Sir_Excellence

Unit 2: Week 2 - Chapter 3 Outline

CHAPTER THREE: TOWARD AN IDEAL SYSTEM

LEARNING OBJECTIVES

After completing this chapter, readers will be able to:

1.   Identify the characteristics of an ideal long-term care system, with particular attention to accessibility, quality, and cost.

2.   Describe what it means for the long-term care system to be consumer-driven, including an understanding of consumers' rights and the responsibilities that go along with those rights.

3.   Identify the roles of formal and informal caregivers and ways for those resources to be coordinated.

4.   Define the components of a full and uniform assessment of a consumer's service needs.

5.   Discuss the need for incentives for providers and consumers to improve the quality and effectiveness of care, and to use the long-term care system wisely.

CHAPTER HIGHLIGHTS

Introduction

The basis for our discussion is a document titled Criteria for Designing or Evaluating a Long-Term Care System developed by Saint Joseph’s College of Maine. Use the Criteria as a foundation for construction of a long-term care system as it should be.

·         While each of the criteria is important in its own right, it is only when taken as a whole that they represent an optimum system. 

·         It is recognized that there is some duplication and overlapping of criteria, but that serves to emphasize the importance of certain aspects of long-term care. 

·         The criteria are stated as general precepts against which a long-term care system should be measured. 

·         Each of them is accompanied by several statements identifying the benchmarks a system must accomplish to meet that particular criterion.

Criterion I. The long-term care system should be based on recognition of the needs, rights, and responsibilities of individuals. It should

A. Be consumer driven

Availability and utilization of long-term care services should be based on the needs (not necessarily the wants) of consumers of those services, rather than on the needs of providers or reimbursement agencies.

B. Meet the needs of the consumers

The long-term care system should address the full range of consumer needs, rather than meeting only some of them. Otherwise, it will be neither complete nor effective.

C. Focus on the individual, recognizing that individuals have unique needs

It should be flexible enough to recognize those needs, including the psychological, social, and financial limitations of recipients of services.

D. Respect different cultures and cultural values

The system should recognize these differences and attempt to accommodate them.

E.   Promote quality, dignity, and self-improvement for consumers. In doing this, it should

1.   Value older adults and those with chronic disabling conditions

2.   Promote a positive approach to living with chronic illness and dependency

3.   Allow care recipients to continue to contribute to life and society

4.   Promote the highest achievable level of functioning

F.   Balance consumer rights and responsibilities

Consumers of long-term care services and their families should be allowed and encouraged to participate in the continuum of care, including making care-related decisions and taking responsibility for lifestyle choices and financing when appropriate.

G. Offer consumers a choice of service providers and service delivery modalities

The consumer’s right to choose should be respected and encouraged.

Criterion II.  The long-term care system should be easily accessible. It should

A. Be universally accessible

Services should be available to all who need them, based on uniform functional criteria.

B. Be user-friendly

The long-term care system should be uncomplicated for the consumer to access and use, with minimal paperwork, simplified financing and approval processes, and no excessive delays in service.

C. Provide care in the least restrictive environment

The long-term care system should facilitate the provision of care in the setting and service modality that will provide the best combination of appropriate care, quality of life, and cost-effectiveness.

D. Encourage single-site care availability

The system should be designed to provide, to the degree possible, all necessary services without requiring the consumer to access multiple sites and/or providers.

Criterion III. The long-term care system should coordinate professional, consumer, family, and other informal caregiver resources. It should

A. Integrate professional, community, family, and other informal caregiver efforts

The various sources of support should be coordinated to take fullest advantage of their availability.

B. Evolve from the current medical model to a holistic model of service delivery

The system should encourage broader involvement of nonmedical personnel in problem solving.

C. Involve families in case management and care delivery

The system should facilitate caring at home by providing resources to family caregivers.

Criterion IV. The long-term care system should be an integral part of the health and social system to promote integration, efficiency, and cost effectiveness. It should

A. Include a full continuum of services

Those services should meet the needs of all with chronic illness, not just the elderly.

B. Include a full and uniform assessment (initial and ongoing) of the consumer’s needs

The assessment should reflect an understanding of chronicity.

C. Provide emphasis on, and reimbursement for, illness prevention efforts as an integral part of the overall system

Although preventive services are not usually seen as part of a long-term care system, their impact on such a system must be considered.

D. Be planned and coordinated to reduce fragmentation and inefficiencies

The system should integrate systemwide coordination with local and regional autonomy.

E.   Be based on outcome-oriented accountability

To attain this accountability, the system must include

1.   Elimination of unnecessary paperwork

2.   A focus on results as they affect quality of life rather than a focus on documentation

3.   Incentives to improve quality of services rather than inspecting for quality

4.   Consistent development and application of standards

5.   Outcome-oriented versus process-oriented accountability

6.   Flexibility that encourages innovation and change

Criterion V. The long-term care system should be adequately and fairly financed. It should

A. Utilize public and consumer resources to assure universal access to services

All available resources, public and private, should be considered in providing services for current and future consumers.

B. Provide incentives for consumers to use services in an appropriate and cost-effective manner

The overall cost of the system can be controlled by avoiding excessive and unnecessary use.

C. Provide incentives for consumers to self-finance their care

Consumers and their families should be encouraged to pay for their own care when possible.

D. Avoid causing impoverishment of consumers and families

Although consumers and families should be encouraged to contribute to the cost of their care, that contribution should be limited to prevent causing undue hardship.

E.   Provide incentives for providers to develop cost-effective measures

Providers of long-term care services can improve the cost-effectiveness of the system, given incentives to do so.

F.   Develop payment mechanisms that allow efficient providers to adequately compensate staff and to allow for appropriate operating surplus and/or return on investment

Both the for-profit and not-for-profit sectors should continue to have significant roles in the long-term care system.

G. Operate within the limits of a well-conceived budget

H. Provide significant flexibility to enable consumers to meet long-term care needs as each consumer defines those needs

The financing of the system should reflect the needs of individuals (as reflected in Criterion I).

I.    Be based on uniform financial eligibility criteria

Criterion VI. The long-term care system should include an education component to create informed consumers, providers, reimbursers, and regulators. It should

A. Include community education

The public should be informed about long-term care, including available service options, limitations, and access methods.

B. Include education for providers

The system should provide for more geriatric education for physicians and others dealing with the elderly.

C. Educate young healthy persons to better prepare them to cope with chronic illness

A better understanding of chronicity will lead to better acceptance of chronic illness in individuals and family members and more effective, efficient use of available resources.

LECTURE OUTLINE

A.  Identify learning objectives for the session

B.  Introduce the lecture topic, explaining the Criteria and how they were developed

C.  Review Criterion I (recognition of the needs, rights, and responsibilities of individuals), discussing:

      1.   The concept of a “consumer-driven” long-term care system

      2.   Meeting all of the needs of consumers

      3.   Unique needs of individuals

      4.   Different cultures and cultural values and their impact on the system

      5.   Promoting quality, dignity, and self-improvement

      6.   Balancing consumer rights and responsibilities

      7.   Offering consumers choices of service providers and delivery modalities

D.  Review Criterion II (an easily accessible system), discussing:

1.   Universal accessibility

2.   User-friendliness

3.   Least restrictive environment

4.   Encourage single-site availability

E.   Review Criterion III (coordination of resources), discussing:

1.   Integrate professional, community, family, and other informal caregiver efforts

2.   Evolve from current medical model to a holistic model

3.   Involve families in case management and care delivery

F.   Review Criterion IV (promote integration, efficiency, and cost effectiveness), discussing:

1.   Full continuum of services

2.   Full and uniform assessment of consumer’s needs

3.   Prevention as an integral part of the system

4.   Be planned and coordinated to reduce fragmentation and inefficiencies

5.   Based on outcome-oriented accountability

G.  Review Criterion V (a system that is adequately and fairly financed), discussing:

1.   Utilize public and consumer resources to assure universal access

2.   Provide incentives for consumers to use services appropriately

3.   Provide incentives for consumers to self-finance their care

4.   Avoid causing impoverishment of consumers and families

5.   Provide incentives for providers to develop cost-effective measures

6.   Develop payment mechanisms allowing for adequate staff compensation and return of investment

7.   Operate within the limits of a well conceived budget

8.   Provide flexibility to enable consumers to meet needs as they define them

9.   Based on uniform financial eligibility criteria

H.  Review Criterion VI (education component), discussing:

1.   Community education

2.   Education for providers

3.   Education of young to prepare them for the future

4.   Increasing focus on customer service

I.    Discuss how the current long-term care system measures up to the ideal

J.    Summarize the discussion, recapping the key points of the lecture.

VOCABULARY TERMS

· AARP (formerly the American Association of Retired Persons) - advocacy organization representing seniors.

·         Acquired immunodeficiency syndrome (AIDS) - A severe immunological disorder caused by the retrovirus HIV, usually resulting in death.

· Alzheimer’s disease - A disease generally affecting elderly and middle-aged people, causing loss of memory and other cognitive function.

· Area Agencies on Aging (AAAs) - Local or regional government agencies providing services for older persons within their areas.

· Baby boomers - People born between 1946 and 1964, representing a post-World War II population boom and a potential large increase in the elderly in the future.

· Chronicity - Lasting for a long period of time or marked by frequent recurrence.

· Consumer-driven - When consumers are the primary focus of care delivery and are in a position to make decisions about the care they receive.

· Consumer responsibilities - The responsibilities of consumers of care to utilize it wisely and effectively.

· Consumer rights - The rights consumers of care have concerning the care they receive.

· Copayment - Amount the consumer must pay for each procedure or episode of care when covered by Medicare or by many private insurances.

· Functional disability - Limitation in one’s ability to perform certain functions associated with everyday life, such as walking or dressing oneself.

· Geriatrician - Physician with expertise in treating all phases of aging.

· Informal caregivers - family, friends, and volunteers who provide various levels of care for an individual, but are not reimbursed for that care.

· Long-term care insurance - Private insurance covering long-term care services specifically.

· Managed care - Term covering a variety of health care systems or organizations (e.g., HMOs, PPOs) that combine the provision of care with payment for that care.

·         Omnibus Budget Reconciliation Act (OBRA) - Also known as the 1987 Nursing Home Reform Act, it established stringent new rules for nursing facilities.

· Private funding sources - Nongovernmental reimbursement sources such as managed care and private insurance.

· Public funding sources - Government reimbursement sources such as Medicare & Medicaid.

· Respite care - Services providing temporary relief for informal caregivers.

· Sandwich generation - Refers to those middle-aged individuals who have the responsibility of caring for both their children and their own parents.

·         Seamless system of care - Term used to describe system of care that is coordinated and integrated to prevent consumers from "falling through the cracks."

·         Single-site care availability- Being able to receive all needed care at a single place, without having to travel around to get services.

·         Uniform assessment - An assessment that is comprehensive and detailed, addressing all of the needs of the individual, with the same assessment tool used for all consumers.

·         Uniform financial eligibility criteria - Eligibility criteria applied to determine how much individuals will pay, based on standards that are comprehensive enough to apply to all consumers fairly.

·         Universally accessible - Services to which all consumers have equal access.

REFERENCE BOOKS

Long-Term Care: Managing Across the Continuum, 4th Ed By: John Pratt

The Medicare Part D Drug Program, 1st Ed By: Fincham, John