chapter 10

An Introduction to the US Health Care System - Long Term Care

Overview

  • Instructor: Joe Konen, MD, MSPH, Adjunct Faculty
  • Date: November 24, 2025

System Processes

  • Focus on Long Term Care (LTC)
  • Components of long term care include:
    • Assisted Living
    • Nursing Home
    • Personal LTC (Long Term Care)
    • Home and Community-Based Services (HCBS)

Common Concerns in Long Term Care

  • Fundamental challenges faced in LTC:
    • Soaring costs: Families face financial pressures in caregiving.
    • Emotional strain: Caregivers report feelings of being tied down (e.g., "I never feel truly free").
    • Individual testimonies:
    • Christine Salhany (Nebraska): spends about $240,000 annually for 24-hour in-home care for her husband with Alzheimer’s.
    • Carolyn Brugioni (Illinois): her father exhausted savings and needed a home-equity line-of-credit for home healthcare.

Long Term Services and Supports (LTSS)

  • Definition:
    • Commonly referred to as “long-term services and supports” (LTSS)
    • LTSS is not exclusive to older adults; younger individuals may also require support.
  • Medicare coverage limitations:
    • Most health insurance plans, including Medicare, do not cover LTSS.
  • Services included in LTSS:
    • Medical and non-medical care for individuals unable to perform Activities of Daily Living (ADLs) such as dressing or bathing.

Who Uses Long Term Care?

  • Statistics from 2018:
    • 14 million adults required LTC services.
    • Demographics:
    • 56% aged over 65 years
    • 44% aged 18 to 64 years
    • 70% of adults will need some form of LTSS during their lives.
    • Includes children needing services due to congenital or acquired disabilities.

Who Receives LTSS?

  • Definitions:
    • Activities of Daily Living (ADLs):
    • Includes personal care tasks such as:
      • Bathing or showering
      • Dressing
      • Mobility (getting in and out of bed or a chair)
      • Walking
      • Toileting
      • Eating
    • Instrumental Activities of Daily Living (IADLs):
    • Activities for independent living, such as:
      • Meal preparation
      • Money management
      • Grocery shopping
      • Housekeeping
      • Telephone usage

Relationship Between LTSS Need and ADLs

  • The need for LTSS correlates with the loss of ability to conduct ADLs.

Age, Gender, and Health Variability in ADLs

  • Table 10-1: Association between age, gender, multimorbidity, and limitations in ADLs/IADLs
    • Data presented based on:
    • Number of Chronic Conditions
    • Differentiated between Age 65-74 and Age ≥75
    • Men versus Women

Goals of Long-Term Care

  • Key characteristics of a well-designed long-term care system:
    • Integration with broader healthcare delivery systems
    • Appropriate service placement based on individual needs
    • Flexible accommodations for changing needs
    • Designed to help compensate existing impairments
    • Promote independence among care recipients

Importance of Quality of Life in LTC

  • Factors influencing quality of life:
    • Engaging in lifestyle pursuits
    • Maintaining a comfortable, safe, and appealing living environment
    • Clinical palliation for relief from distressing symptoms
    • Human-centric factors:
    • Caring
    • Compassion
    • Respect and dignity
    • Personal choices

Types of LTSS Services

  • Comprehensive LTSS services include:
    • Medical, nursing, and rehabilitation care
    • Mental health and dementia care
    • Social support
    • Preventive and therapeutic long-term care
    • Respite care
    • Community and institutional-based services
    • Housing provisions
    • End-of-life care / Hospice services

Medical, Nursing and Rehabilitation Care

  • Focus areas include:
    • Continuity of post-acute care
    • Clinical management of chronic illnesses
    • Restoration or maintenance of physical function, particularly following hospital stays

Mental Health Services and Dementia Care

  • Prevalence statistics:
    • 25% of older adults experience mental health issues like depression or anxiety.
    • Remarkable prevalence in nursing home environments (e.g., 5.8 million Americans 65+ live with dementia).
    • 48% of nursing home residents have forms of dementia.

Institutional Settings for LTC

  • Addressing therapeutic services for ADL functions, including professional assistance for individuals unable to perform necessary tasks.
  • Aims to prevent further functional loss while coordinating non-LTC needs.

Legal Framework: Olmstead vs. LC (1999)

  • Highlights unjustified segregation of individuals with disabilities as unlawful under the Americans with Disabilities Act.
  • Mandates that individuals with disabilities must receive services in the most integrated setting fitting their needs.

Home- and Community-Based Services (HCBS)

  • Objectives:
    • Deliver LTC in cost-effective and least restrictive environments whenever suitable
    • Supplement or replace informal caregiving
    • Provide respite for informal caregivers
    • Help delay or prevent institutionalizations

Financing Long Term Services and Supports

  • Home and Community-Based Services Waiver Program:
    • 1915(c) waivers in Medicaid are the largest providers of LTSS for individuals with developmental disabilities, with state variations.

Program of All-Inclusive Care for the Elderly (PACE)

  • Benefits include:
    • Capitated financing from Medicare and Medicaid.
    • Services delivered without limitations seen in fee-for-service systems.
    • Benefits adults aged 55+ who are certified for nursing home placement yet live within communities.
    • Retains over 90% of participants within home settings.

Continuum of Institutional Care

  • Breakdown of institutional care levels:
    • Skilled Nursing Facilities (SNF)
    • Highly regulated, licensed by the state, eligible for Medicare/Medicaid.
    • Residential and Personal Care Facilities
    • Basic facilities providing no medical services with minimal staffing.
    • Services include meals, housekeeping, laundry, and recreational activities.
    • Assisted Living Facilities
    • Provide personal care, supervision, social services, and some nursing/rehabilitation support. Regulatory variability across states.
    • Subacute Care Facilities
    • Focus on patients necessitating extended hospital stays (long-term care hospitals).

Trends in Nursing Home Capacity, Utilization, and Expenditures

  • Table 10-2 a. Change from 2000 to 2016 in:
    • Number of facilities: 16,886 to 15,647 (-7.3%)
    • Number of beds: 1,795,388 to 1,690,304 (-5.9%)
    • Number of nursing home residents: 1,480,076 to 1,346,941 (-9.0%)
    • Occupancy percentages: 82.4% to 79.7% (-2.7% points)
    • Expenditures: Increased from $85,045 million to $163,029 million (+91.7%)

Continuous Care Retirement Communities (CCRCs)

  • Offer a range of residential services allowing movement across care levels based on individual needs, including those for:
    • Independent living, assisted living, skilled nursing, and memory care.
  • Access to medical services:
    • Transportation for health visits, on-site hospitalization for acute conditions, 24/7 on-call gerontologists, regular visiting specialists.
  • Members typically buy into a membership or pay a monthly fee.
  • Affordability is a concern; often seen as not accessible for all.

Need for Long Term Care Insurance

  • Issues with insurance:
    • Most private health insurance does not cover LTC costs and Medicare only covers acute care.
    • Medicaid requires significant asset depletion to qualify.
  • LTC Insurance challenges:
    • Currently high costs render most plans unaffordable for the middle class.
    • Some LTC plans combine insurance with life insurance benefits.
  • Need for development of affordable LTC Insurance options.

Questions

  • Open floor invitation for questions.