LONG TERM CARE PHP310 Spring 2014 March 5, 2014

Long-Term Care Services that are delivered over extended periods of time (such as over 90 days) Can include a hospital episode, but not as the primary service A system of care, not just a single service Can be rehabilitative or custodial services For younger persons too, not just the elderly

Factors in Long-Term Care Growth Growth of the older population Increased longevity of the older population Medical technology has prolonged life for previously “ fatal ” conditions; PPS for in-patient care reduced length of hospital stay, promoting post-acute care Desire to keep people out of hospitals Desire to keep people out of nursing homes (home care)

Life Expectancy at Age 65 by Sex and Race/Ethnicity, Years Data Source: The National Vital Statistic System

Living Arrangements by Age and Sex, 2006 Percent (%) Data Source: Current Population Survey MaleFemale

Americans with Long Term Care Needs

Source: MEDSTAT HCBS Thirty-Six Percent of Medicaid Spending Goes to Long-Term Care Note: ICF/MR = intermediate care facilities for the mentally retarded

Estimating Who’ll Need LTC and How Long Long Term Care needs often begin as medical problems which, in turn, compromise functioning, physical and/or mental Some people will die quickly and NEVER need long term care; Others will acquire a need for LTC and will need it for a long time Since this is such an important question, researchers have focused on it

Risk of needing LTC after age 65

Years of nursing home use

Years of formal care at home

Years of informal care only

Implications Today’s retirees can expect to be disabled for 4 years and receive LTC for 2.7 years One in three will have at least 5 years of difficulty One in five will have at least 5 years of care There is considerable variation among demographic groups in expected years of disability and LTC Women will be disabled 1.5 years longer than men and will receive more of each type of care Persons divorced or separated are disabled longest but spend a large share of that time without care

Basic Points about LTC Services sick and frail people; “Care” is as important as “cure” ”Functional health” is a key concept; ADLs and IADLs Initially, most of the LTC continuum was custodial -- caring for persons as they steadily approached death. Services provided as a "continuum of care“ The objective is to have a range of services which are combined into client-specific packages

Basic Points: continued One of the major goals is to keep the person as independent as possible. Services are not provided by a single agency. Ability to link services is crucial for "continuity of care”; Case management is important Many of the individual services are not necessarily long-term in nature. It is the combination that makes a LTC “system”. LTC interfaces with many more aspects of life than does acute care.

Measures of Disability ADLs (Activities of Daily Living) : The most commonly used measure of disability. ADLs determine whether an individual needs assistance to perform basic activities, such as eating, bathing, dressing, toileting, or getting into or out of a bed or chair. IADLs (Instrumental Activities of Daily Living): A person’s ability to perform household and social tasks, such as home maintenance, cooking, shopping, and managing money.

Percent of Medicare Beneficiaries Reporting Difficulty with IADLs or ADLs by Age, 2004 Data Source: Medicare Current Beneficiary Survey Percent (%)

Long Term Care Includes Nursing Homes Home Health Care Hospice Care Assisted Living Day Care Programs Case Management Residential Care Adult Foster Care Meals on Wheels Rehabilitation Hospital Rehabilitation Center Physical & Occupational Therapy Personal Care Attendants

Challenges to LTC Public Perception of poor quality Regulation and enforcement Client/Family awareness of services Services often needed in a crisis or at a point of stress; must decide quickly with little information or capacity to absorb it

The Transformation of US Nursing Homes Prior to Medicare/Medicaid Nursing Homes were “Homes for the Aged” (sectarian) Nursing Homes built rapidly: 1960’s & 70’s De-institutionalization of Mental Hospitals Deflection of Cognitively Impaired from Mental Hospital to Nursing Home Emergence of Nursing Home as a Locus of Skilled, Rehabilitation Services & NOT just Custodial Care

Rehabilitation & Sub-Acute Specialization Growth in Rehab & Sub-Acute Units Related to HMO Penetration, Competition and Strategy to Serve Medicare Patients Related to Greater Competition in NH Market Non-Profit Facilities Most Likely to Have Unit Located in Somewhat Larger Facilities

High “Acuity” Care Growth in the Proportion of Facilities Providing Tracheostomy Care Growth in the Proportion of Facilities Without Tube Fed Residents Growth in Proportion of Homes with 10%+ Tube Fed Residents Many SNFs now “mini-hospitals”

30 Day Rehospitalization Rate:2009

Acute hospital use 180 days post

Implications of Expanded Nursing Home Use for PAC Since Hospital PPS, implicit policy has been to expand use of nursing homes Rapid post-acute discharge In lieu of hospitalization in Managed Care As place to die Rise of Assisted Living and home care means NH admissions later and sicker Medicaid rates have grown but not kept up with this expanding role

Hospitalization Rate from NH: 2009

Financing Long Term Care in the Future Major increases in the size of the elderly population, notwithstanding a dropping percentage at each age group using nursing homes; Health Care costs, even long term care, continue to rise quicker than real GDP While real GDP growth somewhat higher than historical rates could pay growing pension liabilities … Health Care cost increases MUST slow to pay for future long term care costs.