LONG-TERM CARE

Objectives

Understand the role and scope of services includedin LTC

Appreciate who uses LTC and under whatcircumstances

Assess how LTC is organized, integrated,evaluated and reimbursed

Be aware of innovative approaches to organizingLTC

Understand national policy issues relating to LTC.

This report was produced by the Federal Interagency Forum on Aging Related Statistics.

For more information visit the Forum’s web site at www.agingstats.gov or call 301-458-4460

Definitions

range of health and social services needed tocompensate

for permanent or temporary functional disabilities, provided over an extended period of time (at least three

months), goal is increasing independence, includes social, medical and custodial services includes diagnostic, preventive, therapeutic,

rehabilitative, supportive and maintenance services(“continuum” of care)

mix depends on client needs and changes over time

chronic disease vs disability vs functional ability vshealth

ADLs- eat, dress, personal care and grooming, transferfrom bed to chair, bathe, walk, maintain bowel andbladder continence

IADLs – handle money, telephone, grocery shopping,housekeeping, chores, arranging for transportation

Health – complete physical, mental and social well-being

Trends

14 % of population will be over 65 in 2010 Oldest old is fastest growing group Family and friends do most care – ‘informal’ 50% of those who live past 65 will be in a nursing

home at some time Five percent of elderly live in nursing homes Many equally dependent people live at home Home care is increasing Prevalence of Alzheimer’s Disease is increasing ALOS in nursing home is two years but some

move in and out quickly

Nursing Homes - history Scandals (fraud, abuse, neglect, poor physical plant) Began as county poor houses Shortage of good nursing home beds Weak regulation Difficult to make a profit when income is from

welfare patients

Some discrimination against public pay patients

Nursing Home Characteristics Mostly proprietary

50% SNF and 50% ICF

1.6 million beds in US

53/1000 population over 65

95% occupancy

ALOS 2 yrs

Some hospitals have SNF beds, some swing beds

Nursing Home Financing Consumes about 10% of personal health

expenditures Medicaid 45% Medicare 5% Private pay 45% Private insurance 1%

4% other

Nursing Home Patients Elderly, female, no relatives, 60% have mental disorder Highly dependent Most people dread nursing home admission

MODELING THE OUTCOMES OF NURSING HOME CARE

Rohrer and Hogan, Soc Sci Med 24(3) 1987

290 VA NH pts - 243 remaining

Are the number of minutes of nursing care associated with outcomes when case mix is controlled?

Results of Regression Analysis of Outcome RUG (R -square=.71, N=234)

LPN/Aides -.005

Psychosocial -.002

Basic .005

MD notes -.159

RN .013

Initial RUG .475

Rehab n.s.

CONCLUSIONS

•The amount of nursing care is associated with outcome functional status.

•

Non-RN time is associated with better outcomes

•RN time is associated with worse outcomes (ameliorative)

•Rehab service was not associated with outcomes (constrained range?)

ORGANIZATIONAL PREDICTORS OF OUTCOMES OF LONG-STAY NURSING HOME RESIDENTS

Rohrer et al, Soc Sci Med, 1993

10 nursing homes, 32 units, 872 cases

Measures•job assignment vs flexible duties•hierarchy (number of levels of supervision)•closeness of supervision (RNs/nonRNS)•pace (discharges/beds)•workload (percent heavy care residents)•initial and outcome functioning

REGRESSION RESULTS (R-Square=.74)

•Job assignment 0.068

•Hierarchy 0.153

•Closeness of supervision n.s.

•Pct heavy care 0.207

•Pace 1.044

•Hierarchy x pace -1.074

•Initial functioning 0.743

CONCLUSIONS

Residents get worse:under strict job assignmenttall hierarchies / large organizationswhere workload is heavywhen pace is fast

Residents get better:in large organizations when pace is fast

Contingency theory applies - optimal structure depends on circumstances

Community-Based Care home care adult day care assisted living hospice continuing care communities case management S/HMO PACE

Substitution-what percent of nursing pts couldbe at home?

Channelling experiment did not save money Admissions were not reduced Health status was not improved Need targeted programs Case mgt may complement informal caregiving Not cost effective, but still considered ‘the right thing

to do’

Long Term Care Reform -Problems

financing fragmentation access quality consumer rights

workforce

Financing Reform expand Medicare private nursing home insurance blend public and private

capitation (e.g., SHMOs)

Integrative mechanisms for continuum ofcare

Inter-entity planning and management

Care coordination

case mgt,

single point of access,

teams

MIS

Organizational Reforms Reduce shortage of nursing home beds Increase training of staff Establish standard of minimal supervision (24 hour

nursing) Increase support for informal care (watch out for

woodwork effect) Increase education and salaries in LTC

Integrate acute care, LTC and social services