Chapter One

1. Chapter One Definition of the Continuum of Care

2. What is Long-Term Care? • A broad term encompassing a wide-array of populations, services, and funding sources • A wide-range of health and health-related support services provided on an informal or formal basis to people who have functional disabilities over an extended period of time with the goal of maximizing their independence

3. Health & Health-Related Support Services • Health • Mental Health • Social Services • Support Services

4. Health & Health-Related Support Services • Provided simultaneously • May change over time • Provided by formal and informal arrangements • Recipients may be people of any age

5. Long-Term Care • Functional disabilities are primary reason • Key  the ability to perform ADL/IADL • Goal  enable the person to maintain the maximum level possible of functional independence

6. Long-Term Care • Care is directed not with the expectation of cure, but with enabling people to do the most they can for themselves given the state of their condition

7. How is Long-Term Care Organized? • On an ad-hoc basis • 80-90% provided by friends and family • Each community has its own combination of available resources, funding sources, and organizations

8. How is Long-Term Care Organized? • Clients need coordination among many different services, transition among services, and changes of service configurations over time

9. Characteristics of Major Health Services

10. Major Federal Legislation Funding LTC Services • Medicare (Title XVIII of Social Security Act) • Year Passed: 1965 • Target Population: • Age 65 and older, Disabled, ESRD • Covered Services: • Short stay nursing homes • Skilled home care • Hospice • Short-term mental health

11. Major Federal Legislation Funding LTC Services • Medicaid (Title XIX of Social Security Act) • Year Passed: 1965 • Target Population: • Poor • Services Covered: • Nursing homes • Social services • Adult day care • Respite, homemaker services (varies by state)

12. Major Federal Legislation Funding LTC Services • Social Services Block Grants (Title XX of Social Security Act) • Year Passed: 1974 • Target Population: • Aged (over 60), disabled, children • Services Covered: • Community-based services (varies by state) • homemaker, chore, adult day care, adult foster care, mental health

13. Major Federal Legislation Funding LTC Services • Older Americans Act • Year Passed: 1965 • Target Population: • Aged (over 60) • Services Covered: • Nutrition services, Home delivered meals • State ombudsman programs • Social/recreational • Supportive services • transportation, outreach, information and referral, legal, in-home services

14. Major Federal Legislation Funding LTC Services • Supplemental Security Income (Title XVI of Social Security Act) • Year Passed: 1972 • Target Population: • Low income, aged (over 60), blind, disabled • Services Covered: • Automatic Medicaid eligible (see Medicaid) • Cash payments • Congregate housing, adult foster care (at state option)

15. Major Federal Legislation Funding LTC Services • Veterans Administration • Year Passed: 1963, 1972, 1975, 1980 • Target Population: • Veterans • Services Covered: • Nursing homes • Outpatient care/visits, Adult day care • Special housing placement • Personal care • Hospice

16. Major Federal Legislation Funding LTC Services • Mental Health • Year Passed: 1967, 1971 • Target Population: • Mentally ill • Services Covered: • Community mental health centers • ICF/MR coverage

17. Major Federal Legislation Funding LTC Services • American Disabilities Act • Year Passed: 1990 • Target Population: • Disabled • Services Covered: • None specifically -- ensures access to all services

18. Ideal LTC System • Provides comprehensive, integrated care on an ongoing basis and offers various levels of intensity that change as a client’s needs change • Provides medical and related support services that enable a person to maximize functional independence • Is a continuum of care

19. Continuum of Care • A client-oriented system composed of both services and integrating mechanisms that guides and tracks patients over time through a comprehensive array of health, mental health, and social services spanning of levels of intensity of care

20. Continuum of Care • extends beyond traditional definitions of long-term care • is client-oriented • emphasizes wellness rather than illness • incorporates both acute and long-term services

21. Continuum of Care • is a comprehensive, coordinated system of care designed to meet the needs of patients with complex and/or ongoing problems efficiently and effectively • is more than a collection of fragmented services; includes mechanisms for organizing those services and operating them as an integrated system

22. Continuum of Care (Ideal) • Matches resources to the patient’s condition, avoiding duplication of services and use of inappropriate services • Monitors the client’s condition, and changes services as the needs change • Coordinates the care of many professionals and disciplines

23. Continuum of Care (Ideal) • Integrates care provided in a range of settings • Streamlines patient flow and facilitates easy access to services needed • Maintains a comprehensive record incorporating clinical, financial, and utilization data across settings

24. Continuum of Care • Should achieve cost-effectiveness by maximizing the use of resources • Should enhance quality and patient satisfaction through appropriateness, ease of access, and ongoing continuity of care • Should increase provider efficiency

25. Continuum of Care Services • Over 60 distinct services grouped in 7 categories: • Extended inpatient care • Acute inpatient care • Ambulatory care • Home care • Outreach • Wellness/Health promotion • Housing

26. Continuum of Care Services • Extended inpatient care • for people who are so sick or functionally disabled that they require ongoing nursing and support services provided in a formal health care institution but who are not so acutely ill that they require the technological and professional intensity of a hospital • e.g., nursing facilities, step-down units, swing beds, nursing home follow-up

27. Continuum of Care Services • Acute inpatient care • hospital care for those who have major and acute health problems • e.g., medical/surgical inpatient unit, psychiatric inpatient unit, rehabilitation inpatient unit, interdisciplinary assessment team, consultation service

28. Continuum of Care Services • Ambulatory care services • provide a wide-spectrum of preventive, maintenance, diagnostic, and recuperative services for people who manifest a variety of conditions • e.g., physicians’ offices, outpatient clinics, interdisciplinary assessment clinics, day hospitals, adult day care centers, mental health clinics, satellite clinics, psychosocial counseling, alcohol and substance abuse care

29. Continuum of Care Services • Home care • represents a variety of nursing, therapy, and support services provided to people who are homebound and have some degree of illness but who are able to satisfy their needs by bringing services into the home setting • e.g., home health (Medicare/private), Hospice, high-technology home therapy, durable medical equipment, home visitors, home delivered meals, homemaker/personal care, caregivers, respite

30. Continuum of Care Services • Outreach programs • make health services and social services readily available in the community rather than within the formidable walls of a large institution • e.g., screening, information and referral, telephone contact, emergency response, transportation, Senior membership programs, Meals on Wheels

31. Continuum of Care Services • Wellness programs • are provided for those who are basically healthy and want to stay that way by actively engaging in health promotion • e.g., educational programs, exercise programs, recreational and social groups, Senior volunteers, congregate meals, and support groups

32. Continuum of Care Services • Housing • for frail populations; increasingly includes access to health and support services and conversely, recognizes that the home setting affects health • e.g., continuing care retirement communities, independent senior housing, congregate care facilities, adult family homes, assisted living facilities, intermediate care facilities for the mentally retarded

33. Continuum of Care Services • Each has different regulatory, financing, target population, staffing, and physical requirements • Each has its own admission policies, patient treatment protocols, and billing system

34. Continuum of Care Integrating Mechanisms • Inter-entity structure • Care coordination • Integrated information systems • Integrated financing

35. Continuum of Care Integrating Mechanisms • Inter-entity structure • management arrangements and operating policies are in place enable services to coordinate care, facilitate smooth patient flow, and maximize use of professional staff and other resources

36. Continuum of Care Integrating Mechanisms • Care coordination • the coordination of the clinical components of care, usually by combination of a dedicated person and established processes that facilitate communication among professionals of various disciplines at multiple sites

37. Continuum of Care Integrating Mechanisms • Integrated information systems • one patient record that combines financial, clinical, and utilization information to be used by multiple providers and payers across multiple sites

38. Continuum of Care Integrating Mechanisms • Integrated financing • removes barriers to continuity and appropriateness of care by having available adequate financing for long-term care as well as acute care, preferably paid by a capitated system

39. Framework for the Future • Demand for long-term care will increase • aging population • increasing in numbers • increasing in age • technology • shift from acute to outpatient

40. Framework for the Future • Challenge is to develop an approach to long-term care that is efficient, affordable, and appropriate for the individual and family and simultaneously, affordable and cost-effective for society