Long Term Care

1. Long Term Care Nancy L. Wilson-Baylor College of Medicine Huffington Center on Aging-Department of Medicine Presentation to Citizen’s Health Care Working Group Houston Hearing July 26, 2005

2. Mission Statement: To improve long-term care and supportive services provided to vulnerable older adults and family caregivers in Harris County through collaborative problem solving and strategic planning that involves consumers, providers, funding organizations, and other major stakeholders of the long-term care system. www.careforelders.org RWJ Community Partnership Program for Older Adults

3. Key Issues and Strategies • Access to Needed Services • Availability of Affordable Services • Quality of Care: Major Workforce Issues • Preparedness for Aging • Individual/Personal • Organizational • Community

4. Today’s Presentation: • Population concerned with long-term care is very diverse in terms of age and level of disability : physical, mental, • My Expertise and Experience Focused on Older Adults– (60-63%) • Who I think about: • My brother –in-law who has managed with functional limitations due to encephalitis : fiercely independent in his own apartment with an electric wheelchair and dependent on daily assistance • My neighbors: Mrs. H, 81 who has congestive heart failure and COPD as well as a closed head injury sustained from a fall. She would like to remain at home with her husband for the duration of her illness. • My niece who is 22-years-old who has mental retardation as a result of complications during birth and has been diagnosed with autism. Her family would like her to live at home indefinitely , but they need help with her care, particularly with a program of supervised daily activities. • Think about the heroic families who support these individuals –and the workplaces who make accommodations for these families

5. Definition and Examples • LTC is difficult to define:boundaries among primary, acute, and long-term care have blurred. • medication management for elders with chronic disabilities ? • Settings of care are confounded with services • Nursing homes provide acute care • Home Health Care delivers medical treatment

6. Long-term care is primarily concerned with maintaining or improving the ability of elderly people with disabilities to function as independently as possible for as long as possible. Long-term care also encompasses social and environmental needs and is therefore broader than the medical model that dominates acute care. Long-term care is primarily low-tech, although it has become more complicated as elderly persons with complex medical needs are discharged to, or remain in, traditional long-term care settings, including their own homes. Services and housing are both essential to the development of long-term care policy and systems. R. Stone (2000) Milbank Memorial Fund

7. Key Issue: Chronic Disease and Disability • 43.5% of Harris County elders report disability • 55.5% report two or more disabilities • 63,400 need help with basic daily living tasks

8. Key Issue: Disability and Long Term Care • Not Just Nursing Homes A range of services to address functional needs and support independence • Everything from a home delivered meal to institutionally based care • Escalating costs National expenditures in long term care expected to triple to $346 billion/year by 2040

9. Long-Term Care “Risk” • The risk of nursing home placement increases with age - 31% of those who are severely impaired and between the ages of 65 and 70 receive care in a nursing home compared to 61% of those age 85 and older. • Most people with long-term care needs (83 percent) live in their own home; among those living at home, the majority (78 percent) does not hire any help and only 8% depend only on paid help

10. Long-Term Care is Expensive • In 2002, the average annual cost for a nursing home was $51,000 for a semi-private room and $61,000 for a private room. • Four hours of home care daily costs $26,000 a year. (national average) • The cost of assisted living can range from less than $10,000 a year to well more than $50,000 a year (depending on the kind of assisted living facility and type of services an older person chooses.)(DHHS:Administration on Aging, 2003))

13. The value of the services family caregivers provide for "free" is estimated to be $257 billion a year. BILLIONS OF DOLLARS Source: Expenditure data from HCFA, Office of the Actuary, Levit K. et all, Health Affairs 2002;21.

14. Economic reality • You can save for college—but most of us can’t “save” for long-term care • Need to Consider how to approach the individual and social risk • Physical, emotional, and social burdens that providing care impose on the caregiver and its economic costs to the caregiver and to society. • Caregiving can conflict with caregivers’ employment, creating economic losses for caregivers and society. • Individuals suffer from inadequate attention to basic needs

15. Best Practice Approaches with Potential to Reduce LTC Costs • Integration of care for long-term care recipients: • PACE: Program of All-Inclusive Care for the Elderly (55+ Medicare/Medicaid population) • EverCare nursing home managed care (Use of NPs and PAs to deliver medical care) • Consumer-Directed Services: Cash and Counseling Demonstration • Public Policy Support of Private Insurance Plans and Consumer Education

16. Other Approaches • Incorporating Geriatric and Prevention Approaches to Chronic Illness

17. A Geriatric PerspectiveFinding the Appropriate Balance and the Right Plan A B C D ProlongingLife Optimizing Qualityof Life Increasing age and frailty

18. Examples of promising complements to primary care of senior populations • Brief GEM/disability prevention with attention to primary care adherence in community (HEP, Stuck) or clinic • Chronic Disease Self-management and other proven self-management support programs • Post-hospital transition care • Linkage to community Alzheimer’s services and supports • Problem-solving therapy for depression • Post-prescription drug monitoring • Senior oriented physical activity (Ed Wagner, Seattle 2005)

19. Threats to Health and Quality of Life • Physical inactivity • Poor diet and nutrition, obesity • Falls • Alcohol and substance abuse • Depression • Smoking • Infection (flu and pneumonia) • Inability to self-manage chronic conditions • Inattention to clinical preventive services • Social isolation

20. Underlying Risk Factors – “The Actual Causes of Death” Behavior% of deaths, 2000 • Smoking 18% • Poor diet & nutrition/ 17% Physical inactivity • Alcohol 4% • Infections, pneumonia 3% • Racial, ethnic, economic ? disparities *Mokdad et al., Actual causes of death in the United States, 2000, JAMA, March 10, 2004.

21. Threats to Health and Well-being Among Seniors • 37% women & 33% men aged 65 – 74 report no physical activity • 24% - obese • 33% - fall each year • 34% - no flu shot • 45% - no pneumococcal shot • 47% - no mammogram • 88% - at least one chronic condition • 37% experience some activity limitation

22. Evidence Based Health Promotion Programs • Administration on Aging and National Council on the Aging (www.healthyagingprograms.org) • Evidence Based Disease Self-Management National Demonstration Program • 3 of 13 projects in Texas

23. Houston Care for Elders/Sheltering Arms Depression intervention Neighborhood Centers, Inc.& St. Joseph’s Physical activity intervention San Antonio and Other Projects Nationally Chronic disease self management Diabetes Heart disease Nutrition and diet Falls prevention Medication management

24. Contact Information Nancy L. Wilson Huffington Center on Aging Baylor College of Medicine One Baylor Plaza M-320 Houston, TX. 77030-3498 713.798-3850 nwilson@bcm.edu