HSC 6636: Long Term Care 1 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Topics Demographics of LTC LTC Needs—A Starting Point Financing LTC LTC Goals LTC Providers Issues and Trends “All to often, the public equates LTC with care in a nursing home or another institution. However, LTC is a broad constellation of services provided in diverse settings to a heterogeneous population with many different needs.” Text, p. 240

HSC 6636: Long Term Care 2 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Demographics of Long Term Care What are the changes of the last 100 years that affect Long Term care? –Family structure and location? –Population distribution by age? –Medical care? Or, how was Long Term care provided in 1900?

HSC 6636: Long Term Care 3 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Needs Table 9.1—Range of LTC Services –Housekeeping and daily living support –Companionship & social support –Transportation (including to medical care) –Personal care –Nursing and healthcare procedures –Rehabilitative services –Palliative care –Care management

HSC 6636: Long Term Care 4 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Needs (cont.) Who Needs LTC? –Those disabled from birth –Victims of injury or disease –The elderly Adults 85+ seven times more likely than adults to need LTC This age group growing “exponentially” Evidence is that the group will be healthier than their predecessors

HSC 6636: Long Term Care 5 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Financing LTC Consider the activi- ties from Table 9.1 –What are typical sources of payment for each? –What is the special burden Medicaid places on recipients of these services? –How might Medicaid spending change as states face continuing budget problems? Why is measuring LTC expenditure levels so difficult? Housekeeping and daily living support Companionship & social support Transportation (including to medical care) Personal care Nursing and healthcare procedures Rehabilitative services Palliative care Care management Table 9.1 List

HSC 6636: Long Term Care 6 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Financing LTC (cont.) Spending sources on Home Health Care * –Medicaid: $15.5 billion (32.6%) –Medicare: $17.9 billion (37.7%) Out of Pocket Nursing and Home and Community Services *: –$37.4 billion –22% of total spending * Note that different services are compared

HSC 6636: Long Term Care 7 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Financing LTC (cont.) LTC Insurance –What does it cover? –Staggered premium structure depending on age when purchased –Is $1,000 - $7,000 / yr too much to spend for piece of mind? Should you charge your kids for the coverage?

HSC 6636: Long Term Care 8 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Goals of LTC

HSC 6636: Long Term Care 9 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Goals of LTC (cont.) See Table 9.2 –Who pays? –Who benefits? –Who decides? –What do terms such as “_____” mean to a policy maker? “Needs” “Adequate” “Long as possible” “Efficient” “Acceptable” “Maximize”

HSC 6636: Long Term Care 10 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers The multidimensional nature of LTC (Table 9.1) results in a multidimensional collection of LTC providers –Unpaid caregivers –Home care agencies –Hospice services –Nursing homes –Adult day services –Community-based residential alternatives –Continuing care retirement communities Q: Is a taxicab driver a LTC provider if he/she takes a patient to an appointment?

HSC 6636: Long Term Care 11 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Unpaid Care –Primarily family and friends –Valued at $7.5 - $11.2 billion / year But no systematic data collection –What are the costs of unpaid care? –What could be done to improve the unpaid care environment? –What are the social costs and benefits of supporting unpaid care providers?

HSC 6636: Long Term Care 12 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Paid Care Providers—Overview –Growth industry but what has fueled the growth? Government programs Dual income families Aging population –What are social and individual costs and benefits? –What future trends will we see? –How could government entitlement changes affect the industry? –Would you want to work in this field?

HSC 6636: Long Term Care 13 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Home Care Agencies –Provide medically related services to patients at home –Provide nonmedical personal services –Recipients of government subsidies subject to both medical and needs tests for eligibility –Industry responds (fairly quickly) to changes in funding and eligibility rules –What is the career potential in this field?

HSC 6636: Long Term Care 14 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Hospice Services –Relatively new service Recognized by Medicare in 1983 –Dramatic growth in use of services –What issues does Hospice care face? –What are the costs and benefits Individual? Aggregate? –What is the career potential in this field?

HSC 6636: Long Term Care 15 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Nursing Homes –Best known of LTC services –Heavily regulated But data gathering is difficult Almost all data is self-reported –Increasing variety of treatments and programs –Some interesting changes in enrollment rates How might these patterns look going forward? –What is the career potential in this field?

HSC 6636: Long Term Care 16 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Adult Day Services –What is the market niche for these services? –Why do you think that 78% of these services are nonprofit? –What are the implications of an unmet need for 5,500 more centers? –Service orientations may differ Medical services Social services Mixed –What is the career potential for these services?

HSC 6636: Long Term Care 17 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Community-Based Residential Alternatives to Institutional Care –Let’s define these facilities by how they differ from other alternatives –Note the wide range of service packages that come under this heading –Also note differing regulatory environments Different state rules Different rules for different types of services –Again, what is the market niche these facilities address?

HSC 6636: Long Term Care 18 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida LTC Providers (cont.) Continuing Care Retirement Communities –A relatively new concept with exciting potential –Many work on a healthcare condominium model with resident ownership interests –Different fee schedules depending on Ownership model –May incorporate an insurance function Pricing structure

HSC 6636: Long Term Care 19 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends Cost vs. Access –LTC incorporates almost all of the HC costs and cost trends of other HC As overall costs grow so do LTC costs –Also include non-HC costs for those not able to perform tasks themselves –Approaches Improve use of LTC insurance Control supply of beds to control use of services Alternatives to more expensive options

HSC 6636: Long Term Care 20 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends (cont.) Quality Assurance –Quality difficult to assure Multitude of facilities and types makes inspection programs difficult Field relies heavily on self-reporting Split responsibility for enforcement Serious flaws routinely found when inspections are performed –The government is taking a market-based approach by providing quality reports online

HSC 6636: Long Term Care 21 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends (cont.) Quality Assurance (cont.) –Home care even more difficult to supervise than institutional care

HSC 6636: Long Term Care 22 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends (cont.) Increasing Consumer Choices –“…there is wide agreement that consumers should have significant choice regarding their long-term care arrangements.” (p. 260) How will these choices be created? Who will pay for them? –Who should manage LTC for a specific patient? –Who decides when the patient’s wishes Conflict with medical advice? Conflict with program rules?

HSC 6636: Long Term Care 23 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends (cont.) Financing Trends –What should be the role of insurance in LTC financing? –What should be the role of the government? –Can universal LTC insurance such as Germany or Japan have be politically practical in the U.S?