidents resulting in paralysis– children with congenital dysfunctions– paralyzing strokes– end-stage cancers– blindness

Mentally Impaired & Retarded, Developmentally Disabled Biomedical and technological advances in

treatments and management now allow large numbers to live long lives

Difficult to estimate precisely the number of people in this group who might be clients for a long-term continuum of care

Although the majority are treated on an outpatient basis, an integrated continuum oriented toward mental health services would be appropriate

AIDS/ARC Unless substantial inroads are made in the

search for a cure or a vaccine, the numbers of infected people are expected to grow dramatically– the CDC estimates that between 650,000 and

900,000 people are living with HIV– at least 40,000 new infections occur each year– through December 1998, a total of 688,200 cases

of AIDS had been reported to the CDC

AIDS/ARC

The majority of HIV+/AIDS/ARC people will be clients for an effective continuum at some stage of their illness– new treatments have extended the healthy

lifespan of many people with AIDS

Acute Episode Patients

Total number difficult to estimate because it is a composite of all of the people who have certain acute illnesses that may involve long-term care

Alzheimer’s Disease

Affects an estimated 4 million Americans– Approximately 19 million Americans say they have

a family member with Alzheimer’s and 37 million know someone with it

Manifested initially by mild forgetfulness, this devastating disease eventually erodes all cognitive and functional abilities, leading to total dependence on caregivers and, ultimately, to death

Alzheimer’s Disease

Prevalence increases dramatically with age– age 65-74 have 1 in 10 chance of having it– age 85+ have 1 in 2 chance of having it

14 million Americans will have Alzheimer’s by the middle of this century unless a cure or prevention is found

US society spends at least $100 billion a year on Alzheimer’s Disease– neither Medicare nor private health insurance

covers the type of LTC most patients need

Alzheimer’s Disease A person with Alzheimer’s lives an average of

8 years and as many as 20 years or more from the onset of symptoms

More than 7 out of 10 people with Alzheimer’s live at home– almost 75% of home care is provided by family

and friends; remainder is “paid” care costing an average of $12,500 per year, most of which is covered by families

Half of all nursing home patients suffer from Alzheimer’s or a related disorder