Long Term Care Case Study

Question 1

The evolution of Long term care (LTC) in the United States (U.S) has seen its evolution in three main phrases: financing, utilization, and quality. Financing being the various means of payment either through Medicare, Medicaid, Veterans Health Administration, private insurance, or out of pocket funds. In the past, nursing homes were considered as warehouses where residents were lifeless, depressed and the quality of care far below average. Residents were subjected to psychotic medicine, more often than not, strap down to keep them quiet. The nursing industry was basically making money out of the frail vulnerable elderly. In 1981, president Regan
proposed deregulating the nursing home industry implementing safety and health standards. This era also saw a movement aimed at empowering nursing homes, families and patients in ways that yields better quality of care and engage patients in extracurricular activities. With Medicaid and Medicare being the main payers of nursing homes, and the continuous reports of abused reported in most nursing homes across the country, the government decided to use its financial leverage to create some sort of accountability to the nursing industry. There were concerns from both the administrative effort to deregulate the industry & others who felt the federal government should increase its regulatory rule to prevent the kind of abuses that were occurring involving the use of very substantial and growing amount of federal funds to nursing homes. The federal government decided to link Medicare and Medicaid payments to benchmarks to boost the care and rights of the old and the frail Americans. After the passing of the reform, residents receive a much better care than they would have done in twenty years ago. Quality is tied to reimbursement. Nursing homes is a place for people who are chronically ill with end of stage diseases. Some are disable for life and other incapable of providing personal care. All these places more demands on the nurses’ aides who are paid far below than counterparts working in a hospital setting. The main payors of nursing homes; Medicaid and Medicare provide less funding necessary for clinical care resulting in poor quality outcomes, with standards falling below decent care. Mor et al, (2011) suggested an increased in Medicaid payments will result in improved clinical quality of care (as cited in Singh, 2016). Another factor related to quality is lack of incentive yet the industry is labor intensive industry and unlike other health care sectors, there exist very few options to increase productivity and slash down the operating cost. The nursing home reform law of 1987 brought the following changes, residents rights, decisions about their plan of care. In the future, residents would have preferences for their care plan. The movement called for quality care, focus on resident’s needs, staffing levels, patient assessments, and imposed penalties to nursing homes that fell below expectations. There was also a shift in focus; what is best for the patients, the establishment of patients’ rights and a plan for every resident. Today, most nursing homes in the country are moving away from the traditional warehouse settings to a modern and more personalized setting providing person-centered care as opposed to task-oriented care. Many nursing care facilities are responding by adopting practices that reflect person-centered care and culture change. Regulators will need to incorporate these evolutionary changes into their oversight policies and practices The nursing reform bill did not completely eradicate the crises faced by the nursing home industry. There exist deficiencies in the quality of care, in the prevention of pressure sores and proper incontinent care. Patients are still subjected to the use of anti-psychotics. A study conducted by the university of CA researchers in 2006, found deficiencies in the treatment and management of pressure sores and incontinent care. The study also found most nursing homes not maintaining and sustaining compliance but rather just doing the minimum required of the standards. Investment homes and big chains are taking over the nursing industry with lesser expenses and lesser staffing needs. Most elderly people would prefer getting at-home care. Starting with the baby boomers, the next generation of elderly will demand care delivery processes in which they will seek the right to dictate their choices and preferences. Utilization is the readily available health care services to the residents. The 1990s saw an increased in nursing home beds with a decrees in the utilization rate. By 2000 to 2005, the increasing number of nursing homes decrees as well as the utilization rate which resulted in improvement in capacity utilization as seen in the fewer occupancy rates. But nonetheless, quality initiatives led to a new trend; shifting nursing home care to the communities due to the low levels of clinical care as required by most of the residents. Out of pocket payers preferred residential homes and assisted living facilities because of their appealing nature and the independent lifestyles. Hawes et al, (1997); Marek et al, (1996); Teno et al, (1997); Zhang & Grabowski, (2004), highlighted the passing of the nursing home reform act of 1987 by the Institute of Medicine (IOM) being a revolutionary change in the quality of care delivered to nursing residents. There was a reduction in the use of physician and chemical restraints, an improvement in the staffing levels, accurate documentation of medical records, care planning that encompasses the patient’s plan of care, increased awareness and use of incontinence training programs to staff, preventing infection through a decrease in the use of urinary catheters, and an introduction of social and recreational activates to increase the participation rate of the residents (as cited in Singh, 2016). Question 2

The long term care (LTC) system also referred to as the continuum of long-term care implies “the full range of long-term care services that increase in the level of acuity and complexity from one end to the other from informal and community-based services at one end of the continuum to the institutional system at the other end” (Singh, 2016 p.15).
The three major components of LTC are: In home, community-based system and the institutional system. The in home system consisting of senior housing, adult day care, home health care, hospice and palliative care is the largest institution financed mostly by private arrangements and
individuals.
Contrary to popular opinion, in home being the largest is provided by friends, family, family members, surrogates such as neighbors, church members or community organizations. In most cases, the services offered ranges from basic nature like general supervision and monitoring, dispensing medications, running errands, assistance with eating, cooking meals, grooming and dressing, transfer and mobility. The level of care depends to the extent at which the individual is connected to the family, friends and the outside world. Studies reveals a reduced number of informal caregivers to the growing population of the elderly. There is also an increase and a continuous growth in the divorced rate, unmarried and without children signifying and increase in the level of care with a decreasing population of informal caregivers. The Community-based system comprised of formal services rendered by various health care agencies.
These health care agencies include intermediate care facility for the mentally retarded (ICF/MF), assisted living community (ALC) and continuing care retirement community (CCRC). Services rendered can be classified under two categories: intramural and extramural services. Intramural services include home health (HH) care and meals on wheels. They include a wide range of support programs and services like chores and errands, homemaking, and handyman assistance. Unlike intramural services that are delivered inside a patient’s home, extramural services are delivered outside the patient’s home to a community-based location. These services include mental health outpatient clinics, adult daycare, and congregate meals provided at senior centers and respite care. The community-based (LTC) system consist of the following objectives.
 Capable of delivery affordable LTC services in a less restricted setting in accordance to the patient’s medical needs.
 To repressed the use of informal care with more advanced and sophisticated skills and
personnel.
 To provide personalized care in a more respectful manner and to avoid the institutionalization of intramural services to patients’ homes like HH care and meals on wheels. The LTC Institutional System as the name implies is suited for patients whose medical and social needs cannot be accommodated in a community-based setting. LTC institutionalized settings include skilled nursing home facilities (SNF), subacute care facility and long-term care hospital (LTACH). Services offered varies with the patient’s level of dependency for care.
Subacute care facilities provide services that were previously provided in an acute hospital. Thus, the patients required a broader level of care that goes beyond long-term care. Singh (2016), cited an example of a patient who undergoes a partial mastectomy for breast cancer in an acute hospital, discharge home to the care of a HH agency. After a brief home stay, the patient had a fall and requires a hip surgery. After surgery, the patient is transferred to a SNF for rehabilitation. While in the SNF, the patient is required to have physical therapy, chemotherapy, recuperation and follow-up visits to the oncologist. After recovery, the patient may want to live in an assisted living facility and depending on the extend of mobility, the patient can be seen transitioning from the various levels and types of LTC services as well as transferring from one LTC to non-LTC services. Question 3

The demographic imperative; an increase in the number of older adults with impairments and limitations from fourteen million in 2007 to more than twenty-eight million in 2030. This growth is in direct correlation with the increase number of older and fragile adults outnumbering the working population between ages twenty-five -sixty-four as estimated by the IOM (2007). This increase is as a result of some prevailing diseases like dementia and Alzheimer’s. In 2013 alone, five million Americans were suffering from Alzheimer disease and it is estimated that the disease could reach thirteen to sixteen million in the upcoming years. The U.S population is witnessing drastic changes in its demographic population with the increasing influx of the Hispanic population and other racial groups. All these different demographic populations especially African Americans and the Hispanic populations are more likely to suffer from Alzheimer’s disease as well (Dilworth-Anderson et al., 2008). With such an increase in the prevalence of diseases, comes increase in the cost of care. The Alzheimer’s Association, noted an increase in health care cost for patients with dementia three times more expensive than those without the disease, (2013). Thus, there lies a great challenge for the nation to finance such cost and at the same time, meet the demands for quality care. The introduction of wellness exam. The Affordable Care Act (ACA) enacted in 2010 by president Obama, “contained provisions to improve the quality and efficiency of healthcare system and test new ways to deliver and pay for healthcare services” (ARRP, 2010). The ACA has since then use its influence in requiring all private and public health insurance plans to conduct preventive care and wellness for all their customers. An example of such preventive care is the annual physical exam (called a Wellness Exam). The main purpose is aimed at conducting a risk assessment and developing an individualized prevention plan for each patient. The short coming of this trend can be seen from the fact that most diseases do not required an annual physical checkup for its prevention but rather a change in personal behaviors and policy interventions. For example, improving community environments that can promote walking, leisure activities that can improve physical activity and promote better health. The World Health Organization (WHO) estimated ten percent of newly diagnose cases of dementia be avoided through public health measures, such as targeting smoking, underactivity, obesity, hypertension, and diabetes (2012). Douglas Inadequate geriatricians, nurses and administrators. Amongst physician specialties in the U.S, there are only nine thousand practicing physicians in geriatrics giving a ratio of 2.5 geriatricians per ten thousand elderlies with formal training in geriatrics. With the growing number of the baby boomer generation, this number is expected to drop to six thousand in the near future. Nurses make the worst number with less than 0.05 percent with advanced certification in geriatrics (Centers for Disease Control and Prevention/ Merck, 2004). In addition to physician and nurses’ shortages, there are limited number of well-trained administrators to provide competent leadership practices in LTC. The Maine Department of Professional and Financial Regulation, (2004) reported a high turnover rate with the recruitment and retention of nursing home administrators (NHA). Such high turnover is due to the lack of appropriate education standards. Douglas

The use of interoperable Health information technology (HIT). Established by the office of the ONC, interoperability enables health systems to exchange and use electronic health information from other systems. Health IT interoperability is expected to transform the health care delivery system from the fragmented nature to one that delivers better care, lesser spending and healthier lives. The goal of the ONC's is for electronic health information to be available to patients wherever and when needed. Nursing home providers can track patients’ health records across several nursing homes, home health agencies, hospitals, pharmacists and physician offices. As much as interoperability is vital for an integrated system that amalgamates with LTC services, it is important for LTC needs to be incorporated in all future interoperable electronic health records. As such, residents’ medical records can easily be accessed from one location to the next since residents especially the elderly with their health situation transition from LTC to short term care. It is predicted that HIT applications will enhance staff efficiency, reduce billing errors, increase quality measures, improve clinical accuracy, and promote communication among providers. Douglas

Jackie Jodd
Singh, Douglas A.. Effective Management of Long-Term Care Facilities (p. 41). Jones & Bartlett Learning. Kindle Edition.
2007 H. J. Kaiser Family Foundation video “Nursing Home Reform Then and Now.” http://kff.org/medicare/video/nursing-home-reform-then-and-now/