1 Chapter 8 Older People and Long-Term Care: Issues of Access 3 Why the New Interest in Long-term Care? • The Baby Boomers are adding to the growth in the population over 65. • There is increasing fear of dependency on long-term care. • Adult children of the elderly having to find care for their parents. • Healthcare reform promises great changes that are not well understood. 4 The Growing Population Needing Care • The need for ADL and IADL assistance continues to grow. • Table 8-1 presents the broad range of services needed by the disabled. • Most of the population needing long-term care do not live in nursing homes. • Many factors contribute to the inability to predict the exact number needing services in the future. 5 The Growing Population Needing Care • Future populations may be better educated which is associated with lower levels of disability. • Ethnic composition suggests a greater need for care and government support. • Boomers will bring greater numbers of people needing services. • The number those over 75 will greatly increase. 6 The Growing Population Needing Care • Disability rate will increase among those who are not in nursing homes. • The most common disability is physical. • In addition, the nursing home population is expected have profound increases until it triples by 2030. • The number of younger persons with disability has also increased. 7 Issues of Access • The current system is far from ideal. • There is not an adequate supply particularly for the poor. • The system itself continues to be so fragmented that many are not aware of what is offered. • Financing is an underlying problem. 8 The Costs of Care • Expenses for this care are sizable and will increase in the future. • Private insurance only pays for a small percentage of the care. • Medicaid pays for over 85% of nursing home care. 9 The Costs of Care • Annual costs of nursing home care can average $58,000 per year and may exceed $100,000. For many, the costs of this care is just not affordable. • With the addition of the Baby Boomers, costs will most certainly increase in the future. • The effects of reform are not currently known. 10 The Care-Giving Role of Families • About 74% of dependent community-based elders receive care from family members. • The majority of caregivers are women. • The number and willingness of family caregivers may decline as the Boomers become in need for assistance. 11 The Role of Private Insurance • Private insurance for long-term care is a relatively new product. • Improvements in coverage are being made, but only an estimated 20% of the population will use it. • CCRCs and LCAHs hold promise for the future. 12 The Role of Medicaid • Medicaid is changing under PPACA to include more eligible adults who will receive benchmark coverage. • Medicaid is .

1. 1
Chapter 8
Older People and Long-Term
Care: Issues of Access
3
Why the New Interest in Long-term Care?
• The Baby Boomers are adding to the growth in
the population over 65.
• There is increasing fear of dependency on
long-term care.
• Adult children of the elderly having to find
care for their parents.
• Healthcare reform promises great changes
that are not well understood.
4

2. The Growing Population Needing Care
• The need for ADL and IADL assistance
continues to grow.
• Table 8-1 presents the broad range of services
needed by the disabled.
• Most of the population needing long-term
care do not live in nursing homes.
• Many factors contribute to the inability to
predict the exact number needing services in
the future.
5
The Growing Population Needing Care
• Future populations may be better educated
which is associated with lower levels of
disability.
• Ethnic composition suggests a greater need
for care and government support.
• Boomers will bring greater numbers of people
needing services.
• The number those over 75 will greatly
increase.

3. 6
The Growing Population Needing Care
• Disability rate will increase among those who
are not in nursing homes.
• The most common disability is physical.
• In addition, the nursing home population is
expected have profound increases until it
triples by 2030.
• The number of younger persons with disability
has also increased.
7
Issues of Access
• The current system is far from ideal.
• There is not an adequate supply particularly
for the poor.
• The system itself continues to be so
fragmented that many are not aware of what
is offered.
• Financing is an underlying problem.
8

4. The Costs of Care
• Expenses for this care are sizable and will
increase in the future.
• Private insurance only pays for a small
percentage of the care.
• Medicaid pays for over 85% of nursing home
care.
9
The Costs of Care
• Annual costs of nursing home care can
average $58,000 per year and may exceed
$100,000. For many, the costs of this care is
just not affordable.
• With the addition of the Baby Boomers, costs
will most certainly increase in the future.
• The effects of reform are not currently known.
10
The Care-Giving Role of Families

5. • About 74% of dependent community-based
elders receive care from family members.
• The majority of caregivers are women.
• The number and willingness of family
caregivers may decline as the Boomers
become in need for assistance.
11
The Role of Private Insurance
• Private insurance for long-term care is a
relatively new product.
• Improvements in coverage are being made,
but only an estimated 20% of the population
will use it.
• CCRCs and LCAHs hold promise for the future.
12
The Role of Medicaid
• Medicaid is changing under PPACA to include
more eligible adults who will receive
benchmark coverage.
• Medicaid is used for those elders who do not
qualify for other assistance.

6. • Medicaid does not pay for the full range of
services including home-based care.
• Some states are using a waiver to offer non-
medical home-care services.
13
The Role of Medicaid
• Some elders qualify for Medicaid once they
are institutionalized and have used all of their
assets.
• Other elders are trying to shelter their assets
so that they can be poor without really being
poor.
• Healthcare reform requires an office within
CMS to address the issue of dual edibility.
14
Forces for Improving Access
• Advocates for Alzheimer’s disease patients
and for others have worked for changes.
• The Pepper Bill and other legislation
recommended changes.

7. • Attempts to limit the grow of Medicaid are
part of the national health care debate.
15
Future Prospects
• Baby Boomer numbers and healthcare reform
will result in changes to the system.
• Government involvement will increase as
demand increases without the funding for
access.
• Government involvement may not be the only
or best answer.
16
Future Prospects
• Future elders are concerned about what their
care will be like under healthcare reform.
• The political climate must be willing to
address future concerns.
• Ethical questions such as beneficence,
autonomy, and justice need to be part of
policy discourse.

8. 17
Future Prospects
• Issues of the elderly and non-elderly disabled
need to be addressed.
• Given the cost and complexity, the medical
model is not the only one to be considered.
• Long term care needs to be part of health
care.
18
Update from a Practitioner’s View
• Even with healthcare reform the trends and
issues for long-term care are the same.
• Barriers to real change are driven by the
political climate that controls funding.
• What will be America’s legacy about the
treatment of its elderly?
19
In Summary…

9. 20
Slide Number 1Chapter 8Slide Number 3Why the New Interest
in Long-term Care?The Growing Population Needing CareThe
Growing Population Needing CareThe Growing Population
Needing CareIssues of AccessThe Costs of CareThe Costs of
CareThe Care-Giving Role of FamiliesThe Role of Private
InsuranceThe Role of MedicaidThe Role of MedicaidForces for
Improving AccessFuture ProspectsFuture ProspectsFuture
ProspectsUpdate from a Practitioner’s View In Summary…
1
Chapter 7
Competency: What It Is, What
It Isn’t, and Why It Matters
3
Why is Competency an Issue?
• Competent adults have the right to refuse
treatment.
• But when a person refuses life saving
treatments, we become uneasy.

10. • We find our refuge in the idea of competency.
• Therefore, it is important to understand what
it is and how it impacts practice
4
Consider Competency
• It is not a medical judgment.
• It may not be based on rational thinking.
• It is a legal and social decision about the
ability to make decisions.
• The criteria used is not precise and may
include our prejudices.
5
Seeking a Definition
• There is no standard definition that fits all
cases.
• Rules of competency differ by situation.
• Definitions are divided into those that
represent end results, and
• Those that represent processes.
6

11. Seeking a Definition
• Definitions concerning end results ask:
• What is the patient’s condition?
• What are the end results of the patient’s
thinking and decision?
• Would an incompetent person make decisions
that lead to serious consequences?
• However, this definition may not work in all
cases.
7
Seeking a Definition
• Definitions also include thought processes.
• These definitions examine a patient’s view of
reality and ability to make rational judgments.
• You need to determine if the patient is making
sense in his or her decisions.
• There is a need to determine the essence of
competency to define it.
8

12. The Essence of Competency
• Competency involves the patient’s ability to
make a decision in any given situation.
• First, the patient must understand the
situation to make a competent decision.
• Determining patient’s understanding level
may be difficult in situations which can lead to
end of life.
9
The Essence of Competency
• We define rational as being sensible to our
way of thinking.
• We use the idea that most people would want
the treatment as a criteria.
• Patients who make decisions based on facts
and logic appear to be competent.
• If the decision does not logically flow from the
facts, we see the patient as being
incompetent.
10

13. Religious Refusals
• Religious beliefs need to be considered
differently since they may not appear to be
rational.
• In this case, the patient is competent if he/she
understands the situation and is making a
decision based on religious beliefs that are
within our common understanding.
11
Religious Refusals
• Think about the decision processes of patients
A and B.
• Both demonstrate “irrational” thinking but
Patient A’s belief fits within our understanding
of religious faith.
• Patient B would be seen as incompetent
because the decision is not based on an
understood faith.
• This criteria is also used in court cases.
12

14. Religious Refusals
• Think about the decision processes of patients
C and D.
• Patient C would be considered incompetent
because her belief is outside of common
religious practice and she does not
understand her situation.
• What about Patient D?
13
Conclusions Related to Competency
• What would a Medical Miranda Card say
about refusing medical treatment?
• If the answers to all four questions shown in
the Chapter are “yes”, the patient should be
considered competent.
• If the answer to any of them is “no”, the
competency is not assured.
14
Why it Matters
• Consider what happens when you decide that
a patient is not competent.

15. • You force your choice on a person against
his/her will.
• You are making a decision that affects the
person’s nature.
• You negate the person’s autonomy in an effort
to assure your determination nonmaleficience
and beneficence.
15
Conclusions
• You must determine competency before you
decide to accept a patient’s refusal.
• Competency is a label we give to patients who
understand their situation and whose reasons
for choices make sense to us.
• It is a serious action to declare a person
incompetent and make choices for him/her.
16
In Summary…
17
Slide Number 1Chapter 7Slide Number 3Why is Competency an
Issue?Consider CompetencySeeking a DefinitionSeeking a

16. DefinitionSeeking a DefinitionThe Essence of CompetencyThe
Essence of CompetencyReligious Refusals Religious Refusals
Religious Refusals Conclusions Related to CompetencyWhy it
MattersConclusions In Summary…