1. Long Term Care in Older Adults
Seki Balogun, MD, FACP

2. Objectives By the end of this session, students will be able to:
Recognize the two main types of long term care
Recognize the differences between the nursing homes and assisted living facilities.
Discuss the different patient characteristics of both institutions.
Relate to older adults who are in long term care.

3. Long Term Care Nursing Homes Assisted living facilities
Focus of care is to achieve and maintain an optimal level of functioning
Interdisciplinary care

4. LTC: Historical background
Twelfth century
“Gerocomeia” in ancient Greece
Early 1900
Europe: special care units for the chronically ill elderly
United States: chronically ill and disabled
Poorhouses

5. Historical background
State licensure programs
Standards and oversight were minimal
Mid – 1900s
Social Security Act
Private nursing homes
Run by nurses
Custodial care
Post- world war II: modeled after hospitals
Minimum standard of care

6. Historical background
Nursing Home Reform Act (OBRA ’87)
State regulations
Quality of care for the cognitively and functionally impaired

7. Nursing homes
1.5 million Americans (most aged 65 years and older) reside in 17,000 nursing facilities nationwide
43% of adults 65 years and older will stay in a nursing home at some time before they die
55% have a lifetime use of at least 1 year
21% have a total lifetime use of 5 years or more

8. Nursing Homes
Skilled nursing care
Long term nursing care
Hospice care

9. Case 1.
Mr. TB is a 90 year old man with multiple medical problems, who was admitted to the hospital last week with community acquired pneumonia.
He is now ready for discharge
He is deconditioned and is unable to ambulate
He lives with and is the caregiver for his wife, who has advanced dementia

10. Nursing Homes Skilled nursing care
Typically for those discharged from an inpt setting with functional deficits and often medically complex
Require one or more forms of therapy (PT, OT, speech)
High degree of nursing care: IV, wound care
Length of stay usually less than 6 months (few days to months)
Paid for by Medicare

11. Case 2.
Ms. TJ is an 85year old woman with paraplegia from a spinal cord injury. She has severe neuropathic pain and is wheelchair dependent.
She lives alone, has no relatives in VA.
She had a paid caregiver, 6hrs/day, who helped her with self care (bathing, toileting) and her instrumental ADLs (cooking, cleaning and shopping).
She can no longer afford to pay her caregiver

12. Nursing Homes Long term nursing care
For those who can no longer live independently
Require assistance for self care and IADLs
Significant functional, cognitive or psychosocial deficits
Paid for:
Private pay
Long term care insurance
Medicaid

13. Nursing Homes Hospice care
Terminal conditions with less than 6 months to live
Usually in conjunction with an independent hospice organization
Team provides a network of services: physicians, nurses, social workers, chaplain
Paid for by Medicare

14. So what should happen to seniors who need some help, but do not require 24 hr nursing care?
They should be admitted to the nursing home: better safe than sorry.
Their family should care for them: it is their responsibility
They could live in an assisted living facility
They should pay for a caregiver

15. Assisted Living facility
Residents require some supervision or physical assistance due to functional or cognitive deficits
Usually owned by private organizations
Provision of individual care needs vary with facility
Provides 3 meals and medication administration
Costs about $2-4K/month
Paid for: Private pay
Long term care insurance

16. Assisted living facility
Better received by seniors
More home - like
Less institutionalized setting
Rare “Auxiliary Grants” for low income people.
A few beds in our area at Mountainside in Crozet.

18. HealthCare Financing in LTC
Medicare
Medicaid
Long term care insurance
Private pay