Download Feb. 14 - Home - University of Chicago

Long-Term Care: The
Basics
Seema S. Limaye, MD
Section of Geriatrics
Department of Medicine
University of Chicago—Pritzker School of Medicine
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…
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
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…
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.
LTCF:




Nursing homes,
Rehabilitation facilities,
Inpatient behavioral health facilities,
Long-term chronic care hospitals
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).
Payer
Medicare
Medicaid
Private LTC
Insurance
Out-of-pocket
Other payer
2000
29.4
43.4
5.0
2010
39.8
36.7
16.7
2030
50.6
36.2
36.2
42.8
<5
35.5
<5
42.9
<5
Source: Congressional Budget Office
How are LTC services
reimbursed?

Depends on the services…
Service
Home Care
Custodial NH
Care
Reimbursement
Part A and Part B
Patient and Medicaid
Rehab: acute
and subacute
Part A
Chronic LTC
hospital
Patient and Medicaid
Hospice
Part A
How are LTC services
reimbursed? (cont)
Services
Durable Medical
Equipment
Homemaker services
Reimbursement
Part B
Department of aging:
State-controlled
Federal Mandate
NURSING HOME 101
Nursing Home 101




Resident pays out-of-pocket
LTC insurance
Medicaid
Medicare DOES NOT pay for custodial,
nursing home care!
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
Types of SNF
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?
Key “Players” in SNF
Executive Director
NH Administrator
Medical Director
Director of Nursing
Social Worker
Rehab services
-PT
-OT
-Speech/Swallow
(More) Key “Players” in SNF
Medical Director
Physicians
APNs
PA’s
(More) Key “Players” in
SNF
Director of Nursing
Asst DON
RN/LPN
CNA
(More) Key “Players” in
SNF


Activities Director
Dietician/Nutritionist
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
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
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
IOM Report 2001
Improving the Quality of LongTerm Care
“Evidence indicates that quality of care in
general has improved over the past decade…”
Areas of
Improvement:
– Restraints
– Psychotropics
Persistent Problems:
–
–
–
–
Pain
Pressure sores
Malnutrition
Urinary Incotinence
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
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
Minimum Data Set





350-item questionnaire
“clinical assessment”
Submitted to Medicare
Done periodically
Used for regulating and research
– Pros and cons?
How is quality improved
upon in the NH?

Quality Assurance meetings
– Often quarterly
– Interdisciplinary
– Look for trends
– Focus on quality indicators: PU, falls, skin
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
1.
2.
3.
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.
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).
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
Components of EthnicallyOriented 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.
Other topics to ponder…



Informal caregivers
Paid caregivers
Home health services