Chapter One Definition of the Continuum of Care

What is Long-Term Care? zA broad term encompassing a wide-array of populations, services, and funding sources zA wide-range of health and health-related support services provided on an informal or formal basis to people who have functional disabilities over an extended period of time with the goal of maximizing their independence

Health & Health-Related Support Services zHealth zMental Health zSocial Services zSupport Services

Health & Health-Related Support Services zProvided simultaneously zMay change over time zProvided by formal and informal arrangements zRecipients may be people of any age

Long-Term Care zFunctional disabilities are primary reason zKey  the ability to perform ADL/IADL zGoal  enable the person to maintain the maximum level possible of functional independence

Long-Term Care zCare is directed not with the expectation of cure, but with enabling people to do the most they can for themselves given the state of their condition

How is Long-Term Care Organized? zOn an ad-hoc basis z80-90% provided by friends and family zEach community has its own combination of available resources, funding sources, and organizations

How is Long-Term Care Organized? zClients need coordination among many different services, transition among services, and changes of service configurations over time

Characteristics of Major Health Services

Major Federal Legislation Funding LTC Services zMedicare (Title XVIII of Social Security Act) yYear Passed: 1965 yTarget Population: xAge 65 and older, Disabled, ESRD yCovered Services: xShort stay nursing homes xSkilled home care xHospice xShort-term mental health

zMedicaid (Title XIX of Social Security Act) yYear Passed: 1965 yTarget Population: xPoor yServices Covered: xNursing homes xSocial services xAdult day care xRespite, homemaker services (varies by state) Major Federal Legislation Funding LTC Services

zSocial Services Block Grants (Title XX of Social Security Act) yYear Passed: 1974 yTarget Population: xAged (over 60), disabled, children yServices Covered: xCommunity-based services (varies by state) homemaker, chore, adult day care, adult foster care, mental health Major Federal Legislation Funding LTC Services

zOlder Americans Act yYear Passed: 1965 yTarget Population: xAged (over 60) yServices Covered: xNutrition services, Home delivered meals xState ombudsman programs xSocial/recreational xSupportive services transportation, outreach, information and referral, legal, in-home services Major Federal Legislation Funding LTC Services

zSupplemental Security Income (Title XVI of Social Security Act) yYear Passed: 1972 yTarget Population: xLow income, aged (over 60), blind, disabled yServices Covered: xAutomatic Medicaid eligible (see Medicaid) xCash payments xCongregate housing, adult foster care (at state option) Major Federal Legislation Funding LTC Services

zVeterans Administration yYear Passed: 1963, 1972, 1975, 1980 yTarget Population: xVeterans yServices Covered: xNursing homes xOutpatient care/visits, Adult day care xSpecial housing placement xPersonal care xHospice Major Federal Legislation Funding LTC Services

zMental Health yYear Passed: 1967, 1971 yTarget Population: xMentally ill yServices Covered: xCommunity mental health centers xICF/MR coverage Major Federal Legislation Funding LTC Services

zAmerican Disabilities Act yYear Passed: 1990 yTarget Population: xDisabled yServices Covered: xNone specifically -- ensures access to all services Major Federal Legislation Funding LTC Services

Ideal LTC System zProvides comprehensive, integrated care on an ongoing basis and offers various levels of intensity that change as a client’s needs change zProvides medical and related support services that enable a person to maximize functional independence zIs a continuum of care

Continuum of Care zA client-oriented system composed of both services and integrating mechanisms that guides and tracks patients over time through a comprehensive array of health, mental health, and social services spanning of levels of intensity of care

Continuum of Care zextends beyond traditional definitions of long-term care zis client-oriented zemphasizes wellness rather than illness zincorporates both acute and long-term services

Continuum of Care zis a comprehensive, coordinated system of care designed to meet the needs of patients with complex and/or ongoing problems efficiently and effectively zis more than a collection of fragmented services; includes mechanisms for organizing those services and operating them as an integrated system

Continuum of Care (Ideal) zMatches resources to the patient’s condition, avoiding duplication of services and use of inappropriate services zMonitors the client’s condition, and changes services as the needs change zCoordinates the care of many professionals and disciplines

Continuum of Care (Ideal) zIntegrates care provided in a range of settings zStreamlines patient flow and facilitates easy access to services needed zMaintains a comprehensive record incorporating clinical, financial, and utilization data across settings

Continuum of Care zShould achieve cost-effectiveness by maximizing the use of resources zShould enhance quality and patient satisfaction through appropriateness, ease of access, and ongoing continuity of care zShould increase provider efficiency

Continuum of Care Services zOver 60 distinct services grouped in 7 categories: yExtended inpatient care yAcute inpatient care yAmbulatory care yHome care yOutreach yWellness/Health promotion yHousing

zExtended inpatient care yfor people who are so sick or functionally disabled that they require ongoing nursing and support services provided in a formal health care institution but who are not so acutely ill that they require the technological and professional intensity of a hospital ye.g., nursing facilities, step-down units, swing beds, nursing home follow-up Continuum of Care Services

zAcute inpatient care yhospital care for those who have major and acute health problems ye.g., medical/surgical inpatient unit, psychiatric inpatient unit, rehabilitation inpatient unit, interdisciplinary assessment team, consultation service Continuum of Care Services

zAmbulatory care services yprovide a wide-spectrum of preventive, maintenance, diagnostic, and recuperative services for people who manifest a variety of conditions ye.g., physicians’ offices, outpatient clinics, interdisciplinary assessment clinics, day hospitals, adult day care centers, mental health clinics, satellite clinics, psychosocial counseling, alcohol and substance abuse care Continuum of Care Services

zHome care yrepresents a variety of nursing, therapy, and support services provided to people who are homebound and have some degree of illness but who are able to satisfy their needs by bringing services into the home setting ye.g., home health (Medicare/private), Hospice, high-technology home therapy, durable medical equipment, home visitors, home delivered meals, homemaker/personal care, caregivers, respite Continuum of Care Services

zOutreach programs ymake health services and social services readily available in the community rather than within the formidable walls of a large institution ye.g., screening, information and referral, telephone contact, emergency response, transportation, Senior membership programs, Meals on Wheels Continuum of Care Services

zWellness programs yare provided for those who are basically healthy and want to stay that way by actively engaging in health promotion ye.g., educational programs, exercise programs, recreational and social groups, Senior volunteers, congregate meals, and support groups Continuum of Care Services

zHousing yfor frail populations; increasingly includes access to health and support services and conversely, recognizes that the home setting affects health ye.g., continuing care retirement communities, independent senior housing, congregate care facilities, adult family homes, assisted living facilities, intermediate care facilities for the mentally retarded Continuum of Care Services

zEach has different regulatory, financing, target population, staffing, and physical requirements zEach has its own admission policies, patient treatment protocols, and billing system Continuum of Care Services

zInter-entity structure zCare coordination zIntegrated information systems zIntegrated financing Continuum of Care Integrating Mechanisms

zInter-entity structure ymanagement arrangements and operating policies are in place enable services to coordinate care, facilitate smooth patient flow, and maximize use of professional staff and other resources Continuum of Care Integrating Mechanisms

zCare coordination ythe coordination of the clinical components of care, usually by combination of a dedicated person and established processes that facilitate communication among professionals of various disciplines at multiple sites Continuum of Care Integrating Mechanisms

zIntegrated information systems yone patient record that combines financial, clinical, and utilization information to be used by multiple providers and payers across multiple sites Continuum of Care Integrating Mechanisms

zIntegrated financing yremoves barriers to continuity and appropriateness of care by having available adequate financing for long-term care as well as acute care, preferably paid by a capitated system Continuum of Care Integrating Mechanisms

Framework for the Future zDemand for long-term care will increase yaging population xincreasing in numbers xincreasing in age ytechnology yshift from acute to outpatient

zChallenge is to develop an approach to long-term care that is efficient, affordable, and appropriate for the individual and family and simultaneously, affordable and cost-effective for society Framework for the Future