Chapter 10 Long-Term Care Learning Objectives (1 of 2) • • • • Concept and features of long-term care (LTC) Discuss the various types of LTC services Describe who needs long-term care and why Home- and community-based LTC services, and who pays Learning Objectives (2 of 2) • LTC institutions and levels of services provided • Specialized LTC facilities and continuing care retirement communities • Institutional trends, utilization, and costs • Explore the aspects of private LTC insurance Introduction (1 of 2) • Long-term care (LTC) is a complex subsystem. • Numerous sources of financing. • Community-based services. – More economical and preferred by older people • Individuals may require LTC from functional deficits arising from chronic conditions. Figure 10-1: People with multiple chronic conditions are more likely to have activity limitations. Reproduced from Partnership for Solutions and Johns Hopkins University. 2002. Chronic conditions: Making the case for ongoing care. Baltimore, MD: Johns Hopkins University. p. 12. Introduction (2 of 2) • Cognitive impairment may lead to functional decline. • Two indicators assess functional limitations – Activities of daily living (ADLs) scale – Instrumental activities of daily living (IADLs) Nature of Long-Term Care (1 of 2) • • • • • Variety of services Individualized services Well-coordinated total care Maintenance of residual function Extended period of care Figure 10-3: Key characteristics of a welldesigned long-term care system. Nature of Long-Term Care (2 of 2) • Holistic care • Quality of life – Loss of self-worth accompanies disability. – Patients remain in LTC settings for long periods. • Use of current technology – Personal emergency response system (PERS) • Use of evidence-based practices Long-Term Care Services (1 of 2) • Medical care, nursing, and rehabilitation • Mental health services and dementia care – Caring for dementia patients is a major focus in LTC. • Social support • Preventive and therapeutic long-term care • Informal and formal care Long-Term Care Services (2 of 2) • Respite care • Community-based and institutional services • Housing – Private and public housing • End-of-life care Figure 10-2: Medicare enrollees age 65 and older with functional limitations according to where they live, 2009. Reproduced from Federal Interagency Forum on Aging-Related Statistics. 2012. Older Americans 2012: Key indicators of well-being. Washington, DC: US Government Printing Office. p. 61. Figure 10-4: Range of services for those in need of long-term care. Modified with permission from Taylor & Francis from Singh, D. A. 1997. Nursing home administrators: Their influence on quality of care. New York: Garland Publishing, Inc. p. 15. Users of Long-Term Care • 50% of LTC users are younger than age 65. – Developmental disability (DD) – Intellectual disability (ID) – Patients with HIV/AIDS Figure 10-5: Users of long-term care by age group. Data from Iglehart, J.K. 2016. Future of long-term care and the expanding role of Medicaid managed care. New England Journal of Medicine 374: 182–187. Level of Care Continuum (1 of 2) • Personal care – Paraprofessionals • Custodial care • Restorative care • Skilled nursing care – Rehabilitation is an important component. Level of Care Continuum (2 of 2) • Four categories of subacute care services 1. 2. 3. 4. Extensive care Special Clinically complex care Intensive rehabilitation Home- and Community-Based Services (1 of 4) • Home health care • Adult day care – Medicaid provides funding. • Adult foster care Home- and Community-Based Services (2 of 4) Figure 10-6 Most frequently provided services to home health patients. Data from Jones, A. L., et al. 2012. Characteristics and use of home health care by men and women aged 65 and over. National health statistics reports, No. 52. Hyattsville, MD: National Center for Health Statistics. Figure 10-7 Sources of payment for home health care, 2014. Data from National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 298. Home- and Community-Based Services (3 of 4) • Senior centers • Home-delivered and congregate meals – Elderly nutrition program (ENP) – Meals-on-wheels • Homemaker services • Continuing care at home Home- and Community-Based Services (4 of 4) • Case management – Brokerage model – Managed care/integrated model • Recent policies related to community-based services – Money follows the person – Community first choice Institutional Long-Term Care Continuum • • • • Residential and personal care facilities Assisted living facilities Skilled nursing facilities Subacute care facilities—three main locations – Long-term care hospitals (LTCHs) – Hospital transitional care units certified as SNFs – Freestanding nursing homes Specialized Care Facilities • Intermediate care facilities for individuals with intellectual disabilities – Most patients have disabilities in addition to ID • Alzheimer’s facilities Continuing Care Retirement Communities • Three common types of CCRC contracts – Life care or extended contract – Modified contract – Fee-for-service contract Institutional Trends, Utilization, and Costs • Community-based services and assisted living absorbed much of the nursing home care. • Rising cost of institutional care. • Five nursing home chains operate more than 9% of U.S. nursing homes. Table 10-1: Trends in Number of Long-Term Care Facilities, Beds/Resident Capacity, and Prices, Selected Years Data from Genworth Financial, Inc. 2010. Genworth 2010 cost of care survey. Richmond, VA: Author; Genworth Financial, Inc. 2015. Genworth 2015 cost of care survey. Richmond, VA: Author; Sanofi-Aventis. 2016. Managed care digest series: Public payer digest, 2016. Bridgewater, NJ: Author. Insurance for Long-Term Care • Medicare does not cover most LTC services. • Medicaid requires spending one’s assets to poverty levels to qualify. • Public policy created few incentives to spur LTC insurance growth. • ACA did little to address the LTC dilemma. Summary (1 of 2) • Need for LTC increases – Due to severe chronic condition, multiple illnesses, or cognitive impairment • LTC includes – Medical care, nursing, rehabilitation, social support, and mental health care – Housing alternatives and end-of-life care Summary (2 of 2) • Nursing homes require – SNF certification to admit Medicare patients – NF certification to admit Medicaid patients • Industry has become more competitive. • Medicaid and Medicare expenditures for LTC will be unsustainable in the long term.
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