Module 6
Long Term Care and Death and Dying
a. Institutional Facilities For Long-Term Care
People with chronic disabilities, cognitive disorders, or physical infirmities
that keep them from living independently may receive treatment in one of a variety of
institutional long-term care settings. These institutions range from hospital-like
facilities to living situations more like independent residences, providing minimal
food and services.
For individuals whose illness or disability requires daily nursing care as well
as other support services, nursing homes provide comprehensive care in a single
setting. A nursing home is a type of medical institution that provides a room, meals,
skilled nursing and rehabilitative care, medical services, and protective supervision.
The care provided in nursing homes includes treatment for problems that residents
have in many basic areas of life including cognition, communication, hearing, vision,
physical functioning, continence, psychosocial functioning, mood and behavior,
nutrition, and dental care. To manage these problems, residents typically need to take
medications on a regular basis. Residents of nursing homes may also receive training
in basic care as well as assistance with feeding and mobility, rehabilitative activities,
and social services. Typically, nursing homes are thought of as permanent residences
for the older adults who enter them, but about 30% of residents are discharged and
able to move back into the community after being treated for the condition that
required their admission. About one quarter of people admitted to nursing homes die
there, and another 36% move to another facility.
Nursing homes are certified by state and federal government agencies to
provide services at one or more levels of care. Skilled nursing facilities provide the
most intensive nursing care available outside of a hospital. Nurses and other health
care workers in these settings apply dressings or bandages, help residents with daily
self-care tasks, and may provide oxygen therapy. They are also responsible for taking
vital signs including temperature, pulse, respiration, and blood pressure. In an
intermediate care facility, health-related services are provided to individuals who do
not require hospital or skilled nursing facility care but do require some type of
institutional care beside food and a place to live.
Nursing home services have become big business in the United States. In the
year 2008, nursing home expenditures were estimated to be $138.4 billion, or about
5% of the total health care expenditures in the United States (Center for Medicare and
Medicaid Services, 2010c). The cost of nursing home care is rising faster than the cost
of other medical care goods and services, with the yearly average privatepay facility
costing slightly over $60,000 (in 2004 prices) (Stewart, Grabowski, & Lakdawalla,
2009). The percent of older adults in nursing homes has declined in the 20 years
between 1985 and 2004, reflecting increases in home health services and generally
better health of the over-65 population. As of 2008, there were approximately 15,700
nursing homes in the Unites States with a total of over 1.7 million beds, 83% of which
were occupied.
An alternative to a nursing home is a residential care facility, which provides
24-hour supportive care services and supervision to individuals who do not require
skilled nursing care. They provide meals, housekeeping, and assistance with personal
care such as bathing and grooming. Some residential care facilities may provide other
services such as management of medications and social and recreational activities.
Board and care homes are group living arrangements designed to meet the
needs of people who cannot live on their own in the community but who also need
some nursing services. Typically, these homes provide help with activities of daily
living such as bathing, dressing, and toileting. Although the name may imply that
these homes provide a ‘‘home-like’’ setting, research refutes this idea. A survey
conducted by the Institute of Medicine determined that board and care homes do not
adjust the care they provide to the specific needs of the residents. They are typically
understaffed, and the staff who work in these settings are not required to receive
training.
Housing complexes in which older persons live independently in their own
apartments are known as assisted living facilities. The residents pay a regular monthly
rent that usually includes meal service in communal dining rooms, transportation for
shopping and appointments, social activities, and housekeeping service. Some
facilities have health services available on location. These facilities are professionally
managed and licensed and may represent one of several levels of care provided within
the same housing community. The cost for living in an assisted living facility may
range from hundreds to thousands of dollars a month. In some states, funds may be
available for those who cannot afford to live in these facilities on their own through
government support programs. However, most residents pay the rental and other fees
out of their own funds. The philosophy of assisted living is to combine private,
residentially oriented buildings with high levels of service allowing residents to
continue living in the same facility even if changes in health or physical and cognitive
functioning occur.
Many facilities, despite their good intentions, struggle to achieve the goals of
providing high-quality care and a comfortable living environment for older adults.
These goals are often outlined with the best of intentions, aiming to offer a safe,
engaging, and dignified living experience for residents. However, the reality is that
many of these facilities fall short in various aspects, failing to deliver the level of
service and care that they aspire to provide. This gap between aspiration and reality
can be attributed to several factors, including inadequate staffing, lack of resources,
and inefficiencies in management.
Furthermore, the cost of accessing these facilities is a significant barrier for
many moderate- and low-income older adults. High-quality facilities that offer a wide
range of services, such as medical care, social activities, and personal assistance, are
often priced at a premium. This makes them inaccessible to a large portion of the
senior population who cannot afford the steep costs. The financial strain on these
individuals and their families is considerable, forcing many to settle for more
affordable options that, unfortunately, do not offer the same level of care or amenities.
Affordable facilities, while providing a necessary service, often lack the
resources to offer high levels of service or privacy. These budget-conscious options
may have fewer staff members, resulting in lower staff-to-resident ratios that can
compromise the quality of care. Additionally, the physical infrastructure of these
facilities might be less modern and less comfortable, with shared rooms and
communal spaces that do not afford residents much privacy. The combination of
limited services and lack of personal space can significantly impact the quality of life
for residents, who deserve better in their later years.
The disparity between high-cost, high-quality facilities and their more
affordable, yet lower-quality counterparts highlights a critical issue in the care of
older adults. It underscores the need for a systemic change that addresses both
affordability and quality. Innovations in care models, increased funding, and policies
that prioritize the well-being of all older adults, regardless of income, are essential to
bridge this gap. Until such changes are implemented, many older adults will continue
to face the challenging choice between quality and affordability in their living
arrangements.
An older adult may receive adult foster care, in which a family provides care
in their home. The services provided in foster care include meals, housekeeping, and
help with dressing, eating, bathing, and other personal care. These settings offer some
advantages because of their home-like feeling, but because they are small and rely on
a live-in caregiver for help with personal care, cooking, housekeeping, and activities,
that caregiver’s resources may be spread thin. If one resident becomes ill and requires
more nursing care, other residents may suffer from lack of attention. Another problem
in adult foster care is lack of privacy compared to a residential care setting.
b. Community-Based Facilities
There are a variety of support services designed to allow older adults, even
those with some form of disability, to live on their own in the community. Some of
these services are offered by volunteer groups at no cost to the individual. Others are
fee based and of these services, some may be paid for by Medicare..
An increasing number of older adults who are ill or disabled are able to
maintain an independent life in the community by utilizing home health services. A
variety of services, some of them free, are available within this broad category of
care. These include ‘‘Meals on Wheels,’’ the provision of a hot meal once a day; so-
called ‘‘friendly visiting,’’ in which a volunteer comes to the home for a social visit;
and assistance with shopping. Other home-based services include laundry, cooking,
and cleaning. Researchers have found that home health care that simulates the types
of restorative services provided in nursing homes such as physical therapy, speech
therapy, occupational therapy, rehabilitation, and interventions targeted at particular
areas of functional decline can help to maintain the older person in the home longer,
staving off institutionalization or emergency room care (Tinetti et al., 2002).
Moreover, teaching older adults who are receiving home health care a variety of
strategies to maintain their functional ability, such as fall prevention, muscle strength
training, and home safety, can help maximize mobility and reduce costs associated
with institutionalization (Gitlin et al., 2009).
According to the most recent figures based on the 2004 National Nursing
Home and Hospice Care Survey, nearly 1 million persons aged 65 years and over are
home health care patients. This substantial number underscores the growing reliance
on home health care services among the elderly population. These services play a
crucial role in allowing older adults to maintain their independence and continue
living in their own homes while receiving the medical care and assistance they need.
The survey conducted by the Centers for Disease Control and Prevention (CDC) in
2004 highlights the importance of these services in the broader context of elder care.
By 2008, the financial landscape of home health care had significantly
evolved, reflecting its increasing importance and demand. In that year alone, a
staggering $64.7 billion was spent in the United States on home health care services.
This expenditure demonstrates a substantial investment in the sector, which is
essential for meeting the diverse and growing needs of the aging population. The
allocation of such a significant amount of resources to home health care indicates the
value placed on enabling older adults to receive care in a familiar and comfortable
environment.
An interesting aspect of the funding for home health care is its source. In
2008, an impressive 79% of the total costs associated with home health care were
publicly funded. This high percentage of public funding highlights the government's
recognition of the importance of supporting older adults in their homes and the role of
public health initiatives in facilitating this. The reliance on public funding also reflects
broader societal and policy priorities, aiming to provide accessible and affordable
health care options for the elderly. Public funding can come from various sources,
including Medicare, Medicaid, and other state and federal programs designed to
support the health and well-being of older adults.
The substantial public investment in home health care suggests a commitment
to ensuring that older adults can age in place, maintaining their independence and
quality of life. It also highlights the challenges and pressures on public health systems
to allocate sufficient resources to meet the needs of an aging population. As the
demand for home health care services continues to rise, driven by an increasing
number of older adults and the preference for receiving care at home, the need for
sustainable and effective funding mechanisms becomes even more critical.
Moreover, the trend towards home health care is likely to have broader
implications for the health care system, including the need for a well-trained
workforce, the development of innovative care models, and the integration of
technology to support remote monitoring and telehealth services. These factors
collectively contribute to the ongoing evolution and improvement of home health
care, ensuring that it remains a viable and high-quality option for older adults
requiring medical and personal care. The investment in home health care reflects a
proactive approach to addressing the needs of the elderly, promoting health, well-
being, and independence in the later stages of life.
In a geriatric partial hospital, daily outpatient therapy is provided with
intensive, structured multidisciplinary services to older persons who have recently
been discharged from a psychiatric facility. The partial hospital may also serve as an
alternative to hospitalization. Therapists in this setting focus on medication
management and compliance, social functioning, discharge planning, and relapse
prevention. A less intense program than the geriatric partial hospital program is
geriatric continuing day treatment, in which clients attend a day treatment program 3
days a week but are encouraged to live independently during the remaining days of
the week. Day care centers are another form of community treatment in which
individuals receive supervised meals and activities on a daily basis.
An older adult may maintain considerable autonomy but still have support
nearby by living in a separate apartment in a relative’s home. An accessory dwelling
unit, also known as an ‘‘in-law apartment,’’ is a second living space in the home that
allows the older adult to have independent living quarters, cooking space, and a
bathroom.
Other alternatives in community care involve the provision of housing in
addition to specialized services that can maintain the person in an independent living
situation. Subsidized senior housing is provided for individuals with low to moderate
incomes. People using subsidized housing live in low-rent apartment complexes and
have access to help with routine tasks such as housekeeping, shopping, and laundry.
A more comprehensive community living setting is a continuing care
retirement community (CCRC), which is a housing community that provides different
levels of care based on the residents’ needs. Within the same CCRC, there may be
individual homes or apartments in which residents can live independently, an assisted
living facility, and a nursing home. Residents move from one setting to another based
on their needs, but they continue to remain part of their CCRC community. CCRCs
typically are on the expensive side. Many require a large down payment prior to
admission and also charge monthly fees. Some communities, however, allow residents
to rent rather than buy into the facility. Residents moving into CCRCs typically sign a
contract that specifies the conditions under which they will receive long-term care.
One option provides unlimited nursing care for a small increase in monthly payments.
A second type of contract includes a predetermined amount of long-term
nursing care; beyond this the resident is responsible for additional payments. In the
third option, the resident pays fees for service, which means full daily rates for all
long-term nursing care. If the older adult can afford this type of housing, there are
definite advantages to living in CCRCs. In addition to the relative ease of moving
from one level of care to another, the CCRCs provide social activities, access to
community facilities, transportation services, companionship, access to health care,
housekeeping, and maintenance. Residents may travel, take vacations, and become
involved in activities outside the community itself. CCRCs are accredited by a
commission sponsored by the American Association of Homes and Services for the
Aging.
To be accredited, a Continuing Care Retirement Community (CCRC) must
undergo a rigorous and comprehensive evaluation process that spans two and a half
days. This accreditation process is designed to ensure that the facility meets high
standards in various critical areas, including governance, administration, resident
services, finance, and health care. Each of these areas is meticulously examined to
assess the quality and effectiveness of the facility's operations and services.
During the governance and administration evaluation, the accrediting body
reviews the organizational structure and leadership of the CCRC. This includes
examining the qualifications and performance of the management team, the
effectiveness of their decision-making processes, and their ability to implement
policies and procedures that align with best practices and regulatory requirements.
The goal is to ensure that the facility is well-managed and that its leadership is
capable of maintaining high standards of care and service.
Resident services are another crucial area of evaluation. This part of the
accreditation process focuses on the quality and range of services provided to
residents. The accrediting body assesses the adequacy and appropriateness of social,
recreational, and support services offered to ensure that residents have access to a
vibrant and engaging community life. This includes evaluating the facility's programs
for physical, mental, and social well-being, as well as the overall environment and
amenities available to residents.
Financial health and management are also critical components of the
accreditation process. The accrediting body examines the CCRC's financial stability
and sustainability to ensure that it can continue to operate effectively and provide
high-quality services to its residents. This includes a thorough review of financial
statements, budgeting practices, funding sources, and financial planning strategies.
The goal is to ensure that the facility is financially sound and capable of meeting its
long-term obligations to residents.
The health care evaluation is perhaps the most critical aspect of the
accreditation process. This involves a detailed review of the medical and health care
services provided by the CCRC, including the qualifications of medical staff, the
quality of care delivered, and the facility's ability to meet the health care needs of its
residents. The accrediting body assesses the range of medical services offered, the
availability of specialized care, the effectiveness of care coordination, and the overall
quality of health outcomes for residents.
In summary, the two-and-a-half-day accreditation process for a CCRC is an in-
depth and comprehensive evaluation that ensures the facility meets high standards in
governance and administration, resident services, finance, and health care. This
rigorous process is essential for maintaining the quality and reliability of CCRCs,
providing peace of mind to residents and their families, and ensuring that these
communities offer a safe, supportive, and high-quality living environment for older
adults.
c. The Financing of Long-Term Care
It is impossible to open the newspaper or turn on the television without
reading or hearing a discussion of the urgent need in the United States to address the
economic issues involved in health care, particularly as the Baby Boomers grow older.
These discussions often occur in the context of other issues affecting adults using a
wide range of health care services, from outpatient medical care to private
psychotherapy. Changes in health maintenance organizations (HMOs) have created
havoc in many sectors of the health care industry, causing great anxiety among the
public, politicians, and health care professionals. In many ways, the health care
financing crisis is a function of the huge expenses associated with the long-term care
of older adults. Insecurity over the financing of health care can constitute a crisis for
adults of any age, but particularly so for older persons with limited financial
resources. The ability to receive proper treatment for chronic conditions is therefore a
pressing social and an individual issue.
Long-term health care financing has a history dating back to the early 1900s
and the first attempts in the United States to devise government health insurance
programs. In the ensuing century, as these programs became established, their benefits
structure and financing grew increasingly complex and diversified. Throughout this
process, the developers of these plans, which involve state and federal agencies along
with private insurance companies, have attempted to respond to the rapidly changing
needs of the population and the even more rapidly changing nature of the nation’s
economy. Other countries, particularly Canada and many European nations, have
worked out different solutions than those existing in the United States and are also
encountering challenges to their economy as their populations age. As you will see
shortly, nursing homes and other facilities in which older adults receive treatment are
subject to strict federal and state requirements to ensure that they comply with the
standards set forth in the legislation that created the funding programs. The intimate
connection between financing and regulation of these long-term care facilities has
provided the incentive for nursing homes to raise their level of care so that they can
qualify for this support.
Title XVIII of the U.S. Social Security Act, passed and signed into law by
President Lyndon B. Johnson in 1965, created the federal funding agency known as
Medicare (designated ‘‘Health Insurance for the Aged and Disabled’’). At the time of
its passage, the ‘‘pay as you go system’’ that formed the funding basis for Medicare
seemed sound. Medicare’s funding comes from payroll taxes, premiums, general
revenue from income taxes, and some payments from the states. In the mid-1960s,
there were far more employed workers than people 65 and older needing health care,
and it appeared that by taxing the employed workers to pay for those requiring care,
the system would maintain itself indefinitely. There was apparently little reason at that
time to be concerned about what would ultimately become a perfect storm of a rapid
increase in life expectancy combined with an even more rapid increase in costs
associated with health care.
Medicare has grown enormously since its inception. In 1966 Medicare
covered 19.1 million people at a cost of $1.8 billion. By 2008 more than 37.6 million
Americans 65 and older were covered, two thirds of whom are enrolled in Medicare
drug plans (Center for Medicare and Medicaid Services, 2010a). Nursing homes
received $25.7 billion from Medicare. The total benefits paid out by Medicare in 2008
totaled over $469 billion in 2009 or 3.2% of the gross domestic product. By 2083
Medicare is expected to reach 11.4% of the gross domestic product (Social Security
Administration, 2010).
It is now projected that by the year 2018, there will be a deficit in the total
Medicare budget due to the fact that expenditures will be greater than revenues. The
gap between expenditures and revenue will continue to increase steadily through at
least the year 2081. The situation was considered grave enough so that in its annual
report of 2007, the Social Security Trustees issued their first-ever warning that the
program is on its way to becoming unsustainable. This impending crisis became the
immediate impetus for the Patient Protection and Affordable Care Act (PPACA) (P.L.
111–148), legislation signed into law by President Barack Obama in the spring of
2010.
Even since it first became law, however, Medicare has been subject to
numerous legislative and administrative changes designed to improve health care
services to older adults, the disabled, and the poor. In 1973 the program was expanded
to broaden eligibility to citizens already receiving Social Security benefits, people
over 65 who qualify for Social Security benefits, and individuals with end-stage renal
disease requiring continuous dialysis or kidney transplant. The Department of Health
and Human Services (DHHS) has the overall responsibility for administration of the
Medicare program, with the assistance of the Social Security Administration (SSA).
In 1977, the Health Care Financing Administration (HCFA) was established under the
DHHS to administer Medicare and Medicaid; it was replaced in July 2001 by the
Centers for Medicare & Medicaid Services (CMS) as part of a large-scale reform of
services to beneficiaries. CMS is now the agency with responsibility for formulation
of policy and guidelines, oversight and operation of contracts, maintenance and
review of records, and general financing. State agencies also play a role in the
regulation and administration of the Medicare program in consultation with CMS.
Medicare Part A (Hospital Insurance or HI) coverage includes the cost of a
semiprivate hospital room, meals, regular nursing services, operating and recovery
room, intensive care, inpatient prescription drugs, laboratory tests, X-rays, psychiatric
hospital, and inpatient rehabilitation. All other medically necessary services and
supplies provided in the hospital are also completely covered. Luxury items, cosmetic
surgery, vision care, private nursing, private rooms (unless necessary for medical
reasons), and rentals of television and telephone are not included in coverage.
Coverage in a skilled nursing facility is included in Part A only if it occurs within 30
days of a hospitalization of 3 days or more and is certified as medically necessary. It
includes rehabilitation services and appliances (walkers, wheelchairs) in addition to
those services normally covered for inpatient hospitalization. Patients must pay a
copayment for days 21–100 of their care in this setting. Home health services are also
included in Part A of Medicare for the first 100 visits following a 3-day hospital stay.
Respite periods are also covered for hospice care to allow a break for the patient’s
caregiver. In 2009, opponents to health care reform stated that the changes would
include ‘‘death panels’’ to decide who would receive palliative care; however, within
existing Medicare legislation, hospice care was already fully insured, covering pain
relief, supportive medical and social services, physical therapy, nursing services, and
symptom management.
Medicare Part B provides benefits available to individuals age 65 and over
with payment of a monthly premium that, starting in 2007, varies according to the
individual’s income. Included in Part B services are preventive treatments, including
glaucoma and diabetes screenings as well as bone scans, mammograms, and
colonoscopies. Other covered services include laboratory tests, chiropractor visits, eye
exams, dialysis, mental health care, occupational therapy, outpatient treatment, flu
shots, and home health services. A one-time physical examination is also included in
Part B.
Part C of Medicare, also called Medicare Advantage, involves coverage
through private health plans. Individuals who have both Part A and Part B can choose
to get their benefits through a variety of risk-based plans including HMOs, Preferred
Provider Organizations (PPOs), private fee-for-service plans, and a health insurance
policy administered by the federal government. Established by the Balanced Budget
Act of 1997 (Public Law 105-33), Part C first became available in 1998. Beginning in
2006, PPOs began to serve beneficiaries on a regional basis. The Department of
Health and Human Services identified 26 regions across the nation in which PPO
plans compete to provide services. The DHHS established these regions to ensure that
all Medicare beneficiaries, including those in small states and rural areas, would have
the opportunity to enroll in a PPO, as well as to encourage private plans to participate.
In 2006, 16% of beneficiaries were enrolled in Medicare Advantage plans, and by
2009, this number increased to 24%, reflecting the growth in the popularity of these
programs.
Part D of Medicare, first available in 2006 provides prescription drug benefits.
Though providing welcome relief for Medicare recipients, as originally passed, its
effectiveness was severely limited by what turned out to be a huge catch. As of 2010,
Medicare pays 75% of drug costs between a deductible of $310 and $2,830. At this
point, participants in the plan encounter a gap in coverage that became known as the
‘‘donut hole.’’ It is called the donut hole because there is no coverage provided at all
between prescription drug spending costs of $2,830 and $6,440 per year. It is only
when drug costs exceed $6,400 (the starting point for catastrophic coverage) per year
that Medicare pays almost the full amount (95%). You might think that recipients
could supplement Part D with private coverage to avoid the donut hole, but once you
sign up for Part D you are no longer eligible to receive prescription benefits through
private insurance companies. Skyrocketing prescription drug costs exacerbate the
problem. Of the 50 drugs most commonly used by older adults, the average annual
cost per prescription is $2,810 (Families USA, 2010). Hence Part D’s prescription
privileges leave many older adults with significant out-ofpocket expenses for
medications required to maintain them in good health. As a result, after Part D
enrollees enter the donut hole, rates of medication adherence decline, as beneficiaries
attempt to save money.
The Patient Protection and Affordable Care Act (PPACA) of 2010 introduced
several measures to alleviate the financial burden on older adults, particularly those
facing high prescription drug costs. One of the significant provisions of the PPACA
was aimed at addressing the infamous "donut hole" in Medicare Part D coverage. The
donut hole refers to a coverage gap where beneficiaries must pay a higher out-of-
pocket cost for their prescription drugs after reaching a certain limit until they qualify
for catastrophic coverage.
In 2010, as an initial relief measure, the PPACA provided older adults who
entered the donut hole with a $250 prescription drug rebate. This one-time rebate was
designed to offer immediate financial relief to seniors who faced substantial costs for
their medications once they hit the coverage gap. This rebate was a critical step in
mitigating the impact of the donut hole, acknowledging the heavy financial strain it
placed on many Medicare beneficiaries.
Starting in 2011, the PPACA implemented further reductions in out-of-pocket
costs for those in the donut hole. Qualified beneficiaries began to receive a 50%
discount on their brand-name prescription drugs while in the coverage gap. This
significant discount was a major step forward, effectively cutting the cost of many
essential medications in half and providing substantial savings to seniors struggling
with high drug costs. The discount was automatically applied at the pharmacy, making
it easier for beneficiaries to afford their medications without additional bureaucratic
hurdles.
In addition to the immediate discounts, the PPACA laid out a roadmap for the
gradual closing of the donut hole over the following decade. Each year, incremental
increases in coverage were implemented, reducing the out-of-pocket costs for both
brand-name and generic drugs. These incremental improvements were part of a
strategic plan to phase out the coverage gap entirely. By 2020, the PPACA aimed to
close the donut hole completely, ensuring that Medicare Part D beneficiaries would no
longer face this significant financial obstacle.
The closure of the donut hole by 2020 meant that Medicare beneficiaries
would only be responsible for a standard 25% coinsurance for their prescription drugs
until they reached the catastrophic coverage threshold. This change represented a
monumental shift in Medicare Part D, providing more consistent and predictable drug
coverage and reducing the financial uncertainty that many seniors faced.
The measures introduced by the PPACA had a profound impact on the
affordability of prescription drugs for older adults. By reducing out-of-pocket costs
and ultimately closing the donut hole, the PPACA significantly improved access to
necessary medications for millions of seniors. This legislative change not only eased
the financial burden on individual beneficiaries but also contributed to better health
outcomes by making it more feasible for older adults to adhere to their prescribed
drug regimens.
In summary, the PPACA of 2010 brought about crucial reforms to Medicare
Part D, targeting the coverage gap known as the donut hole. Starting with a $250
rebate in 2010 and progressing to a 50% discount on prescription drugs in 2011, the
act laid the groundwork for the complete closure of the donut hole by 2020. These
changes greatly alleviated the financial strain on older adults, ensuring more
affordable access to essential medications and fostering improved health and well-
being among Medicare beneficiaries.
Title XIX of the Social Security Act of 1965, known as Medicaid, is a federal
and state matching entitlement program that provides medical assistance for certain
individuals and families with low incomes and resources. Initially, Medicaid was
formulated as a medical care extension of federally funded programs providing
income assistance for the poor, with an emphasis on dependent children and their
mothers, the disabled, and the over-65. Eligibility for Medicaid has expanded,
however, and now is available to a larger number of low-income pregnant women,
poor children, and some Medicare beneficiaries who are not eligible for any cash
assistance program.
Changes in legislation over recent years have increasingly focused on several
key areas to improve the health care system for older adults and the general
population. These changes aim to enhance access to care, improve the quality of care,
provide specific benefits, enhance outreach programs, and reduce limits on services.
Each of these focus areas addresses crucial aspects of health care that directly impact
patient outcomes and overall well-being.
One of the primary goals of recent legislative changes has been to increase
access to health care services. This includes expanding insurance coverage to more
people through programs like Medicaid and the Affordable Care Act (ACA)
marketplaces. By broadening eligibility criteria and providing subsidies, these
legislative efforts have made it possible for millions of previously uninsured
individuals to obtain health insurance. Increased access also involves improving the
availability of care in underserved areas, such as rural or economically disadvantaged
regions, by offering incentives for health care providers to practice in these locations.
Another critical area of focus has been improving the quality of care provided
to patients. Legislative changes have introduced measures to enhance the standards of
care and ensure that health care providers are held accountable for delivering high-
quality services. This includes implementing quality metrics and reporting
requirements for hospitals, clinics, and other health care facilities. Additionally, value-
based care models have been promoted, where providers are rewarded for achieving
positive patient outcomes rather than the volume of services delivered. These models
encourage more comprehensive and patient-centered care, aiming to improve the
overall health of the population.
Specific benefits have also been a major target of legislative reforms. These
benefits are designed to address the particular needs of different population groups,
including older adults, children, and those with chronic conditions. For example,
Medicare has been expanded to cover preventive services without cost-sharing, such
as screenings for cancer, diabetes, and cardiovascular diseases. Legislation has also
mandated coverage for essential health benefits, including maternity care, mental
health services, and prescription drugs, ensuring that insurance plans provide
comprehensive coverage for a wide range of health needs.
Enhanced outreach programs have been developed to educate and inform the
public about available health services and benefits. These programs aim to raise
awareness about preventive care, encourage healthy behaviors, and assist individuals
in navigating the health care system. Outreach efforts often focus on vulnerable
populations, such as low-income families, non-English speaking communities, and
individuals with disabilities, to ensure they receive the information and support
needed to access care effectively.
Legislation has also aimed to reduce limits on services that patients can
access. This includes removing caps on essential health benefits and eliminating
lifetime and annual limits on coverage. By doing so, individuals with serious or
chronic health conditions can receive the ongoing care they need without fear of
exhausting their benefits. Additionally, reforms have targeted reducing barriers to
care, such as prior authorization requirements and excessive out-of-pocket costs,
making it easier for patients to receive timely and appropriate treatment.
Another significant change in the health care landscape has been the addition
of managed care as an alternative means of providing health services. Managed care
plans, such as Health Maintenance Organizations (HMOs) and Preferred Provider
Organizations (PPOs), offer a structured approach to delivering care that focuses on
cost efficiency and coordinated care. These plans often emphasize preventive care and
chronic disease management, aiming to reduce unnecessary hospitalizations and
improve health outcomes. By coordinating care through a network of providers,
managed care plans can offer integrated services that enhance the patient experience
and streamline care delivery.
In summary, legislative changes in health care have concentrated on increasing
access, improving the quality of care, providing specific benefits, enhancing outreach
programs, and reducing limits on services. The addition of managed care as an
alternative means of providing health services has further diversified the options
available to patients, promoting more efficient and coordinated care. These efforts
collectively contribute to a more accessible, high-quality, and patient-centered health
care system, ultimately improving the health and well-being of the population.
Medicaid provides assistance for a wide range of medical services for those
considered in need by their state of residence. For older adults these services include
inpatient and outpatient hospital services, physician services, nursing facility services,
home health care for persons eligible for skilled nursing services, laboratory testing,
X-ray services, prescribed drugs and prosthetic devices, optometrist services and
eyeglasses, rehabilitation and physical therapy services, and home- and community-
based care to cover certain chronic impairments. Individuals covered by Medicare
who are not otherwise ‘‘poor’’ may nevertheless require Medicaid when their benefits
have run out and they cannot afford to pay their medical expenses. Many states have a
‘‘medically needy’’ program for such individuals, who have too much income to
qualify as categorically needy. This program allows them to ‘‘spend down’’ their
assets to the point of being eligible for Medicaid by paying medical expenses to offset
their excess income. Medicaid then pays the remaining portion of their medical bills
by providing services and supplies that are available under their state’s Medicaid
program. Services that are covered by both programs are paid first by Medicare.
The difference is then paid by Medicaid, up to the state’s payment limit. This
financial support is crucial for many individuals who require long-term care but lack
the resources to cover the full cost. Medicaid's role in covering these expenses ensures
that individuals can receive the necessary care without facing insurmountable
financial burdens.
Medicaid also provides coverage for additional services that are essential for
maintaining health and quality of life. For instance, while Medicare covers up to 100
days of care in a skilled nursing facility, many individuals require extended stays
beyond this limit. Medicaid steps in to cover the cost of care beyond the 100-day
limit, ensuring that patients continue to receive the medical attention and support they
need without interruption.
In addition to long-term care, Medicaid covers prescription drugs, which are
vital for managing chronic conditions and maintaining overall health. This includes
medications for a wide range of health issues, such as diabetes, hypertension, and
mental health conditions. By covering prescription drugs, Medicaid helps to reduce
out-of-pocket expenses for beneficiaries, making essential medications more
accessible and affordable.
Eyeglasses are another important service covered by Medicaid. Vision care is
crucial for maintaining independence and quality of life, especially for older adults
and individuals with vision impairments. By providing coverage for eyeglasses,
Medicaid helps ensure that beneficiaries can maintain their vision and perform daily
activities more easily.
Hearing aids are also covered by Medicaid, addressing a critical need for
individuals with hearing loss. Hearing aids can significantly improve communication
and social interaction, enhancing overall well-being and quality of life. By covering
the cost of hearing aids, Medicaid helps to remove financial barriers to obtaining these
essential devices.
Furthermore, Medicaid coverage extends to other essential health services that
support the well-being of its beneficiaries. This includes dental care, which is
important for maintaining oral health and preventing related health issues. Dental
services covered by Medicaid may include routine check-ups, cleanings, fillings, and
more complex procedures as needed.
Medicaid also provides coverage for mental health services, recognizing the
importance of mental well-being in overall health. This includes access to counseling,
therapy, and psychiatric services, which are essential for individuals dealing with
mental health conditions. By offering these services, Medicaid helps to ensure that
beneficiaries receive comprehensive care that addresses both physical and mental
health needs.
Home health care services are another critical component of Medicaid
coverage. These services allow individuals to receive medical care and support in the
comfort of their own homes. This can include assistance with daily living activities,
such as bathing, dressing, and meal preparation, as well as medical care like wound
care, medication management, and physical therapy. Home health care services help
individuals maintain their independence and avoid institutional care whenever
possible.
In summary, Medicaid plays a vital role in providing financial support and
comprehensive health coverage to individuals who need it most. By covering the
difference in costs up to the state’s payment limit and offering a wide range of
additional services—including extended skilled nursing facility care, prescription
drugs, eyeglasses, hearing aids, dental care, mental health services, and home health
care—Medicaid ensures that beneficiaries have access to the essential care and
support they need to maintain their health, independence, and quality of life.
Medicaid is the largest source of funding for medical and health-related
services for those in need of assistance. In 2008 it provided health care assistance
amounting to $344.3 billion. Nursing homes received $56.3 billion from Medicaid in
2008. Together Medicare and Medicaid (federal and state) financed $813.5 billion in
health care services in 2008, which was 34% of the nation’s total health care bill of
$2.3 trillion (private and public funding combined) and 82% of all federal spending
on health (Center for Medicare and Medicaid Services, 2010b).
d. Legislative Issues in Care of Older Adults
The regulation of nursing homes and communitybased services for older
adults and the disabled is a major focus of health policy and legislation in the United
States. As we mentioned earlier, this is because funding of these services is provided
by federal and state agencies. The current U.S. laws governing the operation of
institutional facilities have their origins in a report completed by the prestigious
Institute of Medicine in 1986 called ‘‘Improving the Quality of Care in Nursing
Homes.’’ This report recommended to Congress major changes in the quality and
nature of services provided to nursing home residents. The result of the report was the
Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) that included the Nursing
Home Reform Act (NHRA). OBRA 1987 mandated that facilities must meet physical
standards, provide adequate professional staffing and services, and maintain policies
governing their administrative and medical procedures. A significant component of
this legislation was the provision of safeguards to assure quality of care and protection
of residents’ rights. The bottom line is that each resident must be provided with
services and activities to attain or maintain the highest practicable physical, mental,
and psychosocial well-being. Facilities are required to care for residents in a manner
and an environment that promotes, maintains, or enhances quality of life.
The conditions of the Nursing Home Reform Act specify that nursing homes
must be licensed in accordance with state and local laws, including all applicable laws
pertaining to staff, licensing, and registration, fire, safety, and communicable diseases.
They must have a governing body legally responsible for policies and the appointment
of a qualified administrator. One or more physicians must be on call at all times to
cover an emergency, and there must be 24-hour nursing care services, including at
least one full-time registered nurse. The facility must admit eligible patients
regardless of race, color, or national origin. The specific services that are required in
addition to availability of physicians and nurses are specialized rehabilitation, social
services, pharmaceutical services, dietary services, dental services, and an ongoing
activities program. As designated by the Health Care Reform Act, the goal of the
activities program should be to encourage self-care and the individual’s return to
normal life in the community through social, religious, recreational activities, and
visits with relatives and friends. Nursing homes are required to maintain confidential
records, employ appropriate methods for obtaining and dispensing medications, and
have arrangements in place for obtaining required clinical, laboratory, X-ray, and
other diagnostic services.
The series of resident rights developed as part of the Nursing Home Reform
Act include choice of physician and treatment, freedom from physical and mental
abuse, the right to privacy and treatment with respect and dignity, the right to
confidential records, and the right to have needs and preferences met. In addition,
residents have the right to refuse medications and treatments, voice their grievances,
and transfer or leave the facility when appropriate. They are also required to be
informed in writing about services and fees before entering the nursing home, to have
the right to manage their own money (or choose someone to do so), and be able to
keep personal belongings and property to the extent that these do not interfere with
the rights, health, or safety of others. The legislation also established procedures to
ensure that all conditions are met for maintaining compliance with the law. These
procedures include monitoring of the performance of facilities by outside survey
agencies to determine whether they comply with the federal conditions of
participation.
Changes to the nursing home rates for post-hospital care through Medicare
were incorporated into the Balanced Budget Act of 1997 and implemented in March
2000. These changes involved moving to a prospective payment system in which rates
paid to skilled nursing facilities cover the costs of furnishing most covered nursing
home services, excluding payment for physicians and certain other practitioner
services. Under the prospective payment system, each facility receives a fixed amount
for treating patients diagnosed with a given illness, regardless of the length of stay or
type of care received. Prior to the Balanced Budget Act changes, nursing homes filed
bills to Medicare based on fee for service. The intention of the change in payments
was to curb the rapidly rising costs of Medicare as well as to adjust the payments to
the specific needs of the patient. By paying more for the patients whose medical
expenses are legitimately higher than those who have less expensive medical needs,
nursing homes could therefore provide better health care, adjusted for the needs of the
individual resident.
Ten years after NHRA was put into place, a series of investigations and Senate
hearings were conducted that called attention to serious weaknesses in federal and
state survey and enforcement activities stipulated by that law. In 1997, the U.S. Senate
Committee on Aging received reports that documented inadequate care in California
nursing homes that caused widespread death and suffering of residents. These reports
triggered a hearing in 1998 by the Committee on California nursing homes. At this
hearing, a Government Accountability Office (GAO) report revealed that nationwide
there was weak enforcement of the NHRA, putting many residents at risk of
inadequate care. Fully 98% of nursing homes were found to have more than minimal
(35%), substandard (33%), or serious (30%) deficiencies. Particularly troubling was
the fact that even when serious problems were identified, there was no enforcement of
actions that would ensure that the deficiencies were corrected and did not recur.
These shocking reports about nursing home abuse made it clear that NHRA
enforcement procedures were not working. In response to these findings, President
Bill Clinton’s administration announced the 1998 Nursing Home Initiative. This
initiative proposed a series of steps designed to improve enforcement of nursing home
quality standards that were then adopted by HCFA. These included altering the timing
of nursing home inspections to include both weekends and evenings as well as
weekdays, providing more frequent inspections of previous violators, imposing
immediate sanctions on nursing homes found guilty of a second offense involving
violations that harm residents, allowing states to impose monetary penalties on
violators, and not lifting sanctions against offenders until an onsite visit verified
compliance with federal regulations.
In September 2000, a Senate Committee on Aging held a hearing on the
outcomes of the Nursing Home Initiative. This hearing revealed that the initiative had
resulted in improvements to state survey and federal oversight procedures, including
increases in the number of surveyors, improved tracking of complaints, new methods
to detect serious deficiencies, and improved organization of nursing home oversight
activities. However, additional hearings on nursing home quality held by the Senate
Committee on Aging in 1999 and 2000 revealed that nursing home abuse was still
rampant. Nationwide, 27% of nursing homes were cited with violations causing actual
harm to residents or placing them at risk of death or serious injury; another 43% were
cited for violations that created a potential for more than minimal harm.
The Senate hearings also revealed flaws in the surveys; significant problems
were often missed, such as pressure sores, malnutrition, and dehydration. In some
cases, nursing homes were cited because a member of the nursing staff committed
acts of abuse against residents such as beatings, sexual abuse, and verbal abuse.
Formal complaints made by residents or families were uninvestigated for weeks or
months. Making the problem worse was the fact that the filing of complaints was
discouraged by state governmental agencies. Even if serious deficiencies were found,
there was inadequate enforcement so that the nursing homes involved did not correct
the problems. The Senate Committee also found that the majority (54%) of nursing
homes were understaffed, putting residents at increased risk of hospitalization for
avoidable causes, pressure sores, and significant weight loss.
In November 2002, the federal government initiated the National Nursing
Home Quality Initiative, a program intended to help consumers find the highest
quality nursing homes. The 2002 Initiative combined new information for consumers
about the quality of care provided in individual nursing homes with resources
available to nursing homes to improve the quality of care in their facilities. Quality
Improvement Organizations (QIOs), government contractors, were hired to offer
assistance to skilled nursing facilities to help them improve their services. The 2002
Initiative also included a provision to train volunteers to serve as ombudspersons. The
role of the ombudspersons is to help families and residents on a daily basis find
nursing homes that provide the highest possible quality of care and give consumers
tools they need to make an informed, educated decision on selecting a nursing home.
For example, nursing homes that were cited for harming or abusing residents
can be sanctioned through fines, the assignment of monitors, temporary management,
or even termination from their sources of federal and state financing. However, the
report showed that when violations were reported, the institutions charged with the
violations were often given some type of leeway, either in terms of the amount they
were penalized or the length of time they were granted before being required to pay
the penalty. Many homes showed a ‘‘yo-yo’’ pattern in which they made changes in
order to comply with regulations only to slide back down until they were sanctioned.
Residents continued to suffer abusive treatment because the fundamental problems
were not corrected (Government Accountability Office, 2008). As you will learn
shortly, deficiencies in nursing homes remain a significant problem, limiting severely
the quality of care that many residents receive. Continued reporting of these
deficiencies, monitoring by government agencies, and involvement of family
members advocating for residents are important safeguards. If you have a relative in a
nursing home, it is important for you to be aware of these problems and vigilant for
ways to prevent them from affecting your relatives.
e. Characteristics and Needs of Nursing Homes and Their Residents
Although there is a relatively small percentage overall of people 65 and older
living in nursing homes, the percentage of older adults who are institutionalized
increases dramatically with age. As of 2004 (the most recent date available), the
percentages rise from 0.9% for persons 65 to 74 years to 3.6% for persons 75 to 84
years and 13.9% for persons 85+ (Federal Interagency Forum on Age-Related
Statistics, 2009). The average size of a nursing facility across the United 2007 GAO
Report on Nursing Home Abuse States is 108 beds, up slightly from 2003
(Harrington, Carrillo, & Blank, 2009). Nearly two thirds (67%) of nursing homes in
the United States fall into the category of ‘‘forprofit’’ facilities, meaning that they seek
to have their revenue exceed their expenses. Nonprofit facilities, which includes
primarily those run by religious organizations, constitute the second largest group
(26.5%), and government-owned facilities, primarily those run by the Veterans
Administration, compose the remainder (6%). Therefore, most nursing homes are run
like a business with the goal of making a profit. Perhaps because they are less oriented
toward the ‘‘bottom line,’’ not-for-profit nursing homes have higher quality ratings
than their forprofit counterparts (Comondore et al., 2009). Related to this issue is the
payment mode of residents. When nursing homes have more private pay patients, they
are able to provide better care because the rates for these patients are higher than the
reimbursement rates that facilities receive from governmental subsidies.
Information about nursing homes and nursing home residents comes from the
On-line Survey, Certification, and Reporting system (OSCAR). The OSCAR system
has information from the state surveys of all certified nursing facilities in the United
States, which are entered into a uniform database. Surveyors assess both the process
and the outcomes of nursing home care in 15 major areas. Each of these areas has
specific regulations, which state surveyors review to determine whether facilities have
met the standards. When a facility fails to meet a standard, a deficiency or citation is
given. The deficiencies are given for problems that can result in a negative impact on
the health and safety of residents. Home health agencies are required to submit data
on their effectiveness using the Outcomes Assessment and Information Set (OASIS),
mandated for use by Medicare-certified home health agencies.
The most common primary diagnosis of nursing home residents when
admitted to a nursing home is cardiovascular disease, and the strongest predictors of
admission to a nursing home are inability to carry out basic activities of daily living,
cognitive impairment, and prior nursing home admission (Gaugler, Duval, Anderson,
& Kane, 2007). The greatest form of disability is loss of cognitive skills associated
with Alzheimer’s disease (Schultz, et al., 2002). Given that Alzheimer’s disease is
found in nearly half of all nursing home residents (45% in 2008), this means that
difficulties in carrying out daily living skills are a significant problem among nursing
home residents. In fact, 56.8% of nursing home residents are chairbound, meaning
that they are restricted to a wheelchair. Despite the large number of residents with
Alzheimer’s disease, only 5% of nursing homes have special care units devoted
specifically to their care.
As the U.S. government attempts to improve the quality of care provided by
nursing homes, monitoring continues on a yearly basis through the listing of
deficiencies as reported to OSCAR. In the years between 2003 and 2008, there was a
7.5% average increase in the number of deficiencies from 8.6 to 9.25, showing that
quality of care within nursing homes is on a steady decline. In 2008, 26% of the
nation’s nursing homes received deficiencies for poor quality of care. However, the
average number of deficiencies varied substantially across the states. In 2008, the
state with the highest number of deficiencies was Delaware, at 8% (Harrington,
Carrillo, & Blank, 2009). Deficiencies that cause harm or immediate jeopardy to
residents are considered the most serious of all. In 2008, lack of accident prevention
was the number one deficiency, occurring in 44% of all nursing homes in the United
States. Delaware, Washington State, and Indiana all had percentages of 40% or
greater.
Some other areas of concern also deserve mention. For instance, continence
(control over elimination of urine and feces) is a highly sensitive and personal area of
life. Though training programs exist that are designed to help residents gain and
maintain continence through use of diet, fluids, and regular schedules, these are rarely
used; as of 2008 these were available to only 6.4% of residents despite the fact that
65.5% were reported to have urinary incontinence. Bowel incontinence occurs in
43.3% of all residents, but bowel training is available only to 3.7%. Clearly, when
continence training is a need that is unmet, this can detract from the quality of an
individual’s life as well as the quality of the life of the staff. Worsening continence is
one of the top reasons that older residents of nursing homes become socially
disengaged (Dubeau, Simon, & Morris, 2006). Continuing education that addresses
knowledge, beliefs, and attitudes may help ultimately in encouraging nursing staff to
work on restoring continence in their patients.
The use of physical and chemical (drug) restraints to keep residents from
being aggressive is another key area of adjustment. Overall in 2008 about 4% of
nursing homes employ physical restraints, a percent that is down overall by almost
half from 2003 (Harrington, Carrillo, & Blank, 2009). However, in one New York
State study, researchers found that Black elders living in nursing homes with a high
percentage of White residents were more likely to be placed in restraints than Black
residents living in homes that consisted largely of Blacks.
f. Psychological Issues in Long-Term Care
Just as you wish to control certain aspects of your environment, residents of
nursing homes also have the need to perceive that they can control what goes on
around them. Even though residents may not have actual control, the perception that
they do can help to ease the stress of adjusting to the institutional environment.
Residents who feel that they can have mastery over at least some aspects of life in the
institution feel less anxious and depressed, experiencing less of the stress that so often
accompanies moving from their own homes to the institution. Their adaptation can
further be facilitated if they feel that they have support in this adaptation process
(Keister, 2006). The psychosocial needs of residents and strategies that can be
implemented to enhance the quality of life in nursing homes became a focus of OBRA
1987. Unfortunately, change is slow to come about. Researchers still believe that
nursing homes in the United States had not, at least as of the late 1990s, made
significant changes in the freedom of choice afforded to residents on a day-to-day
basis (Kane et al., 2007). In terms of the rhythm of life in the average nursing home,
although deficiencies in activities exist in less than 10% of nursing homes, there still
remains a good deal of room for improvement. A study of the daily life of residents
conducted in 2002 revealed that, as was the case in the 1960s, residents spend almost
two thirds of the time in their room, doing nothing at all (Ice, 2002). Thus, for many
residents, there are simply not enough activities in the average nursing home (Martin
et al., 2002). At the same time, training of specialists to work with the nursing home
population is lagging; social workers are not given sufficient educational preparation
to work in these challenging and often stressful settings.
Theoretical models attempting to provide insight into the adaptation of the
individual to the institutional environment of a long-term care facility began to
develop in the 1970s with the increasing attention in gerontology given to ecological
approaches to the aging process. In part, this interest developed in response to
practical concerns about the best ways to minimize behavioral disturbances and
maximize adaptation of older adult residents to institutional settings. Many
researchers studying institutionalization believed that it was important to find ways to
maximize the resident’s ability to maintain independence even while having to adjust
to an environment that inevitably fostered dependence.
Maximizing an older individual’s adaptation to the environment is also tied in
with the challenges that large institutions (such as college dorms) face in attempting to
find ways to satisfy the needs of the so-called ‘‘average’’ resident. The average
resident, like the ‘‘average’’ college student is a hypothetical construct. When trying
to satisfy the needs of everyone, administrators of institutions will inevitably satisfy
very few. To put this issue in very concrete terms, consider the issue of temperature.
For some people, a room temperature of 68 degrees is just right, but for others, 76 is
the ideal place to set the thermostat. Most institutions must regulate the temperature of
the entire building, however, because they do not have individual room thermostats.
In attempting to please the average resident, the administrator would need to adjust
the temperature to the mean of these two numbers, which would be 72. Neither group
of residents will find this temperature to be a comfortable one, yet on the ‘‘average’’ it
is the correct level.
Complications also arise from the fact that, in predicting adaptation to the
institution, the actual qualities of the environment are only part of the equation.
Researchers are interested in learning how residents perceive the institution’s physical
qualities and relating these perceptions to their adaptation.
As important as the physical environment is to adaptation, the psychosocial
needs of the residents also play a crucial role. These needs may have more to do with
the amount of control people feel they have over their environments than with the
physical characteristics of the institution. Feeling that you can control the temperature
in your room if you desire may be even more important to your satisfaction than the
actual temperature. This possibility was tested in an interview study of nursing home
residents in Victoria, British Columbia. Scenarios were presented as vignettes in
which residents were asked to make decisions such as what time to go to bed, what
medicines to take, whether to move to a different room, and what type of end-of-life
care to receive. Not everyone wished to have control over these decisions, though.
Older adults with more years of education and a greater number of chronic illnesses
were likely to state that they wished to be able to make these choices rather than have
the decisions made for them by nursing home staff (Funk, 2004). Thus, resident
characteristics are important to factor into the equation when evaluating the impact of
the environment on adaptation to the institution.
Empirical interest in the institutionalization process has dwindled somewhat
from the 1970s, when several teams of researchers were actively investigating
environmental models and aging (Nehrke et al., 1981). However, one of these models
offers some useful concepts for predicting how well people will adapt to an
institutional setting. This model, the competence-press model predicts an optimal
level of adjustment that institutionalized persons will experience on the basis of their
levels of competence (physical and psychological) compared with the demands or
‘‘press’’ of the environment, or the demands it places upon individuals. A small degree
of discrepancy is acceptable, but when the mismatch goes outside this range, the
individual will experience negative affect and maladaptive behaviors. For example,
the intellectually competent older resident (high competence) will do well in a setting
in which autonomous decisions are expected (high press), but a person with a
significant cognitive impairment will adapt maximally when the environment is very
structured.
By considering the interaction between the individual and the environment of
the institution, the competence–press model makes it possible to provide specific
recommendations to institutions about how best to serve the residents. The model is
essentially a biopsychosocial one, allowing room for multiple dimensions of
competence and press to be considered when evaluating older adults (Lichtenburg,
MacNeill, Lysack, Adam & Neufeld, 2003). Competence may be defined in terms of
biological and psychological characteristics such as mobility and cognitive resources.
The social factors in this model are incorporated into the level of press in the
environment which include the expectations of staff and amount of stimulation
provided by other the residents.
