Discussion Board
© 2010 Jones and Bartlett Publishers, LLC
© 2010 Jones and Bartlett Publishers, LLC
Chapter 3
The Long-Term Care Industry
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Introduction
- A long-term care industry is necessary for the efficient delivery of services
- The LTC industry includes:
- Private providers of services
- Tax-supported government agencies that deliver social services
- LTC professionals employed by the industry
- Insurance industry, managed care organizations, case management agencies, and LTC pharmacies
- Developers of medical technology
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The Provider Sector
They deliver and get paid for LTC services
- Community-based service providers
- Quasi-institutional providers
- Institutional providers
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Community-Based Service Providers
Home Health Providers - 1
LTC philosophy: least restrictive environment
Duggan v. Bowen: Expansion of home health under Medicare:
- Removed 3-day prior hospitalization
- Abolished maximum 100 visits
- Skilled observation became covered
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Community-Based Service Providers
Home Health Providers - 2
Skilled nursing care is the most common service provided under Medicare
Most agencies provide home care; some mixed agencies provide home health and hospice services
The majority are private for profit
Medicare is the largest single payer
Numerous non-Medicare certified agencies also exist; they generally do not provide the breadth of services required under Medicare
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Community-Based Service Providers
Homemaker and Personal Care Service Providers
Various private agencies
In-home assistance and chores
Medicare-certified agencies can also deliver these services
Medicare does not pay for these services
Medicaid may pay; in this case services are coordinated through an Area Agency on Aging
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Community-Based Service Providers
Adult Day Care Providers - 1
Community-based extramural service
Respite for family
Some provide transportation back and forth
Services are highly focused on prevention and health maintenance to prevent or delay institutionalization
Many services are alternatives to home health care and assisted living
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Community-Based Service Providers
Adult Day Care Providers – 2
Over 4,800 ADC centers
A little over half are nonprofit
Medicare does not pay, but 75% are certified for Medicaid
Roughly 37% are under age 65; 32% have Alzheimer’s or other dementias
Cost around $70 per day in 2012
Main services are illustrated in Figure 3-1
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Community-Based Service Providers
Hospice Service Providers - 1
Medicare rules:
Physician certification that patient’s life expectancy is 6 months or less
The patient must waive the right to medical treatment for the terminal illness
The average length of service is about 72 days
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Community-Based Service Providers
Hospice Service Providers - 1
Majority of care is provided in private homes and various LTC facilities; about one-fourth receive services in hospice inpatient facilities
Hospice programs have grown
The majority are independent freestanding agencies; others are part of a hospital, home health agency, or nursing home
Medicare is the largest source of payment
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Quasi-Institutional Providers
- Clinical services are nonexistent or minimum
- Two main categories:
- Independent living and retirement centers
- Custodial care providers
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Independent Living and Retirement Centers
- Three main types:
- Government-assisted housing
- Private-pay housing
- Cohousing
- Staff generally not present 24 hours
- Generally, a business manager maintains office hours 5 days a week
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Government-Assisted Housing
Housing and Urban Development (HUD) administers 3 different programs:
- Public Housing program – aid to local housing agencies for low-income residents
- Section 8 program – Vouchers or certificates
- Section 202 Supportive Housing for the Elderly – for low-income elderly 62 years or older
Support services are arranged from community-based providers; clinical services are arranged with a home health agency
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Private-Pay Housing
- Generally upscale retirement centers
- Entrance fee plus a monthly rental or maintenance fee
- An evening meal is often included
- Cleaning, transportation, and basic assistance may be provided at an extra charge
- Nursing and rehabilitation services can be arranged through a home health agency
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Cohousing
Collaborative housing in which residents actively participate in the design and operation of their neighborhoods
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Custodial Care Providers - 1
- Facilities go by various names: adult foster care, board and care, personal care, etc.
- Care is rendered by paraprofessionals, rather than licensed staff
- Funding: Medicaid, insurance, private funds
- Medicare does not pay for custodial care
- There is a greater need for these providers under the Money Follows the Person program
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Custodial Care Providers - 2
- Adult foster care homes
Family-run homes that provide room, board, supervision and custodial care
A skeleton staff generally provides assistance with ADLs, cleaning, and cooking
Many residents have some dementia or psychiatric diagnosis
- Due to low reimbursement, some states are seeing a decline
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Institutional Providers
- The most visible sector of the LTC industry
- Suitable for people with high level of dependency
- These institutions include:
Assisted living facilities
Nursing homes
Continuing care retirement communities
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Assisted Living Facilities - 1
- Services range between custodial care and skilled nursing care
- They provide basic nursing care
- Advanced nursing care and rehabilitation can be obtained through a home health agency
- Fastest growing type of LTC institution
- Facilities are predominantly private pay
- Average monthly cost: $3,550 in 2012, but they vary according to amenities and services
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Assisted Living Facilities - 2
- A basic monthly rate generally covers rent, board, and utilities
- Additional fees are charged for nursing and personal care services
- Medicaid covers in some states through block grants or 1915(c) waivers
- All states require licensure of ALFs
- Rising acuity level in ALFs; many provide services for dementia and Alzheimer’s
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Nursing Homes
- The term “nursing home” has no specific meaning
- In literature, the term is generally applied to licensed and certified facilities that serve Medicare and/or Medicaid patients
- Skilled nursing facilities
- Subacute care facilities
- Intermediate care facilities for individuals with intellectual disabilities (ICFs/IID)
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Skilled Nursing Facilities - 1
- Provide a full range of clinical care from skilled nursing care to rehabilitation to assistance with ADLs
- A variety of disabilities often coexist in these facilities
- A significant number of patients have cognitive impairment and low social functioning
- The need for skilled care must be authorized by a physician
- An attending physician must approve the plan of treatment
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Skilled Nursing Facilities - 2
- To capture market share, some facilities operate a distinct assisted living section; a few operate adult day care
- Many have special Alzheimer’s/dementia units
- Private for-profit chains dominate the nursing home industry
- Types of ownership – see Figure 3-2
- Medicaid is the largest single source of payment for nursing home care
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Subacute Care Facilities
Subacute care
- Patients may be recovering after hospitalization but are subject to complications while in recovery
- These patients need more nursing intervention than what is included in skilled nursing care
- Active monitoring, treatments, and technically complex care are often required
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Subacute Care Facilities
Institutional locations:
Transitional care units (TCUs) in hospitals
– Certified as SNFs
Long-term care hospitals (LTCHs)
– Certified as hospitals
Subacute units in skilled nursing facilities
– Must increase the ratio of licensed nurses
The number of TCUs has steadily declined whereas the number of LTCHs has increased
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ICFs/IID
Intermediate care facilities for individuals with intellectual disabilities
- A separate certification category
- Previously called, ICF/MRs – intermediate care facilities for the mentally retarded
- Most of the patients have additional physical disabilities
- The facilities must provide “active treatment” – aggressive and consistent specialized programs that include skill training to enable the patients function as independently as possible
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CCRCs - 1
Continuing care retirement communities
Different levels of services on one campus
Concept: aging-in-place
Services include housing, health care, social services, and health and wellness programs
Independence is preserved but assistance and nursing care are available when needed
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CCRCs - 2
Continuing care retirement communities
Financing is mostly private except in the Medicare-certified skilled nursing facility
Entrance and fees and monthly fees are common
Three types of contracts:
Life care or extended contract – includes unlimited future LTC services
Modified contract – a certain number of days of care are included
Fee-for-service contract – assistance and care must be paid for out of pocket
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The Insurance Sector
Commercial Insurance
Risk underwriting
Choice of providers is left up to the beneficiaries
It includes home health care, assisted living, and nursing home care
Cost of premiums varies according to the period over which benefits are paid, inflation protection, elimination period, and waiving of premiums when benefits are paid
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The Insurance Sector
Managed Care - 1
- An array of health care services are available
- For a defined group of enrolled members
- Efficient service utilization and payments to providers
Health maintenance organizations (HMOs) are the most common type for delivering LTC
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The Insurance Sector
Managed Care - 2
HMOs are insurance entities that underwrite risk
HMOs have contracts with providers that the beneficiaries must use
HMOs contract with Medicare and Medicaid – growth of enrollees in HMO plans
The Medicare HMO enrollment program is called Medicare Advantage
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LTC Professionals
- Types of personnel vary according to setting
- Main categories:
- Administrative professionals
- Clinicians
- Paraprofessionals
- Ancillary personnel
- Social support professionals
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Administrative Professionals: Administrators
- Manage the organization
- Oversee regulatory compliance
- Ensure care delivery according to policies and standards
- Required knowledge in:
- Financing and reimbursement
- Legal and ethical behaviors
- Skills: human resource, marketing, quality improvement, leadership, communication, financial management, problem solving
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Home Health Agency Administrators
Qualifications:
- Licensed physician, or
- Registered nurse, or
- Training in health services administration and one year of management experience in health care
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Assisted Living Administrators
- License required in many states
- Required qualifications established by each state
- NAB has established a licensure program based on education, experience, 40-hour course, and exam
- Domains of practice for the NAB exam:
- Client/resident services management
- Human resources management
- Leadership and governance
- Physical environment management
- Financial management
© 2010 Jones and Bartlett Publishers, LLC
© 2010 Jones and Bartlett Publishers, LLC
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Nursing Home Administrators - 1
Becoming an NHA:
- License required by every state
- Required qualifications established by each state
- National exam administered by the NAB
- Exam on state nursing home regulations
- Internship may be required
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Nursing Home Administrators - 2
Main responsibilities:
- 24/7 responsibility of a general manager
- Patient orientation:
- clinical, social, and emotional well-being
- promotion of patient rights and dignity
- improve quality of life
- Business orientation:
- Understand legal, regulatory, and reimbursement aspects
- Staff relations, budgets and finances, marketing, quality
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Nursing Home Administrators - 3
Key outcomes that define success:
- Predictable outcomes in patient care quality and financial performance
- Positive image in the community
- Operate within reimbursement allowances
- Adapt to new trends and demands
- Legal and regulatory compliance
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Department Directors:
Middle Management
- Director of nursing
- Food service director (dietary manager)
- Social worker (director of social services)
- Activity director
- Business office manager
- Housekeeping/laundry supervisor
- Maintenance supervisor
- Other administrative personnel vary according to facility size
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Clinicians: Physicians
- Medical director
- Attending physicians
- Authorize admission to a facility or home health care
- Prescribe medical, nursing, rehabilitation, and dietary interventions
- Generalists or family practitioners
- Doctor of medicine (MD) or doctor of osteopathy (DO)
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Clinicians: Nurses
Two main categories:
- RNs
- Graduates of Associate’s degree (ADN) or BSN
- Mainly hold supervisory positions
- Positive effect on quality outcomes
- LPNs/LVNs
- Graduates of one-year programs
- Treatments and medication administration
- Charge nurses and team leaders
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Clinicians: Nonphysician Practitioners
- They practice in many of the areas in which physicians practice
- Two main categories of NPPs; both have advanced training:
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- They have generalist training and they emphasize patient relationships
- NPs enhance medical services in facilities and prevent unnecessary hospitalizations
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Clinicians: Rehabilitation Professionals
- Physiatrists
- Physical therapists and assistants
- Occupational therapists and assistants
- Speech/language pathologists and audiologists
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Clinicians: Dietitians
- Assess nutritional needs, develop nutritional programs, and evaluate the results
- They confer with physicians and other care professionals
- Diet plans for patients who have renal problems, diabetes, heart disease, etc.
- Dietetic technicians:
- Deliver food service according to nutritional guidelines
- Teaching and counseling about nutrition
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Paraprofessional Caregivers
- Render most of the personal care
- Assistance with ADLs
- Change bed linens
- Serve meals to patients
- Categories:
CNAs, therapy aides, personal care attendants, home health aides
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Certified Nursing Assistants
- Work under the direction of nurses
- Are trained to take vital signs, observe and report changes in patients’ condition, and do simple urine tests
- Minimum of 75 hours training required by law, that includes 16 hours of hands-on training
- They must pass a state exam and skill test
- Complete yearly inservice or continuing education
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Ancillary Personnel
- They provide hotel services
- Meal preparation, cleaning, laundry, maintenance
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Social Support Professionals
Social workers:
- Assessment, counseling, conflict resolution
- Assist people cope with issues
- Community resource expertise
Recreation therapists or activity professionals
- Recreational programs for groups and individuals
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Ombudsmen
- Each state is legally required to have an ombudsman program
- An ombudsman works independently to resolve patient-related concerns in nursing homes, personal care homes, and assisted living facilities
The Ancillary Sector
Case Management Agencies
- Do not provide actual LTC services
- Client assistance:
- Assessing needs
- Identifying sources of financing
- Matching services to needs
- Making referrals
- Follow-up and coordination
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LTC Pharmacies
- Pharmaceutical requirements in LTC facilities are complex
- Through their consultant pharmacists, LTC pharmacies offer comprehensive drug management and coordinate related quality improvement activities
- They also dispense emergency medications and intravenous solutions not available through retail community pharmacies
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LTC Technology
Seven main categories:
- Enabling technology
- Safety technology
- Caregiving technology
- Labor-saving technology
- Environmental technology
- Staff training technology
- Information technology
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