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Unit 4: Week 4 - Chapter 8 Outline

CHAPTER EIGHT: COMMUNITY-BASED SERVICES

LEARNING OBJECTIVES

After completing this chapter, readers will be able to:

1.   Understand how community-based long-term care services developed and where they fit in the continuum of care.

2.   Identify and define the components of community-based long-term care services.

3.   Identify and describe regulations affecting community-based service providers.

4.   Understand the financial, ethical, and managerial issues facing community-based long-term care services providers.

5.   Identify and discuss trends in community-based long-term care services and management.

CHAPTER HIGHLIGHTS

What are Community-Based services?

Also described as “non-institutional”, they include home health care, hospice care and adult day care.

·         What is Home Health Care? - health care delivered to consumers in their homes.

·         What is Hospice Care? - services provided to meet the needs of patients who are diagnosed with a terminal illness and have a limited life span.

·         What is Adult Day Care? - a form of long-term care that provides interim (less than 24-hour) supervision for individuals who cannot be without supervision or assistance.

Origins and Development

·         Home Health Care

·         Began in the latter part of the 1800s as a service of city health departments called visiting nurse services.

·         As third party reimbursement became more available, home health care agencies became even more independent.

·         As reimbursement sources, particularly Medicare and Medicaid, looked for ways to reduce their ever-increasing costs, there was a concerted move to divert long-term care residents from institutional care to home-based care.

·         Hospice Care

·         Began in England in 1960s.

·         Came to U.S. in 1974

·         Adult Day Care

·         Developed from the concept of respite

·         Provides a short reprieve from the responsibilities of caregiving for those who have a family member living with them who needs constant care and supervision

Philosophy of Care

·         Home Health Care - to take health services to the consumer rather than requiring the consumer to go to where the services are delivered. Medicare requires:

·         Physician-Ordered Care – separates it from non-health home care

·         Intermittent Care - given fewer than 7 days per week or less than 8 hours per day

·         Homebound Consumers – recipients must be unable to leave home without a major effort.

·         Hospice Care - based on a concept of providing comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments.

·         Goal is to improve the quality of a patient's last days by offering comfort and dignity.

·         A central concept of hospice is provision of palliative care, also called comfort care, which concentrates on providing pain and symptom relief.

·         Adult Day Care – based on providing needed services for both the person receiving the care and those responsible for that care.

·         Family members very important

Ownership

·         Mix of for-profit and not-for-profit.

·         Many affiliated with hospitals or health care systems

·         Some nursing facilities create community-based services if not otherwise available.

Services Provided

·         Home Health Care

·         Deliver a wide variety of health care and supportive services, ranging from professional nursing and HCA care to physical, occupational, respiratory, and speech therapies.

·         May also provide social work and nutritional care and laboratory, dental, optical, pharmacy, podiatry, x-ray, and medical equipment and supply services.

·         Hospice Care – services aimed at easing pain and assisting patients and families, including:

·         Supportive services

·         Pain and symptom management

·         Family and caregiver support

·         Communication among the individuals, families, and program staff

·         Assistance with advance care planning.

·         Adult Day Care - adult day care centers are generally grouped into two categories: social day care and health day care. There is a third group, dementia day care, but it is usually included in one of the others.

Consumers Served

·         Generally elderly, more women than men

·         Home health care consumers may need temporary care

·         Hospice care consumers receive care until they die

·         Adult day care consumers often use services for long period of time.

Informal Caregivers

The family members of the consumers of community-based long-term care services must also be included as beneficiaries of community-based long-term care services. Often, the caregivers are spouses, children, friends, and volunteers. To distinguish them from those who give care as part of their jobs, they are referred to as informal caregivers.

Market Forces Affecting Community-Based Services

·         Consumer Choice – often favors community-based services over institutional services.

·         Cost-Effectiveness – seen by payers as less costly making them more attractive.

·         Social and Demographic Changes – families of the elderly are often not available to help.

·         Competition among Other Providers – adding community-based services can help them improve their market position.

Regulations - regulations affecting community-based services fall into three general categories: (1) Medicare certification, (2) licensing of provider organizations and (3) licensing of professional staff.

1.      Medicare Certification

·         Home health and hospice care are covered by Medicare

·         Adult day care is not.

2.      Licensure of Provider Organizations - is handled at the state level:

·         Most, but not all, states do license home health care agencies.

·         Nearly all states now license hospice providers.

·         Regulation of adult day care centers is highly inconsistent, varying from state to state.

3.      Licensure of Staff

·         Professional staff, such as physicians, nurses, and social workers, must be licensed by their state licensing boards regardless of what type of health care organization they work for.

Accreditation and Certification

·         Accreditation – applies to the organizations, not the staff members as such.

·         Home health care and hospice agencies may be accredited by any of three separate organizations: the Joint Commission, the Community Health Accreditation Program (CHAP), or the Accreditation Commission for Health Care (ACHC).

·         Adult day care is not accredited.

·         Certification of Professionals –applies to individuals acquiring voluntary verification of their qualifications.

Financing of Community-Based Services

·         Medicare

·         Is the largest single payer of home health care and hospice care.

·         A pilot program allows a portion of Medicare home health-care benefits to go toward adult day care.

·         Medicaid

·         Medicaid coverage of community-based services is growing

·         Most states offer a hospice benefit as part of their Medicaid coverage.

·         Some state Medicaid programs pay for adult day care through federal waivers that allow them to waive some Medicaid rules in order to use less costly services.

·         Private Health Insurance and Managed Care

·         Coverage is increasing.

·         Private Out-of-Pocket

Staffing and Human Resource Issues

·         Community-based care services are personnel-intensive, that is, payroll for staff is the largest portion of the budget.

·         They rely on a mix of professional and nonprofessional staff working as a care team. The team includes nurses (both RNs and LPNs), aides, therapists (physical, occupational, speech), social workers, and numerous other specialties.

·         All use some volunteers, but hospice uses more of them and more integrally in the provision of care.

Legal and Ethical Issues

·         Patient Noncompliance – many of these patients want a high level of autonomy, which may be at variance with professional opinions.

·         Patient Safety – is more difficult when patients are not under the supervision of professionals at all times.

·         Patients’ Rights – again, involves balancing patient autonomy and professional responsibilities.

·         The Decision to Accept Hospice Care – Some patients do not want to accept that their conditions are terminal, or their families do not.

·         Inequitable Access – community-based services are not uniformly accessible, depending on geography and/or the urban/rural nature of the community.

Management - administrators of community-based service providers are not regularly licensed as are nursing facility administrators and, in some states, administrators of assisted living facilities.

·         Management Challenges and Opportunities

·         Supervision of Staff: Home Health and Hospice Care – it is difficult to supervise staff who are working in the patient’s homes.

·         Hospice: Coordinating Professional and Volunteer Staff – such coordination can be difficult due to different points of view.

·         Hospice: The Emotional Element – impending death creates emotions for both patients and those who care for them, and must be recognized.

·         Cultural, Religious, and Ethnic Differences – some ethnic groups involve family members more than others, and different religious groups have different views on death.

·         Community and Philanthropic Groups – these services rely on such groups and working with them is essential, but sometimes difficult.

Significant Trends and Their Impact

·         Consumer Choice/Quality of Life – favors community-based services over institutional services.

·         Olmstead Decision – requires treatment in the least restrictive setting.

·         Technology – is changing these services for the better.

·         Managed Care – is rapidly becoming an important player in community-based services.

·         Wellness Programs - some community-based services are beginning to create wellness programs for elderly individuals who are not yet in need of more traditional services.

 

LECTURE OUTLINE

A.  Identify learning objectives for the session

B.  Introduce the lecture topic

C.  Discuss what community-based services are, defining and explaining the terms involved, including:

1.   Home health care

2.   Hospice care

3.   Adult day care

D.  Origins. Discuss how each of the community-based services developed, including:

1.   Home health care

2.   Hospice care

3.   Adult day care

E.   Philosophy of Care. Discuss the philosophy of care of each of the community-based services, including:

1.   Home health care

2.   Hospice care

3.   Adult day care

F.   Ownership. Identify differences in ownership of community-based services:

1.   Types of providers

a.   Home health care

b.   Hospice care

c.   Adult day care

2.   Forms of ownership

a.   Nonprofit

b.   For-profit

c.   Government-owned

3.   Affiliations

a.   Hospitals, rehabilitation facilities, nursing facilities

b.   Freestanding

G.  Services. Discuss the services provided by community-based services:

·         Home health care

·         Nursing

·         Therapy

·         Other services

2.   Hospice care

·         Physician services

·         Nursing

·         Social services

·         Counseling

·         Medical appliances and supplies

·         Pain management

·         Homemaker services

·         Therapies

3.   Adult day care

·         Social model

·         Medical model

·         Dementia care

H.  Consumers. Identify the consumers served by community-based services.

1.   Elderly

2.   May need full-time on-going care, or only temporary post-hospital care

3.   Terminally ill

4.   Needing temporary supervision, socialization

5.   Informal caregivers

I.    Market Forces. Identify and discuss market forces impacting community-based services

1.   Consumer choice

2.   Cost-effectiveness

3.   Social and demographic changes

4.   Competition among other providers

J.    Regulations. Discuss the regulations affecting community-based services, including:

1.   Medicare Conditions of Participation

2.   Licensure of provider organizations

3.   Licensure of staff

K.  Accreditation. Identify who accredits community-based service organizations

1.   Joint Commission

2.   CHAP

3.   ACHC

L.   Financing. Discuss how community-based services are financed, and by whom

1.   Medicare

2.   Medicaid

3.   Other government

4.   Private insurance & managed care

4.   Private out-of-pocket

M.  Staffing/Human Resources. Identify and discuss staffing, including:

1.   Combination of professional and non-professional staff, varying by type of community-based service

2.   Work as team

N.  Legal & Ethical Issues. Identify and discuss legal and ethical issues, including:

1.   Patient non-compliance

2.   Patient safety

3.   Patients’ rights

4.   Decision to accept hospice care

5.   Inequitable access

O.  Management

1.   Discuss management qualifications

2.   Discuss management challenges and opportunities

a.   Supervision of staff – home health and hospice care

b.   Hospice care – coordinating professional and volunteer staff

c.   Hospice – the emotional element

d.   Cultural, religious and ethnic differences

e.   Community and philanthropic groups

P.   Trends. Identify and discuss significant trends impacting home health care, including:

1.   Consumer choice/quality of life

2.   Olmstead decision

3.   Technology

4.   Managed care

5.   Wellness programs

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

 

VOCABULARY TERMS:

Activities of daily living (ADLs) - Those activities that impact a person's functional ability or disability; including bathing, transferring, toileting, eating, and communicating.

Adult day care - A community-based group program providing supervision and some services for a period of a few hours per day.

Balanced Budget Act (BBA) of 1997 - a law that changed the way Medicare reimburses long-term care providers.

Bereavement - a state of mourning, usually following the death of a family member or friend.

Capitation - payment to health care providers on the basis of the number of people covered instead of payment for the services provided.

Caregiver - anyone who provides long-term care. Formal caregivers include organizational entities, while informal caregivers include family members and friends.

Certified Nursing Assistant (CNA) - a staff person who provides personal care to residents or patients, working under the supervision of an RN or LPN.

Dementia - impairment of mental capacity, usually due to organic causes.

Functional independence - ability to perform essential functions of living - lack of functional disability.

Holistic - emphasizing the importance of the whole and the interdependence of its parts.

Home care - personal care provided in the consumer’s home.

Home health care - health services provided in the consumer’s home by a nurse, occupational, speech or physical therapist, social worker, or home health aide.

Hospice care - the concept of providing palliative care to enhance the life of dying person in the last six months of life, emphasizing comfort measures and counseling to provide social, spiritual and physical support to the dying patient and his or her family.

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

Institutional care - health or personal care provided in an institutional setting, such as nursing facilities, and assisted living.

Managed care organizations (MCOs) - systems that integrate the financing and delivery of health care by means of arrangements with a limited number of providers.

Medicaid - Title XIX of the Social Security Act. Passed in 1965, it provides health insurance for those who cannot afford it, the "medically indigent."

Medicare-certified home health agency - a home health care agency that has met Medicare’s conditions of participation.

National Adult Day Services Association (NADSA) - constituency unit of the National Council on Aging (NCOA), representing adult day care providers.

Occupational Therapy - a rehabilitation specialty focusing on assisting individuals to cope with the tasks of everyday living in spite of functional disabilities or limitations.

Oncologist - physician specializing in cancer treatment.

Outcome and Assessment Information Set (OASIS) - method, developed by Medicare, of collecting and monitoring data to improve outcome measures in home health care.

Pain management - medical and other techniques used to limit pain as much as possible.

Palliative care - type of care designed to relieve or lessen pain or discomfort, as in hospice care.

Physical therapy - services provided by licensed physical therapists to relieve pain, restore maximum function, and prevent disability or injury.

Prognosis - the likely future condition or outcome of a particular disease or treatment.

Program of All-inclusive Care for the Elderly (PACE) - model program providing noninstitutional services to keep consumers out of institutional care.

Prospective payment system (PPS) - method by which skilled nursing facilities and some other long-term care providers are paid by Medicare.

Psychosocial support - meeting the psychological and social needs of the patient and the patient's family, especially in hospice care.

Range-of-motion exercises - therapeutic exercises designed to improve the extent to which an individual can move his/her joints.

Rehabilitation- - therapy-oriented services with a goal of improving or maintaining an individual’s functional ability.

Skilled nursing services - a Medicare reimbursable level of long-term care, defined by the extent of clinical care given, and the functional needs and/or disabilities of the consumer.

Social day care - adult day care providing a safe and secure environment for people without significant health care needs, but who may have some minor limitation in the activities of daily living (ADLs).

Speech pathology - specialty service (also known as speech therapy) that helps individuals overcome communication limitations.

Team format - functioning as a team, rather than as individual specialists.

Telemonitoring - using technology to monitor patients from a distance.

United Way - a community-based association that raises and distributes funds to service organizations.

Visiting Nurse Association - a type of home health care provider, historically operated by municipalities.