This document provides an overview of long-term care (LTC) in the United States. It defines LTC and outlines the variety of services available, including home and community-based services as well as institutional care. The main clients in need of LTC are older adults, but it also serves children, young adults, and people with conditions like HIV/AIDS. Both public programs and private insurance play a role in financing LTC. While more services are shifting to home and community settings, nursing homes remain an important option for those requiring medical care or full assistance with daily tasks. The Affordable Care Act aims to further support community-based care.

2. Chapter 10
Long Term Care

3. Learning Objectives
• To comprehend the concept of long-term care and its
main features
• To get an overview of LTC services
• To discover who needs long-term care and why
• To become familiar with the large variety of home- and
community-based long-term care services, and who
pays for these services. To learn about long-term care
institutions and the levels of services they provide

4. Learning Objectives
• To get an overview of specialized long-term
care facilities and continuing care retirement
communities
• To explore institutional trends, utilization, and
costs
• To get a perspective on private long-term care
insurance
• To understand application of the Affordable
Care Act to long-term care

5. Introduction
• A complex subsystem that escapes a simple
definition
• Numerous services and sources of financing
• Regular health insurance generally does not
cover LTC; private LTC insurance has made
limited headway

6. Introduction
• LTC is not confined to the elderly; 37% of the
clients are under the age of 65
• Growing nonwhite elderly population is in poorer
health, and is likely to have a greater need for LTC
services
• About 70% of older Americans will eventually
need LTC; most will get it in their own homes
• Community-based services have grown more
rapidly than institutional services
• The LTC system must interface with the rest of
the health care system

7. Introduction
• LTC is associated with functional deficits
caused by
– multiple chronic conditions
– serious illness or injury
– cognitive impairments
• Functional limitations are assessed by ADLs
and IADLs

8. Introduction
• An estimated 22% of elderly Americans need
LTC
• The number of LTC recipients is likely to rise
from 9 million to 12 million by 2020
• 15.4% of those using LTC are in nursing homes
• ⅔ of total LTC spending is paid by Medicaid;
hence, the financial burden falls on taxpayers
• Other developed countries also face LTC-related
challenges

9. The Nature of Long-Term Care
LTC is multidimensional:
• Variety of services
• Individualized services
• Well-coordinated total care
• Maintenance of residual function
• Extended period of care
• Holistic care
• Quality of life
• Use of current technology
• Use of evidence-based practices

10. Nature of Long-Term Care
• Variety of services
– People’s needs vary and they change over time
• Individualized services
– Comprehensive assessment – individualized plan
of care – customized interventions
• Well-coordinated total care
– LTC providers take responsibility for obtaining
needed non-LTC services

11. Nature of Long-Term Care
• Maintenance of residual function
– Goals: (1) maintain function (2) prevent
further decline
– By letting the person do as much as possible
for himself/herself
• Extended period of care
– Irreversible functional decline
– Short-term rehabilitation
– Indefinite institutional care

12. Nature of Long-Term Care
• Holistic care
– Physical, mental, social, and spiritual needs
must be met
• Quality of life
– It is significant because of a loss of self
worth, and because
– Patients remain in LTC for long durations

13. Quality of Life
• A multifaceted concept:
1. Lifestyle pursuits
2. Living environment
3. Clinical palliation
4. Human factors
5. Personal choices

14. Nature of Long-Term Care
• Use of current technology
– To promote safety and quality of care
• Use of evidence-based practices
– Best practices are evaluated through
clinical research
– Clinical practice guidelines provide
directions and treatment protocols

15. Long-Term Care Services
• Medical Care, nursing, and rehabilitation
• Post-acute continuity of care
• Management of chronic illness and comorbidity
• Restoration or maintenance of physical function
• Transfer to a hospital for acute episodes

16. Long-Term Care Services
• Mental health services and dementia
care
• Mental illness are prevalent among 25% of
elderly
• Comorbid with other chronic illnesses
• Diagnosing mental illness among elderly is
challenging

17. Dementia
• Progressive and irreversible decline in
cognition, thinking, and memory
• 15% of people age 70 and over have dementia
• Alzheimer’s disease is the most common –
affects 5 million elderly in the US
• 40% of those with dementia need institutional
care

18. Long-Term Care Services
• Social support
• Coping with changing life events that create
emotional imbalances
• Adaptation to new surroundings
• Help deal with conflict
• Coordination of total care

19. Long-Term Care Services
• Preventative and Therapeutic LTC
• Main goal of preventive LTC is to prevent or delay
institutionalization
• Various community-based LTC services have a
preventive function
• Therapeutic services include nursing care,
rehabilitation, and therapeutic diets

20. Long-Term Care Services
• Informal and formal care
– Informal: Non-reimbursed care by family and
friends
– Most LTC in the US is informal
– Insufficient informal care is associated with higher
all-cause mortality, hospitalization, and
institutionalization
– Issue:
• Shrinking pool of informal caregivers

21. Long-Term Care Services
• Respite care
– Family caregivers often face numerous physical,
emotional, social, and financial issues
– Respite care relieves stress and burnout
– It includes any type of LTC service that allows
caregivers some free time

22. Long-Term Care Services
• Community-based Home and community-based
services (HCBS) have a four-fold objective:
• Economical and least restrictive setting
• Supplement or substitute informal caregiving
• Temporary respite for informal caregivers
• Delay or prevent institutionalization

23. Long-Term Care Services
• Institutional Services
• Institutionalization: short or long duration
• 3+ ADLs deficits dramatically raise the
probability of institutionalization
• Main goals: (1) deliver therapeutic services (2)
ADL help (3) prevent functional decline (4)
coordinate total care

24. Long-Term Care Services
• Housing
– Noninstitutional housing other than one’s home
– May or may not have support services: meals,
housekeeping, transportation, recreational
activities, etc.
– Home health care meets occasional LTC needs
– Private or public housing

25. Private Housing
– Upscale retirement centers
– Entrance fee + monthly rental
– Some support services may be included

26. Public Housing
–Government-assisted, subsidized housing
–HUD programs:
• Federal aid to local housing agencies to offer
lower rents to qualified low-income people
• Vouchers that can be used for housing of one’s
choice
• Public housing operated by the government
(less common)
• Federal funds may be provided to nonprofit
sponsors to construct rental housing

27. Long-Term Care Services
• End-of-Life Care
• Prevent needless pain and distress for the
terminally ill
• Dignity and comfort
• Care provided by institutional staff or hospice
services

28. Clients of LTC
• Older adults
• Children and adolescents
• Young adults
• People with HIV/AIDS

29. Clients of LTC
• Older adults
• 85+ age group is the fastest growing segment
• Demographic trends have serious implications for
financing and delivery of LTC; 20% of the
population will be age 65+ by 2030
• Elderly in the lowest socioeconomic status are at
the greatest risk of need for LTC and are the least
able to pay for such services.

30. Clients of LTC
• Children and adolescents
– Birth-related disorders (cerebral palsy, autism,
etc.)
– Developmental disabilities (DD)
– Mental retardation (MR), now referred to as ID
(intellectual disability): Down syndrome is the
most common ID in America
– Specialized facilities are equipped to care for
those with severe ID or DD

31. Clients of LTC
• Young Adults
– Neurological malfunctions, degenerative
conditions, traumatic injury (auto, sports, and
industrial), surgical complications
– Sometimes need ventilator care and total
assistance with ADLs
– Adults with MR/DD (or IDD)
– 1999 US Supreme Court ruling in Olmstead v. L.C.:
states must provide community-based services for
MR/DD patients when appropriate

32. Clients of LTC
• People with HIV/AIDS
– Now a chronic condition thanks to highly-active
antiretroviral therapy
– HIV has increased, including among the elderly
– People with AIDS are subject to comorbidities and
cognitive impairment
– Lack of informal support
– High need for LTC and care coordination

33. Level of Care Continuum
• Personal care—basic ADL assistance (e.g., bathing)
• Custodial care—nonmedical care to maintain
function and prevent decline
• Restorative care—help regain or improve function;
professional therapies
• Skilled nursing care—clinical care provided by
licensed nurses under the direction of a physician
• Subacute care—postacute, technically complex
services

34. HCBS
• Both private and public financing
• Older Americans Act, 1965 provides federal
funds to states
• Overseen by the federal Administration on Aging
• Section 1915(c) waivers (to the Social Security
Act) enable states to provider community-
based LTC under Medicaid

35. HCBS
• Title XX Social Services Block Grants are also
used for community-based LTC
• Medicaid Personal Care Services Program
(limited)
• Issues:
– Needs go unmet; inadequate workforce;
transportation barriers; limited supportive
housing

36. Types of Community-Based LTC
Services
• Home health care
• Adult day care
• Adult foster care
• Senior centers
• Home-delivered and congregate meals
• Homemaker services
• Continuing Care at Home
• Case management

37. Home Health Care
– Community or hospital-based agency
– Services must be approved by a physician
– Skilled nursing care is the most common
service provided
– Medicare is the single largest payer; Medicaid
is second
– Mean length of service is higher among the
nonelderly
– Diabetes and heart disease are the most
common health conditions

38. Adult Day Care (ADC)
– Clients stay with family/friends, but cannot be left
alone during the day
– Provides partial respite to families
– ADC centers have increased across the country
– ADCs are highly focused on prevention and health
maintenance, but they also incorporate nursing
care, psychosocial therapies, and rehabilitation
– Nearly half of the clients have dementia; 50% of
ADCs offer specialized services for dementia
– Financing: Medicaid; private sources; Medicare for
rehabilitation services, but not for ADC services

39. Adult Foster Care (AFC)
–Family environment in small community-based
dwellings
–Services primarily focus on room and board,
supervision, and light ADL assistance
–Program differs widely from state to state
–Financing: Medicaid, private sources; Medicare
may pay for rehabilitation services

40. Senior Centers
–Local community centers
–Socializing
–Many offer one or more meals
–Wellness programs, education, counseling,
recreation, health screenings, etc.
–Financing: some public funding; United
Way; private donations

41. Home-Delivered and Congregate
Meals
– Elderly nutrition program
– Hot noon meal, five days per week
– People age 60+ and their spouses qualify
– Area Agencies on Aging do contracting
– Home delivery (meals-on-wheels), senior
centers, and other congregate settings
– The program has successfully targeted at-risk
people
– Financing: Older Americans Act; Title XX block
grants; 1915(c) waivers; private donations

42. Homemaker Services
–Shopping
–Light cleaning
–Errands
–Minor home repairs, etc.
–Financing: Medicaid, title XX block grants,
Older Americans Act, private funds

43. Continuing Care at Home (CCAH)
– A new model
– Extension of the CCRC model (continuum of housing
and institutional LTC on one campus) into home
health
– Initial lump-sum fee + monthly fee
– Future LTC care is guaranteed
– Services typically include care coordination, home
maintenance, home health care, transportation,
meals, and social and wellness programs
– Future institutional needs are met

44. Case Management
Functions:
– Evaluating needs
– Plan to address the needs
– Identifying appropriate services
– Determining eligibility and financing
– Making referrals
– Coordinating the delivery of services
– Reevaluating needs

45. Case Management Models
• Brokerage model—Case managers are
freestanding agents who assess client needs and
make referrals; minimal coordination and
monitoring
– Medicaid Preadmission Screening and Resident
Review (PASRR)
• Managed care model—Services are delivered
through a social managed care plan. All services
are received through the MCO.
– Have been shown to postpone institutionalization
– But, only 4 such programs participate in Medicare

46. Case Management Models
• Integrated care model—PACE — focused on
frail elderly already certified for nursing home
placement under Medicare and/or Medicaid

47. The ACA and Community-based LTC
• Limited financial incentives for states to
enhance HCBS
• Options for states:
– Enhance existing HCBS
– Offer “attendant services and supports” under
Community First Choice
– Undertake structural reforms to increase
services
– Use the existing Money Follows the Person
program

48. The ACA and Community-based LTC
• Balancing Incentives Payment Program
– Greatest amount of financing to states that
currently rely more on nursing homes than on
HCBS, but states must meet certain criteria

49. Institutional LTC Continuum
• Residential and personal care facilities
• Assisted living facilities
• Skilled nursing facilities
• Subacute care facilities

50. Residential and personal care facilities
– Physically supportive dwelling
– Monitoring and/or assistance with
medications, oversight, and personal or
custodial care
– No nursing care or medical services
– Advanced services are arranged with a home
health agency
– Private-pay; SSI payment and other
government assistance
– Services generally include meals,
housekeeping, laundry, and recreational
activities

51. Assisted Living Facilities (ALFs)
– Personal care services; 24-hour supervision;
social services, recreational activities, and
some nursing and rehabilitation services
– Increasingly, ALFs are providing dementia care
– Generally, private rather than shared
accommodations
– All states require ALFs to be licensed
– No federal oversight
– 86% of the residents pay privately

52. Skilled Nursing Facilities
All facilities are licensed by state
– Federal certification is optional
– Certification required for Medicare and/or Medicaid
• Compliance with the federal Requirements of Participation
– Noncertified: No federal or state funding; only privately-
funded patients
– Federal certifications (Nursing Home Reform Act, 1987):
• For Title 18 (Medicare)—SNF, freestanding or distinct part
• For Title 19 (Medicaid)—NF
• Dual certification—SNF and NF

53. Skilled Nursing Facilities
• Level of care has become more complex
• Most common conditions: bladder
incontinence, depression, Alzheimer’s, bowel
incontinence
• Depression and psychiatric diagnoses have
risen
• Quality of care has improved
• Direct care nursing time has increased
• “Culture change” has been underway to
create vibrant living environments

54. ACA Requirements for Nursing Homes
• The administrator of a SNF or NF must provide
written notice at least 60 days prior to closure
• The administrator must also provide a plan for
relocating residents
• SNFs and NFs must institute effective
compliance and ethics programs

55. Subacute Care Facilities
Three types of institutions:
– LTCHs (certified as acute care hospitals)
– Transitional care units in hospitals: SNF certification
– Skilled care nursing homes: SNF certification
• Costs vary; LTCHs are the most expensive
• Medicare reimbursement:
– Severity-based DRGs (MS-LTC-DRGs) for LTCHs
– RUGs for SNFs

56. Specialized Care Facilities
• Intermediate Care Facilities for Individuals
with Intellectual Disabilities (ICFs/IID)
• Separate federal certification
• Financed by Medicaid
• Patients often have other disorders, such as
seizures, behavioral problems, mental
illness, visual or hearing impairment, etc.
• The facility engages in “active treatment”

57. Specialized Facilities
• Alzheimer’s facilities
– Small-group living arrangements
– Lighting, color, pleasant surroundings, protected
pathways for wandering, and special programming
– The objective is to minimize agitation, anxiety, and
disruptive/combative behavior

58. Continuing Care Retirement Communities
(CCRCs)
– Integrates and coordinates independent living
with other institutional services, all located on one
campus
• Independent living cottages or apartments
• Personal care and assisted living
• SNF—Medicare certification

59. Continuing Care Retirement
Communities (CCRCs)
– Care for future higher-level services are
guaranteed
– People generally enter when they are still healthy
– Three types of contracts:
• Life care or extended care
• Modified contract
• Fee-for-service contract

60. Institutional Trends, Utilization, and Costs
• Table 10-1
• Nursing homes and beds have decreased with the rise
of HCBS and aging in place, but a recent slight upturn
• Nursing home beds per 1,000 population has dropped
for 11 years in a row
• Occupancy and ALOS show a declining trend
• Hospitals have drastically cut back on SNFs
• ALFs have been the fasted growing institution
• Nursing home costs have increased, but share of
personal care expenditures has decreased

61. Institutional Trends, Utilization, and Costs
• Most nursing home care is financed by
Medicaid, but the share of Medicaid spending
for LTC has decreased
• Vast disparity between Medicaid and private-
pay nursing home costs, but private financing
has been declining
• Medicare spending for nursing home care has
risen sharply

62. Private LTC Insurance
• Wide range of choices on duration of care and
services covered; prices vary accordingly
• Coverage includes nursing home care and various
community-based services
• Paid 9% of national nursing home expenditures in
2010
• Private long-term care insurance has seen slow
growth. Main issues: affordability; too many
options can be confusing; many mistakenly think
that Medicare will pay for LTC; few public policy
incentives