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

2. 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.

3. 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).

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

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

15. 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.

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

17. 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.

18. 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.

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

20. 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

21. 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.

22. 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.

23. 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.

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

25. 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

26. 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

27. 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.

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

29. Case Management Case identification Assessment Care planning
Service arrangement
Monitoring
Reassessment

30. 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

31. 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.

32. 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.

33. 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.

34. 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

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

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

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

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

39. Older American Act Congregate meals Meals on wheels Homemaker
Case management

40. Title XX
Home care
Chore service

41. 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

42. 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.