The Continuum of Long-Term Care Chapter 9 The Continuum of Long-Term Care

What is Long-Term Care? Health, mental health, residential, or social support provided to a person with functional disabilities over an extended period of time. The ideal is an integrated set of services that provides continuity of care over time and across settings.

Who Needs Long-Term Care? The fundamental reason a person needs long-term care is because they suffer from one or more functional disabilities. Functional ability is a person’s ability to perform the basic activities of daily living (ADLs) or instrumental activities of daily living (IADLs).

Who Needs Long-Term Care? Population segments at high risk include the aged, those with chronic conditions, HIV/AIDS patients, and children with special health care needs. In 2005, approximately 37 million individuals suffered from some type of disability that limited their ability to perform basic ADLs.

Table 1 Terminology for Users of Select Services Term for Clients Nursing Homes Residents Hospitals Patients Adult Day Services Participants Home Care Clients Hospice Outreach Consumers Wellness Durable Medical Equipment (DME) Customers

The Continuum of Care The ideal continuum of care is a comprehensive, coordinated system designed to meet the needs of individuals with complex and/or ongoing problems in an efficient and effective manner.

The Continuum of Care Ideally, a continuum of care does the following: Matches resources to patient’s health and family circumstance Monitors patient’s condition and changes services as needs change Coordinates care of many professionals and disciplines Integrates care provided in a range of services

The Continuum of Care Ideally, a continuum of care does the following: Enhances efficiency, reduces duplication, and streamlines patient flow Arranges financing so that services are based on need rather than narrow eligibility criteria Maintains a comprehensive record incorporating clinical, financial, and utilization data

The Continuum of Care A true continuum should serve three major goals: Provide health and related support services that foster independence. Achieve cost-effectiveness by maximizing use of resources. Enhance quality through appropriateness and continuity of care.

Table 2 Categories and Services of the Continuum of Care Extended Acute Ambulatory Skilled nursing facilities Medical/Surgical inpatient unit Physicians’ offices Step-down units Psychiatric inpatient unit Outpatient clinics Swing beds Rehabilitation inpatient unit Nursing home follow-up Interdisciplinary assessment team Intermediate care facility for the mentally retarded Consultation services

Table 2 Categories and Services of Continuum of Care Outreach and Linkage Wellness and Health Promotion Screening Educational programs Information and referral Exercise programs Telephone contact Recreational and social groups Emergency response system Senior volunteers Transportation Congregate meals Senior membership program Support groups Meals on Wheels Disease management Mail order pharmacy Psychological counseling Alcohol and substance abuse Day hospital Adult day services

Table 2 Categories and Services of the Continuum of Care Home Care Housing Home health – Medicare Continuing care retirement communities Home health – Private Independent senior housing Hospice Assisted living High-technology home therapy Congregate care facilities Durable medical equipment Adult family homes Home visitors Group homes Home-delivered meals Board and care facilities Homemaker and personal care In-home caregiver

Figure 2 Services and Integrating Mechanisms of Continuum of Care Inter-entity Management and Structure Integrated Information Systems Care Coordination Integrated Financing Extended Acute Ambulatory Home Outreach Wellness Housing

Service Categories of Long-Term Care Extended inpatient care Hospitals Ambulatory Care Home Health Outreach Wellness Housing

Extended Inpatient Care Extended inpatient care is for individuals who require ongoing nursing and support services. The majority of extended inpatient care facilities are nursing facilities or nursing homes.

Extended Inpatient Care Specialty facilities range from subacute units in hospitals to intermediate care facilities for the mentally retarded or developmentally disabled.

Hospitals Various hospitals specialize in long-term care. Chronic conditions such as heart problems, cancer, mental illness, stroke, and respiratory conditions, are the leading causes of all hospital admissions. Medicare and private insurance companies are the primary payers for hospital services.

Ambulatory Care ADS represents a daytime program of personal care, therapeutic activities, supervision, socialization, assistance with ADLs, mid-day meals, and skilled care. The ADS program serves over 250,000 people throughout the United States.

Home Health Skilled nursing care and therapies Homemaker/personal care and chore services High-technology home therapy Durable medical equipment Hospice

Hospice Hospice care typically takes place in the patient’s home. Its goals are as follows: To make the person as comfortable as possible To achieve emotional acceptance of death by the patient and family To comfort and assist the family after the person’s death

Outreach Outreach programs make health and social services readily available to the community. Many outreach programs are provided at no or low charge to the consumer.

Wellness Wellness programs include activities for those who are healthy and programs for those with chronic illnesses. Wellness activities may be provided at no or low charge to the client.

Housing Housing accommodations for long-term care include independent housing, independent apartments with support services, formal assisted living, and group homes. Payment for housing is usually the responsibility of the individual.

Integrating Mechanisms Inter-entity structure and management Case management Integrated information systems Comprehensive financing

Inter-entity Structure and Management Ensure channels of communication and cooperation Establish clear lines of authority, accountability, and responsibility for client services Negotiate budgets and financial trade-offs

Inter-entity Structure and Management Address issues of risk management and liability Gather and share data efficiently Present a cohesive, consistent message in interactions with external agencies and the community

Care Coordination Quality is enhanced when information is communicated among all professionals caring for an individual. Efficiency is achieved when duplication of services is avoided.

Care Coordination Techniques for coordinating clinical care include: Case management Interdisciplinary teams Disease management programs

Case Management Case identification Assessment Care planning Service arrangement Monitoring Reassessment

Integrated Information Systems Implement quality assurance and utilization review programs Assess efficiency of operations Track and aggregate client experiences Can calculate the long-term costs of care

Integrated Information Systems EHRs allow patient information to be disseminated more efficiently across various health care organizations. RHIOs allow organizations to share health-related information across settings and over time.

Financing Under Medicare, the federal government established Social HMOs, the Program of All-Inclusive Care for the Elderly (PACE), and hospice. Each program has the legislative authority to blend financing streams or to offer services based on patient needs.

Financing CCRCs provide several levels of housing on the same campus, ranging from independent houses or apartments to assisted living and skilled nursing facilities. CCRCs arrange service deliveries and coordinate on-site services.

Table 4 National Health Expenditures: United States, 1960-2002 (amount in billions) 1970 1980 1990 2000 2002 Home Health Care $0.1 $0.2 $2.4 $12.6 $31.7 $36.1 Nursing Home Care $0.8 $4.2 $17.7 $52.7 $93.8 $103.2

Medicare Skilled nursing Home care Hospice LTC hospital Rehabilitation 100 days only Home care Skilled only Hospice LTC hospital Rehabilitation Mental health

Medicaid Skilled nursing Home care Hospice Rehabilitation therapies Skilled or support care Hospice Rehabilitation therapies

Medicaid Mental health Adult day health care Assisted living (some states only) Case management

Veterans Affairs Skilled nursing Home care Hospice Rehabilitation therapies Mental health Adult day care Respite

Older American Act Congregate meals Meals on wheels Homemaker Case management

Title XX Home care Chore service

The Current State of Long-Term Care in the United States Managing for a seamless continuum of care is challenging from the perspective of the individual client. Due to fragmentation of services, different eligibility criteria, and varying payment streams

The Current State of Long-Term Care in the United States Managing an organization is difficult due to the need to coordinate with external organizations and even to coordinate internally.