Long term care provides support services for those who need assistance with daily living over an extended period of time, often older adults. Services include skilled nursing facilities, assisted living, home care, hospice, respite care, and adult day care. As the population ages, demand for long term care is increasing while availability of informal family caregivers is decreasing. The future will require diversifying and expanding long term care services to meet a wide range of needs within the community-based settings preferred by most.

1. Health Care USA 1

2. Health Care USA 2
Chapter 8
Long Term Care

3. Health Care USA 3
CHAPTER OBJECTIVES
• Define long-term care
• Review major factors in the history and
development of the long-term care industry
• Identify and define types of long-term care
providers

4. Health Care USA 4
Care Needs of the Life Span
• Birth to death, needs may vary in intensity and
duration
– Level of support required for optimal
functioning may vary over time
– Service locations vary with type and intensity of
needs
– Services range from intense medical to social
support; combinations

5. Health Care USA 5
Long Term Care Definition
• Service Continuum: infants to older adults,
meeting diverse needs
• Formal (institutionally based or operated)
• Informal (family/friends); often a combination
• Older adults are predominant users
• Coordination is key for an “ideal” system

6. Health Care USA 6
Changing Socio-demographics
Impact Need
• Lifespan increasing: more chronic conditions
• Lifestyle, family changes limit availability of
informal caregivers
• 65+, 19% of total population by 2030

7. Health Care USA 7
FIGURE 8-1 Projected Number of Persons 65
Years of Age or Older by 2030.
Source: U.S. Bureau of the Census.

8. Health Care USA 8
FIGURE 8-
2 Projected
Population,
Age 65
Years and
Older,
2000–2050.
Source: U.S. Bureau of the Census.

9. Health Care USA 9
Development of Long-Term Care
Services (1)
• Colonial era: almshouses started by European
colonists
• 19th-early 20th century: city, county-operated
homes & infirmaries
• Great Depression: private citizens boarded
older adults for financial benefit; serious
quality of care issues

10. Health Care USA 10
Development of Long-term Care
Services (2)
• Social Security (1935): enabled older adults
and those with certain disabilities to purchase
long-term care services
• 1950s: government loans aided not-for-profit
nursing home development
• 1965: Medicare, Medicaid stimulated for-profit
long-term care businesses

11. Health Care USA 11
Abuses
• 1970s public exposes’: Congressional hearings
on inhumane treatment, e.g.
– Untrained, inadequate staff
– Hazardous, unsanitary conditions
– Over, under-medication
– Discrimination against minorities
– Thefts of belongings

12. Health Care USA 12
Reforms
• State nursing home & home care licensing
• Medicare and Medicaid certification
• Laws for elder abuse reporting
• Regulations on restraints
• Ombudsman programs

13. Health Care USA 13
Current Long-term Care Businesses
• Stand alone, or parts of nursing home or
assisted living corporate entities:
• for-profit
• not-for-profit
• government

14. Health Care USA 14
FIGURE 8-3 Percent Distribution of Nursing Homes,
According to Type of Ownership: United States, 2004.
Source: CDC/NCHS, National Nursing Home Survey, 2004.

15. Health Care USA 15
Modes of Long-term Care Delivery
• Skilled nursing facilities
• Assisted living facilities
• Home care
• Hospice
• Respite
• Adult day care
• Innovations

16. Health Care USA 16
Skilled Nursing Facilities (SNFs) (1)
• Institution-based, “hands-on” nursing;
predominant mode
• 1.5 million Americans reside in 16,100 SNFs
• Federal certification required for Medicare,
Medicaid reimbursement; state licensing of
facilities, administrators

17. Health Care USA 17
Skilled Nursing Facilities (SNFs) (2)
• Costs
– 2009: $13849 B; double cost of home care
– Private room = $ 79,935/year
– Medicare, Medicaid pay ~ 62%; 38% private,
out-of-pocket, long-term care insurance

18. Health Care USA 18
Skilled Nursing Facilities (SNFs) (3)
• Staffing
– Administrator
– Medical Director
– Registered Nurses and Licensed Practical Nurses
– Certified Nurse Assistants
– Social workers
– Nutrition & Dietary Staff
– Rehabilitation (PT & OT)
– Recreational/ Activities
– Housekeeping/Plant & Facilities

19. Health Care USA 19
Assisted Living (1)
• “Combination of housing, personalized
supportive services and health care designed
to meet both scheduled & unscheduled needs
of those needing help with activities of daily
living.”
Assisted Living Federation of America

20. Health Care USA 20
Assisted Living (2)
• Single homes to multi-unit apartments; no
“hands-on” nursing; supportive assistance
• 20,000 facilities house 1 million+; growth
projected to 2 M+ by 2025.
• Primarily personal payment; varying costs;
average monthly cost = $3,131
• State licensing requirements are evolving.

21. Health Care USA 21
FIGURE 8-4 Projected Growth of Assisted
Living Beds Based on Population Growth for
Those 75 Years and Older.
Source: National Center for Assisted Living, reprinted with permission.

22. Health Care USA 22
Home Care Services (1)
• Origin in 1900s as social welfare response to
immigrants in industrialized cities
– Aegis of government public health departments
and private agencies, e.g. Visiting Nurses
Association
• Services at client residence
• Short term during convalescence; long term for
chronic conditions

23. Health Care USA 23
Home Care Services (2)
• Formal home care: local health departments and
private agencies; 9,000 certified agencies serving 3
million; 65%+ for-profit; Medicare predominant
payer
• Informal home care: delivered by family members,
friends; 65 million caregivers (66% women) valued at
$ 354 B/year; 2x cost of nursing home & formal
home care combined

24. Health Care USA 24
Informal Home Care Recognition
• Family Medical Leave Act (1993): important first
step; 12 months unpaid leave makes unworkable for
many
• 2002: CA workers using FMLA to care for family
members eligible for disability payments
• 15 states enacted paid leave for private company
employees; 40 states for government workers

25. Health Care USA 25
Home Care Regulation
• State licensing for Medicare & Medicaid
certification; requirements:
1. Skilled nursing, physical, occupational, speech
therapies; medical social services
2. Client confined to home
3. Physician orders for care
4. Agency meets all Medicare certification
requirements

26. Health Care USA 26
1990s Home Care Reforms
• Federal investigations of rising costs & quality
concerns prompted:
– Operation Restore Trust (ORT) targeted Medicare
billing practices
– BBA of 1997 stiffened requirements for Medicare
certification
– Outcomes & Assessment Information Set (OASIS):
reporting of patient condition, satisfaction

27. Health Care USA 27
2006 CMS “Post Acute Care Reform”
• Consumer-centered approach
– More choice by patient, family, caregivers
– High quality care in most appropriate settings
– Measures to drive quality
– Seamless care continuum through coordination of
post-acute – long-term care transitions

28. Health Care USA 28
Hospice-History
• Roots in medieval Europe
• Modern model (1960s): London, U.K.; Dr.
Cicely Saunders
• First U.S. hospice 1974 in CT; all volunteer
• Now, not-for-profit & for-profit

29. Health Care USA 29
FIGURE
8-5 Tax
Status of
Hospice
Agencies.
Source: The National Hospice and
Palliative Care Organization, reprinted
with permission.

30. Health Care USA 30
Hospice Services (1)
• A philosophy of care for terminally ill
– Palliative care for physical & emotional
symptoms; not cure-directed
• Low-tech: pain control, quality of remaining life
• Settings: home, dedicated hospice facilities,
hospitals, SNFs
• Costs: Highly cost-effective; ~ 2.5% total Medicare
spending

31. Health Care USA 31
Hospice Services (2)
• Medicare reimbursement (1982) freed from
sole reliance on volunteers & charitable
support; 73-fold increase in agencies, 1984-
1998.
• 4,800 hospices serve 1.4 M/year with staff and
550,000 volunteers
• 2008: 39% U.S. deaths in hospice care

32. Health Care USA 32
FIGURE 8-6 Total Hospice Providers by Year.
Source: National
Hospice and
Palliative Care
Organization,
reprinted with
permission.

33. Health Care USA 33
FIGURE 8-7 Total Hospice Patients
Served by Year.
Source: National Hospice and Palliative Care Organization, reprinted with permission.

34. Health Care USA 34
Hospices Services (3)
• Staff: Physician director, physicians, nurses,
social workers, counselors, supportive staff,
volunteers
• Provide drugs, medical appliances, supplies
• Bereavement services for survivors and
general community

35. Health Care USA 35
Respite Care
• 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 at-home
caregivers
• Purpose: forestall placement in institutional setting

36. Health Care USA 36
Respite Services
• Duration: short-term & intermittent
• Settings: homes, day care centers, hospitals, nursing
homes
• Staff: professionals and trained laypersons
• Medicare: no reimbursement
• Medicaid: stringent requirements
• Not-for-profit organizations: grants help to fund
services

37. Health Care USA 37
Respite Models
• Alzheimer’s disease inpatient care for several
weeks
• Community-based adult day care settings
• In-home nurse aids
• Temporary furloughs to hospitals or nursing
homes at regular intervals

38. Health Care USA 38
Respite Care Legislation
• Lifespan Respite Care Act (2006): $ 289 M, 5 years;
state grants for community-based respite program
development “for family caregivers of children &
adults with special needs.”
• Older Americans Act of 2006: AOA pilot
demonstrations on cost-effectiveness & consumer
acceptability of programs for independent living
• 2010 AoA budget: $ 7 M increase for home,
community-based services

39. Health Care USA 39
Adult Day Care (1)
• Origin: Lionel Cousins (1960s) to prepare
institutionalized mental health patients for discharge
into the community
• Supervised social activities (social model)
• Supervised medical, rehabilitative activities
(medical model)
• Temporary relief to caregivers; therapeutic
social contacts for care recipients

40. Health Care USA 40
Adult Day Care (2)
• Staff: variable for social & medical models
• 4,000 licensed, unlicensed centers
– 80% not-for-profit organizations
– Quality & Accreditation (1999): Commission on
Accreditation of Rehabilitation Facilities &
National Adult Day Services Assn. issue standards

41. Health Care USA 41
Innovations in Long-term Care: Aging in
Place
• Program of All-inclusive care for the Elderly
(PACE)
• Continuing Care and Life Care Communities
• Naturally Occurring Retirement Communities
(NORCs)
• High Technology Home Care

42. Health Care USA 42
On Lok Senior Health Services Model
(PACE)
• San Francisco (1972): Medicare demonstration
project: “peaceful & happy abode.”
– Frail older Americans remain at home with
interdisciplinary support services
• Outcomes: lower hospitalization & nursing home
placements
• BBA (1997): PACE approved as permanent
Medicare benefit

43. Health Care USA 43
Continuing Care Retirement and Life
Care Communities (1)
• CCRCs: Older Americans desiring secure,
assisted environment
– 2,200 CCRCs accommodate 725,000 residents
– Comprehensive dietary, social, recreational
services
– Ownership: 80% not-for profit;50% faith-based

44. Health Care USA 44
Continuing Care Retirement and Life
Care Communities (2)
• Continuing Life Care Community: insurance
model, prepaid lifetime services
– Independent living to skilled nursing
– Regulated by state insurance departments & health
care regulators
– Extensive service options available on continuum
of needs

45. Health Care USA 45
NORCs
• Coined by Dr. Michael Hunt (U of Wisconsin),
1980s; apartment residents 60+ years.
– Apartment building residents, neighborhoods,
community sections harboring aging residents
– AOA demonstration grants programs underway:
case management, nursing, social, recreation,
nutrition

46. Health Care USA 46
High Technology Home Care
• Advanced technology for intravenous infusions,
ventilation, dialysis, parenteral nutrition,
chemotherapy available in the home
– Specialist home care personnel (nurses,
pharmacists, respiratory therapists, etc.)
– Cost effective
– Preferred by patients

47. Health Care USA 47
Long Term Care Insurance
• Fastest growing type of health insurance
• 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

48. Health Care USA 48
The Future of Long Term Care (1)
• Increased diversification & specialization to meet
wide range of needs, e.g. dementia
• Managed care integrated provider networks
bundle hospitalization and post-hospital care into
one “episode.”
• More demand for home care: cost-effectiveness,
client preferences prompt legislation favoring
community-based services, e.g. NORC
demonstration projects

49. Health Care USA 49
The Future of Long Term Care (2)
• Staffing shortages
– Private philanthropic, government initiatives
seeking solutions
– Reimbursement allowing competitive wages
• Support for informal caregivers
– Legislation for paid family leave