case study questions

What You Will Learn •  The long-term care (LTC) industry consists of various providers, insurers, LTC professionals, and an ancillary sector. •  Home health care is a prime example of community-based long-term care providers. Others include homemaker and personal care service providers, adult day care providers, and hospice service providers. •  Independent living and retirement centers and custodial care providers such as adult foster care facilities can be referred to as quasi-institutions. •  Institutional providers range from assisted living facilities to a variety of providers that are commonly referred to as nursing homes. Some institutional long-term care services are based in hospitals. Continuing care retirement communities integrate and coordinate the independent living and other institution-based components of the LTC continuum. •  Commercial insurance companies and managed care organizations play a critical role in the financing of long-term care services. •  A variety of health care personnel are involved in the delivery of long-term care. •  The ancillary sector supports the other segments of the industry through case management, pharmacy services, and technology. Introduction Efficient delivery of services to a nation’s population necessitates a long-term care (LTC) industry. The LTC industry mainly consists of private providers—organizations that deliver services and can independently bill for those services. In addition, some tax-supported government agencies deliver social services. This chapter elaborates on these providers as a segment of the LTC industry. Other segments of the industry include LTC professionals employed by the industry; without them the industry cannot function. They can be classified as administrative professionals, clinicians, paraprofessional caregivers, ancillary personnel, and social support professionals. In addition, key partners play vital supportive roles. These partners include the insurance industry, managed care organizations, case management agencies, long-term care pharmacies, and developers of medical technology. The Provider Sector The term provider refers to an entity that gets reimbursed for services delivered. Various private organizations and facilities, both for profit and nonprofit, are part of the LTC industry. Both LTC institutions and community-based service providers are essential to serve a variety of needs. The LTC industry is predominantly funded by the government, and certain sectors of the industry are more stringently regulated than others. Community-Based Service Providers Four main types of providers constitute the community-based sector of the LTC industry: (1) home health providers, (2) homemaker and personal care service providers, (3) adult day care providers, and (4) hospice service providers. Home Health Providers Home health care is consistent with the philosophy of maintaining people in the least restrictive environment possible. Without the availability of skilled nursing care and rehabilitation services in patients’ own homes, the patients would have to be in hospitals or nursing homes to receive the same services at a much higher expense. The organizational setup commonly requires a community- or hospital-based home health agency that sends licensed professionals and paraprofessionals—aides and attendants—to patients’ homes to deliver services approved by a physician. The 1988 class-action lawsuit of Duggan v. Bowen was instrumental in expanding home health benefits under Medicare. The new rules that took effect in 1989 removed the requirement of a 3-day hospital stay before home health visits would be covered under Medicare and abolished the maximum limit of 100 visits, as the former criterion had specified. Between 1990 and 1996 alone, the number of home health care providers grew from 5,800 to 9,900 (Liu et al., 1999). Medicare criteria focus on clinically oriented care, not long-term support and assistance, which is referred to as custodial care. Under Medicare, skilled nursing care is the most common service received by home health patients. According to the most recent 2007 Home and Hospice Care Survey, there were 14,500 home health and hospice care agencies in the United States. Approximately 75% of these agencies provided only home health care; 10% were mixed agencies providing both home health and hospice services (Park-Lee & Decker, 2010). The majority of these agencies are private for profit. Medicare is the single largest payer for home health services; 45% of all home care expenditures in 2010 were attributed to Medicare (National Center for Health Statistics, 2012). For Medicaid beneficiaries, states pay for the same services that Medicare does. Private LTC insurance also includes skilled home care benefits. In addition to Medicare-certified agencies, there are numerous noncertified home care agencies, home care aide organizations, and hospices. Often, such agencies do not provide the breadth of services that Medicare requires. For example, home health aide organizations do not provide skilled nursing care. Homemaker and Personal Care Service Providers Homemaker and personal services include assistance with personal hygiene (such as bathing), light housework, laundry, meal preparation, transportation, and grocery shopping. Various private agencies offer services for in-home assistance. Homemaker and personal care services, however, are not covered under the Medicare program. To varying degrees, states pay for homemaker and personal care for Medicaid beneficiaries, in which case services are coordinated through Area Agencies on Aging.1 Personal funds are used to pay for these services by those who do not qualify for Medicaid. Adult Day Care Providers Adult day care (ADC) is a community-based extramural service. It enables people to live with their families and fulfills family caregivers’ need for respite so they can go to work during the day. These centers may be located in senior centers, nursing facilities, churches or synagogues, or hospitals. Many centers also provide transportation from home to the center and back. Today, most ADC services are highly focused on prevention and health maintenance, with the objective of preventing or delaying institutionalization. Over time, ADC services have become more clinical in nature (see Figure 3–1). As such, ADC services, in many instances, have become alternatives to home health care and assisted living and as a transitional step before placement in a nursing home. Nationally, there are 4,800 ADC centers with a capacity to serve 276,500 clients daily. Approximately, 55% of these centers are nonprofit. Medicare does not pay for ADC, but 75% of the ADC centers are certified for Medicaid. In terms of demographics, 37% of the clients are under the age of 65 and 32% have Alzheimer’s disease or other dementias (Harris-Kojetin et al., 2013). The national average cost of ADC was $70 per day in 2012 (MetLife, 2012). Hospice Service Providers Medicare added hospice benefits in 1983, 9 years after the first hospice opened in the United States. For a patient to receive hospice benefits, a physician must certify that the patient is terminally ill and that the patient’s life expectancy is 6 months or less (Centers for Medicare and Medicaid Services [CMS], 2013a). Benefit payments by Medicare, however, are not limited to 6 months. The patient must also agree to waive the right to medical treatment for the terminal illness. Figure 3–1  Percentage of Adult Day Care Centers Providing Various Services, 2012 Data from Harris-Kojetin, L. et al. (2013). Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics. People most commonly served by hospice have cancer, heart disease, unspecified debility, dementia, or lung disease. Cancer accounts for 37% of all diagnoses. The average length of service in 2012 was 71.8 days. The majority of care was provided in private residences (42%) and in various types of LTC facilities (25%). In addition, 27% of the patients received care in a hospice inpatient facility and 6% received hospice services while in a hospital (National Hospice and Palliative Care Organization [NHPCO], 2013). The number of hospice programs nationwide has grown from 4,850 in 2008 to 5,560 in 2012. Most of these are certified by Medicare. The majority of hospices (57%) are independent, freestanding agencies. The remaining are part of a hospital, home health agency, or nursing home. Hospices served an estimated 1.5 to 1.6 million patients in 2012. Medicare is the largest source of payment (83.7% in 2012) for hospice care. Other sources include private insurance and Medicaid (NHPCO, 2013). Quasi-Institutional Providers The institutional continuum of LTC includes a range of facilities that often do not have clear-cut distinctions. Yet, these facilities can be classified into three broad categories: (1) independent living facilities, which are not truly institutions because they do not generally deliver health care; (2) custodial care providers that limit their services to social support and personal care; and (3) assisted living facilities and nursing homes. Here, the first two categories are referred to as quasi-institutions because clinically oriented services are either nonexistent or minimum in these facilities. Independent Living and Retirement Centers The three main independent living categories are (1) government-assisted housing, (2) private-pay housing, and (3) cohousing. These dwellings differ from other institutional settings in that staff are generally not present 24 hours a day. A business manager generally maintains office hours 5 days a week and may be available on-call for emergencies. Government-Assisted Housing    The U.S. Department of Housing and Urban Development (HUD) administers three different housing programs:   1.  Under the Public Housing program, HUD administers federal aid to local housing agencies that manage the housing for low-income residents at rents they can afford. Anyone with low income, including the elderly and disabled persons, can apply for the program.   2.  The Section 8 program offers vouchers or certificates that allow people to choose any housing in the private market that meets certain requirements and apply the voucher or certificate toward rent. Section 8 program is also managed by local public housing agencies.   3.  The Section 202 Supportive Housing for the Elderly program is specifically meant for low-income people who are at least 62 years old at the time of initial occupancy. HUD provides interest-free capital advances to private, nonprofit sponsors to finance the development of supportive housing. HUD also provides rent subsidies for the projects to help make them affordable. The capital advance does not have to be repaid for 40 years as long as the project serves very low-income elderly persons. A similar program is Section 811 Supportive Housing for Persons with Disabilities. Additional supportive services such as Meals On Wheels, homemaker services, and transportation are arranged from community-based providers. Clinical services are arranged with a home health agency. Private-Pay Housing    Many upscale retirement centers abound, in which one can expect to pay a fairly substantial entrance fee plus a monthly rental or maintenance fee. These complexes have various types of recreational facilities and social programs. The fees often include the evening meal. Cleaning services, transportation, and other types of basic assistance may be provided at an extra charge. Many of these facilities provide monthly blood pressure and vision screenings, and many organize local outings for shopping and entertainment. Nursing or rehabilitation services, when needed, can be arranged with a local home health agency. Cohousing    Cohousing—a type of collaborative housing in which residents actively participate in the design and operation of their own neighborhoods (Cohousing Association of the United States, 2013)—is a relatively new development in the United States. The main features of a cohousing community include condos clustered around a central courtyard, a common house where residents can socialize and share meals, and a system whereby the residents operate and maintain the property themselves (Clark, 2013). The concept originated in Denmark and is expanding into other European countries, Canada, and Australia (Cohousing, 2013). The United States has approximately 125 cohousing communities (Clark, 2013). Custodial Care Providers The facilities in this sector go by various names: adult foster care homes, board-and-care homes, personal care homes, sheltered care homes, and domiciliary care homes. Custodial services are rendered by paraprofessionals rather than licensed nurses or therapists. Each state has established its own standards to license these facilities. Funding typically comes from Medicaid, private insurance, and personal sources. Medicare does not pay for custodial care alone. Depending on temporary needs, home health care can be called in to deliver skilled nursing and rehabilitation services. Some states are trying to boost capacity of custodial care providers. Under the Money Follows the Person program, states see a greater need for quasi-institutional alternatives. Adult foster care (AFC) homes (also called adult family homes or adult family care) are family-run homes that provide room, board, supervision, and custodial care. The homes are modified to accommodate people with disabilities and prevent unsupervised wandering because many residents have some degree of dementia or psychiatric diagnosis. There is 24-hour supervision in the homes. Typically, the caregiving family resides in part of the home. To maintain the family environment, most states license fewer than 10 beds per family unit. However, many people have made a business of AFC by buying several houses and hiring families to live in them and care for the residents. A skeleton staff is employed to provide assistance with ADLs, to clean, and to cook meals. In some states, AFCs are declining in numbers. Low reimbursement rates are seen as one factor in the declining number of persons willing to be AFC providers (Mollica et al., 2008). Institutional Providers Institutional providers are the most visible sector of the LTC industry. Institutional care generally connotes some degree of confinement to an institution because of a relatively high level dependency. Such institutions include assisted living facilities, nursing homes, and continuing care retirement communities. Assisted Living Facilities Assisted living facilities are regarded as LTC institutions that provide services that range between custodial care and skilled nursing care. Assisted living has been the fastest growing type of LTC institution in the United States. In 2012, there were 15,447 assisted living facilities nationwide, an increase of 9% over 5 years (Sanofi-Aventis, 2013). Assisted living facilities generally have a skeleton staff of licensed nurses, mostly licensed practical (or vocational) nurses, who perform admission assessments and deliver basic nursing care. Advanced nursing care and rehabilitation therapies can be arranged through a home health agency. Assisted living facilities operate predominantly on a private-pay basis; 86% of the residents use their own financial resources (Assisted Living Federation of America, 2013). In 2012, the average monthly cost was $3,550, less than half of what it would cost for private accommodation in a nursing home (MetLife, 2012). However, costs vary according to amenities and the services required by a resident. Most facilities charge a basic monthly rate that covers rent, board, and utilities. Additional fees are charged for nursing and personal care services. Many facilities also charge a one-time entrance fee, which may be equal to 1 month’s basic rent. In some states, assisted living care may be covered under the Medicaid program for the recipients of Supplemental Security Income (SSI) or may be funded through Title XX Social Services Block Grants or 1915(c) home- and community-based services waivers. Upscale facilities, however, do not participate in public payment programs. All states now regulate ALFs by requiring them to be licensed. In the absence of federal standards, regulations vary from state to state. These regulations continue to evolve in response to the rising acuity levels of residents. The typical assisted living resident is female, 87 years old, mobile, but needing assistance with two to three ADLs (National Center for Assisted Living, 2013). A growing number of assisted living facilities are providing specialized care for the elderly who have dementia and Alzheimer’s disease. Nursing Homes In the minds of many people, long-term care is synonymous with nursing homes—a common misconception. The appellation “nursing home,” however, has no specific meaning. In health care literature, the term “nursing home” is generally used for facilities that are licensed as nursing homes and are often certified by the federal government. Licensing of nursing homes is mandatory in every state. Certification enables a nursing home to participate in the Medicare and Medicaid programs. Skilled Nursing Facilities    A skilled nursing facility provides a full range of clinical LTC services, from skilled nursing care to rehabilitation to assistance with all ADLs. Examples of skilled nursing care include monitoring of unstable conditions; clinical assessment of needs; and treatments such as intravenous feeding, wound care, dressing changes, or clearing of air passages. Examples of skilled rehabilitation include postsurgical orthopedic care after knee or hip replacement, cardiopulmonary rehabilitation that is necessary after heart surgery or heart catheterization, and improvement of physical strength and balance. A variety of disabilities—including problems with ambulation, incontinence, and behavior—often coexist among a relatively large number of patients in need of skilled care. Compared with other types of facilities, nursing homes have a significant number of patients who are cognitively impaired because of depression, delirium, or dementia. The social functioning of many of the patients is also severely impaired. A physician must authorize the need for skilled care. An attending physician must approve the plan of treatment. Delivery of care is also periodically monitored by the attending physician who makes rounds and follows up on the course of various treatments being given. Rehabilitation services are provided by registered therapists—physical therapists, occupational therapists, and speech/language pathologists—who may be employed in house or contracted from a therapy services provider. The majority of direct care with ADLs is delivered by paraprofessionals, but under the supervision of licensed nurses and therapists. To capture a larger share of the LTC market, some skilled nursing facilities operate a distinct assisted living unit or wing, and a few have adult day care. An increasing number of nursing homes (55% according to MetLife, 2012) operate distinct units or wings for Alzheimer’s and dementia care. The nursing home industry in the United States is dominated by private, for-profit nursing home chains that operate a group of nursing homes under one corporate ownership. Approximately 17% of the nursing homes are operated by the 15 largest nursing home chains; the largest of them, Genesis Health Care (Kennett Square, PA) operated 383 nursing homes with over 46,000 beds in 2012 (Sanofi-Aventis, 2013). A breakdown of U.S. nursing homes according to the type of ownership appears in Figure 3–2. Although the charges for services vary quite substantially among states, the national average for a private room in 2012 was $248 per day (MetLife, 2012). Medicaid is the largest single source of payment for nursing home services. Subacute Care Facilities    The patients needing subacute care may be recovering after hospitalization but are still subject to complications while in recovery. They require more nursing intervention than what is typically included in skilled nursing care. The patients may still have an unstable condition that requires active monitoring and treatment, or they may require technically complex nursing treatments such as wound care, intravenous therapy, blood transfusion, dialysis, ventilator care, or AIDS care. Figure 3–2  Breakdown of Nursing Homes by Type of Ownership, 2012 Data from Harris-Kojetin, L. et al. (2013). Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics. The three main institutional locations for subacute care—long-term care hospitals (LTCHs), hospital transitional care units (TCUs), or freestanding nursing homes—vary in terms of availability, cost, and quality. Unlike TCUs that are certified as skilled nursing facilities, LTCHs are certified as acute care hospitals. Many LTCH patients with complex medical needs are admitted directly from short-stay acute-care hospital intensive care units. Not surprisingly, LTCHs are the most expensive of the three types of subacute settings. Skilled nursing facilities are often a more cost-effective alternative, but they need to increase the ratio of licensed nurses to provide adequate care to subacute patients. The number of hospital-based TCUs has steadily declined whereas the number of LTCHs has grown as hospitals have diverted their resources to capture better reimbursement from Medicare. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)    Federal regulations provide a separate certification category for LTC facilities classified as ICFs/IID since 1971 (formerly known as Intermediate Care Facilities for the Mentally Retarded—ICF/MRs), when Section 1905(d) of the Social Security Act authorized Medicaid coverage for the care of the intellectually/developmentally disabled (IDD) patients in ICF/MR facilities. Most of these patients have other disabilities, in addition to intellectual disabilities (IDs). For example, many of these patients are nonambulatory, have seizure disorders, behavior problems, mental illness, visual or hearing impairments, or have a combination of these conditions. The primary purpose of ICFs/IID is to furnish nursing and rehabilitative services that involve “active treatment.” Active treatment entails aggressive and consistent specialized programs that include skill training to help the patients function as independently as possible. Over 6,000 ICF/IID facilities serve over 100,000 individuals in all 50 states (CMS, 2013b). Continuing Care Retirement Communities Full-service continuing care retirement communities (CCRCs)—also called life-care communities—integrate and coordinate the independent living and other institution-based components of the LTC continuum. Different levels of services are generally housed in separate buildings, all located on one campus. The range of services is based on the concept of aging in place, which accommodates the changing needs of older adults while living in familiar surroundings. The range of services includes housing, health care, social services, and health and wellness programs. The residents’ independence is preserved, but assistance and nursing care are available when needed. In 2009, over 1,800 CCRCs operated in the United States; most were operated by nonprofit organizations (Cackley et al., 2010). CCRCs, for the most part, require private financing, with the exception of services delivered in a Medicare-certified skilled nursing facility (SNF). Three types of CCRC contracts are common in the industry: (1) a life care or extended contract incorporates a complete package of services that includes a commitment to provide unlimited future LTC services without an increase in the monthly fee; (2) a modified contract provides for support services in independent living and includes a limited number of days of care in assisted living and SNF without an increase in the monthly fee; and (3) a fee-for-service contract that includes only support services in independent living; higher level of services must be paid for out of pocket at the prevailing rates. There is a wide variation in entrance and monthly fees based on amenities and the type of contract. In the state of New York, for example, entrance fees begin at approximately $115,000 for a single person independent living unit; monthly fees begin at approximately $2,100 (New York Department of Health, 2013). The CCRC living option is directed at middle- and upper-middle-income clientele. Communities are operated by both for-profit and nonprofit organizations. Residents typically choose to enter these communities when they are in their late 70s and are still relatively healthy. The Insurance Sector The insurance sector includes numerous commercial insurance companies that sell LTC insurance. Insurers offer individual and group LTC insurance. Employees of the federal government can purchase LTC insurance at group rates through the Federal Long-Term Care Insurance Program. Individual insurance is purchased by people directly through insurance companies or insurance brokers very much like they would purchase auto insurance or home insurance. Group insurance is made available to individuals through their employers, unions, professional organizations, or consumer organizations such as the AARP and the Association of Mature American Citizens (AMAC). Generally, group premiums are lower than those for individually purchased insurance because a large number of people band together to purchase insurance through a group sponsor. Managed care organizations (MCOs) are also involved in LTC insurance. Commercial Insurance Commercial insurance companies are risk underwriters. They determine the level of premiums necessary to cover potential claims in the future. They collect premiums and pay claims arising from the utilization of LTC services when the covered beneficiaries use the services in accordance with the insurance contract. Commercial insurance companies, however, do not select the providers of services. That choice is left up to the beneficiaries. The leading companies in the business of long-term care insurance include Genworth Life Insurance Company, John Hancock, and New York Life Insurance Company. Some insurers have stopped selling LTC insurance; others are raising their prices because they overestimated how many people would stop paying their premiums and underestimated the costs of long-term care (Consumer Reports, 2012). LTC insurance typically covers home health care, assisted living, and nursing home care. Besides a person’s age the cost of premiums varies according to critical options selected such as (1) the benefit period over which LTC expenses will be covered (a 3-year plan is considered adequate for most people); (2) automatic inflation protection to keep up with the growing cost of LTC; (3) the elimination period, or the time that has to pass before insurance will begin paying benefits; and (4) waiving of premiums while benefits are being received. Managed Care Managed care is an approach to delivering a comprehensive array of health care services to a defined group of enrolled members through efficient management of service utilization and payment to providers. The most common type of MCO that is active in the delivery of LTC services is health maintenance organizations (HMOs). HMOs enter into financial contracts with Medicaid and Medicare to deliver health care services to the beneficiaries enrolled in these programs. HMOs are also insurance entities that underwrite risk. In contrast with commercial insurance companies, however, HMOs select the providers of services. The selected providers are those with whom the HMO has payment contracts. Between 2007 and 2012, enrollment of Medicaid recipients in HMOs grew steadily from 28.5 million to 43.9 million. Over 75% of Medicaid beneficiaries nationwide were enrolled in HMOs in 2012, up from 63.6% in 2007 (Sanofi-Aventis, 2013). The Balanced Budget Act of 1997 authorized the Medicare+Choice program, which was renamed Medicare Advantage in 2003. Medicare gives its beneficiaries the choice either to remain in the traditional Medicare program or enroll in Medicare Advantage, in which services are provided through various MCOs. Enrollment of Medicare beneficiaries in Medicare Advantage plans grew from 8.7 million in 2007 to 13.3 million in 2012. Over 26% of Medicare beneficiaries nationwide were enrolled in MCOs in 2012, up from 19.5% in 2007 (Sanofi-Aventis, 2013). Long-Term Care Professionals A variety of health care professionals are involved in the delivery of long-term care. They can be classified as (1) administrative professionals, (2) clinicians, (3) paraprofessional caregivers, (4) ancillary personnel, and (5) social support professionals. The types of personnel involved vary according to the level of LTC services delivered in a given setting. For example, independent living and retirement centers may employ one or two administrative professionals and a small staff of ancillary personnel. A nursing home has all five categories of LTC professionals. Certain clinicians may be found only in specialized facilities. Growth of the LTC industry will continue to create jobs in all areas, many of which already have critical shortages. Administrative Professionals Every agency or organization requires at least one administrative professional to manage the organization. The number and types of administrative professionals increase with the organization’s size and complexity. Administrators Administrators are needed to manage LTC organizations. They must also oversee compliance with federal and state regulations and ensure that services are delivered in accordance with the organization’s policies and established standards. Administrators must have a good understanding of financing and reimbursement systems. They must be knowledgeable about legal issues and ethical behavior. Administrators who manage larger organizations must also be skilled in managing human resources, marketing the facility’s services, and overseeing the facility’s quality improvement program. Leadership, communication, financial management, and problem-solving skills are also essential for effective management of LTC organizations. The title for the administrator’s position may vary, such as administrator, executive director, director, manager, or general manager. This section mainly focuses on administrators of home health agencies, assisted living facilities, and nursing homes. Home Health Agency Administrators    According to Medicare’s Conditions of Participation for home health agencies, the administrator must either be a licensed physician, a registered nurse, or someone who has training and experience in health services administration and at least one year of supervisory or administrative experience in home health care or related health programs (CMS, 2005). Agencies often employ a registered nurse or someone with a business degree as administrator. Assisted Living Administrators    A number of states now require administrators of assisted living facilities to be licensed. In a growing regulatory environment, however, it is a matter of time before all states will require administrators to be licensed. Education, experience, and examination requirements vary from state to state. The National Association of Long Term Care Administrator Boards (NAB) has established requirements for licensure as a residential care/assisted living (RC/AL) administrator. The American College of Health Care Administrators (ACHCA) has established its own criteria for certification of administrators, leading to the designation, Certified Assisted Living Administrator. To be licensed by the NAB, individuals must complete a 40-hour state-approved course covering the domains of practice and pass the NAB’s licensure examination. To take the NAB’s licensure exam, an individual must have a combination of education and experience (NAB, 2013): (1) a high school diploma and 2 years of experience in assisted living, including 1 year in a leadership/management position; or (2) an associate’s degree and 1 year of experience in assisted living, including 6 months in a leadership/management position; or (3) a bachelor’s degree and 6 months of leadership/management experience in assisted living. The NAB examination for RC/AL covers five main areas, referred to as the domains of practice: client/resident services management, human resources management, leadership and governance, physical environment management, and financial management. A state may also require working experience with a trained preceptor. A preceptor is a nursing home or assisted living administrator who meets prescribed qualifications and has been certified to mentor interns in an administrator-intraining (AIT) program. Generally, licensed nursing home administrators are allowed to manage assisted living facilities without any further training. Continuing education requirements are also becoming common for license renewal. Nursing Home Administrators    A nursing home administrator (NHA) must be licensed by the state. Qualifications required for licensure vary widely from one state to another. The first step toward becoming a licensed NHA is to contact the particular state’s licensing agency and obtain a copy of the state’s licensure requirements. The prospective administrator must meet the minimum educational qualifications. Most states require a college degree; some states also require completion of a short course in long-term care. A common requirement by all states is passing the national examination administered by the NAB. In addition to the NAB examination, candidates must pass a shorter examination on state nursing home regulations. Some states may also require an internship with a state-certified preceptor who is also a practicing NHA. An administrator licensed in one state may be able to obtain a license in another state if the two states have a reciprocity agreement. Nursing homes are complex organizations to manage and have been the target of much regulatory oversight and public criticism. The NHA position is, in many respects, similar to that of a general manager in a complex human services delivery organization. The NHA must have a 24/7 commitment to an organization that must meet the patients’ clinical needs, support their social and emotional well-being, preserve their individual rights, promote human dignity, ensure their safety, and improve their quality of life. Although the NHA is primarily a manager, he or she must have adequate understanding of legal, regulatory, and reimbursement aspects of managing a long-term care facility; and the clinical, social, and residential aspects of care delivery. The nursing home must also operate as an efficient business. The NHA must manage staff relations, budgets and finances, marketing, and quality. Hence, NHAs typically have a broad range of managerial responsibilities and are closely involved in day-to-day operational details. Over time, effectively managed nursing facilities achieve acceptable levels of organizational stability and have predictable outcomes in patient care quality and financial performance. In the long run, an effectively managed facility gains recognition in the community as a vital service provider and as a facility of choice for those in need of high-quality nursing home care. The LTC industry has evolved over time, and it will continue to change. Hence, the NHA must adapt to new trends and new demands as they become established. Being an NHA is a rewarding career, both financially and professionally. The psychological rewards that can come from delivering high-quality care to patients, helping family members, supporting community initiatives, coaching the staff, and building excellence into the organization often exceed the financial rewards. Department Directors Department directors constitute the middle-management stratum of a nursing home. The organization of nursing homes is well established. The main department directors include the director of nursing, food service director or dietary manager, social worker or director of social services, activity director, business office manager, housekeeping/laundry supervisor, and maintenance supervisor. They report to the administrator and carry out supervisory functions in their respective departments. Their main role is to ensure adequate staffing, availability of supplies and materials, and coordination of service delivery that complies with established standards. Required qualifications are established by state nursing home regulations. Other Administrative Personnel Depending on the size and type of organization, administrative personnel may include assistant administrators, bookkeepers, receptionists, and admissions coordinators. Very large LTC organizations may also employ human resource or personnel directors and marketing directors. At a minimum, most organizations need (1) a receptionist to greet visitors, provide information, and handle basic office tasks and (2) a bookkeeper whose main responsibility is to handle all billings and collections. Additional help is generally needed for payroll and accounts payable functions. Clinicians Various types of clinicians are employed in home health agencies, nursing homes, and assisted living facilities. They mainly include physicians, nurses, rehabilitation professionals, dietitians, and assistants and technicians who work under the direction of these professionals. With the exception of nurses, most others are generally contracted. Physicians Only very large and specialized facilities can afford to employ a full-time physician. Most organizations contract with a physician in the capacity of a medical director, which is typically a part-time position. It is not uncommon for the medical director to also provide medical services to many of the patients in the nursing home. The patient, however, has the right to choose his or her attending physician provided that the physician is willing to follow up on the patient’s medical care in the nursing home. Admission to a nursing facility or care by a home health agency is also authorized by a physician. Physicians play a central role in the medical care of patients. Other clinicians follow physicians’ orders for prescribed medical, nursing, rehabilitation, and dietary interventions. Most physicians practicing in the LTC field are generalists or family practitioners rather than specialists. All states require physicians to be licensed in order to practice. The licensure requirements include graduation from an accredited medical school that awards a doctor of medicine (MD) or doctor of osteopathic medicine (DO) degree, successful completion of a licensing examination governed by either the National Board of Medical Examiners or the National Board of Osteopathic Medical Examiners, and completion of a supervised internship/residency program. Residency is graduate medical education in a specialty that takes the form of paid on-the-job training. Most physicians serve a 1-year rotating internship after graduation from medical school and before entering a residency program. Both MDs and DOs use traditionally accepted methods of treatment, including drugs and surgery. The two differ mainly in their philosophies and approach to medical treatment. Osteopathic medicine, practiced by DOs, emphasizes the musculoskeletal system of the body such as correction of joints or tissues. In their treatment plans, DOs emphasize preventive medicine such as diet and the environment as factors that might influence natural resistance. MDs are trained in allopathic medicine, which views medical treatment as active intervention to produce a counteracting reaction in an attempt to neutralize the effects of disease. MDs trained as generalists also use preventive medicine along with allopathic treatments (Shi & Singh, 2015). Nurses The two main categories of nurses in LTC settings are registered nurses (RNs) and licensed practical (or vocational) nurses (LPNs or LVNs). All nurses must be licensed by the state in which they practice. The two main educational programs today for RNs are associate’s degree (ADN) programs offered by community colleges or vocational technical schools and bachelor of science degree (BSN) programs offered by 4-year colleges and universities. Regulations require the delivery of skilled nursing services to be under the supervision of RNs. In LTC settings, RNs compose only a small percentage of the workforce. They mostly hold administrative and supervisory positions such as director of nursing or head nurse. A number of studies have shown that an adequate number of RNs in nursing homes positively affects quality outcomes. The majority of nurses in LTC settings are LPNs/LVNs who are graduates of 1-year practical nursing programs. LPNs/LVNs render treatments and administer medications. LPNs also function as charge nurses and team leaders and supervise the work of paraprofessional caregivers. Nonphysician Practitioners Nonphysician practitioners (NPPs) are clinical professionals who practice in many of the areas in which physicians practice but who do not have an MD or DO degree. The two main types of NPPs who practice in LTC settings are nurse practitioners and physician assistants. Their generalist training and emphasis on patient relationships make them particularly valuable in LTC caregiving. Nurse practitioners (NPs) are advanced practice nurses who provide health care services similar to those of primary care physicians. They can diagnose and treat a wide range of basic health problems. Some physicians employ NPs to follow up on the medical care of their patients. Studies of NPs in nursing homes suggest that they enhance the medical services available to residents and prevent unnecessary hospital admissions (Institute for the Future of Aging Services, 2005). NPs receive advanced graduate-level education and clinical training beyond what is required for RN preparation. Most have master’s degrees; some specialize in geriatrics (American Academy of Nurse Practitioners, 2007). Physician assistants (PAs) are increasingly employed to provide LTC services under the direction of a physician. PAs are trained at the graduate level. The curriculum includes basic medical sciences, behavioral science, and clinical courses. The program resembles a condensed version of medical school (Cawley, 2012). Their scope of practice includes performing physical examinations, diagnosing and treating illnesses, ordering and interpreting laboratory tests, and making rounds at LTC facilities. Rehabilitation Professionals Rehabilitation therapies enable patients to regain lost functioning and improve current functioning. The most common rehabilitation services are provided by physical therapists, occupational therapists, and speech/language pathologists. Certain treatments can be provided by assistants under the direction and supervision of therapists. Services of a physiatrist are common in facilities that provide intensive rehabilitation. Physiatrists    A physiatrist is a physician who has specialized in physical medicine and rehabilitation. Physiatrists can treat a variety of problems from pain to work- and sports-related injuries. Diagnoses may include severe arthritis, brain injury, spinal cord injury, stroke, multiple sclerosis, amputations, and various conditions requiring postsurgical recovery. Physiatrists may prescribe drugs or assistive devices and direct therapists to carry out various types of treatments to help restore, improve, or maintain function. Physical Therapists and Assistants    A physical therapist (PT) specializes in the treatment of musculoskeletal disorders (loss of function associated with bones, joints, spine, and soft tissue), neuromuscular disorders (loss of function associated with the brain and nervous system, such as stroke), patients recovering from cardiopulmonary problems, and severe wounds. They specialize in the restoration of various ADL functions. PTs need a graduate degree from a physical therapy program accredited by the Commission on Accreditation in Physical Therapy Education. The 218 programs of physical therapy in the United States all offer a Doctor of Physical Therapy (DPT) degree (Bureau of Labor Statistics [BLS], 2014); those who graduated earlier have master’s degrees. The Federation of State Boards of Physical Therapy develops and administers the national examinations for both PTs and physical therapy assistants (PTAs). PTAs can provide part of a patient’s treatment under the direction and supervision of a PT. Most states require PTAs to complete an associate’s degree that includes classroom study and clinical experience (BLS, 2014). Occupational Therapists and Assistants    Occupational therapists (OTs) are involved in a broad range of therapies that help patients recover or maintain their daily living and work skills. Their goal is to help patients achieve independence and satisfaction in all facets of their lives. For example, OTs can teach patients how to strengthen their upper limbs or care for their daily needs such as grooming, cooking, and eating. OTs also evaluate and make recommendations for a person’s living or work environments to ensure safe independent functioning. A master’s degree or higher in occupational therapy is the minimum requirement for entry into the field; OTs who graduated earlier may have bachelor’s degrees. OTs must be licensed to practice. To obtain a license, applicants must graduate from an accredited educational program and pass a national certification examination administered by the National Board for Certification in Occupational Therapy (NBCOT). Occupational therapy assistants help patients with rehabilitative activities and exercises outlined in a treatment plan developed in collaboration with an OT. An associate’s degree is the typical educational requirement. To be licensed in most states, occupational therapy assistants must pass a national certification examination administered by NBCOT after they graduate. Those who pass the examination are awarded the title Certified Occupational Therapy Assistant (COTA). Speech/Language Pathologists and Audiologists    Speech/language pathologists (SLPs)—informally referred to as speech therapists—assess, diagnose, and treat speech, language, and cognitive disorders. Dysphagia, that is, swallowing difficulty, is another common problem that SLPs are called upon to treat in LTC settings. A master’s degree is typically required for licensure in most states; it is mandatory for receiving the Certificate of Clinical Competence from the Council of Clinical Certification of the American Speech-Language-Hearing Association (ASHA). An audiologist is a professional who specializes in the diagnosis and nonmedical treatment of hearing and balance disorders. They can assess hearing and balance problems and administer treatment. They also dispense and fit hearing aids and cochlear implants. A doctoral degree in audiology is the typical educational requirement. Every state licenses audiologists. Clinical Dietitians and Technicians Clinical dietitians, sometimes referred to as nutritionists, provide nutritional information and diet-related services to patients. They assess patients’ nutritional needs, develop and implement nutrition programs, and evaluate the results. They also confer with physicians and other care professionals to coordinate medical and nutritional needs. Clinical dietitians often develop diet plans for patients who have renal problems, diabetes, heart disease, and weight loss or weight gain issues. Minimum qualifications for clinical dietitians include a bachelor’s degree. To qualify as a Registered Dietitian (RD) or Registered Dietitian Nutritionist (RDN), the individual must also complete a supervised internship accredited by the Accreditation Council for Education in Nutrition and Dietetics (ACEND) of the Academy of Nutrition and Dietetics, and then successfully complete the Registration Examination for Dietitians (Commission on Dietetic Registration, 2014). Dietetic technicians assist dietitians in the delivery of food service in accordance with nutritional guidelines. Under the supervision of dietitians, they may plan and produce meals based on established guidelines, and teach or counsel individuals regarding principles of food and nutrition. Becoming a Dietetic Technician, Registered (DTR) requires completing at least a 2-year associate’s degree, completing a dietetic technician program that includes 450 hours of supervised experience accredited by ACEND, and passing the registration examination (Commission on Dietetic Registration, 2014). Paraprofessional Caregivers Long-term care services heavily rely on paraprofessional caregivers, who give most of the hands-on personal care and assist patients with all ADLs. They also change bed linens and serve meals to patients. These paraprofessionals include certified nursing assistants (CNAs), therapy aides, personal care attendants, and home health aides. They constitute the largest group of health care workers in the LTC industry. Paraprofessional positions are at the bottom of the organizational hierarchy. These workers typically carry heavy workloads, are inadequately paid, and are often treated with little respect. In most LTC organizations, such as nursing homes, assisted living facilities, and home health agencies, paraprofessionals work under the direction of licensed nurses. CNAs are also trained to take vital signs; watch for and report any changes in the patients’ condition to nurses; and do simple urine tests for sugar, acetone, and albumin. The 1987 Nursing Home Reform Act mandated that CNAs receive a minimum of 75 hours of training. The training program must include 16 hours of hands-on training in which the trainee demonstrates knowledge while performing tasks for an individual under the direct supervision of a nurse. CNA students must also pass a state certification exam and skills test, and subsequently complete inservice or continuing education each year as required by the state in which the CNA is employed. CNAs can receive further training to become rehabilitation aides who provide basic therapies such as walking and range of motion exercises under the supervision of licensed therapists and nurses. CNAs can also become medication aides after further training to safely give medications to patients. Ancillary Personnel A variety of ancillary personnel provide hotel services such as meals, cleaning, laundry, and maintenance of physical plant and equipment in LTC facilities. Food service personnel such as cooks and cook’s helpers prepare meals. Dietary aides wash dishes and cooking utensils. Building cleaning workers include janitors and housekeepers. Laundry workers sort and wash linens. Others fold, store, and deliver clean linens to patient care areas. Maintenance personnel handle basic repairs and groundskeeping. Social Support Professionals Social support professionals include social workers and recreational therapists/activity professionals. In LTC settings, social workers engage in diagnostic assessment of patients’ cognitive, behavioral, and emotional status; counseling; and conflict resolution. They help people cope with various types of issues in their everyday lives. They also have community resource expertise that is often called upon to obtain professional services available in the community. A bachelor’s degree in social work (BSW) is the minimum requirement for social work positions in nursing homes and assisted living facilities. The Council on Social Work Education accredits educational programs in social work. Recreational therapists and activity professionals provide a variety of recreational programs for groups and individuals to improve and maintain the patients’ physical, mental, and emotional well-being. Programs include arts and crafts, games, music, movies, dance and movement, social celebrations, and community outings. Passive activities such as reading and working with puzzles are prescribed for those who prefer solitude. After completing a bachelor’s degree in therapeutic recreation, a person can obtain the Certified Therapeutic Recreation Specialist (CTRS) credential through the National Council for Therapeutic Recreation Certification (NCTRC). Certification requires a supervised internship of at least 560 hours and passing an examination (BLS, 2014). The National Certification Council for Activity Professionals (NCCAP) offers certifications for activity directors and activity assistants. Ombudsmen Amendments to the Older Americans Act in 1978 mandated that each state have an ombudsman program, which is administered by the Agencies on Aging. An ombudsman is a trained professional who works independently with nursing home residents and their families to resolve concerns they may have about their lives in a facility. As an advocate for residents of nursing homes, board-and-care homes, and assisted living facilities, the ombudsman investigates and resolves complaints on behalf of facility residents and informs consumers on how to obtain quality care. The ombudsman also informs public agencies about the problems of older adults residing in nursing facilities. The Ancillary Sector The ancillary sector produces services and products that help people locate the right kind of services, facilitate caregiving, improve people’s quality of life, or improve organizational efficiencies. Case Management Agencies Case management agencies do not provide actual LTC services. They assist clients in navigating the system by assessing client needs, identifying sources of payment, matching client needs with available services that are likely to best address those needs, making referrals to appropriate services, and providing ongoing follow up and coordination as circumstances change over time. Services are often coordinated both within and outside the LTC system. Case management agencies employ experienced nurses and social workers as case managers. These professionals have specialized training in patient need assessment and a comprehensive knowledge of both financing and service resources. For the financially needy, the local Area Agencies on Aging have qualified staff to assess care needs and community living options. Long-Term Care Pharmacies Historically, LTC facilities have experienced numerous challenges in providing pharmaceutical services to their residents. Medication errors, preventable adverse drug events, and delivery of pharmaceutical services in general have posed the main challenges (Stevenson et al., 2007). The Omnibus Budget Reconciliation Act of 1990 required pharmacies to review Medicaid recipients’ entire drug profile and to evaluate therapeutic duplication, drug–disease contraindications, drug interactions, incorrect dosage, duration of drug treatment, drug–allergy interactions, and evidence of clinical abuse or misuse. To help LTC facilities comply with the regulatory requirement, certain pharmacy providers have specialized in LTC pharmacy practice. Through their consultant pharmacists, LTC pharmacies offer comprehensive drug management services and often coordinate related quality improvement activities (Stevenson et al., 2007). LTC pharmacies also play a critical role in dispensing emergency medications and intravenous medication solutions not available through retail community pharmacists. In 2012, there were 1,246 LTC pharmacies in the United States, and they derived 56% of their revenue from nursing homes (Sanofi-Aventis, 2013). Long-Term Care Technology Technology has played an increasing role in all aspects of health care delivery. Adoption of technology for LTC use has been slow, but it will continue to grow in homes, other residential settings, and LTC institutions. Innovative products are being brought to the market all the time. For example, various types of domotics technology, that is, “smart home” technology, can enable a growing number of elderly people to live in their own homes. Long-term care technology can be classified into seven main categories:   1.  Enabling technology. Also referred to as assistive technology, this includes various devices and equipment that enable people to do things independently despite functional impairments. Examples include hearing aids, simple self-feeding aids such as specially designed eating utensils, and custom-fitted mobility scooters that improve people’s quality of life regardless of whether they are living independently in their own homes or in LTC institutions. Some newer technologies enable people to live independently. These technologies include reminder systems that are particularly useful for those with mild cognitive impairments. Automatic enunciators remind people of tasks they must do that day, such as keeping a doctor’s appointment. Enunciators are also being integrated with medication administration systems to remind people when certain medications must be taken. Talking blood sugar monitors, thermometers, blood pressure monitors, and automated pill dispensers are now available for use in the home (Cheek et al., 2005). The National Association of Home Builders has developed an aging-in-place certification specialist program. A Certified Aging-in-Place Specialist (CAPS) has specialized skills in home remodeling solutions to enable older adults to live in their own homes as they age. Various products and devices are used to promote accessibility and safety in the bathroom, bedroom, or kitchen. For example, clapper lighting systems turn on the lights at the sound of clapping. Enabling technology also finds applications in nursing homes. For example, radio frequency identification tags help residents and caregivers quickly locate lost dentures, glasses, and hearing aids, which has been a common occurrence in nursing homes (McKnight’s Long-Term Care News, 2013).   2.  Safety technology. Personal emergency response systems (PERS) are now widely available for people living alone to summon help in an emergency. Technology that uses signals, alarms, and wireless transmitters can be installed in nursing facilities to notify staff when a wandering patient opens a door to go out. Wireless sensors to ensure patient safety are also being developed. Fall detection devices can signal the staff when an at-risk resident attempts to leave a bed, wheelchair, or toilet unattended.   3.  Caregiving technology. Feeding and nutritional therapies—such as enteral and parenteral feeding—have been around for a long time. Other technologies such as in-home dialyzers for people with kidney failure are more recent. Caregivers are now increasingly using automated medication dispensing systems that improve accuracy and efficiency. A variety of beds and overlays are available to promote healing of pressure ulcers. Ultrasound bladder scanners are used for the management of urinary incontinence. Barcode technology has been adopted to verify patient identification and dispense medications. Home telehealth systems use telecommunication technology for the distance monitoring of patients and delivery of care with or without the use of video technology. They have the potential to improve access and reduce costs by minimizing the need for the patient to make trips to physicians’ offices or for home health nurses to make frequent visits to the patient’s home. Interactive technology enables “virtual visits” between clinicians and patients. It enables distance monitoring of the patient and promotes self-management of chronic conditions. Remote patient monitoring systems collect data on vital signs and blood pressure and allow a nurse to also observe any behavior changes.   4.  Labor-saving technology. Labor-saving technology is designed to improve worker efficiency and reduce physical injuries in LTC facilities by decreasing the need for heavy transfers and lifting. Electrically operated ceiling-suspended dining tables can convert a dining room to a multipurpose room at the flip of a switch. Ceiling-mounted patient lifting and transfer equipment and labor-saving bathing systems are other examples of labor-saving technology. Computerized medical records that replace handwritten charting can save caregivers time that can be spent in delivering patient care.   5.  Environmental technology. Products and fibers that have greater fire resistance; improved fabrics for upholstered furniture that resist soil and fluid absorption; new fibers for carpeting that resist soil, stains, and odors; and nonskid floor coverings are some examples that enhance the aesthetics and safety of living environments. Computerized controls for hot water systems are designed to save energy and prevent the supply of overheated water that can cause severe burns. Sensorial signals, such as color and textured materials, are employed to support orientation of cognitively impaired individuals in their own homes and in institutions (Cheek et al., 2005).   6.  Staff training technology. Interactive tools, CD-ROMs, and remote video teleconferencing are available to provide training and continuing education on a large variety of topics.   7.  Information technology. Information technology (IT) deals with the transformation of data into useful information. IT is a broad area. In health care organizations, application of IT falls into three main categories: •  Clinical information systems are designed to be used by various clinicians to support the delivery of patient care. Electronic health records, for example, can provide quick and reliable information necessary to guide clinical decision making and to produce timely reports on quality of care delivered. Computerized provider order entry (CPOE) systems enable electronic transmission of medication orders to the pharmacy and help reduce errors. Clinical information systems also support patient assessment, care planning, and clinical documentation. These systems can be integrated with other applications such as administrative and financial systems, menu planning, and food ordering. •  Administrative information systems are designed to assist in carrying out financial and administrative support activities such as payroll, patient accounting, billing, accounts receivable, materials management, budgeting and cost control, and management of residents’ personal funds. •  Decision support systems provide information and analytical tools that support effective management. For example, the system can help analyze performance indicators, staffing adequacy, staff productivity, rates of infections and patient incidents such as falls, and staff injuries. Terminology for Review adult foster care homes aging in place allopathic medicine audiologist cohousing custodial care dietitian domotics dysphagia group insurance managed care nonphysician practitioners nurse practitioners occupational therapist ombudsman osteopathic medicine paraprofessionals physiatrist physical therapist physician assistants preceptor provider speech/language pathologist For Further Thought Case Pathway to Dining Contributed by Elizabeth A. Berzas, PhD, Our Lady of the Lake College; and Mary Jean Davies, BS, Baton Rouge, LA. In Slidell, Louisiana, a blind, married couple was living in their own home until the wife’s health started to decline and she became wheelchair bound. The couple then moved into an assisted living facility. Both were about 75 years old. Assessment by a health care professional found that both residents could sense some light differentiation. Placement of low-voltage recessed floor lighting down the middle of the main hallway leading to the dining room was recommended, and the administrator followed up on the recommendation. The blind husband could then look up and track the light so that he could orient and guide himself to the dining room while pushing his wife in the wheelchair. Because of this modification, the residents were able to regain at least some independent mobility for accessing the dining room. The staff was educated to not move or rearrange the patients’ living environment, because blind people orient themselves by counting steps, using spatial reference points and tactile cues. Questions 1.  Which health care professional, discussed in this chapter, should take the lead in assessing the need for a lighted pathway and also educating the staff? 2.  What quality of life factors exist in this case? How were they addressed by installing floor lighting? 3.  The floor lighting can be best classified under which of the seven types of technology discussed in this chapter? 4.  Should the facility arrange to provide any additional services that would facilitate daily living for this couple? Who should have this responsibility? FOR FURTHER LEARNING Administration on Aging: An agency of the U.S. Department of Health and Human Services provides information on various community-based programs. http://www.aoa.gov Assisted Living Federation of America: A group that offers basic consumer-oriented information on assisted living and gives a directory of assisted living facilities. This trade organization represents assisted living and other senior housing facilities. http://www.alfa.org Home Care Research Initiative: This organization supports research projects to address issues in long-term care. Research articles and fact sheets can be downloaded. http://www.vnsny.org/hcri/index.html Hospice Foundation of America: A nonprofit organization that provides leadership in the development and application of hospice and its philosophy of care. http://www.hospicefoundation.org National Adult Day Services Association: This organization represents the adult day care industry and also furnishes consumer information. http://www.nadsa.org National Association for Home Care and Hospice: The nation’s largest trade association representing the interests and concerns of home care agencies, hospices, home care aide organizations, and medical equipment suppliers. http://www.nahc.org National Association of Long Term Care Administrator Boards (NAB). This organization administers the national licensure examinations for assisted living and nursing home administrators. It has publications available to prepare for the examination. The website also provides links to the licensing agencies in all states. http://www.nabweb.org REFERENCES American Academy of Nurse Practitioners. (2007). Frequently asked questions: Why choose a nurse practitioner as your healthcare provider. Retrieved November 2008 from http://awareness.aanp.org/about.html. Assisted Living Federation of America. (2013). Assisted living. Retrieved August 2013 from http://www.alfa.org/alfa/Assisted_Living_Information.asp. Bureau of Labor Statistics. (2014). Occupational outlook handbook, 2014–15 Edition. Retrieved January 2014 from http://www.bls.gov. Cackley, A. P. et al. (2010). Continuing care retirement communities can provide benefits, but not without some risk. Washington, DC: U.S. Government Accountability Office. Cawley, J. F. (2012). Physician assistants and their role in primary care. Virtual Mentor, 14(5), 411–414. Centers for Medicare and Medicaid Services. (2005). State operations manual: Appendix B—Guidance to surveyors: Home health agencies. Centers for Medicare and Medicaid Services. Retrieved November 2008 from http://cms.hhs.gov/manuals/Downloads/som107ap_b_hha.pdf. Centers for Medicare and Medicaid Services. (2013a). Medicare hospice benefits. Baltimore, MD: Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. (2013b). Intermediate care facilities for individuals with intellectual disabilities (ICFs/IID). Retrieved August 2013 http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/ICFMRs.html. Cheek, P. et al. (2005). Aging well with smart technology. Nursing Administration, 29(4), 329–338. Clark, J. B. (2013). Creative housing for seniors. Kiplinger’s Personal Finance, 67(6), 54. Cohousing Association of the United States. (2013). What is cohousing? Retrieved January 2014 from http://www.cohousing.org/what_is_cohousing. Commission on Dietetic Registration. (2014). Certifications. Retrieved January 2014 from http://cdrnet.org/certifications. Consumer Reports Money Advisor. (2012). Long-term-care insurance: Insurers are forced to boost premiums or stop selling policies. Retrieved January 2014 from http://www.consumerreports.org/cro/2012/08/long-term-care-insurance/index.htm. Harris-Kojetin, L. et al. (2013). Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics. Institute for the Future of Aging Services. (2005). The long-term care workforce: Can the crises be fixed? Washington, DC: Author. Liu, K. et al. (1999). Medicare’s post-acute care benefit: Background, trends, and issues to be faced. Retrieved October 2008 from http://aspe.hhs.gov/daltcp/reports/1999/mpacb.htm. McKnight’s Long-Term Care News. (2013). The terraces of Los Gatos thrives on smartbed technology. McKnight’s Long-Term Care News, 34(12), 20. MetLife. (2012). Market survey of long-term care costs. 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Retrieved February 2009 from http://www.medpac.gov/documents/Jun07_Part_D_contractor.pdf.       ______________________ 1Over 600 Area Agencies on Aging (AAA) operate in all states under the auspices of the Administration on Aging, a unit of the Administration for Community Living (under the U.S. Department of Health and Human Services). The main objective of the AAAs is to promote community-based LTC services for the most needy through education, case management, and financing of services. Grants are made available to provide financial assistance to those most at risk of nursing home placement. The program is funded through the Older Americans Act of 1965.