Toward a National Strategy for Long-Term Care of the Elderly A Study Plan (1986) / Chapter Skim
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Exhibit B: Major Problems and Issues in Long-Term Care
Exhibit B: Major Problems and Issues in Long-Term Care
Pages 53-94
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From page 53... ...
Major initiatives to solve them that are being undertaken on an experimental or demonstration basis, and other initiatives that have been proposed, also are briefly described. INFORMAL CARE Between 70 and 75 percent of the functionally dependent elderly population live in their own homes or in the homes of their family members.
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From page 54... ...
Also included is Supplemental Security Income (SSI) which provides cash benefits to low income persons who are aged, blind or disabled in order to bring their total incomes up to federally established minimums associated with estimated "poverty" levels.
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From page 55... ...
FORMAL INSTITUTIONAL CARE The bulk of formal, that is organized and paid, long-term care services are provided in institutions. More than half of institutional care is provided in nursing homes, including both skilled nursing and intermediate care facilities; long-stay hospitals, including psychiatric hospitals and residential care facilities, such as board and care homes, provide the remainder.
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From page 56... ...
Nursing home occupancy rates generally are running very high and many communities report long waiting lists for placement of functionally dependent persons in nursing homes. The generally mediocre, frequently very poor, quality of nursing home care was widely perceived and dramatically portrayed nation-wide during the 1970s, and although anecdotal evidence suggests there has been some general improvement, quality of care in all long-term care institutions is a pervasive continuing concern.
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From page 57... ...
Of the nearly $15 billion expended by Medicaid in 1983 for institutional care of all sorts, about 57 percent was financed by the federal government and 43 percent by state governments. About 6.5 percent of all Medicaid expenditures was for care in psychiatric hospitals, about 26 percent was for care in intermediate care facilities for the mentally retarded; the remaining two-thirds was for care in other intermediate care and skilled nursing home facilities, with at least 85 percent of the residents in those homes being age 65 or over.
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From page 58... ...
· Nearly three-fourths of the states are employing some type of prospective payment system for nursing home care, rather than a retrospective cost-reimbursement system, as a cost-control mechanism. Finally, many states have undertaken programs to develop coordinated systems of community-based and in-home care services for the elderly and other functionally dependent persons.
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From page 59... ...
Systematic information on the quality of formally provided community services also is not readily available and more difficult to assess at present than institutional care. As noted previously, the utilization of institutional care in nursing homes is associated with lack of a suitable community residence, as well as weak community service support systems, for many functionally dependent persons whose needs for assistance are greater than can be provided by family members or friends in their homes, who have no family or friends available.
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From page 60... ...
· Within the past decade, the Health Care Financing Administration sponsored a number of research and demonstration projects aimed at testing the efficacy and cost effectiveness of financing expanded home and community based long-term care services. The primary thrust of these projects has been the prevention/postponement of nursing home use, lowered cost as compared to nursing home costs, and better if not equal impact on patient health status and mortality rates.
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From page 61... ...
· A number of programs have been initiated primarily under private sector auspices, but with federal and state government support and involvement in many instances, to provide alternative residential arrangements in the community for the functionally dependent. These involve congregate housing and domiciliary care programs, both of which may include the provision of long-term care services either on the premises or in community-based facilities.
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From page 62... ...
Also during the same period, new admissions to the psychiatric hospitals were drastically reduced, particularly along younger adults. There is a widespread view that most nursing homes do not have the kinds of skilled rehabilitation services needed, by younger patients particularly, to reintegrate them into the community.
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From page 63... ...
Developmentally Disabled, Including Mentally Retarded The developmentally disabled population is the only functionally dependent group whose long-term care needs have been targeted purposively in federal legislation, Public Law 94-103, the Developmentally Disability Assistance Bill of Rights Act of 1978. That act reinforced deinstitutionalization of the mentally retarded, a movement that began about in 1967, from large state and county mental hospitals to small public and private residential communities, and since 1978, to intermediate care nursing homes officially designated for the mentally retarded.
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From page 64... ...
It is clear that a substantial population of the expenditures under Medicaid and other federal and state service programs, such as special education, were for the developmentally disabled. For example, an estimated 3.9 billion was expended under Medicaid in FY 1983 on intermediate care for the mentally retarded in nursing homes; the developmentally disabled represent over 80 percent of the handicapped children served in federal special education programs, for which the budget in FY 1984 totaled about $1.3 billion.
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From page 65... ...
The elderly are not only disproportionate users of the long-term care system but also are the highest users of hospital and physician services. Changes in the way that hospitals and physicians provide services, therefore, can impact the appropriateness, timeliness and continuity of care for functionally dependent persons.
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From page 66... ...
The ownership and management of the nation's health care system is undergoing both horizontal and vertical consolidation. More and more health care facilities of all types, including hospitals, nursing homes and various free-standing specialized service facilities, are being incorporated into national multi-institutional chains, both proprietary and not-for-profit.
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From page 67... ...
o Devising new mechanisms, both public and private, for financing long-term care services 0 Containing the disproportionate growth in costs and inappropriate utilization of nursing home care · Increasing the availability of and access to cost-effective communty-based and in-home services programs as alternatives to nursing home care o Improving coordination/integration within community long-term care services and among community services, institutional long-term care, primary health care, and acute care, and improving continuity of the care provided 0 Developing integrated approaches to organizing and managing comprehensive health and social services, including long-term care services in various residential configurations in the community continued residence in homes, retirement living complexes, congregate and domiciliary housing · Improving the appropriateness and quality of long-term care services, particularly in nursing homes and in psychiatric and other long-stay hospitals · Sustaining, in policy choices related to the preceding issues, appropriate existing informal care arrangements The above issues obviously overlap and interact; thus, actions to resolve one issue may conflict with actions to resolve another. For example, attempting to simultaneously achieve effective cost control and increased availability and access to com~unity-based and home services may involve trade-offs between costs and care that pose difficult policy choices.
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From page 68... ...
This pervasive fragmentation also has placed a burden on private sector long-term care service providers. Most providers serve all the functionally dependent population groups, but have to cope with the different eligibility requirements for different services and with differing arrays of regulatory mechanisms relating to quality of care, payment for services, and accountability of the various programs.
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From page 69... ...
There have been a number of proposals to develop alternative mechanisms of financing both institutional and non-institutional long-term care services, in which the continued development and expansion of formal community service programs would be enhanced. Major types of proposals include the following: -69
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From page 70... ...
, perhaps with favorable tax treatment of use of the accumulated savings for long-term care insurance premiums or expenditures for long-term care. O Home equity conversion programs involving either reverse mortgages or sale lease-backs to elderly home-owners, perhaps with tax treatment similar to IRA's above · Alternative indexed block grants to the states, which would subsume some or all federal financing programs, for discretionary long-term care use by the states · Alternative cash benefit programs, such as voucher systems, for the disabled of all ages for purchase of long-term care services, perhaps as an indexed addition to the current Supplemental Security Insurance program -70
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From page 71... ...
In contrast to federal and state sources of public funding, very little, if any, funding for long-term care is available at the local level with the exception of a modest amount of funding for county nursing homes, public health visiting nurse services and United Way/Community Chest funds which subsidize visiting nurse and homemaker/chore social service agencies.
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From page 72... ...
1Health Care Financing Administration, Office of Research, Demonstrations and Statistics, Division of National Cost Estimates. 2Robert Gibson, et al.
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From page 73... ...
Data are summarized by the period in which claims were approved and should be considered preliminary for all periods after 1982 due to processing lags.) 2Chris Howe, Division of Medicaid Cost Estimates, Bureau of Data Management and Strategy, Health Care Financing Administration.
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From page 74... ...
1. Locus of Service Nursing Home Community Services Services Social SecuritY Title XVIII 394.61 1,273.7 (Medicare)
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From page 75... ...
However, although we know that private pay constitutes a very important source of institutional long care funding, our knowledge about private expenditures for community-based care is considerably more limited since very few, if any, studies to date have addressed the extent of out of pocket payments for home care services. Despite this gap in our knowledge, there are some indicators that a reasonably good private pay home care market might exist.1 For example, proprietary home care chains which market heavily to private pay consumers recent years.
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From page 76... ...
We now have HMO's doing case management for the elderly, with the new HCFA HMO Medicare experiments that are under way.6 Also, with the Section 2176 Community Care Medicaid waiver, more home care agencies are beginning to provide services to Medicaid patients than ever before. Thus there is some evidence available which indicates that providers are beginning to integrate more services at their level.
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From page 77... ...
If it will buy X days of nursing home care vs. X days or hours of home care, families/consumers can decide what they prefer.
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From page 78... ...
To summarize, there are many important issues involved in integrating multiple funding streams. There are many more than those listed in this brief review and a very important function of this study will be an examination of these issues, with attempts to safeguard against potential abuses, while at the same tome maximizing access and consumer choice.
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From page 79... ...
Hughes, Susan L.; Cordray, David S.; and Spiker, V Alan Evaluation of a Long Term Home Care Program.
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From page 81... ...
the proportion of the mobility-impaired elderly who live in housing units that do not meet minimal standards of adequacy is surprisingly high -- roughly 17 percent fail the Department of Housing and Urban Development's (HUD) test for physically adequate housing, about two times as great as those elderly with no mobility limitations; (b)
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From page 82... ...
Housing Programs Serving the Elderly My cursory review of the HUD's Fiscal Year 1986 budget requests of Congress indicates that, in terms of new housing units to be authorized, the Department is requesting nothing in any of the major programs that have traditionally served the elderly poor. However, -82
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From page 83... ...
The main housing assistance programs to date, in terms of numbers of persons served, have been the Public Housing and the Section 8 Existing Housing programs. It is important to note that for these HUD programs, three groups of households are categorized as eligible for assistance in ' such a way that, at least theoretically, they do not compete with each other for program slots.
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From page 84... ...
But there is little coordination among these programs, and very little information on the number of individuals served by each. Hi, Future Housing Needs of the Elderly The Section 202 program, introduced more than 20 years ago, along with a more recent HUD Experimental Congregate Housing Services Program under which about 2,000 housing units currently operate, represent an acknowledgment by the federal government of the need and feasibility of integrating services and housing.
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From page 85... ...
These are all options that have developed entirely as a result of individual initiative in the private sector. While we do not have precise estimates on how many people reside in them, surely it is no more than a fraction of one percent of the total elderly population.
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From page 87... ...
The graying of the population generates a new ethical agenda and changes culture itself. It profoundly influences family life as well as public policy.
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From page 88... ...
behavior, but not necessarily our convictions. In a society such as ours, it is deliberately minimalist in dealing with the human enterprise.
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From page 89... ...
Existing programs such as Medicare, Medicaid and the Veterans Administration health activities will be at the center of the public debate. Initial discussions are about cost containment measures, such as the utilization of prospective reimbursement systems and diagnostic related groupings of illness/disease as a method of determining payment for health care.
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From page 90... ...
Each person can look forward to a long life with periods of greater or less dependency and independence, and periods of greater or less productivity. A Fundamental Question A fundamental moral/ethical question is the obligation that a prolonged life span puts upon the individual.
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From page 91... ...
We have yet to address the implications of the changing family in the context of prolonged life spans, particularly in regard to family relationships with disabled members who are older. It has been part of our societal ethos that children care for their frail parents.
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From page 92... ...
Consistent rulings through various administrations that interpreted Congressional intent, as well as the Medicaid statute itself, as precluding states from seeking the participation of children in paying for health care services for their otherwise eligible parents, has been reversed by the current administration. As of this writing, only the State of Idaho has taken advantage of this opportunity.
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From page 93... ...
Some are universal in their coverage, while others are means tested. They deal with acute health problems, housing, services and income, but neither individually nor collectively do they reach the problem of frailty and disability of dependent elderly people.
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From page 94... ...
It must address the expectations that we "ought" to have of: individual responsibilities in the light of prolonged life expectancies; the responsibilities of families as they exist today and will tomorrow; the role of the private sector, including so-called mediating structures and insurance; and the role of government at all levels -- in helping us share one another's burdens, particularly the burdens of those who are the poorest and most vulnerable among us.
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