CHAPTER 10
Long-Term Care
Services
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Introduction (1 of 3)
Long-term care (LTC) is needed under three main circumstances:
Physical or mental deficits (cognitive impairment) that limit a person’s ability
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to do daily tasks
Need for continuity of care after hospitalization
Need for care in specialized environments
Introduction (2 of 3)
The primary clients of LTC services are the elderly, but most elderly do not need
LTC.
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Some young adults may need LTC.
LTC services are provided in both institutions and community-based
settings.
Most LTC is provided informally by family and friends.
Introduction (3 of 3)
LTC includes:
Home health brought to a person’s home
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Home-delivered meals
Minimal assistance in residential settings
Care in a nursing home
Aging and Long-Term Care
The aging process leads to chronic ailments, comorbidity, disability, and
dependency.
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This progression increases the probability that a person will need LTC.
Long-Term Care Among the Elderly (1 of 2)
Functional ability is assessed using the:
ADL scale
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IADL scale
Severe ADL limitations may suggest the need for institutionalization.
IADLs are necessary for living independently in the community.
See Exhibits 10.1 and 10.2.
Long-Term Care Among the Elderly (2 of 2)
Table 10.1
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Multimorbidity, age, and gender predict ADL/IADL limitations.
Ethnicity is an additional factor.
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What Is Long-Term Care?
A Variety of Health Care Services
Individual needs differ.
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Needs change over time.
LTC must interface with various non-LTC services.
Both therapeutic and preventive services are necessary.
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Individualized Services
Individualized plan of care
Based on assessment
Coordinated Services
Services must be well coordinated.
Spectrum of available services must be matched with the changing needs
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of clients.
The health care delivery system is complex and can be difficult to navigate.
Maximum Possible Functional Independence
Adaptive equipment and environmental modification promote independent
living.
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Motivate and assist the patient to do as much as possible.
Extended Period of Time
Compared to acute care, LTC is sustained over a longer period of time—weeks,
months, years.
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Short-term: 90 or fewer days
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Four dimensions are addressed:
Holistic Approach
Physical
Spiritual
Mental
Social
Quality of Life
The total living experience that results in overall satisfaction with one’s life
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At least five factors are emphasized:
Lifestyle pursuits
Living environment
Clinical palliation
Human factors
Autonomy and independence
Community-Based Long-Term Care Services (1 of 11)
Objectives of community-based LTC services:
To deliver LTC in the most economical and least-restrictive setting
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To supplement informal caregiving
To provide respite to family members
To delay or prevent institutionalization
Community-Based Long-Term Care Services (2 of 11)
Elderly services offered through an administrative network that includes:
The Federal Administration on Aging
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State Units on Aging
Area Agencies on Aging
Nationally, more than 600 Area Agencies on Aging administer funds
appropriated by the federal government under the Older Americans Act of 1965.
Community-Based Long-Term Care Services (3 of 11)
Sources of funding:
Medicare and Medicaid
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Title III of the Older Americans Act
Title XX Social Services Block Grants
State and local government funds
Home and Community Based Services waiver program
Private savings
Private donations
Community-Based Long-Term Care Services (4 of 11)
Home health care
Medicare is the largest single payer.
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To qualify for home care under Medicare, a patient must:
Be homebound
Have a plan of treatment that is periodically reviewed by a physician
Require intermittent or part-time skilled nursing and/or rehabilitation
therapies
Under Medicaid, states can develop services for people who would
otherwise end up in an institution.
Community-Based Long-Term Care Services (5 of 11)
Adult day care
A daytime, community-based group program
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Designed for people who live with their families
Enables families to work (partial respite)
Most are focused on prevention and health maintenance, supplemented by
nursing care, psychosocial therapies, and rehabilitation.
Community-Based Long-Term Care Services (6 of 11)
Adult foster care
Small, family-run homes to care for nonrelated adults
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Room, board, oversight, and personal care
To maintain the family environment, most states license fewer than 10 beds
per family unit.
Community-Based Long-Term Care Services (7 of 11)
Senior centers
Local community centers for older adults to congregate and socialize
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Many serve a noon meal
May sponsor health screening and wellness programs
Community-Based Long-Term Care Services (8 of 11)
Home-delivered and congregate meals
Elderly nutrition program operated under the U.S. Administration on Aging
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One hot noon meal, 5 days a week.
To qualify, people must be at least 60 years of age (or be the spouse of a
qualified person).
Congregate meals served in senior centers
Meals-On-Wheels delivered by volunteers
Community-Based Long-Term Care Services (9 of 11)
Homemaker and handyman services
Simple tasks necessary for independent living:
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Grocery shopping
Household chores
Handyman services
Light cleaning
General errands
Minor home repairs
Homemaker programs may be staffed largely or entirely by volunteers.
Community-Based Long-Term Care Services (10 of 11)
Emergency response systems
Person wears or carries a transmitter that enables the individual to send a
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medical alert to a 24-hour monitoring and response center.
Available at a reasonable fee
Community-Based Long-Term Care Services (11 of 11)
Case management
A method of linking, managing, and coordinating services to meet the varied
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and changing health care needs of elderly clients
Often useful when adult children of disabled people live far away
Assessment, care plan, identify appropriate services, determine eligibility for
services, make referrals, coordinate care, financing, and ensure that
services are received
Institutional Long-Term Care (1 of 8)
Suited for patients whose needs cannot be adequately met in community-based
settings
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Institutional options meet the varying needs of the elderly in:
Retirement centers
Residential or personal care facilities
Assisted living facilities
Nursing homes
These facilities provide varying levels of assistance along a continuum.
Institutional Long-Term Care (2 of 8)
Continuing care retirement community (CCRC)
Different levels of institutional/living services offered on one campus:
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Retirement living
Personal care
Nursing care
Concept of aging-in-place
Addresses the changing needs as people age
Institutional Long-Term Care (3 of 8)
Retirement facilities
Emphasis on privacy, security, independence, active lifestyles
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When needed, nursing care and rehabilitation are obtained through a home
health agency.
Supportive environment promotes independence.
Organized programs, such as socializing, physical fitness, recreation,
shopping, and entertainment
Some offer hotel services.
Institutional Long-Term Care (4 of 8)
Personal care facilities
Nonmedical custodial care: Basic assistance in a protected environment
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Institutional Long-Term Care (5 of 8)
Assisted living facilities
A residential setting that provides:
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Personal care services
24-hour supervision
Scheduled and unscheduled assistance with ADLs
Social activities
Some nursing care services
Help with medications
These facilities border between personal care homes and nursing homes.
Institutional Long-Term Care (6 of 8)
Skilled nursing facilities
Provide a full range of clinical long-term care services.
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Skilled nursing care:
Medically oriented care provided by a licensed nurse
Plan of treatment is authorized by a physician.
Direct ADL care is delivered by paraprofessionals.
Rehabilitation, therapeutic diets, and nutritional supplements are
important components of skilled care.
The patient’s treatment plan is highly individualized based on a
multidisciplinary assessment.
Institutional Long-Term Care (7 of 8)
Subacute care facilities
Subacute care: A blend of intensive medical, nursing, and other services
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that are technically complex
Cheaper alternative to a hospital stay
Three main avenues for service delivery:
Long-term care hospitals (LTCHs)
Special units in skilled nursing facilities
Home health may provide certain services.
Institutional Long-Term Care (8 of 8)
Specialized care facilities
Some facilities specialize in specific areas:
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Ventilator care
Wound care
Alzheimer’s
Intensive rehabilitation
Closed head trauma
AIDS
Licensing and Certification of Nursing Homes (1 of 4)
Nursing homes are heavily regulated through licensure and certification
requirements.
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It is illegal to operate a nursing facility without a license.
Licensing and Certification of Nursing Homes (2 of 4)
Licensing
A license to operate a facility is issued by the state.
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Standards for licensure vary from state to state.
One exception: The Life Safety Code is a national standard.
Compliance with standards is verified yearly through inspections.
The state’s department of health has oversight responsibility.
Licensing and Certification of Nursing Homes (3 of 4)
Certification
It allows a nursing home to admit patients who are on public assistance
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(Medicare and Medicaid).
Nursing homes must first be licensed by the state.
To serve Medicaid and/or Medicare clients, the home must be certified by
the Centers for Medicare & Medicaid Services (CMS).
A noncertified facility can only admit private-pay patients.
Licensing and Certification of Nursing Homes (4 of 4)
Three distinct federal certification categories
SNF certification: Medicare
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NF certification: Medicaid
ICF/IID certification: Intellectually/developmentally disabled clients
Most facilities have dual SNF/NF certification.
Other Long-Term Care Services (1 of 3)
Respite care
Temporary services to help address family caregivers’ feelings of stress and
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burden
Virtually any kind of service: Adult day care, home health care, and
temporary institutionalization
Other Long-Term Care Services (2 of 3)
Restorative care
Restorative care: To regain or improve function
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Maintenance rehabilitation: To preserve existing function and prevent further
decline
Adaptive rehabilitation: To improve function despite deficits that remain
Other Long-Term Care Services (3 of 3)
Hospice (end-of-life care)
Services for the terminally ill (life expectancy of 6 months or less)
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Emphasizes dignity and comfort
Medical interventions are minimized.
Life-prolonging treatments are suspended.
An approach to care
The ACA and LTC
States have the option to provide home- and community-based attendant
services under Community First Choice—increased federal matching funds for
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Medicaid.
Elder Justice Act of 2010 was made a part of the ACA.
All certified facilities must comply with a Quality Assurance Performance
Improvement program.
Nursing Home Industry and Expenditures (1 of 2)
The number of nursing homes, bed capacity, and number of residents have
continued to decline.
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Mainly due to growth of community-based options
In the future, a growing elderly population with chronic conditions,
comorbidities, and disability will need LTC services.
The industry is dominated by nursing home chains and private for-profit nursing
homes.
Nursing Home Industry and Expenditures (2 of 2)
Medicaid
Main source of financing for nursing home care
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Medicare
Pays for eligible beneficiaries under Part A, but the coverage is for a short
duration
LTC insurance
Expensive; few people have it
Conclusion (1 of 2)
LTC should not be an isolated component of the health care system.
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LTC includes medical care, social services, and housing.
The range of LTC services varies according to individual needs.
Impairment with ADL and IADL functions determines the need for long-term
care.
Conclusion (2 of 2)
Respite care can provide temporary relief to informal caregivers.
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Informal care is supplemented with community-based services as the need for
intensive services increases.
LTC facilities range from those providing basic personal care to complex
specialized care.
Hospice-based end-of-life care is also part of LTC.
