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Chapter 9

Long-Term Care

Define long-term care
Review major factors in the history,
development and financing of the
long-term care industry
Identify and define modes of longterm care service delivery and
Identify and review ACA provisions
affecting long-term care

Introduction (1)
Care needs of a lifespan may vary in
intensity and duration
Level of support required for optimal
functioning may vary over time on a
Service locations vary with type and
intensity of needshome to institution
Services range from intense medical to
social support; many combinations

Introduction (2)
Care needs, contd
Formal LTC (institutionally-based or
Informal LTC (family, friends)
72 M 65+ by 2030; 6.6 M 85+ by 2020
(Figs. 9-1, 9-2)
Long-term care needs increase due to
medical advances that increase
longevity; changes in social structures
that preclude home/informal care

Development of LongTerm Care Services

Colonial era: almshouses started by
charitable colonists who purchased
private homes for communal
19th-early 20th century: city, countyoperated homes & infirmaries for
impoverished older adults;
professional home care began as
response to living conditions of
immigrants (e.g. VNA) & expanded to

Development of Long-Term Care

Great Depression (1929): private citizens
boarded older adults for financial
benefit; many quality of care issues
Social Security (1935): enabled older
adults and those with certain disabilities
to avoid reliance on charity
1950s: government loans aided not-forprofit nursing home development
1965: Medicare and Medicaid passage
had profound effects on the LTC industry

Development of Long-Term Care

Medicare & Medicaid
Stimulated nursing home industry
development as a profitable
Required minimum standards of
care for reimbursement
Attracted scrupulous &
unscrupulous operators

1970s public exposes: Congressional
hearings on inhumane treatment, by
Ralph Nader, others, e.g.
Untrained, inadequate staff
Hazardous, unsanitary conditions
Over, under-medication
Discrimination against minorities
Thefts of belongings

Medicare and Medicaid certification
State nursing home & home care
Appropriate staff credentialing
Laws for elder abuse reporting
Regulations on restraints
Nursing home residents bill of
Ombudsman programs

Modes of Long-term Care Service

Delivery (1)
Institutions such as nursing homes
and skilled nursing facilities (SNFs):
custodial; chronic care management
Community-based: adult day care,
residential group homes, in-home

Modes of Long-term Care Service

Delivery (2)

Skilled nursing care

Assisted living facilities
Home care
Adult day care

Skilled Nursing Care (1)

Skilled nursing facility:
(Medicare/Medicaid certified): a
facility or distinct part of one,
primarily engaged in providing skilled
nursing care and related services for
people requiring medical or nursing
care, or rehabilitation services.
3.3 M reside in 15,884 facilities; 86%
>65 years

Skilled Nursing Care (2)

Annual national expenditures: $138.4 B;
double cost of home care
Medicare, Medicaid pay ~ 62%; 38%
private, out-of-pocket, long-term care
Private room = $ 90,520/year; semiprivate= $81,030/year

Occupancy declining: More assistedliving, community-support options; staying

healthy longer

Skilled Nursing Care:

Medical Director
Registered Nurses and Licensed Practical
Certified Nurse Assistants
Social workers
Nutrition & Dietary Staff
Rehabilitation (PT & OT)
Recreational/ Activities
Housekeeping/Plant & Facilities

Skilled Nursing Care (4)

1987 OBRA increased government regulations
re: periodic functional assessments of
residents, aide training, restraints, bill of
rights, medical director oversight
States licensure administrators
Analyses indicate quality variations between
for-profit & not-for-profit entities
ACA: certified SNFs must publicly disclose
ownership information, expenditures, quality
indicators on the web

Assisted Living Facilities

Appropriate for people not requiring skilled
nursing services whose needs lie in the
custodial and supportive realm: a program
that provides and/or arranges for daily meals,
personal and other supportive services, health
care and 24-hour oversight to persons residing in
a group residential facility who need assistance
with the activities of daily living.
Includes residential group homes for
developmentally disabled, physically challenged

Assisted Living Facilities

Single homes to multi-unit
6,315 communities with 475,000
apartments housing 1 million+;
growth projected to ~2 M+ by 2030.
Primarily personal payment; varying
costs; average monthly cost =
State regulations vary; quality is
function of ownership policies

Home Care (1)

Community-based care provided in private
residences; long-term for chronically ill; short-term
for rehabilitation after illness or hospitalization
Formal system: agency-employed professionals or
self-employed who contract privately with clients
Agency rapid growth following Medicare
reimbursement in 1965; by 1987 5,900+
dominated by public health agencies; 1990s
growth again: Olmstead decision, MC & MA
changes, evolving demographics & technology

Home Care (2)

3.4 M Medicare receipts among 11,900
agencies, 70% for- profit; $74.3 B annual
costs; MC & MA covered 81.4% total
expenditures (Table 9-2)
Medicare reimbursement initially required
professional nursing, allied health
services; home confinement; physician
order; agency certification; ACA includes
added patient assessment requirements
to guard against fraud

Home Care (3)

Additional ACA provisions support
home & community based care:
Medicaid Follows the Person for home
& community services for individuals
transitioning from institutional to home
Community First Choice Options in
Medicaid, State Balancing Incentive
Program, Federal Coordinated Health
Care Office: to encourage community
based over institutional care

Home Care (4)

Medicare & Medicaid certification requires
agency state licensing; accreditation by
private organizations, e.g. the Joint
Commission is voluntary
Extensive research 2000-2010 from multiple
sources documents significant costeffectiveness of home care compared with
institutional care for conditions requiring IV
antibiotic therapies, diabetes, chronic
obstructive pulmonary disease and congestive
heart failure

Informal Home Care (1)

Provided by family/friends; 80% by family
61 M family caregivers; 75% female who
also work outside the home; sandwich
generation may have triple caring roles
with aged relative, children and
grandchildren; burnout is common
Market value: $ 450 B/yr., 2x+ value of
nursing home and agency supplied home
care combined

Informal Home Care (2)

Caregiver needs:
FMLA 1993: 12 weeks job-protected
unpaid leave in companies of >50
employees (excludes 50% of workers)
Other leave provisions: CA , a few other
states allow partial payment for limited
periods, other states under
consideration; federal employees in 40+

Informal Home Care (3)

ACA: Independence at Home
Medical Practice Pilot Program
provides Medicare recipients with at
home primary care services;
Community Care Transitions
Program for high-risk Medicare
patients following hospital discharge

1990s Home Care

Federal investigations of rising costs & quality
concerns prompted:
Operation Restore Trust (ORT) targeted Medicare
billing practices
BBA of 1997 stiffened requirements for Medicare
Outcomes & Assessment Information Set (OASIS):
reporting of patient condition, satisfaction
Dept. of Justice, FBI, Inspector General, state law
enforcement coordinate anti-fraud/abuse

Hospice Care (1)

A philosophy of care for terminally ill
Palliative, comprehensive care for physical
& emotional symptoms; not cure-directed
Low-tech: pain control, quality of remaining
Settings: home, dedicated hospice facilities,
hospitals, SNFs; 450,000 volunteers
Medicare certification requires 5% patient
care hours as volunteers

Hospice Care (2)

Roots in medieval Europe
Modern model (1960s): London, U.K.;
Dr. Cicely Saunders
First U.S. hospice 1974 in CT as
grassroots movement; all volunteer
2011: 1.6M patients in 5,300
agencies; ~45% U.S. deaths
60% for-profit; 34% not-for-profit; 5%

Hospice Care (3)

Staff: Physician director, physicians,
nurses, social workers, counselors,
supportive staff
Provide all required drugs, medical
appliances, supplies
Bereavement services for survivors
and general community

Respite Care (1)

Temporary, surrogate care for a patient in
primary care giver(s) absence
1970s origin: deinstitutionalization of
developmentally disabled and mentally ill
Short-term service gives respite to athome caregivers
Purpose: forestall placement in
institutional setting by providing
caregivers periods of relief

Respite Care (2)

Duration: short-term & intermittent
Settings: homes, day care centers,
hospitals, nursing homes
Staff: professionals and trained laypersons
Not-for-profit organizations: grants help to
fund services
Models: Alzheimers disease inpatient;
adult-day care centers; in-home
assistance; temporary hospital or nursing
home placement

Respite Care: Funding

Medicare payment: requires
placement in certified hospital,
hospice or nursing home; recipient
pays 5% of Medicare-approved fee
Medicaid payment: very limited,
stringent requirements
Barriers: viewed as social not
medical need benefitting
caregivers; difficult planning for
intermittent, unpredictable needs

Respite Care (4)

Enabling Legislation: Lifespan Respite
Care Act of 2006- $ 289 M for state
respite care program grants
acknowledged value of informal care
Administration on Aging (AoA)
advocates for federal support of
demonstration programs on costeffectiveness of community services
to enable continued independent

Adult Day Care (1)

Origin: Lionel Cousins (1960s) to prepare
institutionalized mental health patients for
discharge into the community

Supervised social activities (social

Supervised medical, rehabilitative
activities (medical model)
Temporary relief to caregivers;
therapeutic social contacts for care

Adult Day Care (2)

Staff: variable for social & medical
4,600 centers; most state-licensed
80% not-for-profit
Payment by private fees, grants,
charitable funds

Quality & Accreditation (1999):

Commission on Accreditation of
Rehabilitation Facilities & National
Adult Day Services Assn. issued

Innovations in Long-term Care:

Program of All-inclusive care for the
Elderly (PACE)
Continuing Care and Life Care
Naturally Occurring Retirement
Communities (NORCs)
High Technology Home Care

Innovations in Long-term Care:

Aging in Place
San Francisco (1972): Medicare demonstration
project for Chinatown community: On Lok:
peaceful & happy abode.
Frail older Americans remain at home with
coordinated interdisciplinary support services
Outcomes: lower hospitalization & nursing
home placements
BBA (1997): PACE approved as permanent
Medicare benefit; 2012: 88 PACE programs in
29 states

Innovations in Long-term Care:

Aging in Place
Programs coordinate continuum of
services e.g. nursing, home care aide
assistance, homemakers, 24-hour
emergency response systems, homedelivered groceries, transportation to
health appointments

Continuing Care Retirement

(CCRC) & Continuing Life Care
(CCLC) Communities

CCRCs for those desiring an alternative to

residing in their own homes as they age;
2,200+ with 725,000 residents; 80% notfor-profit, 50% faith based.
Residences located on campuses offering
social services, meals, access to
contractual medical services in addition to
Life care or extended contract/continuing
life care community (CCLC): Most
expensive; unlimited assisted living,
medical treatment, skilled nursing care

Continuing Care Retirement

(CCRC) & Continuing Life Care
(CCLC) Communities

Modified contract: set of services of

specific duration; higher monthly
fees for added services
Fee-for-service contract: initial
enrollment fee lower; assisted living,
skilled nursing paid at market rates
Fees: vary but require upfront
payment of $100,000- $1M; monthly
charges $3,000-5,000.

Continuing Care Retirement

(CCRC) & Continuing Life Care
(CCLC) Communities
Use insurance-based model;
regulated by state insurance
departments and other agencies for
applicable services
~1% of older Americans choose this
CCRC option due to cost and
extended commitment

Innovations in Long-term
Care (7)
Naturally-occurring retirement
communities (NORCs)
Coined by Dr. Michael Hunt (U of Wisconsin
Prof. of urban planning), 1980s
Apartment building residents,
neighborhoods, community sections
harboring aging residents
AOA demonstration grants programs
underway: case management, nursing,
social, recreation, nutrition

Innovations in Long-term
Care (8)
High-technology home care
Advanced technology for intravenous
infusions, ventilation, dialysis, parenteral
nutrition, chemotherapy available in the
Specialist home care personnel (nurses,
pharmacists, respiratory therapists, etc.)
Cost effective
Preferred by patients

Long Term Care

Insurance (1)
1970s: first offered for nursing home care only
2010: AARP estimates 7-9 M policy owners;
95% cover continuum of services
Many employers now offer as benefit
Federal government offers tax deductions
for employer contributions; many states
offer tax incentives to individual purchasers
Broad spectrum of benefit options & costs
Increases choices & avoids public dependency

Long Term Care

Insurance (2)
ACA Community Living Assistance
Services & Supports Act (CLASS Act):
proposed national voluntary LTCI
program funded by payroll
deductions with benefits eligibility in
5 years.
Abandoned by DHHS in 2011: design
flaws: voluntary enrollment lacked
adequate risk base; age range of benefit
eligibility too broad
Would have provided opportunity to shift

The Future of Long Term

Care (1)
Increased diversification & specialization
to meet wide range of needs, e.g.
dementia, other chronic disease
management of aging population
Managed care integrated provider
networks bundle hospitalization and posthospital care into one episode;
ACA provisions will support increased
community-based care; ACOs with PCMHs
integrate LTC into continuum of services

Future of Long-Term Care

Staffing shortages due to low wages, workload
and conditions, lack of social supports for
workers, lack of career mobility; Private
philanthropic, government initiatives continue
to seek solutions
Support for informal caregivers
Legislation for paid family leave on horizon in
several states
Continued experimentation with ACA
demonstration project outcomes to suggest
system refinements