the long-term care industry

47

Chapter 3

The Long-Term Care Industry

What You Will Learn

• The primary component of the long-term care industry consists ofvarious providers in community-based settings, quasi-institutions,and institutional facilities. The industry cannot function without otherkey partners.

• Home health care is a prime example of community-based long-termcare providers. Others include homemaker and personal care serviceproviders, adult day care providers, and hospice service providers.

• Independent living and retirement centers and custodial care providerssuch as adult foster care facilities can be referred to as quasi-institutions.

• Institutional providers are the most visible sector of the long-termcare industry. They range from assisted living facilities to a varietyof providers that are commonly referred to as nursing homes. Someinstitutional long-term care services are based in hospitals.

• Commercial insurance companies and managed care organizationsplay a critical role in the financing of long-term care services.

• A variety of health care personnel are involved in the delivery oflong-term care. They can be classified as administrative profession-als, clinicians, paraprofessional caregivers, ancillary personnel, andsocial support professionals.

• The ancillary sector includes case management agencies that assistclients with identifying and obtaining appropriate long-term careservices, long-term care pharmacies that provide drug managementand pharmaceuticals to facilities, and developers of long-term caretechnology.

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Scope of the IndustryEfficient delivery of services to a nation’spopulation necessitates a long-term care(LTC) industry. The industry in the UnitedStates has been shaped primarily by LTCpolicy. But, the government’s role has beenmainly indirect—as a financier and regula-tor. The government plays a very small rolein the direct delivery of LTC services. TheLTC industry mainly consists of providersof services other than informal caregiversand government agencies that deliver socialservices. Among the providers are hospital-based LTC services that emerged in the late1980s. Hospice services provide end-of-lifecare and are regarded as a component oflong-term care. The industry cannot functionwithout other key partners. These partners in-clude the insurance industry, managed careorganizations, professionals employed in theLTC industry, case management agencies,long-term care pharmacies, and developersof technology.

The Provider SectorProviders are organizations or individualsthat deliver LTC services and get paid for theservices delivered. The health care industryis replete with examples of providers, includ-ing hospitals, nursing homes, home healthagencies, hospices, physicians, pharmacists,and laboratories. Various private organiza-tions and facilities, both for-profit and non-profit, are part of the LTC industry. Mostof these organizations deliver institutionalcare, but the private sector that deliverscommunity-based services has also grown.A prime example is home health care, which

has been a growing industry in itself. TheLTC industry is predominantly funded by thegovernment, and certain sectors of the indus-try are more stringently regulated than others.

Community-Based Service ProvidersFour main types of providers constitute thecommunity-based sector of the LTC industry:(1) certified home health providers, (2) home-maker and personal care service providers,(3) adult day care providers, and (4) hospiceservice providers.

Certified Home Health ProvidersHome health care is consistent with the phi-losophy of maintaining people in the leastrestrictive environment possible. Without theavailability of skilled nursing care and reha-bilitation services in patients’ own homes,the patients would have to be in hospitals ornursing homes to receive the same servicesat a much higher expense.

As pointed out in Chapter 2, the 1988class-action lawsuit of Duggan v. Bowen wasinstrumental in expanding home health ben-efits under Medicare. The new rules that tookeffect in 1989 (1) removed the requirement ofa three-day hospital stay before home healthvisits would be covered under Medicare, (2)abolished the maximum limit of 100 visits,and (3) included coverage for skilled obser-vation with stable health needs rather than ex-pectations of improvement, as the formercriterion had specified. In spite of thesechanges, Medicare criteria continue to focuson recovery from acute illness, not long-termmaintenance or assistance with functional dis-ability (Hughes & Renehan, 2005). Althoughvisits continue until the client’s plan of care isaddressed, this period is short, often a few

48 CHAPTER 3 • The Long-Term Care Industry

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weeks in length for most clients (Dieckmann,2005).

Between 1990 and 1996 alone, the num-ber of home health care providers grew from5,800 to 9,900 (Liu et al., 1999). In 2007,there were 9,284 Medicare-certified homehealth agencies. Of these, 17% were affili-ated with an institution such as a hospital ornursing facility and 83% were freestanding(NAHC, 2008). Medicare is the largest sin-gle payer for home health services. ForMedicaid beneficiaries, states pay for thesame services that Medicare does. Privateinsurance also includes skilled home carebenefits.

In addition to Medicare-certified agen-cies, there are numerous noncertified homecare agencies, home care aide organizations,and hospices. Often, such agencies do notprovide the breadth of services that Medicarerequires. For example, home health aide or-ganizations do not provide skilled nursingcare (NAHC, 2008).

Homemaker and Personal Care Service ProvidersVarious private agencies offer services forin-home assistance. Some of these agenciesare also Medicare-certified to deliver skillednursing and rehabilitation care. Homemakerand personal care services, however, are notcovered under the Medicare program. Tovarying degrees, states pay for homemakerand personal care for Medicaid beneficiaries.Personal funds are used to pay for these ser-vices by those who do not qualify for Med-icaid. Homemaker and personal servicesinclude assistance with personal hygiene(such as bathing), light housework, laundry,meal preparation, transportation, and gro-cery shopping.

Adult Day Care ProvidersAdult day care is a nonresidential, communi-ty-based extramural service. It enables peo-ple to live with their families and fulfillsfamily caregivers’need for respite so they cango to work during the day. These centers maybe located in senior centers, nursing facilities,churches or synagogues, or hospitals. Manycenters also provide transportation from hometo the center and back. On the other hand, lackof transportation and the high cost of trans-portation are also major impediments to theuse of adult day services (O’Keeffe & Siebe-naler, 2006).

Based on their focus, there are three mainmodels of adult day services (NADSA,2008): (1) the social model emphasizes recre-ation and furnishes meals and some basichealth-related services; (2) the medical/healthmodel provides nursing care and rehabilita-tion therapies in addition to social activities;and (3) the specialized model provides ser-vices only to specific care recipients, such asthose with dementia or developmental dis-abilities. Many programs combine the firsttwo models. Among those using adult dayservices nationwide, 52% have some cogni-tive impairment and are the largest users ofthis type of service. Other users are frail el-derly who need supervision and those withmental retardation/developmental disabilities(PIC, 2003).

In 2002, more than 3,400 adult day cen-ters were operating in the United States, andthey provided care to 150,000 adults each day(PIC, 2003). The vast majority were operatedby a parent organization, such as a hospital ornursing facility, on a nonprofit basis. Adultday care has become a growth industry be-cause of rising demand, and an increasingnumber of for-profit centers are being opened.

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The national average for adult day carecost is around $56 per day (Feldstein, 2008).Costs often vary by the type of service, par-ticularly the extent of health care services theparticipant requires. Medicare does not payfor adult day care, but expenses can be cov-ered through a variety of other sources. Un-der the home- and community-based services(HCBS) waiver program, introduced in Chap-ter 2, Medicaid is the leading source of pay-ment for adult day care. Other sources offunding include Title III of the Older Amer-icans Act, Veterans Health Administration,private long-term care insurance, and privateout-of-pocket funds. Some rehabilitation ther-apies may be covered under Medicare.

Hospice Service ProvidersHospice services were introduced in Chapter1. Medicare added hospice benefits in 1983,10 years after the first hospice opened in theUnited States. For a patient to receive hospicebenefits, a physician must certify that the pa-tient is terminally ill and that the patient’s lifeexpectancy is six months or less. Benefit pay-ments by Medicare, however, are not limitedto six months. The patient must also agree towaive the right to benefits for the medicaltreatment of the terminal illness.

People most commonly served by hos-pice have cancer, heart disease, unspecifieddebility, dementia, or lung disease. Canceraccounts for approximately 41% of all diag-noses. In 2007, 39% of all deaths in the Unit-ed States occurred in hospices (NHPCO,2008).

Hospice can be a part of home health carewhen the services are provided in the patient’shome. In other instances, services are takento patients in nursing homes, retirement cen-ters, or hospitals. Services can be organizedout of a hospital, nursing home, freestanding

hospice facility, or home health agency. In2007, there were roughly 4,700 hospiceproviders located in all 50 states, the Districtof Columbia, Puerto Rico, Guam, and theU.S. Virgin Islands. The majority of hospicesare independent, freestanding agencies (Fig-ure 3–1).These hospices served 1.4 millionpatients in 2007 (NHPCO, 2008).

Medicare is the primary source of pay-ment (83.6% in 2007) for hospice care (NH-PCO, 2008). Other sources include privateinsurance and Medicaid.

Quasi-Institutional ProvidersAs noted in Chapter 1, the institutional con-tinuum of LTC includes a range of facilitiesthat often do not have clear-cut distinctions.Yet, these facilities can be classified intothree main categories: (1) independent living


Sources: Data from National Hospice and Palliative Care Organization,2008; and NHPCO Facts and Figures: Hospice Care in America,retrieved October 2008 from http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_2008.pdf.

Nursing home based,1%

Home health based,20%

Hospital based,21%

Independent,58%

Total hospices: 4,700Nonprofit 49%, for-profit 47%, government-owned 4%

Figure 3–1 Types of Hospice Agencies, 2007

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facilities, which are not truly institutions be-cause they do not generally deliver healthcare; (2) custodial care providers that limittheir services to social support and personalcare; and (3) assisted living facilities andnursing homes. Here, the first two categoriesare referred to as quasi-institutions becauseclinically oriented services are either nonex-istent or minimum in these facilities.

Independent Living and RetirementCentersThe variety of community-based LTC ser-vices that are now available have enabledmany older and disabled adults to live inde-pendently in supportive housing units. Theresidents can come and go as they please. Fa-cilities include designated parking spaces.

The two main independent living cate-gories are (1) government-assisted housingand (2) private-pay housing. These dwellingsdiffer from other institutional settings in thatstaff are generally not present 24 hours a day.A business manager generally maintains of-fice hours five days a week and may be avail-able on-call for emergencies.

Government-Assisted HousingThe U.S. Department of Housing and UrbanDevelopment (HUD) administers three dif-ferent housing programs:

1. Under the Public Housing program,HUD administers federal aid to localhousing agencies that manage thehousing for low-income residents atrents they can afford. Anyone withlow income, including the elderly anddisabled persons, can apply for theprogram.

2. The Section 8 program offers vouch-ers or certificates that allow people tochoose any housing in the private mar-ket that meets certain requirementsand apply the voucher or certificatetoward rent. Section 8 program is alsomanaged by local public housingagencies.

3. The Section 202 Supportive Housingfor the Elderly program is specifical-ly meant for low-income people whoare at least 62 years old at the time ofinitial occupancy.

HUD provides interest-free capital ad-vances to private, nonprofit sponsors to fi-nance the development of supportive housingfor the elderly. HUD also provides rent sub-sidies for the projects to help make them af-fordable. The capital advance does not haveto be repaid for 40 years as long as the pro-ject serves very-low-income elderly persons.A similar program is Section 811 Support-ive Housing for Persons with Disabilities.Additional supportive services such as MealsOn Wheels, homemaker services, and trans-portation are arranged from community-based providers.

Private-Pay HousingMany upscale retirement centers abound, inwhich one can expect to pay a fairly substan-tial entrance fee plus a monthly rental ormaintenance fee. These complexes have var-ious types of recreational facilities and socialprograms. The fees often include the eveningmeal. Cleaning services, transportation, andother types of basic assistance may be pro-vided at an extra charge. Many of these facil-ities provide monthly blood pressure andvision screenings, and many organize local


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outings for shopping and entertainment. Nurs-ing or rehabilitation services, when needed, canbe arranged with a local home health agency.

Custodial Care ProvidersCustodial care is nonmedical care that in-cludes routine assistance with the activities ofdaily living (ADLs), but does not include ac-tive nursing or rehabilitative treatments. Suchcare is provided to maintain function becausethe person’s overall condition is not likely toimprove. It is the focus of residential or per-sonal care. Custodial services are rendered byparaprofessionals, such as aides, rather thanlicensed nurses or therapists. The facilitiesin this sector go by various names: adult fos-ter care homes, board-and-care homes, per-sonal care homes, sheltered care homes, anddomiciliary care homes. Each state has es-tablished its own standards to license thesefacilities. Funding typically comes fromMedicaid, private insurance, and personalsources. Medicare does not pay for custodialcare alone. Depending on temporary needs,home health care can be called in to deliverskilled nursing and rehabilitation services.

Adult foster care (AFC) homes (alsocalled adult family homes or adult familycare) are family-run homes that provide room,board, supervision, and custodial care. Thehomes are modified to accommodate peoplewith disabilities and prevent unsupervisedwandering because many residents have somedegree of dementia or psychiatric diagnosis.There is 24-hour supervision in the homes.Typically, the caregiving family resides in partof the home. To maintain the family environ-ment, most states license fewer than 10 bedsper family unit. However, many people havemade a business of AFC by buying severalhouses and hiring families to live in them andcare for the residents. A skeleton staff is em-

ployed to provide assistance with ADLs, toclean, and to cook meals.

Some states are trying to boost capacityof custodial care providers. Under the Mon-ey Follows the Person program, states see agreater need for quasi-institutional alterna-tives. However, in some states, such facilitiesare declining in numbers. Low reimburse-ment rates relative to assisted living are seenas one factor in the declining number of per-sons willing to be AFC providers (Mollica etal., 2008).

Institutional ProvidersInstitutional providers are the most visiblesector of the LTC industry. Most peopleequate LTC with long-term care institutions.Institutional care generally connotes somedegree of confinement to an institution be-cause of a relatively high level dependency.

Assisted Living FacilitiesFor lack of clear-cut distinctions, there canbe considerable overlap among personal care,custodial care, and assisted living. Here, as-sisted living facilities are regarded as thosefacilities that provide services that range be-tween custodial care and skilled nursingcare. Most assisted living residents requireassistance with some ADLs, such as bathing,dressing, and toileting, but do not need in-tensive medical and nursing care. Flexibleservices that meet residents’ scheduled andunscheduled needs and allow residents to agein place are key elements of the philosophyof assisted living (Hawes, 2001).

Assisted living has been the fastest grow-ing type of LTC institution in the UnitedStates. These facilities generally have a skele-ton staff of licensed nurses, mostly licensedpractical (or vocational) nurses, who perform


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admission assessments and deliver basicnursing care. Advanced nursing care and re-habilitation therapies can be arranged througha home health agency.

There are an estimated 39,500 assistedliving facilities serving more than 900,000residents in the United States (AAHSA,2008). Assisted living is paid for on a privatebasis for the most part. The average month-ly charges are approximately $3,200, whichis about half of what a private room wouldcost in a skilled nursing facility (Prudential,2008). Costs, however, vary considerablyamong states. Costs also vary according toamenities, room size and type (e.g., sharedversus private), and the services required bythe resident. Most facilities charge a basicmonthly rate that covers rent, board, and util-ities. Additional fees are charged for nursingand personal care services. Many facilitiesalso charge a one-time entrance fee, whichmay be equal to one month’s basic rent. Insome states, assisted living care may be cov-ered under the Medicaid program for the re-cipients of Supplemental Security Income(SSI) or may be funded through Title XXSocial Services Block Grants or 1915(c)HCBS waivers. The main purpose of thesegrants and waivers is to extend Medicaid ser-vices to people who otherwise would have toreside in nursing homes at a much higher costto the Medicaid program. Upscale facilities,however, do not participate in public paymentprograms.

Although most states license assistedliving facilities, the trend is toward increas-ing the regulatory oversight of these facili-ties. This is mainly because there is a generaltrend for assisted living providers to expandservices to keep their residents as long asthey are able to stay. For example, many as-sisted living facilities are providing special-ized care for the elderly who have dementia

and Alzheimer’s disease. On the other hand,moderate to severe cognitive impairment andbehavioral problems in particular are oftenthe most common reason for discharging aresident from an assisted living facility(Mead et al., 2005).

Nursing HomesIn the minds of many people, long-term careis synonymous with nursing homes. The ap-pellation “nursing home,” however, has nospecific meaning. In health care literature,the term “nursing home” is generally used forfacilities that are licensed as nursing homesand are often certified by the federal govern-ment. Licensing of nursing homes is manda-tory in every state. In addition to licensing,certification enables a nursing home to par-ticipate in the Medicare and Medicaid pro-grams. Details on licensure and certificationof nursing homes are covered in Chapter 5.

Skilled Nursing FacilitiesA skilled nursing facility (SNF) provides afull range of clinical LTC services, fromskilled nursing care to rehabilitation to as-sistance with all ADLs. Skilled nursing careis medically oriented care provided by a li-censed nurse. Examples of skilled nursingcare include monitoring of unstable condi-tions; clinical assessment of needs; and treat-ments such as intravenous feeding, woundcare, dressing changes, or clearing of air pas-sages. Examples of skilled rehabilitation in-clude post-surgical orthopedic care after kneeor hip replacement, cardiopulmonary reha-bilitation that is necessary after heart surgeryor heart catheterization, and improvement ofphysical strength and balance. A variety ofdisabilities—including problems with am-bulation, incontinence, and behavior—often


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coexist among a relatively large number ofpatients in need of skilled care. Comparedwith other types of facilities, nursing homeshave a significant number of patients who arecognitively impaired because of depression,delirium, or dementia. The social function-ing of many of the patients is also severelyimpaired.

A physician must authorize the need forskilled care. An attending physician mustapprove the plan of treatment. Delivery ofcare is also periodically monitored by the at-tending physician who makes rounds andfollows up on the course of various treatmentsbeing given. Rehabilitation services are pro-vided by registered therapists—physical ther-apists, occupational therapists, and speech/language pathologists—who may be em-ployed in-house or contracted from a therapyservices provider. The majority of direct carewith ADLs is delivered by paraprofessionals,such as certified nursing assistants and thera-py assistants, but under the supervision of li-censed nurses and therapists.

In June 2006, there were 15,899 nursinghomes in the United States (National Centerfor Health Statistics, 2007). According to a2008 industry survey, 17% of skilled nursingfacilities had an assisted living unit or wingand 30% had an Alzheimer’s unit or wing(MetLife, 2008). Between 1995 and 2006,the number of nursing home beds declinedby 2%, and the number of residents receivingcare in these facilities declined by 3% (seeTable 2–1 in Chapter 2). This is mainly be-cause government policy has increasinglysupported utilization of community-basedLTC alternatives. On the other hand, there issome evidence that occupancy rates in nurs-ing homes may be gradually creeping up(Kramer, 2003). This trend is expected to con-tinue as the community-based LTC industrymatures. A growing population with chronic

conditions, comorbidities, and subsequentdisability along with increased lifespans willeventually need nursing home care.

The nursing home industry in the Unit-ed States is dominated by private, for-profitnursing home chains that operate a group ofnursing homes under one corporate owner-ship. Approximately 54% of all nursing homebeds in the United States are chain affiliatedbecause chains have acquired an increasingnumber of independent facilities. In 2007,the 10 largest nursing home chains operatedat least 100 nursing homes each (Sanofi-Aventis, 2008a). About 62% of all nursinghome beds are operated by proprietary (for-profit) nursing homes, and 29% are operatedby private nonprofit entities (U.S. Census Bu-reau, 2008, Table 183). The remaining 9% aregovernment owned (most of which are ownedand operated by local counties; approximate-ly 135 are operated by the Veterans HealthAdministration). The average size of a nurs-ing home (108 beds) has changed little overtime.

Although the charges for services varyquite substantially among states, the nation-al average for a private room in 2008 was$217 per day (Prudential, 2008). Medicaidis the largest single source of payment fornursing home services. Coverage underMedicare is for a short duration subsequent toa hospital stay. Less than 8% of institutionalLTC services are paid through private insur-ance. Some LTC insurance policies maycover only a portion of the total expenses—especially when care in a nursing home isneeded over several years.

Subacute Care FacilitiesSubacute care includes post-acute servicesfor people who require convalescence fromacute illnesses or surgical episodes. These


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patients may be recovering but are still sub-ject to complications while in recovery. Theyrequire more nursing intervention than whatis typically included in skilled nursing care.According to the National Association ofSubacute/Post Acute Care (NASPAC), theseverity of a patient’s condition often requiresactive physician contact, professional nurs-ing care, involvement of an interdisciplinaryteam in total care management, and complexmedical or rehabilitative care (NASPAC,2005). The patients may still have an unsta-ble condition that requires active monitoringand treatment, or they may require technical-ly complex nursing treatments such as woundcare, intravenous therapy, blood transfusion,dialysis, ventilator care, or AIDS care.

Subacute services are generally found inthree types of locations:

1. Transitional care units (TCUs),which are skilled nursing units locat-ed within hospitals. Hospitals enteredinto this service after they started fac-ing severe occupancy declines becauseof payment restrictions from the gov-ernment, starting in the mid-1980s.They generally have higher staff-to-patient ratios and can provide moreintensive rehabilitation and nursingtherapies than freestanding skilledcare facilities.

2. Unlike TCUs that are certified asskilled nursing facilities, long-termcare hospitals (LTCHs) are certified asacute care hospitals. Here, LTCHs areclassified as nursing homes becausethey compete with other types of LTCinstitutions. LTCHs treat patients withsubacute or multiple chronic problemsrequiring long-term, hospital-levelcare. Many LTCH patients are admit-ted directly from short-stay acute-care

hospital intensive care units with com-plex medical needs. Not surprising-ly, LTCHs are the most expensive ofthe three types of subacute settings.Skilled nursing facilities are often amore cost-effective alternative, and atleast some physicians think that thelevel and intensity of care in the twosettings is comparable. LTCHs playan important role in providing high-level continuity of care to Medicarepatients. Nationwide, the number ofLTCHs has grown rapidly from 105facilities in 1993 to 392 in 2006(MedPAC, 2004, 2008).

3. Many skilled nursing facilities havedeveloped subacute units by offeringtechnology intensive services and byraising the staff skill-mix by hiringadditional registered nurses and hav-ing therapists on staff. Some suba-cute type services are also renderedby community-based home healthagencies.

Specialized FacilitiesSpecialized facilities generally provide spe-cial services for individuals with distinctmedical needs. For example, inpatient reha-bilitation facilities (IRFs) provide intensetherapies, an intermediate care facility for thementally retarded (ICF/MR) has specializedprograms for the mentally retarded and/ordevelopmentally disabled populations, andAlzheimer’s facilities have developed a spe-cialized niche within the institutional contin-uum of LTC.

Inpatient Rehabilitation FacilitiesIRFs are either freestanding facilities, some-times called rehabilitation hospitals, or theymay be rehabilitation units located within


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acute care hospitals. These specialized facil-ities provide intensive rehabilitation thera-pies that can last three hours or more per day,five days per week. The most common reha-bilitation diagnoses include spinal cord andtraumatic brain injuries, orthopedic condi-tions, stroke, and complex arthritis-relatedconditions.

Intermediate Care Facilities for theMentally RetardedFederal regulations provide a separate certi-fication category for LTC facilities classifiedas ICF/MRs. In 1971, Public Law 92–223authorized Medicaid coverage for care inICF/MR facilities. States have been requiredby federal law to provide appropriate servicesto each person with MR/DD in an ICF/MRor in a community-based setting outside ofinstitutional care (see Olmstead v. L.C. inChapter 2). However, all 50 states have at leastone ICF/MR facility for those who cannot behoused in community settings. This programserves approximately 129,000 people withmental retardation and other related condi-tions. Most have other disabilities in addi-tional to mental retardation. Many of theindividuals are nonambulatory and haveseizure disorders, behavior problems, mentalillness, visual or hearing impairments, or acombination of these. All beneficiaries mustqualify for Medicaid assistance financially(CMS, 2006).

Alzheimer’s FacilitiesAlzheimer’s disease is a progressive degen-erative disease of the brain, producing mem-ory loss, confusion, irritability, and severefunctional decline. The disease becomes pro-gressively worse and eventually results indeath. Alzheimer’s facilities provide specialprogramming and have special security fea-tures because the residents tend to wander.

Carefully designed lighting, color, and sig-nage are used to orient the residents (Skaggs& Hawkins, 1994).

Continuing Care RetirementCommunitiesFull-service continuing care retirement com-munities (CCRCs)—also called life-carecommunities—integrate and coordinate theindependent living and other institution-basedcomponents of the LTC continuum. Differ-ent levels of services are generally housed inseparate buildings, all located on one campus.The range of services is based on the conceptof aging-in-place, which accommodates thechanging needs of older adults while living infamiliar surroundings. The range of servicesincludes housing, health care, social services,and health and wellness programs. The resi-dents’ independence is preserved, but assis-tance and nursing care are available whenneeded. Approximately 1,900 CCRCs oper-ate in the United States (AAHSA, 2008).

The CCRC living option is directed atmiddle- and upper-middle-income clientele.Communities are operated by both for-profit and nonprofit organizations. Residentstypically choose to enter these communitieswhen they are in their late 70s and are stillrelatively healthy. A CCRC commonly has thefollowing levels of LTC services available:

• Independent living units may be in theform of cottages or apartments. Gener-ally, various size options are availablefrom studio apartments to two- or three-bedroom apartments.

• Custodial care and assisted living areavailable in an adjoining facility.

• A skilled nursing facility is located in aseparate building. Residents of the CCRCreceive priority in admission.


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CCRCs, for the most part, require privatefinancing, with the exception of servicesdelivered in a Medicare-certified SNF. Tobecome a resident in a CCRC, customarilythe client must pay an entrance fee that canrange between $60,000 and $120,000 (AAH-SA, 2008). In addition, a monthly accom-modation fee is charged (average monthlycost is about $2,700). The monthly chargesare adjusted when a resident needs personal ornursing care. A contract, called a continuingcare agreement, which lasts for more than oneyear and that describes the service obligationsof the CCRC and the financial obligations ofthe resident, must be signed. The contractoften has a cancellation clause that specifiesthe amount of refund a resident may be en-titled to upon leaving the community.

Three types of CCRC contracts are com-mon in the industry: extensive, modified, andfee-for-service. Extensive contracts includea complete package of services and a com-mitment to provide unlimited future LTC ser-vices when needed. A modified contractpromises to offer future LTC services at a dis-counted fee. The fee-for-service contract hasthe lowest entrance fee, but future LTC ser-vices are billed at the full rates applicable atthe time.

The Insurance SectorThe insurance sector plays an importantrole in the financing of LTC services. It in-cludes numerous commercial insurancecompanies. Companies that have the largestmarket share are Genworth Life InsuranceCompany, John Hancock, and MetropolitanLife Insurance Company, although there aremany others that offer LTC insurance. Thesecompanies offer individual and group LTCinsurance. Employees of the federal govern-

ment can purchase LTC insurance at grouprates through the Federal Long-Term Care In-surance Program.

Individual insurance is purchased by peo-ple directly through insurance companies orinsurance brokers very much like they wouldpurchase auto insurance or home insurance.Group insurance is made available to indi-viduals through their employers, unions,professional organizations, or consumer or-ganizations such as the AARP. Generally,group premiums are lower than those for in-dividually purchased insurance because alarge number of people band together to pur-chase insurance through a group sponsor.Managed care organizations (MCOs) are alsoinvolved in LTC insurance.

Commercial InsuranceApproximately 8 million Americans haveLTC insurance; 400,000 people obtained cov-erage in 2007 alone. In 2007, 180,000 indi-viduals received insurance benefits, and theinsurance industry paid out $3.5 billion inclaims for the three main types of coveredLTC services (Figure 3–2). Alzheimer’s is theprimary reason for claim payment; 27% ofAlzheimer’s-related claims are paid for nurs-ing home care and 18% for home health care.

Half the people who apply to purchaseinsurance are between the ages of 55 and 64;the average age is 57 (American Associationfor Long-Term Care Insurance, 2008). Pur-chase of insurance becomes increasingly un-affordable later in life, and the denial rates ofpeople applying to purchase insurance in-crease because of the presence of chronic con-ditions. Besides a person’s age, premium costsalso vary according to the type of coverageand the state in which a person resides. A typ-ical plan may offer $150 in daily benefits witha 5% compounded increase in benefits each

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year, a coverage period of 36 months, and a90-day elimination period, which is the ini-tial waiting period during which LTC servicesare used but not covered by insurance.

Commercial insurance companies arerisk underwriters. They determine the level ofpremiums necessary to cover potential claimsin the future. They collect premiums and payclaims arising from the utilization of LTCservices when the covered beneficiaries usethe services in accordance with the insurancecontract. Commercial insurance companies,however, do not select the providers of ser-vices. That choice is left to the beneficiaries.

Managed CareManaged care is an approach to deliveringa comprehensive array of health care servicesto a defined group of enrolled membersthrough efficient management of service uti-lization and payment to providers. The mostcommon type of MCO that is active in thedelivery of LTC services is health mainte-

nance organizations (HMOs). HMOs enterinto financial contracts with Medicaid andMedicare to deliver health care services tothe beneficiaries enrolled in these programs.

HMOs are also insurance entities thatunderwrite risk. In contrast with commercialinsurance companies, however, HMOs se-lect the providers of services. The selectedproviders are those with whom the HMO haspayment contracts. Under the Medicaid pro-gram, the Balanced Budget Act of 1997 gavestates the authority to enter into contracts withtwo broad types of managed care entities:HMOs and Prepaid Health Plans (PHPs).HMOs take the responsibility to provide acomprehensive package of health care ser-vices included in the Medicaid benefits. PHPsoffer a less comprehensive package of Med-icaid benefits. For example, a PHP may onlydeliver services covered under an HCBSwaiver program.

Both HMOs and PHPs employ a utiliza-tion management function in which a prima-ry care physician or some other managingentity authorizes medically necessary ser-vices before care is delivered. Beneficiariesmust use approved providers for receivingvarious health care services.

In 2007, all states except Alaska, Mis-sissippi, and Wyoming had Medicaid recip-ients enrolled in HMOs. Approximately 15states had 80% or more of their Medicaidbeneficiaries enrolled in HMOs. Of all Med-icaid beneficiaries nationwide, 63.5% re-ceived health care services through HMOsin 2007 (Sanofi-Aventis, 2008b).

The Balanced Budget Act of 1997 alsoauthorized the Medicare+Choice program,which was renamed Medicare Advantage in2003. Medicare gives its beneficiaries thechoice to either remain in the traditionalMedicare program or enroll in Medicare


Sources: Data from American Association for Long-Term CareInsurance. 2008; and The 2008 Sourcebook for Long-Term CareInsurance Information. Westlake Village, CA: AALTCI.

Nursing home,25.7%

Assisted living,30.5%

Homehealth care,

43.0%

Total paid: $3.5 billion

Figure 3–2 Claims For Services Paid Under Long-Term CareInsurance Coverage, 2007

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Advantage, in which services are providedthrough various MCOs. In 2007, almost 20%of the beneficiaries were enrolled in MedicareAdvantage (Sanofi-Aventis, 2008b).

Long-Term Care ProfessionalsA variety of health care professionals are in-volved in the delivery of long-term care. Theycan be classified as (1) administrative pro-fessionals, (2) clinicians, (3) paraprofession-al caregivers, (4) ancillary personnel, and (5)social support professionals. The types ofpersonnel involved vary according to the lev-el of LTC services delivered in a given set-ting. For example, independent living andretirement centers may employ one or twoadministrative professionals and a small staffof ancillary personnel. A nursing home hasall five categories of LTC professionals. Cer-tain clinicians may be found only in special-ized facilities. Growth of the LTC industrywill continue to create jobs in all areas, manyof which already have critical shortages.

Administrative ProfessionalsEvery agency or organization requires at leastone administrative professional to managethe organization. The number and types of ad-ministrative professionals increase with theorganization’s size and complexity.

AdministratorsAdministrators are needed to manage the or-ganization. They must also oversee compli-ance with federal and state regulations andensure that services are delivered in accor-dance with the organization’s policies and es-tablished standards. Administrators must have

a good understanding of financing and reim-bursement systems pertinent to their organi-zation. They must be knowledgeable aboutlegal and ethical constraints. Administratorswho manage larger organizations must alsobe skilled in managing human resources, mar-keting the facility’s services, and overseeingthe facility’s quality improvement program.Leadership, communication, financial man-agement, and problem-solving skills are alsoessential for effective management of LTCorganizations.

The title for the administrator’s positionmay vary, such as administrator, executive di-rector, director, manager, or general manager.This section mainly focuses on administratorsof home health agencies, assisted living fa-cilities, and nursing homes.

Home Health Agency AdministratorsAccording to Medicare Conditions of Par-ticipation for home health agencies, theadministrator must either be a licensed physi-cian, a registered nurse, or someone who hastraining and experience in health services ad-ministration and at least one year of super-visory or administrative experience in homehealth care or related health programs (CMS,2005). Agencies often employ a registerednurse or someone with a business degree asadministrator.

Assisted Living AdministratorsA number of states now require administra-tors of assisted living facilities to be licensed.Education, experience, and examination re-quirements vary from state to state. On theother hand, the National Association of LongTerm Care Administrator Boards (NAB) hasestablished requirements for licensure as a

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residential care/assisted living (RC/AL) ad-ministrator. To be licensed, individuals mustcomplete a 40-hour state-approved coursecovering the domains of practice and pass theNAB’s licensure examination. To take theNAB’s licensure exam, an individual musthave a combination of education and expe-rience (NAB, 2007): (1) a high school diplo-ma and two years of experience in assistedliving, including one year in a managementposition; or (2) an associate’s degree and oneyear of experience in assisted living, includ-ing six months in a management position,or (3) a bachelor’s degree and six months ofmanagement experience in assisted living.The NAB examination for RC/AL coversfive main areas, referred to as the domainsof practice: resident care management, hu-man resource management, organizationalmanagement, physical environment manage-ment, and business/financial management.A state may also require working experiencewith a trained preceptor. A preceptor is anursing home or assisted living administra-tor who meets prescribed qualifications andhas been certified to mentor interns in anadministrator-in-training (AIT) program.Generally, licensed nursing home adminis-trators are allowed to manage assisted livingfacilities without any further training. Con-tinuing education requirements are also be-coming common for license renewal.

Nursing Home AdministratorsA nursing home administrator (NHA) mustbe licensed by the state. Qualifications re-quired for licensure vary widely from onestate to another. The first step toward becom-ing a licensed NHA is to contact the partic-ular state’s licensing agency and obtain a copyof the state’s licensure requirements. Theprospective administrator must meet the min-

imum educational qualifications. Most statesrequire a college degree; some states also re-quire completion of a short course in long-term care. A common requirement by allstates is passing the national examination ad-ministered by the NAB. In addition to theNAB examination, candidates must pass ashorter examination on state nursing homeregulations. Some states may also require aninternship with a state-certified preceptorwho is also a practicing NHA. Many stateshave reciprocity agreements, meaning thatan administrator licensed in one state can ob-tain a license in another state if that state hasa reciprocity agreement with the other state.

Nursing homes are complex organiza-tions to manage and have been the target ofmuch regulatory oversight and public criti-cism. The NHA position is, in many respects,similar to that of a general manager in a com-plex human services delivery organization.The NHA must have a 24/7 commitment toan organization that must meet the patients’clinical needs, ensure their social and emo-tional well-being, preserve their individualrights, promote human dignity, and improvetheir quality of life. The NHA must have ad-equate understanding of the clinical, social,and residential aspects of care delivery.

The nursing home must also operate asan efficient business. The NHA must managestaff relations, budgets and finances, market-ing, and quality. Hence, NHAs typically havea broad range of managerial responsibilitiesand are closely involved in day-to-day opera-tional details.

Nursing home administration entailsmuch more than overseeing the various func-tions in an organization or following set rou-tines. Over time, effectively managed nursingfacilities achieve acceptable levels of organi-zational stability and have predictable out-comes in patient care quality and financial


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performance. In the long run, success isachieved by managing six critical areas:

1. The community must come to viewthe nursing home as a vital service or-ganization. One of the NHA’s primaryroles should be to serve the commu-nity in partnership with other publicand private health agencies and caredelivery organizations.

2. NHAs must understand and operatewithin the confines of what reim-bursement will allow.

3. The LTC industry has evolved overtime, and it will continue to change.The NHA must adapt to new trendsand new demands as they becomeestablished.

4. Compliance with legal and regulatoryrequirements is essentials. The organi-zation must also be managed accord-ing to the highest standards of ethicalconduct.

5. The internal operations must bestreamlined to deliver services in aseamless fashion.

6. NHAs must manage the operationthrough effective leadership, humanresource development, strategic mar-keting, financial control, and data-driven quality improvement.

Risk taking and innovation will mark suc-cessful administrators of the future. Being anNHA is a rewarding career, both financiallyand professionally. The psychological rewardsthat can come from delivering quality care topatients, helping family members, supportingcommunity initiatives, coaching the staff, andbuilding excellence into the organization of-ten exceed the financial rewards.

Department DirectorsDepartment directors constitute the middle-management stratum of a nursing home. Theorganization of nursing homes is well estab-lished. The main department directorsinclude the director of nursing, food servicedirector or dietary manager, social worker ordirector of social services, activity director,business office manager, housekeeping/laundry supervisor, and maintenance super-visor. They report to the administrator andcarry out supervisory functions in their re-spective departments. Their main role is toensure adequate staffing, availability of sup-plies and materials, and coordination of ser-vice delivery that complies with establishedstandards. Required qualifications are es-tablished by state nursing home regulations.Qualifications for the various department di-rectors are covered in Part III of the book.

Other Administrative PersonnelDepending on the size and type of organiza-tion, administrative personnel may includeassistant administrators, office managers,bookkeepers, and receptionists. Very largeLTC organizations may also employ humanresource or personnel directors, admissionscoordinators, and marketing directors. At aminimum, most organizations need (1) a re-ceptionist to greet visitors, provide informa-tion, and handle basic office tasks and (2) abookkeeper whose main responsibility is tohandle all billings and collections. Addition-al help is generally needed for payroll andaccounts payable functions.

CliniciansVarious types of clinicians are employed inhome health agencies, nursing homes, and


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assisted living facilities. They mainly includephysicians, nurses, rehabilitation profession-als, dietitians, and assistants and technicianswho work under the direction of these pro-fessionals. With the exception of nurses, mostothers are generally contracted.

PhysiciansOnly very large and specialized facilities canafford to employ a full-time physician. Mostorganizations contract with a physician in thecapacity of a medical director, which is typ-ically a part-time position and is discussedin Chapter 10. It is not uncommon for themedical director to also provide medical ser-vices to many of the patients in nursinghomes. The patient, however, has the right tochoose his or her attending physician pro-vided that the physician is willing to followup on the patient’s medical care while he orshe is in the nursing home. The patient’sphysician is also involved in the plan of carefor services provided by a home healthagency. Admission to a nursing facility or careby a home health agency is also authorized bya physician. Physicians play a central role inthe medical care of patients. Other cliniciansfollow physicians’orders for prescribed med-ical, nursing, rehabilitation, and dietary in-terventions. Most physicians practicing in theLTC field are generalists or family practi-tioners rather than specialists.

All states require physicians to be li-censed in order to practice. The licensurerequirements include graduation from an ac-credited medical school that awards a doctorof medicine (MD) or doctor of osteopathicmedicine (DO) degree, successful completionof a licensing examination governed by eitherthe National Board of Medical Examinersor the National Board of Osteopathic MedicalExaminers, and completion of a supervised

internship/residency program. Residency isgraduate medical education in a specialty thattakes the form of paid on-the-job training.Most physicians serve a one-year rotating in-ternship after graduation from medical schooland before entering a residency program.Both MDs and DOs use traditionally accept-ed methods of treatment, including drugsand surgery. The two differ mainly in theirphilosophies and approach to medical treat-ment. Osteopathic medicine, practiced byDOs, emphasizes the musculoskeletal systemof the body such as correction of joints or tis-sues. In their treatment plans, DOs empha-size preventive medicine such as diet and theenvironment as factors that might influencenatural resistance. MDs are trained in allo-pathic medicine, which views medical treat-ment as active intervention to produce acounteracting reaction in an attempt to neu-tralize the effects of disease. MDs trained asgeneralists may also use preventive medicinealong with allopathic treatments (Shi &Singh, 2008).

NursesThe two main categories of nurses in LTCsettings are registered nurses (RNs) and li-censed practical (or vocational) nurses (LPNsor LVNs). All nurses must be licensed by thestate in which they practice. The two maineducational programs today for RNs areassociate’s degree (ADN) programs offeredby community colleges and bachelor of sci-ence degree (BSN) programs offered byfour-year colleges and universities. Regula-tions require the delivery of skilled nursingservices to be under the supervision of RNs.In LTC settings, RNs compose only a smallpercentage of the workforce. They mostlyhold administrative and supervisory positionssuch as director of nursing or head nurse. A


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number of studies have shown that an ade-quate number of RNs in nursing homes pos-itively affects quality outcomes.

The majority of nurses in LTC settingsare LPNs/LVNs who are graduates of one-year practical nursing programs offered atcommunity colleges or vocational technicalschools. LPNs/LVNs render treatments andadminister medications. LPNs also functionas charge nurses and team leaders and super-vise the work of paraprofessional caregivers.

Nonphysician PractitionersNonphysician practitioners (NPPs) areclinical professionals who practice in manyof the areas in which physicians practice butwho do not have an MD or DO degree. Thetwo main types of NPPs who practice in LTCsettings are nurse practitioners and physicianassistants.

Nurse practitioners (NPs) are advancedpractice nurses who provide health care ser-vices similar to those of primary care physi-cians. They can diagnose and treat a widerange of health problems. Some physiciansemploy NPs to follow up on the medical careof their patients. Studies of NPs in nursinghomes suggest that they enhance the med-ical services available to residents and pre-vent unnecessary hospital admissions (IFAS,2005). NPs receive advanced graduate-leveleducation and clinical training beyond whatis required for RN preparation. Most havemaster’s degrees; some specialize in geriatrics(American Academy of Nurse Practitioners,2007).

Physician assistants (PAs) are increas-ingly employed to provide LTC services un-der the direction of a physician. Both NPs andPAs are sometimes referred to as physicianextenders because they enable physicians tosee more patients and make better use of their

skills and time. Admission to a PA trainingprogram requires roughly two years ofscience-based college coursework. After en-rolling in a PA program, students study thebasic medical sciences and physical exami-nation techniques, followed by clinical train-ing that includes classroom instruction andclinical rotations in primary care and sever-al medical and surgical specialties. Overall,the PA student completes more than 2,000hours of supervised clinical practice prior tograduation. The didactic and clinical trainingtakes an average of 26 months. Their scopeof practice includes performing physicalexaminations, diagnosing and treating ill-nesses, ordering and interpreting laboratorytests, and making rounds at LTC facilities(American Academy of Physician Assistants,2007). Both NPs and PAs can prescribe drugswhen authorized to do so under state law.Their generalist training and emphasis on pa-tient relationships make them particularlyvaluable in LTC caregiving.

Rehabilitation ProfessionalsRehabilitation therapies enable patients to re-gain lost functioning and improve currentfunctioning. The most common rehabilitationservices are provided by physical therapists,occupational therapists, and speech/languagepathologists. Certain treatments can be pro-vided by assistants under the direction andsupervision of therapists. Services of a physi-atrist are common in facilities that provide in-tensive rehabilitation.

PhysiatristsA physiatrist is a physician who has special-ized in physical medicine and rehabilitation.Physiatrists can treat a variety of problemsfrom pain to work- and sports-related injuries.


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Diagnoses may include severe arthritis, braininjury, spinal cord injury, stroke, multiplesclerosis, amputations, and various conditionsrequiring post-surgical recovery. Physiatristsmay prescribe drugs or assistive devices anddirect therapists to carry out various types oftreatments to help restore, improve, or main-tain function.

Physical Therapists and AssistantsPhysical therapists (PTs) specialize in thetreatment of musculoskeletal disorders (lossof function associated with bones, joints,spine, and soft tissue), neuromuscular disor-ders (loss of function associated with the brainand nervous system, such as stroke), patientsrecovering from cardiopulmonary problems,and severe wounds. They specialize in therestoration of various ADL functions.

PTs need a master’s degree from a phys-ical therapy program accredited by the Com-mission on Accreditation in Physical TherapyEducation. Of the 209 accredited physicaltherapy programs in 2007, 43 offered master’sdegrees and 166 offered doctoral degrees.Master’s degree programs typically last twoyears, and doctoral degree programs last threeyears. In the future, a doctoral degree mightbe the required entry-level degree. All statesrequire PTs to pass national and state licen-sure exams before they can practice (BLS,2007). The Federation of State Boards ofPhysical Therapy develops and administersthe national examinations for both PTs andphysical therapy assistants (PTAs).

PTAs can provide part of a patient’s treat-ment under the direction and supervision of aPT. In many states, PTAs are required by lawto have at least an associate’s degree (BLS,2007). Most states also require PTAs to belicensed.

Occupational Therapists and AssistantsOccupational therapists (OTs) are involvedin a broad range of therapies that help patientsrecover or maintain the daily living and workskills. Their goal is to help patients achieveindependence and satisfaction in all facets oftheir lives. For example, OTs can help patientslearn how to use a computer or care for theirdaily needs such as dressing, cooking, andeating.

A master’s degree or higher in occupa-tional therapy is the minimum requirementfor entry into the field. In 2007, 124 master’sdegree programs offered entry-level educa-tion, 66 programs offered a combined bach-elor’s and master’s degree, and 5 offered anentry-level doctoral degree. OTs must be li-censed to practice. To obtain a license, ap-plicants must graduate from an accreditededucational program and pass a national cer-tification examination. Those who pass theexamination are awarded the title “Occupa-tional Therapist, Registered (OTR)” (BLS,2007). OTR is a registered trademark of theNational Board for Certification in Occupa-tional Therapy (NBCOT), which administersthe national certification examination.

Occupational therapy assistants help pa-tients with rehabilitative activities and exer-cises outlined in a treatment plan developedin collaboration with an OT. An associate’sdegree or a certificate from an accreditedcommunity college or technical school is gen-erally required to qualify as an occupationaltherapy assistant. To be licensed in moststates, occupational therapy assistants mustpass a national certification examination ad-ministered by NBCOT after they graduate.Those who pass the examination are awardedthe title “Certified Occupational Therapy As-sistant (COTA)” (BLS, 2007).


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Speech/Language PathologistsSpeech/language pathologists (SLPs)—informally referred to as speech therapists—assess, diagnose, and treat speech, language,and cognitive disorders. Dysphagia, that is,swallowing difficulty, is another commonproblem that SLPs are called upon to treat inLTC settings.

A master’s degree is commonly requiredfor licensure in most states; it is mandatoryfor receiving the Certificate of ClinicalCompetence from the Council of Clinical Cer-tification of the American Speech-Language-Hearing Association (ASHA). In 2007, morethan 230 colleges and universities offeredgraduate programs in speech/languagepathology accredited by the Council onAcademic Accreditation in Audiology andSpeech-Language Pathology of ASHA(BLS, 2007).

Clinical Dietitians and TechniciansClinical dietitians, sometimes referred to asnutritionists, provide nutritional informationand diet-related services to patients. They as-sess patients’ nutritional needs, develop andimplement nutrition programs, and evaluatethe results. They also confer with physiciansand other health care professionals to coor-dinate medical and nutritional needs. Clini-cal dietitians often develop diet plans forpatients who have renal problems, diabetes,heart disease, and weight loss or weight gainissues.

Minimum qualifications for clinicaldietitians include a bachelor’s degree from aprogram approved by the Commission on Ac-creditation for Dietetics Education (CADE)of the American Dietetic Association (ADA),completion of a CADE-accredited and super-

vised practicum at a health care facility thatcan be 6 to 12 months in length, and passinga national examination administered by theCommission on Dietetic Registration (CDR)of the ADA (ADA, 1997a). Those who com-plete these requirements are awarded the title“Registered Dietitian (RD).” As of 2007, therewere 281 bachelor’s degree programs and 22master’s degree programs approved by CADE(BLS, 2007).

Dietetic technicians assist dietitians inthe delivery of food service in accordancewith nutritional guidelines. Under the super-vision of dietitians, they may plan and pro-duce meals based on established guidelines,teach principles of food and nutrition, orcounsel individuals. Becoming a DieteticTechnician, Registered (DTR), requires com-pletion of at least a two-year associate’s de-gree from a program accredited or approvedby CADE, completion of 450 hours of su-pervised practicum, and passing a nationalexamination administered by CDR (ADA,1997b).

Paraprofessional CaregiversLong-term care services heavily rely onparaprofessional caregivers, who give mostof the hands-on personal care and assist pa-tients with all ADLs. They also change bedlinens and serve meals to patients. These para-professionals include certified nursing as-sistants (CNAs), therapy aides, personal careattendants, and home health aides. They con-stitute the largest group of health care work-ers in the LTC industry. Paraprofessionalpositions are at the bottom of the organiza-tional hierarchy. These workers typically car-ry heavy workloads, are poorly paid, and areoften treated with little respect.


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In most LTC organizations, such as nurs-ing homes, assisted living facilities, and homehealth agencies, paraprofessionals work un-der the direction of licensed nurses. CNAsare also trained to take vital signs; watch forand report any changes in the patients’ con-dition to nurses; and do simple urine tests forsugar, acetone, and albumin. The 1987 Nurs-ing Home Reform Act mandated that CNAsreceive a minimum of 75 hours of training.The training program must include 16 hoursof hands-on training in which the traineedemonstrates knowledge while performingtasks for an individual under the direct su-pervision of a nurse. CNA students must alsopass a state certification exam and skills test,and subsequently complete 12 hours of in-service or continuing education each year(Wright, 2006). CNAs can received furthertraining to become rehabilitation aides whoprovide basic therapies such as walking andrange of motion exercises under the super-vision of licensed therapists and nurses.CNAs can also become medication aides af-ter further training to safely give medicationsto patients.

Ancillary PersonnelA variety of ancillary personnel providehotel services such as meals, cleaning, laun-dry, and maintenance of physical plant andequipment in LTC facilities. Food servicepersonnel such as cooks and cook’s helpersprepare meals. Dietary aides wash dishes andcooking utensils. Building cleaning workersinclude janitors and housekeepers. Laundrywashers sort and wash linens. Others fold,store, and deliver clean linens to patient careareas. Maintenance personnel handle basicrepairs and groundskeeping.

Social Support ProfessionalsSocial support professionals include socialworkers and activity professionals. In LTCsettings, social workers engage in diagnosticassessment of patients’cognitive, behavioral,and emotional status; counseling; and con-flict resolution. They help people cope withvarious types of issues in their everyday lives.They also have community resource exper-tise that is often called upon to obtain pro-fessional services available in the community.A bachelor’s degree in social work (BSW) isthe minimum requirement for social work po-sitions in nursing homes and assisted livingfacilities. The Council on Social Work Edu-cation accredits educational programs in so-cial work. In 2008, there were 463 accreditedbachelor’s degree programs and 191 accred-ited master’s social work programs (Councilon Social Work Education, 2008).

Activity professionals provide a varietyof recreational programs for groups andindividuals to improve and maintain thepatients’ physical, mental, and emotionalwell-being. Programs include arts and crafts,games, music, movies, dance and movement,social celebrations, and community outings.Passive activities such as reading and work-ing with puzzles are prescribed for those whoprefer solitude. Although no specific degreesare specified for activity professionals, theNational Certification Council for ActivityProfessionals (NCCAP) offers four differenttracks, based on education and experience,for the credential, Activity Director, Certified(ADC). NCCAP also offers three differenttracks for the credential, Activity Assistant,Certified (AAC). Another organization, theNational Council for Therapeutic RecreationCertification (NCTRC) offers the CertifiedTherapeutic Recreation Specialist (CTRS)


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credential based on education, experience,and a certification examination.

The Ancillary SectorThe ancillary sector produces services andproducts that help people locate the rightkind of services, facilitate caregiving, im-prove people’s quality of life, or improve or-ganizational efficiencies.

Case Management AgenciesCase management was discussed in Chapter1. The myriad LTC services can presentdaunting challenges for most people who ei-ther need services for themselves or for thosewho need to help family or friends find ap-propriate services. Case management agen-cies do not provide actual LTC services. Theyassist clients in navigating the system by as-sessing client needs, identifying sources ofpayment, matching client needs with avail-able services that are likely to best addressthose needs, making referrals to appropriateservices, and providing ongoing follow-upand coordination as circumstances changeover time. Services are often coordinatedboth within and outside the LTC system.

Case management agencies employ ex-perienced nurses and social workers as casemanagers. These professionals have special-ized training in patient need assessment anda comprehensive knowledge of both financ-ing and service resources.

Long-Term Care PharmaciesHistorically, LTC facilities have experiencednumerous challenges in providing pharma-

ceutical services to their residents. Medica-tion errors, preventable adverse drug events,and delivery of pharmaceutical services, ingeneral, have posed the main challenges(Stevenson et al., 2007). The OmnibusBudget Reconciliation Act of 1990 requiredpharmacies to review Medicaid recipients’entire drug profile and to evaluate therapeu-tic duplication, drug-disease contraindica-tions, drug interactions, incorrect dosage,duration of drug treatment, drug–allergy in-teractions, and evidence of clinical abuse ormisuse. In part because of this regulatoryrequirement, certain pharmacy providershave specialized in LTC pharmacy practice.Through their consultant pharmacists, LTCpharmacies offer comprehensive drug man-agement services and often coordinate relat-ed quality improvement activities (Stevensonet al., 2007). Such comprehensive services,round-the-clock attention to critical andemergency medications, and dispensing ofintravenous medication solutions are gener-ally not available through retail communitypharmacists.

Long-term care pharmacies are estimatedto serve three out of every five residents inLTC facilities (LTCPA, 2006). In 2007, therewere 1,125 LTC pharmacies in the UnitedStates that derived at least half of their rev-enue from LTC facilities (Sanofi-Aventis,2008a).

Long-Term Care TechnologyTechnology has been playing an increasingrole in all aspects of health care delivery.Adoption of technology for LTC use has beenslow, but it will continue to grow in homes,other residential settings, and LTC institu-tions. Innovative products are being brought

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to the market all the time. For example, var-ious types of domotics technology, that is,“smart home” technology, can enable a grow-ing number of elderly people live in theirown homes. Long-term care technology canbe classified into seven main categories:

1. Enabling technology. Also referred toas assistive technology, this includesvarious devices and equipment thatenable people to do things indepen-dently despite functional impairments.Examples include hearing aids, simpleself-feeding aids such as specially de-signed eating utensils, and custom-fitted mobility scooters that improvepeople’s quality of life regardless ofwhether they are living independent-ly in their own homes or in LTC in-stitutions. Some newer technologiesenable people to live independently.These technologies include remindersystems that are particularly usefulfor those with mild cognitive impair-ments. Automatic enunciators remindpeople of tasks they must do that day,such as keeping a doctor’s appoint-ment. Enunciators are also beingintegrated with medication adminis-tration systems to remind people whencertain medications must be taken.Talking blood sugar monitors, ther-mometers, blood pressure monitors,and automated pill dispensers are nowavailable for use in the home (Cheeket al., 2005). The National Associationof Home Builders has developed anaging-in-place certification specialistprogram. A Certified Aging-in-PlaceSpecialist (CAPS) has specializedskills in home remodeling solutions toenable older adults live in their ownhomes as they age. Various products

and devices are used to promote ac-cessibility and safety in the bathroom,bedroom, or kitchen. For example,clapper lighting systems turn on thelights at the sound of clapping.

2. Safety technology. Personal emergencyresponse systems (PERS) are nowwidely available for people livingalone to summon help in an emer-gency. Technology that uses signals,alarms, and wireless transmitters canbe installed in nursing facilities to no-tify staff when a wandering patientopens a door to go out. Wireless sen-sors to ensure patient safety are alsobeing developed. Fall detection de-vices can signal the staff when an at-risk resident attempts to leave a bed,wheelchair, or toilet unattended.

3. Caregiving technology. Feeding andnutritional therapies—such as enteraland parenteral feeding (discussed inChapter 12)—have been around for along time. Other technologies such asin-home dialyzers for people with kid-ney failure are more recent. Caregiversare now increasingly using automatedmedication dispensing systems thatimprove accuracy and efficiency. Avariety of beds and overlays are avail-able to reduce pressure to promotehealing of pressure ulcers. Ultrasoundbladder scanners are used for the man-agement of urinary incontinence. Bar-code technology has been adopted toverify patient identification and dis-pense medications. Home telehealthsystems use telecommunication tech-nology for the distance monitoringof patients and delivery of health carewith or without the use of video tech-nology. They have the potential to


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improve access and reduce costs byminimizing the need for the patient tomake trips to physicians’ offices orfor home health nurses to make fre-quent visits to the patient’s home. In-teractive technology enables “virtualvisits” between clinicians and pa-tients. It enables distance monitoringof the patient and promotes self-management of chronic conditions.Remote patient monitoring systemscollect data on vital signs and bloodpressure and allow a nurse to also ob-serve any behavior changes.

4. Labor-saving technology. Introduc-tion of labor-saving technology is de-signed to improve worker efficiencyand reduce physical injuries by de-creasing the need for heavy transfersand lifting. Electrically operatedceiling-suspended dining tables canconvert a dining room to a multipur-pose room at the flip of a switch.Ceiling-mounted patient lifting andtransfer equipment and labor-savingbathing systems are other examplesof labor-saving technology. Comput-erized medical records that replacehandwritten charting can save care-givers time that can be spent in deliv-ering patient care.

5. Environmental technology. Productsand fibers that have greater fireresistance; improved fabrics for up-holstered furniture that resist soil andfluid absorption; new fibers for car-peting that resist soil, stains, andodors; and nonskid floor coverings aresome examples that enhance the aes-thetics and safety of living environ-ments. Computerized controls for hotwater systems are designed to save en-

ergy and prevent the supply of over-heated water that can cause severeburns. Sensorial signals, such as colorand textured materials, are employedto support orientation of cognitivelyimpaired individuals in their ownhomes and in institutions (Cheek etal., 2005).

6. Staff training technology. Interactivetools, CD-ROMs, and remote videoteleconferencing are available to pro-vide training and continuing educa-tion on a large variety of topics.

7. Information technology. Informationtechnology (IT) deals with the trans-formation of data into useful informa-tion and is covered in more detail inChapter 14. IT is a broad area. Inhealth care organizations, applicationof IT falls into four main categories:

• Clinical information systems aredesigned to be used by various clin-icians to support the delivery ofpatient care. Electronic medicalrecords, for example, can providequick and reliable information nec-essary to guide clinical decisionmaking and to produce timely re-ports on quality of care delivered.Computerized provider order entry(CPOE) systems enable electronictransmission of medication orders tothe pharmacy and help reduce errors.Clinical information systems alsosupport patient assessment, careplanning, and clinical documenta-tion. These systems can be integrat-ed with other applications such asadministrative and financial systems,menu planning, and food ordering.

• Administrative information systemsare designed to assist in carrying out

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financial and administrative sup-port activities such as payroll, patientaccounting, billing, accounts re-ceivable, materials management,budgeting and cost control, and man-agement of residents’personal funds.

• Decision support systems provideinformation and analytical tools thatsupport effective management. Forexample, the system can help ana-lyze performance indicators, staffingadequacy, staff productivity, rates ofinfections and patient incidents suchas falls, and staff injuries.

• The Internet, or the Web as it iscommonly called, is now widely usedby clients and providers to access in-formation. A vast amount of clinicaland caregiving information can beaccessed online. Various IT applica-tions, however, have also becomeWeb-based. In this manner, updatedsoftware applications can be accessedand used on the Internet at all times.Various LTC providers increasinglyuse the Web for advertising their ser-vices and provide other client-relatedinformation.


For Further Thought1. In what ways is the long-term care industry likely to evolve in the future?

2. Are hospitals likely to play a bigger role in the future delivery of long-term care?

For Further LearningAssisted Living Federation of America: A group that offers basic consumer-oriented information onassisted living and gives a directory of assisted living facilities. This trade organization represents as-sisted living and other senior housing facilities.

www.alfa.org

Home Care Research Initiative: This organization supports research projects to address issues in long-term care. Research articles and fact sheets can be downloaded.

http://www.vnsny.org/hcri/index.html

Hospice Foundation of America: A nonprofit organization that provides leadership in the developmentand application of hospice and its philosophy of care.

http://www.hospicefoundation.org

National Adult Day Services Association: This organization represents the adult day care industry andalso furnishes consumer information.

http://www.nadsa.org

National Association for Home Care and Hospice: The nation’s largest trade association representingthe interests and concerns of home care agencies, hospices, home care aide organizations, and med-ical equipment suppliers.

http://www.nahc.org

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National Association of Long Term Care Administrator Boards (NAB). This organization administersthe national licensure examinations for assisted living and nursing home administrators. It has publi-cations available to prepare for the examination. The website also provides links to the licensing agen-cies in all states.

http://www.nabweb.org

National Association of Subacute and Post-Acute Care. The association was formed in 1995 througha consolidation of the International Subacute Healthcare Association and the American Subacute CareAssociation.

http://www.naspac.net/faq.asp

National Hospice Foundation: A nonprofit, charitable organization affiliated with the National Hos-pice and Palliative Care Organization that provides support and information about hospice care options.

www.nationalhospicefoundation.org

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AAHSA. 2008. Aging Services: The Facts. American Association of Homes and Services for theAging. Retrieved December 2008 from http://www.aahsa.org/article.aspx?id=74#GeneralFacts.

American Association for Long-Term Care Insurance. 2008. The 2008 Sourcebook for Long-TermCare Insurance Information. Westlake Village, CA: AALTCI.

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