HCA 361: Chapter 1 Notes - Dimensions of Long-term Care

Learning Objectives

• Define long-term care (LTC) and long-term services and supports (LTSS).
• Explain changing patterns of demographics in the United States in terms of growing demand for LTC services and supports.
• Understand the history of LTC service delivery.
• Describe models for LTC service delivery.
• Discuss the providers and payers of LTSS, including informal sources of support such as family caregivers.
• Apply the theoretical foundations of LTC service delivery to assess their impact on healthcare policy.
• Understand the impact of COVID-19 on health disparities in LTC service delivery and new directions for LTSS.

Older Americans

• Americans today compared with previous generations: living longer, more racially and ethnically diverse, more prosperous.
• By $2050$, the number of people aged $65+ ext{ years}$ is expected to double to $89\,000\,000$, and the number aged $85+\text{ years}$ is expected to triple to $18\,000\,000$.
• Common chronic conditions among older adults: heart disease, cancer, stroke, chronic lower respiratory diseases, Alzheimer’s disease, diabetes.

Adults with Disabilities

• CDC (2015) reports that $22\%$ of adults in the United States have some type of disability.
• Historically, LTC needs of older adults and adults with disabilities were addressed through separate laws and separate government organizations (e.g., Older Americans Act [OAA], Developmental Disabilities Assistance and Bill of Rights Act of 2000).
• In 2012, the US Department of Health and Human Services established the Administration for Community Living (ACL).

Long-Term Care (LTC) and Long-Term Services and Supports (LTSS)

• LTC: a variety of health services, support services, and other assistance provided informally or formally to individuals with chronic illness or disability who cannot function independently.
• LTSS: services and supports provided to individuals at any age, in a wide range of settings, corresponding to problems in performing ADLs and IADLs.

Administration for Community Living (ACL)

• ACL is an umbrella agency of the US government that provides services and supports for older adults and individuals with disabilities.
• The ACL encompasses the Administration on Aging and the Administration on Disabilities (as well as other centers).

Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

• ADLs: basic and routine daily activities (e.g., eating, bathing, dressing, toileting, walking).
• An individual’s ability to perform ADLs determines the level of LTSS needs.
• IADLs: activities not essential for basic functioning but enable independent living (e.g., shopping, house cleaning, cooking, managing finances).
• Importance: both ADLs and IADLs gauge independence and care requirements.

Caregivers

• Caregivers provide healthcare or supportive LTSS on a formal (paid) or informal (unpaid) basis.
• Approximately $18\,000\,000$ Americans provide care for chronically ill, disabled, or aged family members or friends in a given year.
• Caregivers: more likely to be women; about $50\%$ are between ages $45$ and $64$.
• Approximately 2/3\sfrac{}{ } of individuals aged 65+ rely exclusively on unpaid care for personal care needs.

The History of LTC Service Delivery

• Overview of how LTC service delivery has evolved historically (policy, delivery models, and funding streams).

Hill-Burton Act of 1946

• Amended in 1954 to provide federal grants (plus construction and design guidelines) to public and not-for-profit entities building nursing homes.
• Required nursing homes to be affiliated with hospitals.
• The 1959 Housing Act and Kerr-Mills Act of 1960 further changed the law.
• Today: federal loans supported building nursing homes affiliated with hospitals, with the stipulation of providing charity care in the future.

Medicare and Medicaid

• Medicare: federal health insurance for the following groups: people aged $65+$, individuals receiving Social Security disability benefits for more than 2 years, individuals with Lou Gehrig’s disease, and individuals with end-stage renal disease.
• Medicare covers care provided in skilled nursing facilities and home care for up to $100\text{ days}$.
• Medicaid: means-tested federal program covering medical care and other supportive services for low-income individuals, people living with disabilities, and poor older persons.

Olmstead v. United States (1999)

• Supreme Court decision requiring states to eliminate discrimination against people with disabilities by providing services in the most integrated setting appropriate.
• This decision provided impetus for expanding home and community-based services (HCBS).
• Led to new home-like care models such as assisted living, Eden Alternative housing, and Green House cottages.

COVID-19 Pandemic

• A worldwide epidemic marking the beginning of the “Seventh Period.”
• Impacted healthcare and senior living providers, global economies, and heightened awareness of health and racial disparities affecting older adults.

The Passage of the ACA: A New Period

• ACA (Affordable Care Act) passage focused attention on: integration and coordination of LTC services, opportunities to innovate service delivery and reimbursement, emphasis on preventive care and primary care delivery, innovative uses of technology for LTSS, and support for informal services provided by caregivers.

Aging, Disability, and Chronic Health Conditions

• There is an aging process driven by aging itself and chronic health conditions.
• The International Classification of Functioning, Disability, and Health (ICF) defines functioning and disability.
• Geriatrics vs Gerontology:
  • Geriatrics: branch of medicine dealing with health and care of older adults.
  • Gerontology: study of the process of aging and problems of older adults.
• Key concept: Aging, Disability, and Chronic Health Conditions.

The Aging Process and Determinants

• The manner in which a person ages depends on a mix of genetic and environmental factors and access to healthcare services.
• About $20\%$ of a person’s health is due to genetics, about $20\%$ is due to the medical care received, and the remaining $60\%$ is due to social, behavioral, and environmental factors.
• Genetic and Environmental Factors: contributions to health and aging can be partitioned as:
  ext{Genetics} = 20\%,
  ext{Medical Care} = 20\%,
  ext{Social/Behavioral/Environmental Factors} = 60\%.

Physical Signs of Aging

• Normal aging includes changes in height, skin, and senses.
• Aging also affects how the body regulates circulatory, nervous, respiratory, and digestive systems.

Under the ICF, Disability and Dimensions

• Disability is an impairment that relates to individual functioning and encompasses physical, sensory, cognitive, and intellectual impairments, as well as various types of chronic disease.
• Disability can be multidimensional with three dimensions:
  1) Bodily function,
  2) Activity restrictions,
  3) Participation restrictions.
• Disability studies is a field focusing on issues pertaining to disabilities and people with disabilities.
• Disabling Conditions.

Chronic Health Conditions and Wellness

• A chronic condition is a persistent health condition or disease lasting for an extended period and typically without a cure.
• Such conditions can affect physical and intellectual functioning and can be medical or psychological in nature.
• There is a growing number of individuals with multiple chronic conditions, which has become a significant issue.

Continuum of Long-Term Care and Single Point of Entry (POE)

• Continuum of Long-Term Care: a holistic system comprising services and mechanisms to assist individuals over time with a wide range of physical health, mental health, and social service needs across all levels of care intensity.
• Single-point-of-entry (POE) model: a model where patients can obtain all required services through a single agency or organization.

Models of Long-Term Care Delivery (Cont.)

• Dimensions of Long-Term Care model: a fluid, nonlinear approach recognizing services in the continuum of care.
• It allows consumers to have a single point of entry into the LTC delivery system.
• Emphasizes the option for LTC consumers to use technology and supportive services to remain independent within their community.

Settings and Providers of LTSS

• LTSS are typically provided in the following settings:
  • Acute care,
  • Ambulatory care,
  • Home and community,
  • Residential,
  • Outreach and linkage,
  • Technological.
• Healthcare systems, nursing homes, and other residential care organizations provide a large portion of LTSS.
• Providers may be privately owned for-profit, not-for-profit, governmental entities, or faith-based organizations.

Paying for LTSS

• Payment for formal LTSS in the United States primarily comes from government sources (e.g., Medicare and Medicaid).
• Medicaid covered $51\%$ of total LTSS expenditures; other public programs paid $21\%.$
• Consumers’ out-of-pocket funds covered $19\%$.
• Private insurance (commercial insurance, managed care plans, and LTSS insurance plans) accounted for $8\%$.

Quality and Safety in LTSS

• The quality of LTSS has been a growing concern.
• CMS has attempted to address quality through regulations, including new requirements for assessment of LTC needs, staffing of LTC communities, and a mandate for all nursing homes to have a Quality Assurance and Performance Improvement (QAPI) plan.

Looking Ahead

• The LTC delivery system remains fragmented and patched together; an increasing number of clients will enter the system as America ages.
• The US faces strains from the COVID-19 pandemic, declining tax revenues, rising costs of public health and retirement programs, and a growing population eligible for benefits.
• The Affordable Care Act (ACA) and the reauthorization of the Older Americans Act provide a philosophical foundation for wellness and health promotion across all life stages.