Pauline Vaillancourt Rosenau with the assistance of Paul
Newhouse
Management , Policy, and Community Health
School of Public Health
University of Texas Health Science Center
Houston, Texas, USA
I.
Types of post-acute, institutional, residential, and community-based
settings for older adults
II.
Types of clients served in select settings
III.
Facility and patient demographics
IV.
Payment and cost of long-term care
V.
Community Living Assistance Services and Supports program (CLASS
Act)
VI.
Initiating the process and making challenging decisions
VII.
Transitioning from one setting to another
Health, mental health, residential or social
support provided to a person with functional
disabilities on an informal or formal basis
over an extended period of time with the
goal of maximizing the person's
independence. Services change over time
as the person's and caregivers' needs
change."
*Note*
Sources can be found in the notes of each slide.
The full presentation will be made available to the class .
Home Care: "Services (as nursing or personal care) provided to a homebound
individual (as one who is convalescing, disabled, or terminally ill) <home care as an
alternative to institutionalization> <home care providers> Informal care refers to
long-term services carried out by families and unpaid caregivers, whereas, formal
home care service involves the aid of paid care.
Supportive Housing: "Combines affordable housing with individualized health,
counseling and employment services for persons with mental illness, chemical
dependency, chronic health problems, or other challenges. Generally it is transitional
housing, but it can be permanent housing in cases such as a group home for persons
with mental illness or developmental disabilities. Supportive housing is a solution to
homelessness because it addresses its root causes by providing a proven, effective
means of re-integrating families and individuals into the community by addressing
their basic needs for housing and on-going support."
Independent Living: "Residents in Independent Living are just that - totally
independent. Independent living residences provide meals and services as required.
Some people confuse Independent Living and Assisted Living and justifiably so - they
are very similar. Assisted Living residences provide two or more meals, and offer
Planned Care."
Assisted Living: A subcategory of residential care that includes, "housing and
limited care that is designed for senior citizens who need some assistance with daily
activities but do not require care in a nursing home usually hyphenated when used
attributively
Nursing Homes: "A facility licensed with an organized professional staff and
inpatient beds and that provides continuous nursing and other health-related,
psychosocial, and personal services to patients who are not in an acute phase of
illness, but who primarily require continued care on an inpatient basis."
Chronic Care Facilities: "Long-term care of individuals with long-standing,
persistent diseases or conditions. It includes care specific to a problem as well as
other measures to encourage self-care, promote health and prevent loss of function."
Acute Care Programs: "Medical care administered, frequently in a hospital or by
nursing professionals, for the treatment of a serious injury or illness or during
recovery from surgery. Medical conditions requiring acute care are typically periodic
or temporary in nature, rather than chronic."
Hospice Care: "Care designed to give supportive care to people in the final phase
of a terminal illness and focus on comfort and quality of life, rather than cure. The
goal is to enable patients to be comfortable and free of pain, so that they live each
day as fully as possible."
Home Care (formal) Community: resident individuals who require ADL aid beyond
the capabilities and/or availabilities of family members and friends.
Assisted Living: Individuals "who are not able to live independently, but do not
require the level of care provided by a nursing home."
Nursing Homes: Individuals in poor health who need aid in performing daily
activities.
Hospice Care: Individuals who need supportive and palliative care at the end of
life.
Number of facilities in the US:
Home Care (formal) 11,488 (2010) Assisted Living 38,412
(2007) Residential Care 131,407 (2007) Nursing Homes 15,658
(2009) Hospice Care 3,407 (2010)
Number of clients:
Home Care (formal) 1,623,000 (2005-06)
Nursing Homes 1,393,127 (2009)
Hospice Care 1,054,722 (2008)
Number of beds:
Home Care (formal) 1,623,000 (2005-06)
Residential Care 1,483,691 (2007)
Nursing Homes 1,663,959 (2009)
Average length of stay:
Home Care (formal) :
Initial 3 months9: 19.7% (2005-06)
Months 4-6: 12.0% (2005-06)
Months 7 and Beyond: 68.8% (2005-06)
Assisted Living:
29.3 months (2010)
Nursing Homes:
30 days: 10.5% (2004)
31-90 days: 9.7% (2004)
91 days - 1 year: 24.1% (2004)
13 months - 3 years: 30.2% (2004)
> 3 years: 25.6% (2004)
Hospice Care:
<7 days: 32.4% (2007)
7-30 days: 30.5% (2007)
31-180 days: 26.7% (2007)
181-364 days: 6.4% (2007)
> 1 year: 4.1% (2007)
Age of clients:
Home Care (formal):
Under 65: 33.4%
65+: 66.6%
Assisted Living:
86.9 (2010)
Nursing Homes:
65+: 81.8% (2007)
Median Age (Years): 82 (2007)
Hospice Care:
< 50: 3.5% (2007)
50-64: 13.6% (2007)
65-74: 14.8% (2007)
75-84: 29.6% (2007)
85-89: 19.5% (2007)
90+: 19.0% (2007)
Picture dollar signsyou get the idea!
Medicare, Medicaid, the Veterans Affairs, Long-term care commercial
insurance, and private pay are the most significant sources
Medicare and Medicaid pay the majority of costs (>65%)
Medicare offers only short-term assistance because individuals have to be
deemed in need of skilled care, rather than custodial care, in order to
qualify
Custodial care is what many of those seeking long-term care need
i.e. help with activities of daily living
Medicaid covers long-term care for those without other resources to
pay for it. Rules vary by state, but to qualify for Medicaid coverage
in a long-term residential facility in most states, an individual with
savings must first spend down most of their assets. Generally,
spouses are entitled to keep some of the assets, however.
Federal certification for Medicare and Medicaid payments is
separate and not all nursing homes in a state may seek
federal certification for such payments.
About 95% of nursing home beds in the US are in facilities
that are dual-certified. Residential care and assisted living
facilities are not eligible for Medicare funds and generally
do not receive Medicaid payments, except under special
state Home and Community-Based Services waiver
programs, so all payments for those services are private
pay.
Nursing home care: ~ $110,000/year
Assisted living: ~ $70,000-$80,000/year
Small residential care facilities have much lower costs
Individuals must use their social security and/or
supplemental security income (SSI) (for low income
persons) to pay for care. If they are poor, Medicaid will pay
for the additional costs for nursing home care, but not
residential care. Assisted living is generally only private
pay, but some residential care facilities will accept social
security and SSI as payment.
Private long-term care insurance plays a
minor role in the US less than 10% of the
total long-term care is covered by private
policies. Long-term care insurance products
are sold on the private markets to
individuals both through employers and
individually and usually cover nursing
homes, assisted living facilities, or home
care for those who require help.
Included in ACA, the CLASS Act establishes a national, voluntary
insurance program for purchasing community living services and
supports
Effective Date: January 1, 2011 CANCELLED October 14, 2011
The HHS Secretary was expected to define the CLASS benefit by
October 2012 with enrollment to begin subsequently
CLASS is designed to help individuals with functional and/or
cognitive limitations remain in the community by purchasing
non-medical services and supports such as home health care
and adult day care.
Source: The Henry J. Kaiser Family Foundation, April 2010
WHO CAN ENROLL IN CLASS? Working adults will be able to make voluntary
premium contributions either through payroll deductions through their employer or
directly.
WHO IS ELIGIBLE FOR BENEFITS? Adults with multiple functional limitations,
or cognitive impairments, will be eligible for benefits if they have paid monthly
premiums for at least five years and have been employed during three of those five
years.
WHAT ARE THE BENEFITS? Adults who meet eligibility criteria will receive a
cash benefit that can be used to purchase non-medical services and supports
necessary to maintain community residence; payments for institutional care are
permitted. The amount of the cash benefit is based on the degree of impairment or
disability, averaging no less than $50 per day.
HOW IS THE PROGRAM FINANCED? CLASS is financed by voluntary
premium contributions paid by working adults, either through payroll deductions or
direct contributions.
HOW DOES CLASS INTERACT WITH MEDICAID? CLASS will generally be
the primary payer for individuals who are also eligible for Medicaid.
Source: The Henry J. Kaiser Family Foundation, April 2010
Choosing a long-term care option is a difficult task.
However, this process becomes even more difficult if all
members of the family arent on the same page.
For instance, how do you breach the subject of LTC to a
person who may be completely unaware or disagree that
they need/should seek help?
And, of course, the terms need and should seek are
very subjective.
What can families do to mitigate any issues that may come
up when initiating this process?
Long-term care "conversation checklist" for fa
milies and seniors
By SNAPforSeniors, Inc.
1111 WA 98101 Third Avenue, Suite 1860
Seattle
http://www.snapforseniors.com/Services/FreeContent/ConversationChecklist.aspx
Source: SNAPforSeniors
Making the decision to opt for long-term care, along with
choosing the appropriate setting, is no easy task.
There are physical, social, and emotional factors an
individual and/or his or her family must consider, not to
mention cost, payment, and simply breaching the subject
to initiate the process.
A diligent review of available information from credible
resources is an advisable first step.
1) Assess your needs
2) Research financing and care choices
3) Find what is right for you
4) Visit your available options
Medicare.gov - Steps to Choosing Long-Term Care
http://www.medicare.gov/longtermcare/static/stepsoverview.asp
The Agency for Healthcare Research and Quality, an entity
of the US Dept. HHS, also provides a checklist to identify
the help required by the individual to complete activities of
daily living, as well as their health care needs.
They also provide guidance on how to find high-quality
services in both home care and nursing home care settings.
Your Guide to Choosing Quality Health Care: Long-term Care
http://archive.ahrq.gov/consumer/qnt/qntltc.htm
Agency for Healthcare Research and Quality
540 Gaither Road Rockville, MD 20850
Telephone: (301) 427-1364
Resident Rights in Nursing Homes
Nursing home residents have patient rights and certain protections
under the law. The nursing home must list and give all new residents a
copy of these rights. Resident rights usually include:
Respect: You have the right to be treated with dignity and respect.
Services and Fees: You must be informed in writing about services and
fees before you enter the nursing home.
Money: You have the right to manage your own money or to choose
someone else you trust to do this for you.
Privacy: You have the right to privacy, and to keep and use your
personal belongings and property as long as it doesn't interfere with
the rights, health, or safety of others.
Medical Care: You have the right to be informed about your medical
condition, medications, and to see you own doctor. You also have the
right to refuse medications and treatments.
Source: Medicare.gov
According to the American Medical
Association, informed consent is a process
of communication between a patient and
physician that results in the patients
authorization or agreement to undergo a
specific medical intervention.
Why might this be an issue in the long-term
care setting?
Like many other groups of patients (e.g.
those with linguistic, cultural, and emotional
challenges), long-term care patients are not
always able to provide informed consent.
Functional limitations may prevent a patient
from providing consent that is truly
informed.
This is an issue that requires more attention
as there is not much literature on informed
consent in the long-term care setting.
There are challenges that can occur when an older adult
transitions from one setting to another. This can cause a
great deal of stress and anxiety for individuals and their
families.
The main concern during these transitions is the health of
the individual and the potential for there to be a temporary
lapse in critical health care.
Strategies to reduce abrupt changes to routine, comfort
level, and medical care should be adopted.
Transitions between care settings in which family
members play an important role bring the varied
elements of health and long-term care together for a
fleeting but critical moment. (Levine et al., p. 120)
Miscommunication and medication error can lead to
significant lapses in patient safety.
In turn these lapses can lead to costly and traumatic
rehospitalizations, and repeated cycles of transitions to
rapid deterioration and even death. (Levine et al., p. 120)
Hospital-based nurses who have not practiced in home
health care may find it difficult to anticipate patients needs
during the transition from hospital to home. (Drury, 2008)
[C]lear, concise and accurate information about patients
preferences and goals might not be a part of [transitions of
care between home and different care facilities]. (Hauser,
2009)
Medication error: Discrepancies in certain drug classes
more often caused ADEs (adverse drug events) than other
types of discrepancies in hospitalized nursing-home
patients. (Boockvar et al., 2009)
Clear communication and cooperation between both types of
caregivers family and professional is central to a smooth
transition.
Improved transitional caredepends on family caregivers
involvement. Yes explicit attention to family caregivers is largely
absent. (Levine et al., p. 122)
The ability to develop strong relationships with family caregivers
and provide necessary training and support throughout the
continuum of care should be defined as a core competency for all
health care professionals and built into professional training and
continuing education. (Levine et al., p. 122)
On the continuum of care, transition between care
settings is managed with difficulty. For example:
Hospital to Home
Hospital to Nursing Home
Nursing Home to Hospital
Nursing Home to Nursing Home
Department to Department within a Hospital
Keys to success:
Good record keeping
Coordination
Planning
Follow-up
