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The crisis of longer-term care is twofold...?

1) Shitloads of people lose their savings to pay for chronic illness 2) Long-term care often takes place in dehumanizing institutions that rob their occupants of their last remaining vestiges of independence.


What does long-term care involve?

Includes health, social, housing, transportation, and other supportive services needed by people with physical, mental, or cognitive limitations sufficient to compromise independent living (ADLs and IADLs)


ADLs v. IADLs?

ADLs are basic human functions (dressing, bathing, etc) and IADLs are Instrumental activities of daily living, necessary to remain independent, like laundry, housework, meal preparation, grocery shopping, transportation, financial management, taking meds, and telephoning.


Top 3 payers for nursing home care, in decreasing order?

MCAID, OOP, and Private Insurance


Top 3 payers for home care, in decreasing order?

MCARE, MCAID, and home care


Top 3 payers for TOTAL long term care, in decreasing order?



How does MCARE decide to pay for long term shit?

1) Skilled care is covered, custodial care isn't. 2) MCARE covers services for a few weeks/months after cute hospitalization, but not for stable chronic conditions.


Skilled v. Custodial Care?

Custodial services involve assistance with ADLs and IADLs rather than treatment or rehab care related to a disease process...often provided by nurses' aides, home health aides, etc. instead of skilled practitioners upwards of nurses


MCAID long term coverage?

MCAID covers more nursing home stuff, but you have to lose most of your savings to be eligible. MCAID's coverage of home health services has increased over the past 30 years in an attempt to prevent nursing home admissions.


Private insurance long term coverage?

Less than 10% covered by private insurance...experience rating is a big factor. Elderly are charged high premiums cuz they're at risk of requiring long-term care services. Major attractive market is younger employed population but few of those people actually want long-term insurance. Premiums rise with Age!!


Why might private long term coverage be a poor investment?

Some private policies specify that a policyholder must be dependent in 3+ ADLs before receiving benefits for home health services....but lots of people are like, <3. Coverage is pretty limited too, so a lot of out-of-pocket expenditures are involved.


Where do most people needing long term care services get their care from? Is this effective?

Family/friends, who often have to reduce work hours/quit jobs to make shit work. Elderly people with caregivers have shorter hospital stays, fewer readmissions, and lower inpt expenses, so YEAH it does work.


What kind of community-based long term is available? (3)

Custodial and specialty home care, hospice care, assisted living


Issue with custodial and specialty home care?

Right now MCARE pays a lump sum to home care agencies for 60-days of care. There have been lots of advancements in shifting specialty care from hospitals to homes, BUT they haven't been matched by growth in the paid personal custodial care needed so disabled people can stay at home.


Issues with hospice care?

Provides great nursing services but is limited in ADL support. They may also not accept terminal pts without an informal caregiver at home.


Issues with assisted living?

Average annual cost is rising, usually pretty out of reach to low-moderate income families.


2 main differences between chronically ill inside/outside nursing homes?

Nursing home residents have no family able to care for them, and a large proportion of nursing home pts suffer from dementia (very difficult to care for)


Omnibus Budget Reconciliation Act (1987)?

Set standards for nursing home quality and mandated surveys to enforce these standards


Facilities/Standards/Oversight of Nursing homes is the responsibility of who?

STATE (not fed govt)


How will trend of long term care needs look like?

It's going to continue to GROWWWW


Who is responsible for most care in nursing homes, and issues?

Nurse's aides. Paid very little, receive minimal training, are inadequately supervised, and are required to care for more residents than they can handle. Really crappy, difficult job description aiding with ADLs.


Who owns nursing homes, and issues?

For-profit ownership - associated with lower staffing levels, poorer quality of care compared with nonprofit ownership.


4 proposals for improving long-term care?

Developing social insurance to finance long-term care, shifting form nursing home care to community-based care, training and supporting family members as caregivers, and expanding the number of comprehensive acute and long-term care organizations modeled on On Lok Senior Health Services


What is the On Lok Program?

it's a successful program based in Chinatown, San Francisco. Merges most important services into one program, small minority spends time in a nursing home.


Where does On Lok get their money from?

Assumes full financial risk, receives monthly capitation payments from MCARE and MCAID. 17% of finances go to hospital/nursing homes, 8% goes to community-based home services.


Different levels of institutional care?

SNF, ICF/ID (Intermediate Care Facility for the Intellectually Disabled), and Nursing homes


What percentage of people who need long term care are over 65?

Actually, around half.


What gender/ethnicity of >65 nursing home services?

3/4 are women, and over 80% are white.


What happens to pts who are dual eligibles?

MCAID pays for majority of long term care costs, often gets complicated cuz source of payment is coming from two sources.


T/F all states are federally required to over nursing facility and community-based benefits.

FALSE: REQUIRED For nursing facility benefits, OPTIONAL for community-based services.