Instructor: James Birch, MD
Module Developed by Holly Cranston, MD
Specific Learning Objectives
A. Introduction
This module will introduce you to Long Term Care (LTC) and the varied services and sites that encompass LTC. We will review physical, mental, and financial criteria that help to determine which type of services are available to the long-term care recipient (patient/resident). The information in this module should broaden your understanding of LTC and aid in the hospital disposition planning, clinic disposition planning, and counseling of patients and families about the future possibilities for care.
Before reviewing the learning objectives and content, please take the following Pre-test before you complete the module.
B. Attitudes - The student will recognize that:
C. Knowledge - The student should be able to:
D. Introduction to the Nursing Home
E. Readings
The following link will lead you to a Medicare website that will allow you to look up nursing homes and compare the quality of those facilities.
http://www.medicare.gov/NHCompare/Home.asp?version=alternate&browser=IE|6|WinXP&language=
English&defaultstatus=0&pagelist=Home&CookiesEnabledStatus=TrueThe website liked below will lead you to a map of the United States and will show the average cost of nursing homes, assisted living, home care, and homemaker services. You might be surprised at which states cost the most!
H. Cases
Long Term Care – Care services such as health, personal, and social that are provided to the physically disabled, chronically ill, debilitated, or mentally disabled person. These services may be given to any age of person over a prolonged time. LTC services occur in diverse settings.
For comparison,
Acute Care – Medically oriented care that is delivered in a more intense setting. This type of care usually occurs over a shorter course of time, in a hospital-like environment.Long Term Care can be broken up into several different areas:
Home Health Care – These services are usually not long-term services, but patients may have various disorders that frequently require these services. HHC is available to patients when they have a documented need for nursing care or rehab therapies. Medicare part A will cover home health care if it is in association with a qualifying diagnosis post-hospitalization. Medicare part B may pay for therapies on an outpatient basis if the patient’s physician has ordered the therapies and the patient has a qualifying diagnosis.
There are various services available through home health care such as:
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Social Workers
- Nursing services
- Home-health aid
Adult Day Care – This service can be provided at a specialized day care center or at a nursing home. These services provide meals, activities, and supervision of the adult in a safe environment, thus allowing the spouse to work or have time away from their loved one for various activities. This service allows for piece of mind knowing that the loved one is cared for and safe.
Continuing Care Retirement Communities – This type of LTC is a housing community that has various levels of care attached to the facility. You have to “buy-in” to these communities, but you live in the area based on your need level. Many people start out in independent apartments or homes, and progress through the stages from assisted living into the nursing home. CCRCs generally charge a large payment before you move in (called an entry fee) and then charge monthly fees.
Assisted Living – This is a type of group living environment, but each resident has his or her own room or apartment. The AL facility may provide help with activities of daily living such as eating, bathing, using the bathroom, and dispensing/taking medicine. Most of the facilities offer group meals and social and recreational activities are usually provided. Some assisted living facilities have health services on site.
Rehab Care – for those patients who need physical therapy, occupational therapy, speech therapy, or nursing therapies after an illness or injury. This type of care can occur in several different settings.
- Inpatient Rehabilitation – in a hospital setting or in a rehab facility
- Skilled Nursing Home Rehab – occurs in a nursing home setting
- Home Health Rehab – skilled therapists may go to patient’s homes and deliver rehabilitative services at their homes
- Outpatient Rehab – the patient is discharged to home and goes to a free-standing rehabilitation clinic for the needed therapies
Dementia Care – Reserved for those patients who need special care due to a mentally debilitating dementia. These patients often require a more specialized area for their care, and thus, are referred to dedicated units in Assisted Living facilities or Nursing homes that focus on demented patients.
Respite Care – When families or caregivers are taking care of a loved one at home, there is often a time when they need a little time away from the responsibility of care. At the time this occurs, they may seek a nursing home in which to place the patient for a short stay of a few days or a few weeks. Families will often turn to respite care for vacations, funerals, or simply for a break from their daily life of caregiver.
Nursing Homes/Facilities – This type of service is offered to provide care for patients who cannot care for themselves at home, or cannot be cared for in the community by others. Often there is a need such as they need assistance with activities of daily living such as: dressing, bathing, and using the bathroom. Nursing homes provide a wide range of personal care and health services for their residents. For most people, this care generally is to for people who cannot take care of themselves due to physical, emotional, or mental problems.
- Not every resident of the nursing home is extremely disabled, some people become residents of nursing homes because they cannot stay at home any longer, and cannot afford alternative means to care for themselves at home or in an assisted living facility
Terminal Care/Hospice Care – For some who are near the end of their life, the special type of care offered by hospice is quite comforting for the patients and their families. Terminal or Hospice care can be delivered in virtually any setting, most often occurring in the home of the patient, but can also be delivered in a nursing home, or assisted living facility. In the hospital, this service is usually more acute in nature and is considered palliative care.
Over the years, LTC has changed to a more diverse population of patients. In the past, the nursing home was a place that people entered and never left. Now, the residents of facilities have different goals. Some of the residents are in the nursing home for a short stay for rehabilitation, respite care, or prolonged recovery. Whereas, other nursing home residents are in the facility for the rest of their life – it is now their home.
United States Census Estimates on the population as of July 1, 2005 was a total population of -
- 296,410,404
- Those 65 years and older were 36,790,113
- 12.4% of the US population
- Of those, 5,095,938 were 85 year or older
- 1.7% of the US population
- In the state of Kansas, the total population estimate in 2005 was 2,744,687
- Those 65 and older were estimated at 357,005
- 13% of the KS population
- Of those, 57,665 were 85 or older
- 2.1% of the KS population
- In Missouri, the total population estimate in 2005 was 5,800,310
- Those 65 and older were estimated at 773,171
- 13.3% of the MO population
- Of those, 103,752 were 85 or older
- 1.7% of the MO population
So the question becomes, how many people in the US are in facilities?
- Six% of the US population is institutionalized!
Divided into population segments, those numbers are as follows:
- In the 65 – 74 y/o group – 2% are institutionalized
- In the 75 – 84 y/o group – 6% are institutionalized
- In The 85 and over group – 23% are institutionalized
The US government has estimated that in 2007 about 9 million people will require LTC services. By the year 2020, 12 million people will require LTC services.
- About 70% of the elderly are cared for in their home by family or friends.
- The U.S. Department of Health and Human Services conducted a study that shows:
- People who reach 65 y/o have a 40% chance of entering a nursing home.
- 10% of those who enter a nursing home will stay there five years or more
Payment Methods: In the table below, you will see just a few of the available financing options that can be used by the patients or families to pay for various services of LTC.
Funding Options
Risk of Insufficient Funds
Cost
Family support
Moderate risk - family may be unable/unwilling to provide funds
You pay for the services out of pocket – therefore, high cost
Personal Savings
High risk – LTC costs usually quickly exceed savings
You are responsible for all cost. If/when you run out of funds, other payment methods must be found
LTC Insurance
Moderate risk – LTC costs often exceed coverage amount
Monthly premiums paid for the life of the policy.
Veterans Benefits
Moderate risk amt received from the benefit may not pay all LTC costs
No cost to Vet, unless the benefit does not cover the cost of LTC.
Medicare
Moderate – Medicare does not pay for nursing home care, but usually pays for some of skilled care
Costs of LTC are usually not part of Medicare benefits, only skilled care is partially paid. The patient still has co-payments and deductibles.
Medicaid
High risk – Medicaid may not pay all of the LTC costs
You pay for the services not covered by Medicaid. Patients have to become impoverished to qualify for Medicaid services.
Medicare Part A covers 100% of the first 20 days and 80% up to 100 days for a skilled care nursing home stay. The patient must have a 72-hour hospital stay with a qualifying diagnosis to be allowed this benefit, and the patient must be admitted to the skilled unit within 30 days from hospital discharge. To remain on the benefit the entire 100 days, the patient must show progress in their therapies.
As stated above, Medicare does not pay for most LTC services. Most nursing home care is paid for by Medicaid or from personal funds. See the breakdown below as provided by the Centers for Medicare offices:
- Medicaid = 48%
- Private pay = 26%
- Medicare = 12%
- Private Insurance = 8%
- Other = 6%
In the mid 1980’s there was an investigation that took place in the world of nursing homes. The result of this investigation was the passage of a reform bill called OBRA ’87.
OBRA ‘87 – Omnibus Budget Reconciliation Act ’87 - This reform bill was aimed at nursing homes, asking them to provide better care for their residents, respect resident rights, defined the role of the physician, and medical director in the nursing home. There was a lot of other information and changes written into this reform bill, but for physicians, some of that language is as follows:
- The health care of every resident is to be supervised by a physician.
- The initial and periodic reviews of the care plan are to be completed by a team that includes the physician.
- A physician must see each resident for routine evaluation every 30 days for the first 90 days, and every 60 days thereafter.
- Physicians may delegate every other visit to a physician extender, except for services that explicitly require the services of a physician.**
- Physicians must be available or arrange for the provision of emergency services 24 hours per day.
** The term “physician extender” for NPs (nurse practitioners) and PAs (physician assistants) is now antiquated, and even the newer “mid-level practitioner” is giving way to other terms such as non-physician practitioner. Individual states determine the scope of practice for these providers. In the state of Kansas, the only task that requires a physician order is admission to a nursing facility or admission to Hospice.
“The Centers for Medicare & Medicaid Services (CMS) has established regulations regarding the physician delegation of tasks to mid-level practitioners in both skilled nursing facilities (SNFs) and nursing facilities (NFs). The major distinction between allowed activities of mid-level practitioners depends both on the care setting (SNF or NF) and the employment relationship between the facility and the NP or PA. . . . These regulations have been the source of some confusion within the long-term care community, causing CMS to issue clarifications in late 2003. The essential points of the regulations are summarized below:
- All NPs and PAs are allowed to perform medically necessary services to residents regardless of the care setting and within the scope of practice defined by the State.
- In SNFs, only the physician can perform the full initial comprehensive visit in which a history, physical examination, assessment, and a care plan are formulated.
- Physician assistants are not authorized to sign the initial certification or recertifications in SNFs; however, a nurse practitioner who is not an employee of the SNF may sign the certification or recertifications subject to State requirements.
- A physician may delegate alternate follow-up visits required by regulations (usually 30- or 60-day resident evaluations subsequent to the admission) to a collaborating NP or PA in the SNF.
- For the care of nonskilled nursing facility residents, the employment by the facility is the important determinant of the scope of practice for mid-level practitioners as determined by CMS. Wide latitude is generally given to NPs and PAs to substitute for the physician in the NF and perform the initial comprehensive visit, subsequent required visits, certification, and recertification, as long as they are not an employee of the facility, are working in collaboration with a physician, and are subject to individual State regulations regarding scope of practice.”
[Thomas V. Caprio, MD. Physician Practice in the Nursing Home: Collaboration with Nurse Practitioners and Physician Assistants. Annals of Long Term Care, (14) 3. Publication Date: March 01, 2006.]
For more information go to: http://www.annalsoflongtermcare.com/article/5474
In the state of Kansas, the only task that requires a physician order is admission to a nursing facility or admission to Hospice. NPs in Kansas have prescriptive authority and may also apply for a federal DEA number.
Another safety net created for nursing home residents is an Ombudsman. Under the federal Older Americans Act, every state is required to have an Ombudsman program. The Ombudsman helps to address complaints made by or for the residents of LTC facilities. They also act as advocates for resident rights, and promote community involvement in the LTC facilities.
According to a follow up investigation reported in 2001, the OBRA ’87 reform bill did have a positive impact on the care of the nursing home patient. There are still areas that need improvement, but overall, the bill hit its intended target – better care for the nursing home patients.
As listed in the previous section, the physician has the potential to serve in more than just an attending role in the nursing home. First – a few definitions:
Attending Physician – a physician in charge of the care of the nursing home resident. Depending on what type of medicine you plan on practicing, nursing home patients may or may not be a regular part of your patient panel. Many physicians are choosing to give up the care of their patients once they make the transition into a nursing home or assisted living facility.
Medical Director – a physician who is designated by the nursing facility to be responsible for:
- Implementation of resident care policies
- Organize and coordinate the medical care in the facility
- Participate in administrative decision making and recommending and approving policies and procedures
- Participate in quality assurance to ensure the quality of the medical care in the facility.
- There are many other responsibilities associated with the medical director role.
As a Medical Director for a facility, you can also be an Attending physician and see your own patients in the facility, but you do NOT have to have any patients in a facility to be a medical director.
In the past, the role of medical director was usually given to the physician with the most residents in the facility. However, after OBRA ’87, there has been a movement in the LTC community to bring forth more physicians interested in the role of the medical director. The American Medical Director’s Association has developed a course for physicians interested in becoming Certified Medical Directors (CMD’s). This is an intensive course that covers the vast amount of responsibilities associated with a medical director role. The wave of the future is aimed at having CMD’s in the medical director role at nursing homes as the government becomes stricter in requirements to be met by each nursing facility.
There is so much more information available to you on the web about long term care. If you are interested, visit the Medicare website at: www.Medicare.gov
Mr Jones
Mr. Jones is a 76 year old male who currently resides at home with his wife of 55 years. He has been a patient in your clinic for the last 15 years and during this time you have developed an excellent relationship with him and his wife. Over the past 7 years, you have been treating him for Alzheimer’s dementia and his wife has been caring for him at home.
As a proactive physician, you have counseled Mr. and Mrs. Jones and their children about the likelihood that he may eventually need placement in an Assisted Living facility or a Nursing home with an Alzheimer’s Unit. Although Mrs. Jones has done an excellent job of caring for him in their home, she has been less able to give him the care that he needs as he is 6’4” and 220# and Mrs. Jones is 5’1” and 110#. You have noticed that his grooming has slipped and he has smelled of urine at his last few clinic visits over the past 2 months. Mrs. Jones has confessed to you that he is often refusing to allow her to bathe him or brush his teeth. He has also been fighting her about toileting. Mrs. Jones breaks down in your clinic and begins to cry about her lack of ability to care for her spouse. She asks you what she should do next. She wants to know more about her options.
Questions
She asks that you meet with her and her children to discuss the options that you mention in the clinic visit today.
At the family meeting with the children and Mrs. Jones, you lay out the different options available to the family. Mrs. Jones seems to be most interested in the nursing home Alzheimer’s Unit, but the children don’t think that their father needs placement.
The family reveals that Mr. and Mrs. Jones are quite wealthy. The children are worried about what placement will do to the finances, but Mrs. Jones does not seem to be worried about her future finances.
Mrs. Jones
You are on call this weekend for your group practice and get a phone call that one of your patient’s has been admitted to the hospital. Apparently, Mrs. Jones, age 78, was in a motor vehicle accident and sustained a femoral neck fracture. She went to surgery and is out now and doing well. You are called to take over care of the patient.
You know Mrs. Jones quite well, as a matter of fact, she has been a patient in your practice for the past 16 years. Her husband is currently one of your patients and has been in a local nursing home Dementia Care unit for the past year.
About week has passed and the Orthopedic surgeon feels that Mrs. Jones is ready for discharge and rehabilitation. You have called the inpatient rehabilitation service to evaluate Mrs. Jones for inpatient rehab.
Questions
The inpatient rehab team does not feel that Mrs. Jones will qualify for inpatient rehab and they suggest that she be sent to a nursing home for skilled rehabilitation.
Mrs. Jones at first insists that she will not go to a nursing home because she cannot afford it, and she does not want to “get stuck” in the nursing home.
Mrs. Jones states that she is willing to go to the nursing home for a short period of time, and if she does not like it, she wants to go home. You tell her that this is acceptable and if she does not like the rehab unit, she may choose to go home.
Mrs. Jones is doing well in the nursing home rehab unit and after about 16 days of therapy, she gets discharged to home. She has received home physical therapy through a local home health agency. However, 20 days after discharge from the nursing home, she develops pneumonia and is sent to the hospital.
After her hospitalization, she is quite debilitated and has lost about 12 pounds, putting her at 98 pounds. She is weak, and has lost a lot of the progress that she made after her hip fracture. You plan on discharging her back to the skilled rehab unit that she had been in for her hip fracture rehab stay.
Mrs. Jones ends up using 60 days of rehab, but fails to show progress in her rehabilitation, what is the next step? As her physician, you have to decide if she still qualifies for rehab services. Does she qualify?
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The University of Kansas Medical Center