1. Long-Term Care: The Basics Seema S. Limaye, MD Section of Geriatrics Department of Medicine University of Chicago—Pritzker School of Medicine

2. LTC BASICS What is LTC? What is LTC? Who uses LTC services? Who uses LTC services? How is LTC reimbursed? How is LTC reimbursed? Nursing Home 101: Nursing Home 101: –Organization –Regulation –Reimbursement In the context of health disparities… In the context of health disparities…

3. What is long-term care? Definition: medical, social, personal care, and supportive services needed by people who have lost some capacity for self-care because of a chronic illness or condition. Definition: medical, social, personal care, and supportive services needed by people who have lost some capacity for self-care because of a chronic illness or condition. –Home Care –Adult Day Programs –Nursing Home –Rehabilitation –Long-term chronic care

4. Who uses LTC services? Patients who have lost capacity for self-care because of illness Patients who have lost capacity for self-care because of illness Common medical reasons: Common medical reasons: –Urinary Incotinence –Dementia/wandering Common social reasons… Common social reasons…

5. What is a LTCF? Long-term care facility: A facility that provides rehabilitative, restorative, and/or ongoing skilled nursing care to patients or residents in need of assistance with activities of daily living. Long-term care facility: A facility that provides rehabilitative, restorative, and/or ongoing skilled nursing care to patients or residents in need of assistance with activities of daily living.

6. LTCF: Nursing homes, Nursing homes, Rehabilitation facilities, Rehabilitation facilities, Inpatient behavioral health facilities, Inpatient behavioral health facilities, Long-term chronic care hospitals Long-term chronic care hospitals

7. Projection of Expenditures of National LTC services—in billions of 2000 dollars Payer200020102030 Medicare29.439.850.6 Medicaid43.436.736.2 Private LTC Insurance 5.016.736.2 Out-of-pocket42.835.542.9 Other payer <5<5<5 Total Long Term Care Services (Includes services provided in home and institutional setting). Source: Congressional Budget Office

8. How are LTC services reimbursed? Depends on the services… Depends on the services… ServiceReimbursement Home Care Part A and Part B Custodial NH Care Patient and Medicaid Rehab: acute and subacute Part A Chronic LTC hospital Patient and Medicaid Hospice Part A

9. How are LTC services reimbursed? (cont) ServicesReimbursement Durable Medical Equipment Part B Homemaker services Department of aging: State-controlled Federal Mandate

10. NURSING HOME 101

11. Nursing Home 101 Resident pays out-of-pocket Resident pays out-of-pocket LTC insurance LTC insurance Medicaid Medicaid Medicare DOES NOT pay for custodial, nursing home care! Medicare DOES NOT pay for custodial, nursing home care!

12. Subacute Rehab Payor: Medicare RUG: Resource Utilization Group RUG: Resource Utilization Group –Medicare A pays based on categories of utilization—53 RUGs as of 2006 –3 midnights –Up to 100 days covered* First 20d are fully covered, D21-100 are partially covered –Need 60 day break between next 100 day coverage period

13. Types of SNF For-Profit 2/3 of NH 2/3 of NH Lower case mix Lower case mix Accept Medicaid pending and Medicaid Accept Medicaid pending and MedicaidNot-for-Profit 1/3 of NH 1/3 of NH Higher case mix Higher case mix Higher Staffing #’s Higher Staffing #’s Tax exemption Tax exemption Usually have a limited number of Medicaid beds Usually have a limited number of Medicaid beds Most are religiously affiliated organizations Most are religiously affiliated organizations ?Higher quality? ?Higher quality?

14. Key “Players” in SNF Executive Director NH AdministratorMedical DirectorDirector of NursingSocial Worker Rehab services -PT -OT -Speech/Swallow

15. (More) Key “Players” in SNF Medical Director PhysiciansAPNsPA’s

16. (More) Key “Players” in SNF Director of Nursing Asst DONRN/LPNCNA

17. (More) Key “Players” in SNF Activities Director Activities Director Dietician/Nutritionist Dietician/Nutritionist

18. Quality in the NH Who regulates quality in Illinois nursing homes? Who regulates quality in Illinois nursing homes? –City of Chicago Due to budget cuts, not as large a presence Due to budget cuts, not as large a presence –IDPH State codes State codes Follow federal guidelines, also Follow federal guidelines, also –Medicare/CMS What is regulated? What is regulated? –over 150 regulatory standards Everything from safe storage and preparation of food to protecting residents from physical or mental abuse or inadequate care practices Everything from safe storage and preparation of food to protecting residents from physical or mental abuse or inadequate care practices

19. Why all the regulations? IOM report 1986 “Improving the Quality of Care in Nursing Homes” IOM report 1986 “Improving the Quality of Care in Nursing Homes” –“Appallingly bad” medical and nursing care (avoidable decline) –Poor quality of life (lack of personal choice, lack of respect, fear) –Regulation is essential to protect vulnerable elderly –Free market approach will not work

20. OBRA 87 Nursing Home Reform 1990: 1990: –Resident rights –Maintain highest practicable level of functioning –Medical Director responsibilities –Physician visits and physician extenders –Resident Plan of Care MDS Assesment MDS Assesment –Stricter enforcement

21. IOM Report 2001 Improving the Quality of Long- Term Care Areas of Improvement: –Restraints –Psychotropics Persistent Problems: –Pain –Pressure sores –Malnutrition –Urinary Incotinence “Evidence indicates that quality of care in general has improved over the past decade…”

22. Quality in the NH Annual State and Federal surveys Annual State and Federal surveys –3-5 day visit –Inspect facilities –Chart audit –Resident/family interviews Resident/Family Complaint Resident/Family Complaint –State investigates within 72h –Fine + plan of correction

23. Survey Reporting Nursing Home Compare-on Medicare website Nursing Home Compare-on Medicare website –MDS database: NH reports NH reports –On-line Survey Certification and Reporting: OSCAR database Surveyor reports from annual visit Surveyor reports from annual visit

24. Minimum Data Set 350-item questionnaire 350-item questionnaire “clinical assessment” “clinical assessment” Submitted to Medicare Submitted to Medicare Done periodically Done periodically Used for regulating and research Used for regulating and research –Pros and cons?

25. How is quality improved upon in the NH? Quality Assurance meetings Quality Assurance meetings –Often quarterly –Interdisciplinary –Look for trends –Focus on quality indicators: PU, falls, skin

26. Disparities in SNF Access to LTC facilities: Access to LTC facilities: –Blacks are concentrated in a smaller proportion of LTC facilities 1 –Blacks are more likely to occupy Medicaid facilities with deficiencies 2 –Blacks more likely to live in understaffed facilities 2 –LTC facility racial segregation well-documented in Chicago 3 1.Smith DB. Feng Z. Fennell ML. Zinn JS. Mor V. Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes. Health Affairs. 2007; 26 (5): 1448-1458. 2.Grabowski DC. The admission of blacks to high-dificiency nursing homes. Medical Care. 2004; 42(5):456-64 3.Reed SC. Davis N. The Jane Dent Home: The rise and fall of homes for the aged in low-income communities. Journal of Health Care for the Poor & Underserved. 2004; 15(4): 547-61.

27. Disparities in SNF Racial Health Disparities: Racial Health Disparities: –development of pressure ulcer (Rosen et al. 2006 and Baumgarten et al. 2004), –treatment of diabetes mellitus (Allsworth et al. 2005), –assessment and treatment of vision loss (Friedman et. al. 2004), –treatment for secondary prevention of stroke (Christian et. al.2003), –use of advance care planning (Degenholtz et. al. 2002).

28. Ethnogeriatrics and LTC Older literature: Older literature: “Cultural aversion process”—explains that minority older adults seek NH care at later ages because of cultural difference: –family and social support Newer literature: Newer literature: Family structure and roles are changing –Many ethnic groups are moving towards patterns of larger culture

29. Components of Ethnically- Oriented NH Care 4 Location Location Selection and training of staff Selection and training of staff Admission policy and process Admission policy and process Cost Cost Interaction with Family Interaction with Family Language Language Food Food Activity Program Activity Program Religious Observances Religious Observances Personal and Nursing Care Personal and Nursing Care 4. Yeo GW. Ethnicity and Nursing Homes: Factors Affecting Use and Successful Components for Culturally Sensitive Care. Ethnicity and Long-Term Care. Springer Publishing company.1993: 161-177.

30. Other topics to ponder… Informal caregivers Informal caregivers Paid caregivers Paid caregivers Home health services Home health services