Long-Term Care

1. Long-Term Care The Historical Evolution

2. 17th Century • English Poor Laws • established 1601-1890 • the impotent poor (sick, elderly, and those unable to work) were helped via outdoor relief or almshouses; these people were classified as “would work but couldn’t” • abuse was rampant; living conditions were horrible • amendments to the laws were made that were specifically and explicitly aimed at discouraging people from applying for relief

3. 17th Century • Almshouses • established from 1622 to 1736 • communal facilities where the lame, sick, blind, orphaned, and aged could be cared for • people were sent to these places only if there was no one else to care for them • no government agencies were involved; any relief was considered to be a local responsibility handled by the churches and social organizations

4. 18th Century • Many of the social organizations converted private homes into “homes” to care for the lame, sick, blind, orphaned, and aged • these people were known as “inmates” or “wards”

5. Early 19th Century • Communal “Collection Pot” of the Eastern European immigrants • these “homes” served the aged, orphaned, handicapped, disabled, and mentally ill • feared and dreaded by the community • The Altenheim Model of the Germany and Scandinavia immigrants • a kind of “club-residence” for those who had saved and planned for a respectable retirement • nice, but cost a fair amount of money • resembled our current retirement homes

6. 19th Century • Convalescent Homes for Children • initially children received attention in an effort to conserve their usefulness to the developing economy in expanding the available manpower for work in factories and farms • emphasis was placed on providing an institutional climate in which the natural recuperative powers of the body would not be impeded

7. 19th Century • Convalescent Homes for Young Adults • a limited number of younger working-age adults were provided care • the objective was to restore the individual to permit him to fulfill his obligation as a working member of society • Home for the Elderly • typically a small, culturally homogeneous institution that catered to the “worthy poor”

8. Mid-19th Century • Private Nursing Homes • experienced tremendous growth after the American Civil War (1861-1865), which continued through the turn of the century

9. Early 20th Century • Private Nursing Homes • of the approximately 1200 facilities in the U.S. in 1939, nearly 2/3 were founded between 1875 and 1919 • originally these were custodial rather than medical facilities, and they were ethically or religiously homogeneous

10. Early 20th Century • Medical Model of the Mental Hospital • after WWI (1914-1918), the level of care for the dependent elderly shifted away from the custodial and social model to the medical model • Publicly-supported Almshouses/Charitable, Private Old Age Homes (1920s) • roughly 1/2 of the institutionalized elderly lived in publicly-supported almshouses and the other 1/2 in charitable, private old age homes

11. Early 20th Century • There was a shift from almshouses to mental hospitals because of new legislation which mandated state responsibility for all mentally ill persons

12. 20th Century • Old Age Assistance Program • established under the Social Security Act in 1935 • continued the trend away from almshouses as the means of caring for the elderly in order to discourage institutional care for that group • the effect, however, was to stimulate the growth of proprietary and voluntary nursing homes since federal assistance was made available to individuals residing in such facilities

13. 20th Century • Hill Burton Act • passed by Congress in the 946, the Hospital Survey and Construction Act was sponsored by Senators Lister Hill and Harold Burton • it was the Nation’s major health facility construction program under Title VI of the Public Health Service Act • it granted public money for building nursing homes modeled on hospitals

14. 20th Century • Hill Burton Act • with this public money came federal regulations • the Public Health Service became the agency responsible for formulating staffing and design requirements • at that time, decisions about what constituted good care for the elderly were not based on an analysis of their actual needs; instead, the Public Health Service recreated the only environment with which they were familiar -- the general hospital

15. 20th Century • Older Americans Act, Medicare, Medicaid • the nursing homes with which we are currently familiar began to grow in earnest after the passage of the Social Security Act in 1935, especially since the advent of the OAA in 1965, and the financial reimbursement provided through the 1965 amendments to the SSA known as Medicare and Medicaid • with the general hospital as the model institution, the passage of Medicare and Medicaid legislation I 1965 permitted the proprietary nursing home industry to develop and expand according to the medical model

16. 20th Century • Medicare • created by the Social Security Amendments of 1965 • health insurance program for those age 65 and above, regardless of income or wealth; also covers disabled people under age 65 who have been entitled to Social Security or Railroad Retirement disability benefits for at least two consecutive years and those who suffer from End-Stage Renal Disease (ESRD) • provides: up to 100 days in a SNF, with Medicare paying the full cost for the first 20 days and the patient paying a set amount each day thereafter; unlimited home health visits; and Hospice care

17. 20th Century • Medicaid • created by the Social Security Amendments of 1965 • it is the primary payment source for nursing homes today • it is a federal-state financed program to pay for health services for the categorically needy and medically needy • categorically needy - those receiving public assistance from AFDC or SSI because they are blind, aged, or disabled • medically needy - those who have enough money to live on, but not enough to pay for medical care

18. 20th Century • National Certification Begins • in 1967, providers certified for Medicare became subject to the first national certification programs for long-term care facilities • federal standards for Medicaid followed in 1970 • Long-Term Care goes Public • Beverly Enterprises became the publicly traded long-term care company when it joined the roster of stocks on the American Stock Exchange

19. 20th Century • Ralph Nader publishes Old Age: The Last Segregation (1970), marking the beginning of the public cry for quality care in nursing homes and influencing public policy • President Nixon, in 1971, unveils his “Eight Point Plan” to improve the care provided in nursing homes

20. 20th Century • In 1975, a group of nurses became the first to earn certification for excellence in geriatric nursing practice • The National Citizens’ Coalition for Nursing Home Reform is born in 1975 as representa-tives of citizen groups and ombudsman programs unite at a meeting of the American Health Care Association

21. 20th Century • In 1980, an amendment sponsored by senator David Boren gives states more latitude in developing their reimbursement systems but requires that rates be “reasonable and adequate” • Paul Klaasen opens his first Sunrise Assisted Living Facility in 1981, fostering a new form of long-term care in the U.S.

22. 20th Century • Seeking to trim Medicaid spending and the LOS in nursing homes, in 1981 HCFA introduces home and community-based waivers, allowing states to use alternative forms of care for Medicaid beneficiaries • Media attention to Alzheimer’s Disease sparks growth in the number of special care units starting in 1983

23. 20th Century • In 1983, Medicare shifts from cost-based reimbursement for hospitals to prospective payment under diagnostic related groups (DRGs); patients leave hospitals “sicker and quicker”, necessitating post-acute care • EverCare brings managed care to long-term care facilities when it is launched in 1987 in Minneapolis; a capitated plan, EverCare aims to limit the need for acute care

24. 20th Century • A part of the Omnibus Budget Reconciliation Act (OBRA) of 1987, the Nursing Home Reform Act, enacts the most sweeping reforms to nursing home regulations since the passage of Medicare and Medicaid • In 1988, the influential Untie the Elderly campaign is born, increasing the awareness of the damaging effects of physical restraints

25. 20th Century • A “central link” of the OBRA 1987 provisions, the MDS is introduced in 1990 as a tool for standardized assessment of nursing facility residents • The oldest baby boomers turn 50 in 1996, calling attention to the graying of America and the need for more consumer choice in long-term care

26. 20th Century • The Balanced Budget Act of 1997 repeals the Boren amendment, leaving the industry without its reimbursement protections • The balanced Budget Act of 1998 replaces cost-based Medicare payments with a prospective payment system

27. In Summary... • The U.S. has never had an explicit, coherent policy regarding long-term care; the American policy for care of the chronically ill has evolved incrementally and disjointedly • Certain key pieces of legislation passed during the last 50 years have significantly impacted the provision of long-term care

28. In Summary... • Long-term care has grown from almshouses to state mental hospitals to voluntary homes for the aged to nursing homes and other more contemporary settings • The SSA (1935) played an important role in expanding the demand for proprietary and voluntary nursing homes by providing aged individuals, who qualified under a means test, with income through OAA that could be used for personal and nursing care

29. In Summary... • Since then, a variety of legislation has alternately: • increased the demand for nursing homes • increased the number of nursing homes • increased reimbursement to nursing homes • placed controls on nursing home care • regulated nursing home care • created a confusing array of services, eligibility requirements, and reimbursement services which frequently create barriers to care