Chapter 10

long-term care

includes health, social, housing, transportation, and other supportive services needed by persons with physical, mental, or cognitive limitations sufficient to compromise independent living

need for long term care

determined by evaluating a person’s impairment of activities of daily living (ADLs = eating, dressing, bathing, toileting, and getting in/out of bed or a chair) and instrument activities of daily living (IADLS = housework, meal preparation, grocery shopping, transportation, financial management, taking medications, telephoning)

qualifying for long-term care

needing assistance for one or more ADLS and IADLs; unable to complete/carry out to the point of dysfunction, disease/death, and lack of independence

• private policies may specify that policyholder must be dependent in two or three ADLs before receiving benefits

benefits of long-term care

provides essential assistance with daily activities and medical support for people with chronic illnesses, disabilities, or cognitive decline

• skilled medical support, relief for family caregivers, safety and supervision, flexibility in setting, preservation of independence and dignity, social and mental engagement, financial/asset protection (in SOME cases)

in-hospital care

acute care that provides comprehensive medical management for acute conditions of exacerbation of chronic conditions

rehabilitation facility

provides complex medical management and/or intensive rehabilitation services

• if patient is coming for rehabilitation, pt must be able to tolerate and benefit from a minimum of 3 hours of therapy per day

skilled nursing facilities

provides skilled nursing and rehabilitative services; may be separate building sometimes referred to as an “extended care facility”

• Medicare pays for short term SKILLED care, in skilled nursing facility

• May have two levels of care within the same building: skilled nursing level; maintenance/custodial level

• Medicare covers up to 100 days in a SNF for skilled care

nursing home

some provide only CUSTODIAL care; patients might receive a functional maintenance program carried out by certified nursing aides

• not a benefit under medicare

• custodial care

custodial care

maintenance care = unskilled care

pros of nursing home

provide 24 hour care

cons of nursing home

quality varies widely, avg age of resident is in the 80s, 65% of residents have cognitive impairment and 93% have restricted mobility

hospice

covered under medicare if a doctor certifies that a patient is TERMINALLY ILL (less than 6 months to live) and care is provided by a Medicare-participating Hospice

services (covered care) for hospice

intermittent nursing, PT, OT, SP; doctor’s services, drugs (including outpatient drugs for pain relief), home health aide and homemaker, medical social services, medical supplies, short term inpatient care including rest care, counseling

gaps in hospice coverage

many hospice patients need some form of 24 hour care; only intermittently care is provided and patient must pay for additional care

home health conditions to meet medicare coverage

patient needs intermittent skilled nursing, PT, OT, or SP; patient is homebound (leaving home MUST be a major effort and if a patient leaves home, it must be infrequent, for a short time or to get medical care); physician must certify that there is a reasonable expectation that significant functional improvement will result from treatment

home health agencies

provide short term care

• part time/intermittent skilled nursing care

• PT, OT, SP

• Medical social services

• Medical supplies

• Some durable medical equipment

home health care system

does not provide help to people with long term care needs

• medicare reimbursement based on episode of illness model; agency paid lump sum for 60 days of care

• Mismatch between high tech needs of many patient and inadequate skill of home care personnel

Omnibus Budget Reconciliation Act, 1987

set standards for nursing home quality and mandated surveys to enforce these standards

reforms of Omnibus Budget Reconciliation Act, 1987

resident-focused standards, comprehensive assessments, elevated patient rights, restraint and antipsychotic restrictions, staff training requirements, enforcement sanctions

who pays for long term care

1. Medicare

2. Medicaid

3. Private long-term care insurance

medicare payment of long term care

no coverage for custodial care; coverage for MOST skilled care

medicaid coverage of long term care

will cover nursing homes, but not 24 hour custodial home care

private long-term care insurance

people who need it cannot afford it or are rejected due to chronic disease, policies have high deductibles, may not cover the services a person needs

how to improve long term care

develop social insurance, shift to community based care, train and support family members as caregivers, expand comprehensive acute and LTC organizations modeled on “On Lok”

social insurance

the principle of making small payments when you are well and earning money against sickness, unemployment, and retirement

Pepper Commission in 1990

recommended the country expand Medicare (social insurance plan for hospital care for elders) to cover LTC

• could be publicly funded through increased social security contributions

• would help cover services that help people stay independent that are NOT covered by Medicare

• challenge = funding 

• if developed, will meet desire of many reformers to maintain quality of life and personal independence by supporting services to keep people at home

On Lok program

merges adult day services, in-home care, home-delivered meals, housing and transportation assistance, comprehensive medical care, respite care of caregivers, hospital care, and skilled nursing care into ONE program; provides services (organize by a multidisciplinary team including physicians, nurses, social workers, rehabilitation and recreation therapists, + nutritionists) 52 weeks/year to 800 frail elders in San Francisco

• elders have avg 7 medical conditions (arthritis, diabetes, cerebral vascular disease, coronary artery disease, Alzheimer’s, hypertension, stroke) and avg 4 areas of dependency in ADLs (bathing, walking, transferring, grooming, dressing, toileting, eating); 94% dependent in IADLs and 62% have significant cognitive impairment

• Rate of hospital use: 1320 days/1000/annum compared to Medicare 1998 rate of hospital use (2357 days/1000/annum)