Inpatient Long-term Care Facilities

Inpatient Long-term Care Facilities

Types of Long-term Care Facilities

• Post-acute care / skilled rehab / transitional care

• Nursing facilities

• Assisted living facilities

• Continuing Care Retirement Communities (CCRCs)

Post-Acute Care

• Definition: Comprehensive treatment for an acute illness, injury, or exacerbation of a disease process that occurs immediately after or in place of an acute care stay.

• Type of Care: It is more intensive than nursing facility care, but less so than acute care.

Examples of Post-Acute Care Needs

• Recovery from hip replacement

• Treatments for spinal cord or brain injuries

• Care following cerebrovascular accidents (CVAs)

• Management of cancer

• Care for AIDS

• Wound care management

• Cardiac and respiratory disease requiring ventilation

• Conditions requiring intravenous (IV) therapy or tube feedings

Types of Post-Acute Care Facilities

1. Inpatient Rehabilitation Facility (IRF)

   • Can be freestanding or part of a hospital unit

   • Accounts for 20% of Medicare spending on post-acute care

   • Classification requires meeting specific criteria to qualify as an “IRF” patient according to Medicare coverage guidelines

2. Skilled Nursing Facility (SNF)

   • Accounts for 80% of Medicare spending on post-acute care

   • Medicare classification established to define eligible care levels

Services Provided in Post-Acute Care

• Rehabilitation services including Physical Therapy (PT) and Occupational Therapy (OT)

• Respiratory therapy

• Cardiac rehabilitation

• Speech therapy

• Wound care services

• Chemotherapy treatments

• Total Parenteral Nutrition (TPN)

• Dialysis treatments

• Pain management strategies

• Patient Complexity: Generally, IRFs serve patients who are more clinically complex than those in standard nursing facilities.

Why Post-Acute Care is Important

• Reimbursement Structures:

  • Involves several factors including Medicare MS-DRGs (Medicare Severity Diagnosis-Related Groups), managed care, and DRGs bundling

  • The Bundling and Coordinating Post-Acute Care Act of 2015 shifted payments to fixed amounts for 90 days of care

  • Encourages use of preferred providers and shared savings arrangements

Reimbursement Statistics (Source: U.S. Census Bureau 2018)

• Medicare: 68.00%

• Managed Care: 10.00%

• Medicaid: 8.00%

• Other: 14.00%

Nursing Facilities

• Perception: Historically viewed negatively as "the place where one goes to die"; associated with family guilt and the for-profit nature of the industry which has previously lacked sufficient self-regulation.

What is a Nursing Facility?

• Provides ongoing care including:

  • Skilled nursing care

  • Wound care management

  • IV antibiotics administration

  • Physical, Occupational, and Speech therapy

  • Specialty care for advanced stages of illnesses like Parkinson's and Alzheimer's

  • Custodial care related to Activities of Daily Living (ADLs) available mainly in conjunction with skilled nursing services

Appropriate Candidates for Skilled Nursing Facilities (SNF)

• Individuals unable to care for themselves due to physical or mental health problems

• Individuals who cannot perform ADLs

• Patients at risk of wandering away

• Individuals with extensive medical needs requiring Registered Nurse (RN) supervision

• Patients in need of temporary skilled care or rehabilitation before transitioning home or to another residential facility

Demographics of Residents

• Age Distribution (Source: NCHS 2018)

  • Under 65: 7.2%

  • Age 65-74: 10.4%

  • Age 75-84: 29.9%

  • Age 85+: 52.6%

  • Mean age of residents: 85

  • Gender: 68% female

  • Racial Composition: 76% Caucasian

Primary Diagnoses of Nursing Facility Residents

• Circulatory system issues (Heart disease, stroke)

• Mental disorders, including Alzheimer's and other forms of dementia

• Nervous system disorders like Multiple Sclerosis and Parkinson's

Functional Dependency Statistics (Source: NCHS 2018)

• Need assistance with:

  • Bathing: 96.1%

  • Dressing: 90.9%

  • Transferring: 79.5%

  • Toileting: 86.6%

  • Eating: 56.0%

Characteristics of Nursing Homes (Comparison 2009 vs. 2019)

• 2009:

  • Total Facilities: 15,700

  • For-profit: 68%

  • Government-owned: 7%

  • Chain-affiliated: 61%

  • Facilities with <50 beds: 13%

  • Average # beds: 109

  • Occupancy rate: 83%

• 2019:

  • Total Facilities: 16,100

  • For-profit: 67%

  • Government-owned: 8%

  • Chain-affiliated: 60%

  • Facilities with <50 beds: 14%

  • Average # beds: 107

  • Occupancy rate: 86%

  • Source: CMS 2020

Chances of Nursing Home Placement

• Lifetime Probability of Needing Nursing Home Care by Age 65 in the U.S.:

  • Men: 33%

  • Women: 52%

• Average Length of Stay: 892 days

  • Breakdown of length of stay: 30% < 3 months, 25% > 3 years

Administration of Nursing Homes

• Operated by licensed administrators

• Requirements for Nursing Home Administrators (NHA):

  • Typically require a bachelor’s degree

  • Completion of an Administrator in Training (AIT) program

  • Passing of State Licensing Board examination

  • Continuing education is mandatory

Payment System for SNFs

• Prospective Payment System (PPS):

  • Described as a “cat and mouse” game relating to reimbursement structures, changing funding policies, and requirements

  • Built on a classification system initiated in 1997 for Medicare payment, tied to the Minimum Data Set (MDS)

  • MDS assessment required at multiple points: admission, quarterly, significant changes, and discharge

  • Payment rates are determined based on a patient’s functional status and required therapy minutes

Changes to SNF Reimbursement Policies

• As of October 2019:

  • Transition from RUG-IV to Patient-Driven Payment Model (PDPM)

  • Payments now depend on ICD-10 codes and no longer rely on the number of therapy minutes

  • Provides more accurate compensation reflecting individual patient needs

  • Fewer MDS assessments required (quarterly assessments eliminated)

Reimbursement Breakdown (2018)

• Medicare: 62%

• Medicaid: 20%

• Private insurance: 14%

• Private pay: 4%

  • Source: CMS 2019

Why Isn’t Medicare the Largest Payer for SNFs?

• Role of ‘spend down’ in financial planning for long-term care

Regulation of Nursing Homes

• Known to be one of the most regulated industries within the U.S.

  • Licensing managed by State Department of Health

  • Certification required for Medicare and/or Medicaid participation

  • Increasing Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation due to DRG bundling

  • The Omnibus Budget Reconciliation Act (OBRA) 1987, known as the “Nursing Home Reform Act”, sets comprehensive standards

  • Facilities face state inspections and are required to develop care plans and MDS assessments

Quality of Care in Nursing Homes

• Inspections revealing deficiencies help measure quality enforcement

  • In 2019, 92.3% of facilities reported at least one deficiency

  • Average deficiencies per facility: 7

  • 18% of facilities contained deficiencies that led to actual harm or jeopardized resident safety

Common Deficiencies in Nursing Homes

• Types of deficiencies observed include:

  • Accidents within the environment

  • Food sanitation issues

  • Quality of care lapses

  • Lack of professional standards

  • Inadequate comprehensive care plans

  • Housekeeping failures

  • Incontinence care inadequacies

  • Shrinking instances of pressure sores

  • Over-prescription of unnecessary drugs

  • Infection control breaches

Quality Indicators Monitored

• Measures of pressure sores development

• Restraint use frequency

• Fall incidents

• Catheter-related outcomes

Quality of Life in Nursing Homes

• Evaluated through measures of:

  • Quality of care associated outcomes

  • Inspection deficiencies

  • Quality indicators and patient outcomes

  • Social engagement opportunities for residents

  • Usage and effectiveness of tools like Nursing Home Compare and