Chapter 9

Chapter 9Long-Term CareCHAPTER OBJECTIVESDefine long-term careReview major factors in the history, development and financing of the long-term care industryIdentify and define modes of long-term care service delivery and innovationsIdentify and review ACA provisions affecting long-term care

Introduction (1)Care needs of a lifespan may vary in intensity and durationLevel of support required for optimal functioning may vary over time on a continuumService locations vary with type and intensity of needshome to institutionServices range from intense medical to social support; many combinations

Introduction (2)Care needs, contdFormal LTC (institutionally-based or operated)Informal LTC (family, friends)72 M 65+ by 2030; 6.6 M 85+ by 2020 (Figs. 9-1, 9-2)Long-term care needs increase due to medical advances that increase longevity; changes in social structures that preclude home/informal care

Development of Long-Term Care ServicesColonial era: almshouses started by charitable colonists who purchased private homes for communal residences19th-early 20th century: city, county-operated homes & infirmaries for impoverished older adults; professional home care began as response to living conditions of immigrants (e.g. VNA) & expanded to education about hygiene, nutrition Development of Long-Term Care ServicesGreat Depression (1929): private citizens boarded older adults for financial benefit; many quality of care issuesSocial Security (1935): enabled older adults and those with certain disabilities to avoid reliance on charity1950s: government loans aided not-for-profit nursing home development1965: Medicare and Medicaid passage had profound effects on the LTC industryDevelopment of Long-Term Care ServicesMedicare & MedicaidStimulated nursing home industry development as a profitable businessesRequired minimum standards of care for reimbursementAttracted scrupulous & unscrupulous operators Abuses 1970s public exposes: Congressional hearings on inhumane treatment, by Ralph Nader, others, e.g.Untrained, inadequate staffHazardous, unsanitary conditionsOver, under-medicationDiscrimination against minoritiesThefts of belongingsReformsMedicare and Medicaid certificationState nursing home & home care licensingAppropriate staff credentialingLaws for elder abuse reportingRegulations on restraintsNursing home residents bill of rights Ombudsman programs

Modes of Long-term Care Service Delivery (1)Institutions such as nursing homes and skilled nursing facilities (SNFs): custodial; chronic care managementCommunity-based: adult day care, residential group homes, in-home care Modes of Long-term Care Service Delivery (2)Skilled nursing careAssisted living facilitiesHome careHospiceRespiteAdult day careInnovations

Skilled Nursing Care (1)Skilled nursing facility: (Medicare/Medicaid certified): a facility or distinct part of one, primarily engaged in providing skilled nursing care and related services for people requiring medical or nursing care, or rehabilitation services.3.3 M reside in 15,884 facilities; 86% >65 yearsSkilled Nursing Care (2)CostsAnnual national expenditures: $138.4 B; double cost of home careMedicare, Medicaid pay ~ 62%; 38% private, out-of-pocket, long-term care insurancePrivate room = $ 90,520/year; semi-private= $81,030/yearOccupancy declining: More assisted-living, community-support options; staying healthy longer

Skilled Nursing Care: StaffingAdministratorMedical DirectorRegistered Nurses and Licensed Practical NursesCertified Nurse AssistantsSocial workersNutrition & Dietary StaffRehabilitation (PT & OT)Recreational/ ActivitiesHousekeeping/Plant & FacilitiesSkilled Nursing Care (4)1987 OBRA increased government regulations re: periodic functional assessments of residents, aide training, restraints, bill of rights, medical director oversightStates licensure administratorsAnalyses indicate quality variations between for-profit & not-for-profit entitiesACA: certified SNFs must publicly disclose ownership information, expenditures, quality indicators on the webAssisted Living Facilities (1)Appropriate for people not requiring skilled nursing services whose needs lie in the custodial and supportive realm: a program that provides and/or arranges for daily meals, personal and other supportive services, health care and 24-hour oversight to persons residing in a group residential facility who need assistance with the activities of daily living.Includes residential group homes for developmentally disabled, physically challengedAssisted Living Facilities (2)Single homes to multi-unit apartments6,315 communities with 475,000 apartments housing 1 million+; growth projected to ~2 M+ by 2030.Primarily personal payment; varying costs; average monthly cost = $3,326State regulations vary; quality is function of ownership policies coupled with regulation

Home Care (1)Community-based care provided in private residences; long-term for chronically ill; short-term for rehabilitation after illness or hospitalizationFormal system: agency-employed professionals or self-employed who contract privately with clientsAgency rapid growth following Medicare reimbursement in 1965; by 1987 5,900+ dominated by public health agencies; 1990s growth again: Olmstead decision, MC & MA changes, evolving demographics & technology advances

Home Care (2)3.4 M Medicare receipts among 11,900 agencies, 70% for- profit; $74.3 B annual costs; MC & MA covered 81.4% total expenditures (Table 9-2)Medicare reimbursement initially required professional nursing, allied health services; home confinement; physician order; agency certification; ACA includes added patient assessment requirements to guard against fraud

Home Care (3)Additional ACA provisions support home & community based care:Medicaid Follows the Person for home & community services for individuals transitioning from institutional to home careCommunity First Choice Options in Medicaid, State Balancing Incentive Program, Federal Coordinated Health Care Office: to encourage community based over institutional careHome Care (4)Medicare & Medicaid certification requires agency state licensing; accreditation by private organizations, e.g. the Joint Commission is voluntaryExtensive research 2000-2010 from multiple sources documents significant cost-effectiveness of home care compared with institutional care for conditions requiring IV antibiotic therapies, diabetes, chronic obstructive pulmonary disease and congestive heart failureInformal Home Care (1)Provided by family/friends; 80% by family members61 M family caregivers; 75% female who also work outside the home; sandwich generation may have triple caring roles with aged relative, children and grandchildren; burnout is commonMarket value: $ 450 B/yr., 2x+ value of nursing home and agency supplied home care combinedInformal Home Care (2)Caregiver needs:FMLA 1993: 12 weeks job-protected unpaid leave in companies of >50 employees (excludes 50% of workers)Other leave provisions: CA , a few other states allow partial payment for limited periods, other states under consideration; federal employees in 40+ states Informal Home Care (3)ACA: Independence at Home Medical Practice Pilot Program provides Medicare recipients with at home primary care services; Community Care Transitions Program for high-risk Medicare patients following hospital discharge1990s Home Care ReformsFederal investigations of rising costs & quality concerns prompted:Operation Restore Trust (ORT) targeted Medicare billing practicesBBA of 1997 stiffened requirements for Medicare certificationOutcomes & Assessment Information Set (OASIS): reporting of patient condition, satisfactionDept. of Justice, FBI, Inspector General, state law enforcement coordinate anti-fraud/abuse activitiesHospice Care (1)A philosophy of care for terminally illPalliative, comprehensive care for physical & emotional symptoms; not cure-directedLow-tech: pain control, quality of remaining lifeSettings: home, dedicated hospice facilities, hospitals, SNFs; 450,000 volunteersMedicare certification requires 5% patient care hours as volunteers

Hospice Care (2) Roots in medieval EuropeModern model (1960s): London, U.K.; Dr. Cicely SaundersFirst U.S. hospice 1974 in CT as grassroots movement; all volunteer2011: 1.6M patients in 5,300 agencies; ~45% U.S. deaths60% for-profit; 34% not-for-profit; 5% govt.Hospice Care (3)Staff: Physician director, physicians, nurses, social workers, counselors, supportive staff Provide all required drugs, medical appliances, suppliesBereavement services for survivors and general community

Respite Care (1)Temporary, surrogate care for a patient in primary care giver(s) absence1970s origin: deinstitutionalization of developmentally disabled and mentally illShort-term service gives respite to at-home caregivers Purpose: forestall placement in institutional setting by providing caregivers periods of relief

Respite Care (2)Duration: short-term & intermittentSettings: homes, day care centers, hospitals, nursing homesStaff: professionals and trained laypersonsNot-for-profit organizations: grants help to fund servicesModels: Alzheimers disease inpatient; adult-day care centers; in-home assistance; temporary hospital or nursing home placementRespite Care: FundingMedicare payment: requires placement in certified hospital, hospice or nursing home; recipient pays 5% of Medicare-approved feeMedicaid payment: very limited, stringent requirementsBarriers: viewed as social not medical need benefitting caregivers; difficult planning for intermittent, unpredictable needsRespite Care (4)Enabling Legislation: Lifespan Respite Care Act of 2006- $ 289 M for state respite care program grants acknowledged value of informal care systemsAdministration on Aging (AoA) advocates for federal support of demonstration programs on cost-effectiveness of community services to enable continued independent living Adult Day Care (1)Origin: Lionel Cousins (1960s) to prepare institutionalized mental health patients for discharge into the communitySupervised social activities (social model)Supervised medical, rehabilitative activities (medical model)Temporary relief to caregivers; therapeutic social contacts for care recipientsAdult Day Care (2)Staff: variable for social & medical models4,600 centers; most state-licensed80% not-for-profitPayment by private fees, grants, charitable funds Quality & Accreditation (1999): Commission on Accreditation of Rehabilitation Facilities & National Adult Day Services Assn. issued quality standards

Innovations in Long-term Care: TypesProgram of All-inclusive care for the Elderly (PACE)Continuing Care and Life Care CommunitiesNaturally Occurring Retirement Communities (NORCs)High Technology Home CareInnovations in Long-term Care: Aging in Place San Francisco (1972): Medicare demonstration project for Chinatown community: On Lok: peaceful & happy abode. Frail older Americans remain at home with coordinated interdisciplinary support servicesOutcomes: lower hospitalization & nursing home placementsBBA (1997): PACE approved as permanent Medicare benefit; 2012: 88 PACE programs in 29 states

Innovations in Long-term Care: Aging in Place Programs coordinate continuum of services e.g. nursing, home care aide assistance, homemakers, 24-hour emergency response systems, home-delivered groceries, transportation to health appointmentsContinuing Care Retirement (CCRC) & Continuing Life Care (CCLC) CommunitiesCCRCs for those desiring an alternative to residing in their own homes as they age; 2,200+ with 725,000 residents; 80% not-for-profit, 50% faith based. Residences located on campuses offering social services, meals, access to contractual medical services in addition to housingLife care or extended contract/continuing life care community (CCLC): Most expensive; unlimited assisted living, medical treatment, skilled nursing care without additional costContinuing Care Retirement (CCRC) & Continuing Life Care (CCLC) CommunitiesModified contract: set of services of specific duration; higher monthly fees for added servicesFee-for-service contract: initial enrollment fee lower; assisted living, skilled nursing paid at market ratesFees: vary but require upfront payment of $100,000- $1M; monthly charges $3,000-5,000.Continuing Care Retirement (CCRC) & Continuing Life Care (CCLC) CommunitiesUse insurance-based model; regulated by state insurance departments and other agencies for applicable services~1% of older Americans choose this CCRC option due to cost and extended commitmentInnovations in Long-term Care (7)Naturally-occurring retirement communities (NORCs)Coined by Dr. Michael Hunt (U of Wisconsin Prof. of urban planning), 1980sApartment building residents, neighborhoods, community sections harboring aging residentsAOA demonstration grants programs underway: case management, nursing, social, recreation, nutrition

Innovations in Long-term Care (8)High-technology home careAdvanced technology for intravenous infusions, ventilation, dialysis, parenteral nutrition, chemotherapy available in the homeSpecialist home care personnel (nurses, pharmacists, respiratory therapists, etc.) Cost effectivePreferred by patients

Long Term Care Insurance (1)1970s: first offered for nursing home care only2010: AARP estimates 7-9 M policy owners; 95% cover continuum of services Many employers now offer as benefitFederal government offers tax deductions for employer contributions; many states offer tax incentives to individual purchasersBroad spectrum of benefit options & costsIncreases choices & avoids public dependency

Long Term Care Insurance (2)ACA Community Living Assistance Services & Supports Act (CLASS Act): proposed national voluntary LTCI program funded by payroll deductions with benefits eligibility in 5 years.Abandoned by DHHS in 2011: design flaws: voluntary enrollment lacked adequate risk base; age range of benefit eligibility too broad Would have provided opportunity to shift costs from Medicaid to private insuranceThe Future of Long Term Care (1)Increased diversification & specialization to meet wide range of needs, e.g. dementia, other chronic disease management of aging populationManaged care integrated provider networks bundle hospitalization and post-hospital care into one episode; ACA provisions will support increased community-based care; ACOs with PCMHs integrate LTC into continuum of services

Future of Long-Term Care (2)Staffing shortages due to low wages, workload and conditions, lack of social supports for workers, lack of career mobility; Private philanthropic, government initiatives continue to seek solutionsSupport for informal caregiversLegislation for paid family leave on horizon in several statesContinued experimentation with ACA demonstration project outcomes to suggest system refinements