Long Term Care

The Continuum of Care

What is Long Term Care?

Health, mental health, social and residential services provided to temporarily or chronically disabled person over extended period of time

Characteristics of LT Care

Physical or mental, temporary or permanent Need based on functional disabilities Promotes or maintains health and independence in

functional abilities and quality of life To enable us to die peacefully and with dignity Multiple services and multiple professions spanning

broad spectrum Multifaceted Designed around unique needs of the individual Service can change over time

Who needs LT Care

Chronic – permanent or indefinite period of time Impaired – a decrease in or loss of ability to

perform Disabled – short or long term; varies by age

group Functional ability – person’s ability to perform

the basic activities of daily living

Understanding demand for LT Care

Patient represent “mosaic of sub-segments” of the population. Often co-morbid conditions

Services can be organized across dimensions of users

Some users of LT care have significant differences from other users

Organization of LT Care

Informal organization – most LT care is provided by family and friends

Each community may be different regarding availability of services

Ideal system – client oriented continuum of care.

What is Continuum of Care?

Matches resources to patient’s condition Monitors the client’s condition and changes

services as needs change Coordinates care across disciplines Integrates care in a range of settings Enhances efficiency, reduces duplication,

streamlines patient flow Maintains comprehensive record keeping

Categories of Continuum of Care

Extended care Acute inpatient care Ambulatory care Home care Outreach Wellness HousingNOTE: Not all LT care clients get this full range of care.

This is ideal that may offset or delay chronic illness.

Providers of LT Care

Hospitals Nursing homes (average costs $4,500 per

month) Home health agencies Hospices Adult day service programs Housing organizations

Types of LT Care Services(Source: http://www.medicare.gov/LongTermCare/Static/CommunityServices.asp

  Help with activities

of daily living Help with additional

services Help with care

needs Range of costs

Community-Based Services

Yes Yes No Low to medium

Home Health Care Yes Yes Yes Low to high

In-Law Apartments Yes Yes Yes Low to high

Housing for Aging and Disabled Individuals

Yes Yes No Low to high

Board and Care Homes

Yes Yes Yes Low to high

Assisted Living Yes Yes Yes Medium to high

Continuing Care Retirement Communities

Yes Yes Yes High

Nursing Homes Yes Yes Yes High

Paying for LT Care

Nursing home care represents approximately 8% of personal health care expenditures

Home health care about 2% of expenditures though this is trending higher

Since LT care is provided mostly by family and friends, these figures don’t represent full cost

Medicare, Medicaid cover much of the cost Out of pocket costs for LT care are significant Little private insurance currently pays for LT care though

incentives have been implemented to cover that area

How we pay for LT Care Long Term care insurance – only about 10% of

LT care recipients have this coverage Using personal funds – method typically used

first until funds run out Medicare – only provides short term percentage

of LT care (does not include custodial care) Medicare covers 100% cost for first 100 days Provides 80% costs for next 80 days Provides no reimbursement for subsequent

Medicaid – once income eligibility is met, pays for most of the cost of LT care

Medicaid Spend Down – Exempt Assets Medicaid eligibility based on income Pays for skilled care and custodial care Some exemptions apply

Up to $2,000 in cash assets Home, no matter the value Personal belongings One car or truck Burial spaces Up to $1,500 designated as burial fund for applicant and spouse Value of life insurance if less than $1,500 (otherwise, must

surrender value in excess of amount up to cost of care)

Medicaid Spend Down Non-exempt Assets All cash assets above $2,000 Certificates of deposit Stocks, bonds, mutual funds Land contracts or mortgages for real estate sold U.S. Savings bonds Most IRAs Nursing home accounts Prepaid funeral contracts issued in Nevada Most trusts Real estate other than primary residence More than 1 car or truck Boats or recreational vehicles

Getting around the Spend Down process IRS allows $11,000 gift tax per child, but this does not

apply to Medicaid and gifts over $4,500 3 years prior to care will result in loss of eligibility until full gift costs are met.

Division of assets At home spouse is able to keep ½ of all assets up to $92,000 The other half must be spent down for care

Spousal support: At home spouse is allowed to make up to $1,561 per month in income. If income does not meet that much, allowed to use other LTC spouse income up to that amount. (Court orders can increase this amount)

Mental Health Care

The Forgotten Population

Incidence and Prevalence of MH Disorders in U.S. 30-40% experience some psychiatric disorder in

their lifetime 21% of children ages 9 – 17 receive MH

services in a year Ranks 2nd in terms of burden of disease in

established economies In general, 19% of population have mental

disorder alone, 3% have dual diagnosis, and 6% have addictive disorder

MH Descriptives

Most people with Psych disorders experience onset prior to age 38

Men More common among men (mostly alcohol abuse and antisocial

personality disorder or “Cochran’s Syndrome”) Phobia and alcohol abuse most common Cognitive impairment most common among those 65 and older

Women Somatization disorders (somatization of symptoms masking underlying

psych disorder), obsessive compulsive, and depressive disorder Rates for MH disorders drop after age 45 (except for

cognitive disorders)

Early Views on Mental Illness

Based primarily on values. Aberrant behavior could be viewed as demonic or evil spirits.

Lunatic hospitals began in Elizabethan England (primarily to protect society from misfits)

Mental illness began as diagnosis during scientific revolution in Germany

Freud changed the way we viewed mental illness and related it to unconscious development difficulties

Mental Illness Attitudes in U.S.

During 20th century, there has been increasing acceptance of pluralistic determinants of mental illness

Greater reliance on the disease concept Better understanding of the role of personality

development from social or cultural influences Still an underlying current of the “Eurocentric”

perspective – abnormal or deviant behavior as a reflection of values, norms and belief systems of the mainstream

Recent U.S. Mental Health Policy

Development of psychopharmacology in the 1950s Mental Retardation Facilities and Community Mental

Health Centers Constructions Act of 1964 built more mental health centers

Mental Health System Act proposed by Pres. Carter would have provided better funding but was not implemented by Reagan or Bush the First.

Expansion of health insurance to cover treatment (generally significantly less coverage than other health insurance)

MH Delivery System

1955-80, most services provided in state or county mental hospitals

Public and private sector health care Public sector primarily paid by Medicare or Medicaid

Major decline in state mental health hospitals Outpatient services account for nearly 75% of

MH services

Mental Health and the Future

Greater reliance on psychopharmacology Debate of MH vs. Values will continue

Is Mental Illness an excuse? Are all of our personality problems attributable to mental illness?

Relationship of mental illness and homelessness (approximately 20-25% of homeless have mental illness) Up to 50% have co-occurring mental illnesses and substance use

disorders. Their symptoms are often active and untreated, thus difficult to obtain

basic needs for food, shelter and safety and causing distress to those who observe them.

They are impoverished, and many are not receiving benefits for which they may be eligible.

Mental Illness and Las Vegas

Overcrowding of emergency rooms by mentally ill

Shortage of mental health facilities and professionals

Implementation of Legal 2000 to transport and hold mentally ill

Nevada ranks 2nd nationally in suicide

Don’t feed the

homeless! It’s the law!