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Chapter9-LTC4.pptx
Chapter 9
Long-Term Care
CHAPTER OBJECTIVES
Define long-term care
Review major factors in the history, development and financing of the long-term care industry
Identify and define modes of long-term care service delivery and innovations
Identify and review ACA provisions affecting long-term care
Introduction (1)
Care needs of a lifespan may vary in intensity and duration
Level of support required for optimal functioning may vary over time on a continuum
Service locations vary with type and intensity of needs…home to institution
Services range from intense medical to social support; many combinations
Introduction (2)
Care needs, cont’d
Formal 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 Services
Colonial era: almshouses started by charitable colonists who purchased private homes for communal residences
19th-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 Services
Great Depression (1929): private citizens boarded older adults for financial benefit; many quality of care issues
Social Security (1935): enabled older adults and those with certain disabilities to avoid reliance on charity
1950s: government loans aided not-for-profit nursing home development
1965: Medicare and Medicaid passage had profound effects on the LTC industry
Development of Long-Term Care Services
Medicare & Medicaid
Stimulated nursing home industry development as a profitable businesses
Required minimum standards of care for reimbursement
Attracted scrupulous & unscrupulous operators
Abuses
1970s public exposes’: Congressional hearings on inhumane treatment, by Ralph Nader, others, e.g.
Untrained, inadequate staff
Hazardous, unsanitary conditions
Over, under-medication
Discrimination against minorities
Thefts of belongings
Reforms
Medicare and Medicaid certification
State nursing home & home care licensing
Appropriate staff credentialing
Laws for elder abuse reporting
Regulations on restraints
Nursing 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 management
Community-based: adult day care, residential group homes, in-home care
Modes of Long-term Care Service Delivery (2)
Skilled nursing care
Assisted living facilities
Home care
Hospice
Respite
Adult day care
Innovations
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 years
Skilled Nursing Care (2)
Costs
Annual national expenditures: $138.4 B; double cost of home care
Medicare, Medicaid pay ~ 62%; 38% private, out-of-pocket, long-term care insurance
Private room = $ 90,520/year; semi-private= $81,030/year
Occupancy declining: More assisted-living, community-support options; staying healthy longer
Skilled Nursing Care: Staffing
Administrator
Medical Director
Registered Nurses and Licensed Practical Nurses
Certified Nurse Assistants
Social workers
Nutrition & Dietary Staff
Rehabilitation (PT & OT)
Recreational/ Activities
Housekeeping/Plant & Facilities
Skilled Nursing Care (4)
1987 OBRA increased government regulations re: periodic functional assessments of residents, aide training, restraints, bill of rights, medical director oversight
States licensure administrators
Analyses indicate quality variations between for-profit & not-for-profit entities
ACA: certified SNFs must publicly disclose ownership information, expenditures, quality indicators on the web
Assisted 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 challenged
Assisted Living Facilities (2)
Single homes to multi-unit apartments
6,315 communities with 475,000 apartments housing 1 million+; growth projected to ~2 M+ by 2030.
Primarily personal payment; varying costs; average monthly cost = $3,326
State 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 hospitalization
Formal system: agency-employed professionals or self-employed who contract privately with clients
Agency 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 care
“Community First Choice Options in Medicaid,” “State Balancing Incentive Program,” “Federal Coordinated Health Care Office:” to encourage community based over institutional care
Home Care (4)
Medicare & Medicaid certification requires agency state licensing; accreditation by private organizations, e.g. the Joint Commission is voluntary
Extensive 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 failure
Informal Home Care (1)
Provided by family/friends; 80% by family members
61 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 common
Market value: $ 450 B/yr., 2x+ value of nursing home and agency supplied home care combined
Informal 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 discharge
1990s Home Care Reforms
Federal investigations of rising costs & quality concerns prompted:
Operation Restore Trust (ORT) targeted Medicare billing practices
BBA of 1997 stiffened requirements for Medicare certification
Outcomes & Assessment Information Set (OASIS): reporting of patient condition, satisfaction
Dept. of Justice, FBI, Inspector General, state law enforcement coordinate anti-fraud/abuse activities
Hospice Care (1)
A philosophy of care for terminally ill
Palliative, comprehensive care for physical & emotional symptoms; not cure-directed
Low-tech: pain control, quality of remaining life
Settings: home, dedicated hospice facilities, hospitals, SNFs; 450,000 volunteers
Medicare certification requires 5% patient care hours as volunteers
Hospice Care (2)
Roots in medieval Europe
Modern model (1960s): London, U.K.; Dr. Cicely Saunders
First U.S. hospice 1974 in CT as grassroots movement; all volunteer
2011: 1.6M patients in 5,300 agencies; ~45% U.S. deaths
60% for-profit; 34% not-for-profit; 5% gov’t.
Hospice Care (3)
Staff: Physician director, physicians, nurses, social workers, counselors, supportive staff
Provide all required drugs, medical appliances, supplies
Bereavement services for survivors and general community
Respite Care (1)
Temporary, surrogate care for a patient in primary care giver(s) absence
1970s origin: deinstitutionalization of developmentally disabled and mentally ill
Short-term service gives “respite” to at-home caregivers
Purpose: forestall placement in institutional setting by providing caregivers periods of relief
Respite Care (2)
Duration: short-term & intermittent
Settings: homes, day care centers, hospitals, nursing homes
Staff: professionals and trained laypersons
Not-for-profit organizations: grants help to fund services
Models: Alzheimer’s disease inpatient; adult-day care centers; in-home assistance; temporary hospital or nursing home placement
Respite Care: Funding
Medicare payment: requires placement in certified hospital, hospice or nursing home; recipient pays 5% of Medicare-approved fee
Medicaid payment: very limited, stringent requirements
Barriers: viewed as “social” not “medical” need benefitting caregivers; difficult planning for intermittent, unpredictable needs
Respite Care (4)
Enabling Legislation: Lifespan Respite Care Act of 2006- $ 289 M for state respite care program grants acknowledged value of informal care systems
Administration 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 community
Supervised social activities (social model)
Supervised medical, rehabilitative activities (medical model)
Temporary relief to caregivers; therapeutic social contacts for care recipients
Adult Day Care (2)
Staff: variable for social & medical models
4,600 centers; most state-licensed
80% not-for-profit
Payment 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: Types
Program of All-inclusive care for the Elderly (PACE)
Continuing Care and Life Care Communities
Naturally Occurring Retirement Communities (NORCs)
High Technology Home Care
Innovations 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 services
Outcomes: lower hospitalization & nursing home placements
BBA (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 appointments
Continuing Care Retirement (CCRC) & Continuing Life Care (CCLC) Communities
CCRCs 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 housing
Life care or extended contract/continuing life care community (CCLC): Most expensive; unlimited assisted living, medical treatment, skilled nursing care without additional cost
Continuing Care Retirement (CCRC) & Continuing Life Care (CCLC) Communities
Modified contract: set of services of specific duration; higher monthly fees for added services
Fee-for-service contract: initial enrollment fee lower; assisted living, skilled nursing paid at market rates
Fees: vary but require upfront payment of $100,000- $1M; monthly charges $3,000-5,000.
Continuing Care Retirement (CCRC) & Continuing Life Care (CCLC) Communities
Use 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 commitment
Innovations in Long-term Care (7)
Naturally-occurring retirement communities (NORCs)
Coined by Dr. Michael Hunt (U of Wisconsin Prof. of urban planning), 1980s
Apartment building residents, neighborhoods, community sections harboring aging residents
AOA demonstration grants programs underway: case management, nursing, social, recreation, nutrition
Innovations in Long-term Care (8)
High-technology home care
Advanced technology for intravenous infusions, ventilation, dialysis, parenteral nutrition, chemotherapy available in the home
Specialist home care personnel (nurses, pharmacists, respiratory therapists, etc.)
Cost effective
Preferred by patients
Long Term Care Insurance (1)
1970s: first offered for nursing home care only
2010: AARP estimates 7-9 M policy owners; 95% cover continuum of services
Many employers now offer as benefit
Federal government offers tax deductions for employer contributions; many states offer tax incentives to individual purchasers
Broad spectrum of benefit options & costs
Increases choices & avoids public dependency
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 insurance
The Future of Long Term Care (1)
Increased diversification & specialization to meet wide range of needs, e.g. dementia, other chronic disease management of aging population
Managed 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 solutions
Support for informal caregivers
Legislation for paid family leave on horizon in several states
Continued experimentation with ACA demonstration project outcomes to suggest system refinements
