Long-Term Care: The Basics

1. Long-Term Care: The Basics Seema S. Limaye, MD Section of Geriatrics Department of Medicine University of Chicago—Pritzker School of Medicine

2. LTC BASICS • What is LTC? • Who uses LTC services? • How is LTC reimbursed? • Nursing Home 101: • Organization • Regulation • Reimbursement • In the context of health disparities…

3. What is long-term care? • Definition: medical, social, personal care, and supportive services needed by people who have lost some capacity for self-care because of a chronic illness or condition. • Home Care • Adult Day Programs • Nursing Home • Rehabilitation • Long-term chronic care

4. Who uses LTC services? • Patients who have lost capacity for self-care because of illness • Common medical reasons: • Urinary Incotinence • Dementia/wandering • Common social reasons…

5. What is a LTCF? • Long-term care facility: A facility that provides rehabilitative, restorative, and/or ongoing skilled nursing care to patients or residents in need of assistance with activities of daily living.

6. LTCF: • Nursing homes, • Rehabilitation facilities, • Inpatient behavioral health facilities, • Long-term chronic care hospitals

7. Projection of Expenditures of National LTC services—in billions of 2000 dollars Total Long Term Care Services (Includes services provided in home and institutional setting). Source: Congressional Budget Office

8. How are LTC services reimbursed? • Depends on the services…

9. How are LTC services reimbursed? (cont)

10. NURSING HOME 101

11. Nursing Home 101 • Resident pays out-of-pocket • LTC insurance • Medicaid • Medicare DOES NOT pay for custodial, nursing home care!

12. Subacute Rehab Payor: Medicare • RUG: Resource Utilization Group • Medicare A pays based on categories of utilization—53 RUGs as of 2006 • 3 midnights • Up to 100 days covered* First 20d are fully covered, D21-100 are partially covered • Need 60 day break between next 100 day coverage period

13. For-Profit 2/3 of NH Lower case mix Accept Medicaid pending and Medicaid Not-for-Profit 1/3 of NH Higher case mix Higher Staffing #’s Tax exemption Usually have a limited number of Medicaid beds Most are religiously affiliated organizations ?Higher quality? Types of SNF

14. Key “Players” in SNF

15. (More) Key “Players” in SNF

16. (More) Key “Players” in SNF

17. (More) Key “Players” in SNF • Activities Director • Dietician/Nutritionist

18. Quality in the NH • Who regulates quality in Illinois nursing homes? • City of Chicago • Due to budget cuts, not as large a presence • IDPH • State codes • Follow federal guidelines, also • Medicare/CMS • What is regulated? • over 150 regulatory standards • Everything from safe storage and preparation of food to protecting residents from physical or mental abuse or inadequate care practices

19. Why all the regulations? • IOM report 1986 “Improving the Quality of Care in Nursing Homes” • “Appallingly bad” medical and nursing care (avoidable decline) • Poor quality of life (lack of personal choice, lack of respect, fear) • Regulation is essential to protect vulnerable elderly • Free market approach will not work

20. OBRA 87 Nursing Home Reform • 1990: • Resident rights • Maintain highest practicable level of functioning • Medical Director responsibilities • Physician visits and physician extenders • Resident Plan of Care • MDS Assesment • Stricter enforcement

21. Areas of Improvement: Restraints Psychotropics Persistent Problems: Pain Pressure sores Malnutrition Urinary Incotinence IOM Report 2001Improving the Quality of Long-Term Care “Evidence indicates that quality of care in general has improved over the past decade…”

22. Quality in the NH • Annual State and Federal surveys • 3-5 day visit • Inspect facilities • Chart audit • Resident/family interviews • Resident/Family Complaint • State investigates within 72h • Fine + plan of correction

23. Survey Reporting • Nursing Home Compare-on Medicare website • MDS database: • NH reports • On-line Survey Certification and Reporting: OSCAR database • Surveyor reports from annual visit

24. Minimum Data Set • 350-item questionnaire • “clinical assessment” • Submitted to Medicare • Done periodically • Used for regulating and research • Pros and cons?

25. How is quality improved upon in the NH? • Quality Assurance meetings • Often quarterly • Interdisciplinary • Look for trends • Focus on quality indicators: PU, falls, skin

26. Disparities in SNF • Access to LTC facilities: • Blacks are concentrated in a smaller proportion of LTC facilities1 • Blacks are more likely to occupy Medicaid facilities with deficiencies2 • Blacks more likely to live in understaffed facilities2 • LTC facility racial segregation well-documented in Chicago3 • Smith DB. Feng Z. Fennell ML. Zinn JS. Mor V. Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes. Health Affairs. 2007; 26 (5): 1448-1458. • Grabowski DC. The admission of blacks to high-dificiency nursing homes. Medical Care. 2004; 42(5):456-64 • Reed SC. Davis N. The Jane Dent Home: The rise and fall of homes for the aged in low-income communities. Journal of Health Care for the Poor & Underserved. 2004; 15(4): 547-61.

27. Disparities in SNF • Racial Health Disparities: • development of pressure ulcer (Rosen et al. 2006 and Baumgarten et al. 2004), • treatment of diabetes mellitus (Allsworth et al. 2005), • assessment and treatment of vision loss (Friedman et. al. 2004), • treatment for secondary prevention of stroke (Christian et. al.2003), • use of advance care planning (Degenholtz et. al. 2002).

28. Ethnogeriatrics and LTC • Older literature: “Cultural aversion process”—explains that minority older adults seek NH care at later ages because of cultural difference: • family and social support • Newer literature: Family structure and roles are changing • Many ethnic groups are moving towards patterns of larger culture

29. Components of Ethnically-Oriented NH Care4 • Location • Selection and training of staff • Admission policy and process • Cost • Interaction with Family • Language • Food • Activity Program • Religious Observances • Personal and Nursing Care 4. Yeo GW. Ethnicity and Nursing Homes: Factors Affecting Use and Successful Components for Culturally Sensitive Care. Ethnicity and Long-Term Care. Springer Publishing company.1993: 161-177.

30. Other topics to ponder… • Informal caregivers • Paid caregivers • Home health services