Chapter One

Definition of the Continuum of Care

What is Long-Term Care?

A broad term encompassing a wide-array of populations, services, and funding sources

A wide-range of health and health-related support services provided on an informal or formal basis to people who have functional disabilities over an extended period of time with the goal of maximizing their independence

Health & Health-Related Support Services

HealthMental HealthSocial ServicesSupport Services

Health & Health-Related Support Services

Provided simultaneouslyMay change over timeProvided by formal and informal

arrangementsRecipients may be people of any age

Long-Term Care

Functional disabilities are primary reason

Key the ability to perform ADL/IADL

Goal enable the person to maintain the maximum level possible of functional independence

Long-Term Care

Care is directed not with the expectation of cure, but with enabling people to do the most they can for themselves given the state of their condition

How is Long-Term Care Organized?

On an ad-hoc basis80-90% provided by friends and

familyEach community has its own

combination of available resources, funding sources, and organizations

How is Long-Term Care Organized?

Clients need coordination among many different services, transition among services, and changes of service configurations over time

Characteristics of Major Health Services

Service # Adm. Per yr. ALOS Major PayersHospitals 6,650 33.8 m 5-8 days Medicare-40%

Nursing Homes 14,000 1.3 m 30 days-2 yrs

Medicaid-49%Individual-48%

Home HealthAgencies(Medicarecertified)

6,500 1.6 m 6 wks Medicare-80%

Home HealthAgencies(private)

5,500 N/A N/A Individuals-90%

Adult Day CareCenters

1,800 42,000 clientseach weekday

1-2 yrs State/Local publicsources-80%Individuals-20%

Major Federal Legislation Funding LTC Services

Medicare (Title XVIII of Social Security Act) Year Passed: 1965 Target Population:

Age 65 and older, Disabled, ESRD

Covered Services:Short stay nursing homesSkilled home careHospiceShort-term mental health

Medicaid (Title XIX of Social Security Act) Year Passed: 1965 Target Population:

Poor

Services Covered:Nursing homesSocial servicesAdult day careRespite, homemaker services (varies by state)

Major Federal Legislation Funding LTC Services

Social Services Block Grants (Title XX of Social Security Act) Year Passed: 1974 Target Population:

Aged (over 60), disabled, children

Services Covered:Community-based services (varies by state)

• homemaker, chore, adult day care, adult foster care, mental health

Major Federal Legislation Funding LTC Services

Older Americans Act Year Passed: 1965 Target Population:

Aged (over 60)

Services Covered:Nutrition services, Home delivered mealsState ombudsman programsSocial/recreationalSupportive services

• transportation, outreach, information and referral, legal, in-home services

Major Federal Legislation Funding LTC Services

Supplemental Security Income (Title XVI of Social Security Act) Year Passed: 1972 Target Population:

Low income, aged (over 60), blind, disabled

Services Covered:Automatic Medicaid eligible (see Medicaid)Cash paymentsCongregate housing, adult foster care (at

state option)

Major Federal Legislation Funding LTC Services

Veterans Administration Year Passed: 1963, 1972, 1975, 1980 Target Population:

Veterans

Services Covered:Nursing homesOutpatient care/visits, Adult day careSpecial housing placementPersonal careHospice

Major Federal Legislation Funding LTC Services

Mental Health Year Passed: 1967, 1971 Target Population:

Mentally ill

Services Covered:Community mental health centersICF/MR coverage

Major Federal Legislation Funding LTC Services

American Disabilities Act Year Passed: 1990 Target Population:

Disabled

Services Covered:None specifically -- ensures access to all

services

Major Federal Legislation Funding LTC Services

Ideal LTC System

Provides comprehensive, integrated care on an ongoing basis and offers various levels of intensity that change as a client’s needs change

Provides medical and related support services that enable a person to maximize functional independence

Is a continuum of care

Continuum of Care

A client-oriented system composed of both services and integrating mechanisms that guides and tracks patients over time through a comprehensive array of health, mental health, and social services spanning of levels of intensity of care

Continuum of Care

extends beyond traditional definitions of long-term care

is client-orientedemphasizes wellness rather than

illnessincorporates both acute and long-

term services

Continuum of Care

is a comprehensive, coordinated system of care designed to meet the needs of patients with complex and/or ongoing problems efficiently and effectively

is more than a collection of fragmented services; includes mechanisms for organizing those services and operating them as an integrated system

Continuum of Care (Ideal)

Matches resources to the patient’s condition, avoiding duplication of services and use of inappropriate services

Monitors the client’s condition, and changes services as the needs change

Coordinates the care of many professionals and disciplines

Continuum of Care (Ideal)

Integrates care provided in a range of settings

Streamlines patient flow and facilitates easy access to services needed

Maintains a comprehensive record incorporating clinical, financial, and utilization data across settings

Continuum of Care

Should achieve cost-effectiveness by maximizing the use of resources

Should enhance quality and patient satisfaction through appropriateness, ease of access, and ongoing continuity of care

Should increase provider efficiency

Continuum of Care Services

Over 60 distinct services grouped in 7 categories: Extended inpatient care Acute inpatient care Ambulatory care Home care Outreach Wellness/Health promotion Housing

Extended inpatient care for people who are so sick or functionally

disabled that they require ongoing nursing and support services provided in a formal health care institution but who are not so acutely ill that they require the technological and professional intensity of a hospital

e.g., nursing facilities, step-down units, swing beds, nursing home follow-up

Continuum of Care Services

Acute inpatient care hospital care for those who have major

and acute health problems e.g., medical/surgical inpatient unit,

psychiatric inpatient unit, rehabilitation inpatient unit, interdisciplinary assessment team, consultation service

Continuum of Care Services

Ambulatory care services provide a wide-spectrum of preventive,

maintenance, diagnostic, and recuperative services for people who manifest a variety of conditions

e.g., physicians’ offices, outpatient clinics, interdisciplinary assessment clinics, day hospitals, adult day care centers, mental health clinics, satellite clinics, psychosocial counseling, alcohol and substance abuse care

Continuum of Care Services

Home care represents a variety of nursing, therapy, and

support services provided to people who are homebound and have some degree of illness but who are able to satisfy their needs by bringing services into the home setting

e.g., home health (Medicare/private), Hospice, high-technology home therapy, durable medical equipment, home visitors, home delivered meals, homemaker/personal care, caregivers, respite

Continuum of Care Services

Outreach programs make health services and social services

readily available in the community rather than within the formidable walls of a large institution

e.g., screening, information and referral, telephone contact, emergency response, transportation, Senior membership programs, Meals on Wheels

Continuum of Care Services

Wellness programs are provided for those who are basically

healthy and want to stay that way by actively engaging in health promotion

e.g., educational programs, exercise programs, recreational and social groups, Senior volunteers, congregate meals, and support groups

Continuum of Care Services

Housing for frail populations; increasingly includes

access to health and support services and conversely, recognizes that the home setting affects health

e.g., continuing care retirement communities, independent senior housing, congregate care facilities, adult family homes, assisted living facilities, intermediate care facilities for the mentally retarded

Continuum of Care Services

Each has different regulatory, financing, target population, staffing, and physical requirements

Each has its own admission policies, patient treatment protocols, and billing system

Continuum of Care Services

Inter-entity structureCare coordinationIntegrated information systemsIntegrated financing

Continuum of Care Integrating Mechanisms

Inter-entity structure management arrangements and

operating policies are in place enable services to coordinate care, facilitate smooth patient flow, and maximize use of professional staff and other resources

Continuum of Care Integrating Mechanisms

Care coordination the coordination of the clinical

components of care, usually by combination of a dedicated person and established processes that facilitate communication among professionals of various disciplines at multiple sites

Continuum of Care Integrating Mechanisms

Integrated information systems one patient record that combines

financial, clinical, and utilization information to be used by multiple providers and payers across multiple sites

Continuum of Care Integrating Mechanisms

Integrated financing removes barriers to continuity and

appropriateness of care by having available adequate financing for long-term care as well as acute care, preferably paid by a capitated system

Continuum of Care Integrating Mechanisms

Framework for the Future

Demand for long-term care will increase aging population

increasing in numbersincreasing in age

technology shift from acute to outpatient

Challenge is to develop an approach to long-term care that is efficient, affordable, and appropriate for the individual and family and simultaneously, affordable and cost-effective for society

Framework for the Future