Improving the Quality of Long-Term Care (2001) / Chapter Skim
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Profile of Long-Term Care
Profile of Long-Term Care
Pages 36-72
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From page 36... ...
Those needs are met in a variety of care settings such as nursing homes, residential care facilities or people's homes. People follow various paths in long-term care, reflecting differences in their health and functional status, variations in individual and family preferences and values, economic circumstances, and geographic location.
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From page 37... ...
The information on providers and users of longterm care services in this chapter is based mostly on the periodic national surveys of nursing homes and home health and hospice care conducted by the National Center for Health Statistics (NCHS) and a few ad hoc studies of other providers such as board and care homes and assisted living facilities.
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From page 38... ...
and more likely to be women, to be cognitively impaired, and to have a greater number of ADL limitations. Table 2.1 summarizes the demographic characteristics and levels of functional limitations of elderly and nonelderly users of long-term care in nursing homes and community-based settings, broadly defined to include both formal and informal services.
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From page 39... ...
and from the 1996 Medical Expenditures Panel Survey Nursing Home Components (nursing home users)
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From page 40... ...
For nursing home residents, dementia was the most common health condition (Krause and Altman, 1998~. Children and Adolescents Among the small number of children with severe disabilities requiring long-term care, about 45 percent have major developmental problems (primarily mental retardation)
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From page 41... ...
Organized providers include residential institutions and long-term care facilities (such as nursing homes and residential care facilities) , as well as nonresidential service providers (such as agencies that manage home health and hospice care services)
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From page 42... ...
3Nursing homes are defined by NCHS as facilities with three or more beds that routinely provide nursing care services. Facilities may be certified by Medicare or Medicaid, or not certified but licensed by the state as a nursing home.
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From page 43... ...
Other such units referred to as "post-acute" or "subacute" care units serve the relatively short-term needs of people discharged from acute care hospitals to recuperate from surgery. Nursing homes also provide a considerable amount of long-term care for people with severe mental or cognitive problems, especially older people with dementia or people with other disabling health problems (Mechanic, 1998~.
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From page 44... ...
More than 2,500 Medicare- or Medicaid-certified nursing facilities in the country today are hospital based, and another 10 percent of the remaining freestanding facilities concentrate on serving relatively short-stay Medicare patients. The entry of nursing homes into the post-acute and recuperative market began in the early 1980s but accelerated in the late 1980s with the
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From page 45... ...
Some residential care arrangements, such as board and care homes, adult foster homes for older persons and small group homes for those with mental retardation, are intended to be like family homes; and others, such as assisted living facilities, are intended to be more like apartments and sometimes like hotel rooms. Depending on the state and the services provided, residential care settings may or may not be licensed.
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From page 46... ...
Compared to nursing homes, residents in board and care homes are on the average less impaired. Yet 40 4The committee did not address care that may be needed by or provided to people with serious mental illness in other '~sheltered settings such as jails, prison, and homeless shelters.
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From page 47... ...
Some states use licensing criteria to limit assisted living to people with lower levels of disabling conditions than nursing home residents. Other states treat assisted living as an alternative to nursing home care.
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From page 48... ...
6Unless otherwise noted, the data on assisted living facilities (ALFs) discussed in this chapter are based on the National Study of Assisted Living for the Frail Elderly.
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From page 49... ...
Further, 76 percent would not retain a resident who needed nursing care for more than 14 days, and 72 percent had discharged a resident within the last six months because the resident needed skilled nursing care. An estimated 24 percent of the residents received help with three or more activities of daily living, and about 34 percent had moderate to severe cognitive impairments.
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From page 50... ...
An estimated 10,600 of the 13,500 agencies had only home health care patients, 1,300 had only hospice care patients, and 1,600 had both types. Medicare's prospective payment system for hospital services combined with Medicare's coverage of home health care has contributed to the rapid growth of home health care agencies and to more frequent and intense use of post-acute services, including home health care, nursing homes, or both (Neu and Harrison, 1988; Shaughnessey and Kramer, 1990~.
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From page 51... ...
About half of the home health care patients were served by voluntary nonprofit agencies and about 42 percent were served by proprietary agencies, compared to 85 percent of hospice care patients who were served by voluntary nonprofit agencies and only 11 percent who received care from proprietary agencies. Figures 2.3 and 2.4 summarize the distribution of the types of services received by patients from home health care agencies and the types of caregivers providing services.
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From page 52... ...
Organizations A1150 states and the District of Columbia now have one or more HCBS waivers to provide long-term care to various populations7 (see Table 2.5~. For example, waivers have been granted for elderly persons, persons with physical disabilities, persons with persistent and serious 7A1150 states offer HCBS services; however, Arizona's Medicaid program is administered differently and they do not specifically have separate waivers for their HCBS programs.
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From page 53... ...
SOURCE: NCHS, 1998. Type of Service Nursing Services Homemaker-Household Services Physical Therapy Other Services Medications Social Services Continuous Home Care Occupational Therapy Nutritionist Services Physician Services Counseling Speech Therapy/Audiology Mental Health Services None or Unknown Transportation Volunteers 19.4 10.8 10.6 25.8 j , j 20 30 40 50 60 70 80 90 0 10 Percent of Patients Receiving These Services FIGURE 2.3 Percent of patients receiving home health care services by type of service: United States, 1996.
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From page 54... ...
Personal care. Many states provide personal care services under the Medicaid HCBS waivers, (See Table 2.5~.
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From page 55... ...
Although originally conceived as a means of assisting individuals and families in obtaining information and access to social, housing, and other non-medical services, care management has recently become a prominent mechanism for controlling service use and costs (Applebaum and Austin, 1990; Vourlekis and Green, 1991; Evashwick, 1996~. In part because users of such assistance have viewed the term as reinforcing the image of consumers as "subservient to a powerful case manager" (Perrin and Bloom, 1994, p.
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From page 58... ...
Some states delegate the function to local area agencies on aging, some delegate it to county health departments or county human services departments, other states create regional offices of a state agency. Still others contract the function out to a variety of agencies within the state, including care providers, such as home care agencies, hospitals, and nursing homes.
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From page 59... ...
Others are offered by freestanding providers of the particular service, but often meal programs or adult day care programs are sponsored by organizations such as nursing homes and home health care agencies. Individual Caregivers Informal Caregivers Although discussions of long-term care policy appropriately emphasize the role of paid professionals, paraprofessionals, and other workers, most long-term care is provided by unpaid, informal caregivers, including family members, neighbors, friends, volunteers from religious and community organizations, and others.
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From page 60... ...
In 1998, there were more than 3 million paid jobs in nursing homes, residential care settings, and home health organizations. More than half of these jobs were accounted for by registered nurses (RNs)
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From page 61... ...
Staffing shortages and the low reimbursement rates are receiving much attention among policy makers and in the media. These problems have serious implications for the quality of care provided.
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From page 62... ...
Most available data are for nursing home care and home health care services. More9Reflecting concern about fragmentation of the medical profession, the American Board of Medical Specialties (ABMS)
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From page 63... ...
Out-of-pocket payments represented a substantial share of funds for both types of care: 31 percent 1O''Nursing home care" covers services provided by skilled nursing facilities and intermediate care facilities including those administered by the Department of Veterans Affairs and those provided in Medicaid funded Intermediate Care Facilities for people with mental retardation. Hospital-based nursing facilities and home health expenditures are included under hospital expenditures (Braden et al., 1998~.
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From page 64... ...
From the outset, however, the program has covered some nursing home and home health services, in part because they were seen as potential alternatives to more expensive, hospital-based acute care services. Medicare covers nursing home care only when a beneficiary requires daily skilled inpatient nursing or rehabilitation services and has had a 3day hospital stay in the 30 days prior to nursing home admission.
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From page 65... ...
These guidelines require that states cover nursing facility care for those over age 20 and home health care for those eligible for skilled nursing services. In addition, states may receive federal matching funds to cover certain optional services including nursing facility care for people under age 21, services in intermediate care facilities for those with mental retardation, and personal care services.
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From page 66... ...
Medicaid Waivers for Home and Community-Based Care. Since 1975, states have had the choice to offer personal care services (PCS)
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From page 67... ...
Some states, such as Colorado, screen people to assess, first, whether they need nursing home care and second, whether they are likely to enter institutional care (Wiener and Stevenson, 1998~. This targeted approach, although consistent with federal legislative intent, has been criticized as being too restrictive and unduly limiting access to home and community-based services.
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From page 68... ...
Many states offer higher supplementation for individuals living in board and care, personal care homes, or foster care homes. Each state sets its own rates for SSP and these rates determine the amount that many residential care facilities receive as monthly payments for services.
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From page 69... ...
Although private insurance accounts for about 5 percent of nursing home and 12 percent of home health spending, most of this is ordinary health insurance that, like Medicare, provides limited benefits for extended care. Among elderly Americans those most at risk perhaps 7 percent have long-term care insurance (Wiener and Stevenson, 1998)
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From page 70... ...
Often nurse practitioners are responsible for this coordination, attempting to follow the consumer whether they are in clinics, hospitals, home care, or nursing homes. The PACE (Program of All-Inclusive Care for the Elderly)
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From page 71... ...
Generally, nursing homes with a consumer-centered focus may emphasize resident service in staff training, actively involve residents and or their families in care planning, provide a physical environment that supports, to the extent applicable, resident privacy and autonomy, and regularly solicit feedback from residents and families regarding their experiences and satisfaction with care. The philosophy of residential care settings such as assisted living emphasize autonomy and they may be expected to allow for individual preferences and privacy.
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From page 72... ...
It depicts a "system" of long-term care that is highly variable across states and communities, fragmented, and unevenly coordinated. Different kinds of long-term care services have evolved, in part to meet the varying needs and, to an uncertain degree, the preferences of users.
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