Long-Term Care

The Historical Evolution

17th CenturyEnglish Poor Laws

established 1601-1890 the impotent poor (sick, elderly, and those

unable to work) were helped via outdoor relief or almshouses; these people were classified as “would work but couldn’t”abuse was rampant; living conditions were

horribleamendments to the laws were made that were

specifically and explicitly aimed at discouraging people from applying for relief

17th CenturyAlmshouses

established from 1622 to 1736 communal facilities where the lame, sick,

blind, orphaned, and aged could be cared for people were sent to these places only if

there was no one else to care for them no government agencies were involved; any

relief was considered to be a local responsibility handled by the churches and social organizations

18th CenturyMany of the social organizations

converted private homes into “homes” to care for the lame, sick, blind, orphaned, and aged these people were known as “inmates” or

“wards”

Early 19th CenturyCommunal “Collection Pot” of the Eastern

European immigrants these “homes” served the aged, orphaned,

handicapped, disabled, and mentally ill feared and dreaded by the community

The Altenheim Model of the Germany and Scandinavia immigrants a kind of “club-residence” for those who had saved

and planned for a respectable retirement nice, but cost a fair amount of money resembled our current retirement homes

19th CenturyConvalescent Homes for Children

initially children received attention in an effort to conserve their usefulness to the developing economy in expanding the available manpower for work in factories and farms

emphasis was placed on providing an institutional climate in which the natural recuperative powers of the body would not be impeded

19th CenturyConvalescent Homes for Young Adults

a limited number of younger working-age adults were provided care

the objective was to restore the individual to permit him to fulfill his obligation as a working member of society

Home for the Elderly typically a small, culturally homogeneous

institution that catered to the “worthy poor”

Mid-19th CenturyPrivate Nursing Homes

experienced tremendous growth after the American Civil War (1861-1865), which continued through the turn of the century

Early 20th CenturyPrivate Nursing Homes

of the approximately 1200 facilities in the U.S. in 1939, nearly 2/3 were founded between 1875 and 1919

originally these were custodial rather than medical facilities, and they were ethically or religiously homogeneous

Early 20th CenturyMedical Model of the Mental Hospital

after WWI (1914-1918), the level of care for the dependent elderly shifted away from the custodial and social model to the medical model

Publicly-supported Almshouses/Charitable, Private Old Age Homes (1920s) roughly 1/2 of the institutionalized elderly lived

in publicly-supported almshouses and the other 1/2 in charitable, private old age homes

Early 20th CenturyThere was a shift from almshouses to

mental hospitals because of new legislation which mandated state responsibility for all mentally ill persons

20th CenturyOld Age Assistance Program

established under the Social Security Act in 1935 continued the trend away from almshouses as

the means of caring for the elderly in order to discourage institutional care for that group

the effect, however, was to stimulate the growth of proprietary and voluntary nursing homes since federal assistance was made available to individuals residing in such facilities

20th CenturyHill Burton Act

passed by Congress in the 946, the Hospital Survey and Construction Act was sponsored by Senators Lister Hill and Harold Burton

it was the Nation’s major health facility construction program under Title VI of the Public Health Service Act

it granted public money for building nursing homes modeled on hospitals

20th CenturyHill Burton Act

with this public money came federal regulations the Public Health Service became the agency

responsible for formulating staffing and design requirementsat that time, decisions about what constituted good

care for the elderly were not based on an analysis of their actual needs; instead, the Public Health Service recreated the only environment with which they were familiar -- the general hospital

20th CenturyOlder Americans Act, Medicare, Medicaid

the nursing homes with which we are currently familiar began to grow in earnest after the passage of the Social Security Act in 1935, especially since the advent of the OAA in 1965, and the financial reimbursement provided through the 1965 amendments to the SSA known as Medicare and Medicaid

with the general hospital as the model institution, the passage of Medicare and Medicaid legislation I 1965 permitted the proprietary nursing home industry to develop and expand according to the medical model

20th CenturyMedicare

created by the Social Security Amendments of 1965 health insurance program for those age 65 and

above, regardless of income or wealth; also covers disabled people under age 65 who have been entitled to Social Security or Railroad Retirement disability benefits for at least two consecutive years and those who suffer from End-Stage Renal Disease (ESRD)

provides: up to 100 days in a SNF, with Medicare paying the full cost for the first 20 days and the patient paying a set amount each day thereafter; unlimited home health visits; and Hospice care

Medicaidcreated by the Social Security Amendments of 1965it is the primary payment source for nursing homes

todayit is a federal-state financed program to pay for

health services for the categorically needy and medically needy

• categorically needy - those receiving public assistance from AFDC or SSI because they are blind, aged, or disabled

• medically needy - those who have enough money to live on, but not enough to pay for medical care

20th Century

20th CenturyNational Certification Begins

in 1967, providers certified for Medicare became subject to the first national certification programs for long-term care facilities

federal standards for Medicaid followed in 1970Long-Term Care goes Public

Beverly Enterprises became the publicly traded long-term care company when it joined the roster of stocks on the American Stock Exchange

20th CenturyRalph Nader publishes Old Age: The

Last Segregation (1970), marking the beginning of the public cry for quality care in nursing homes and influencing public policy

President Nixon, in 1971, unveils his “Eight Point Plan” to improve the care provided in nursing homes

20th CenturyIn 1975, a group of nurses became the

first to earn certification for excellence in geriatric nursing practice

The National Citizens’ Coalition for Nursing Home Reform is born in 1975 as representa-tives of citizen groups and ombudsman programs unite at a meeting of the American Health Care Association

20th CenturyIn 1980, an amendment sponsored by

senator David Boren gives states more latitude in developing their reimbursement systems but requires that rates be “reasonable and adequate”

Paul Klaasen opens his first Sunrise Assisted Living Facility in 1981, fostering a new form of long-term care in the U.S.

20th CenturySeeking to trim Medicaid spending and

the LOS in nursing homes, in 1981 HCFA introduces home and community-based waivers, allowing states to use alternative forms of care for Medicaid beneficiaries

Media attention to Alzheimer’s Disease sparks growth in the number of special care units starting in 1983

20th CenturyIn 1983, Medicare shifts from cost-based

reimbursement for hospitals to prospective payment under diagnostic related groups (DRGs); patients leave hospitals “sicker and quicker”, necessitating post-acute care

EverCare brings managed care to long-term care facilities when it is launched in 1987 in Minneapolis; a capitated plan, EverCare aims to limit the need for acute care

20th CenturyA part of the Omnibus Budget Reconciliation

Act (OBRA) of 1987, the Nursing Home Reform Act, enacts the most sweeping reforms to nursing home regulations since the passage of Medicare and Medicaid

In 1988, the influential Untie the Elderly campaign is born, increasing the awareness of the damaging effects of physical restraints

20th CenturyA “central link” of the OBRA 1987

provisions, the MDS is introduced in 1990 as a tool for standardized assessment of nursing facility residents

The oldest baby boomers turn 50 in 1996, calling attention to the graying of America and the need for more consumer choice in long-term care

20th CenturyThe Balanced Budget Act of 1997

repeals the Boren amendment, leaving the industry without its reimbursement protections

The balanced Budget Act of 1998 replaces cost-based Medicare payments with a prospective payment system

In Summary...The U.S. has never had an explicit,

coherent policy regarding long-term care; the American policy for care of the chronically ill has evolved incrementally and disjointedly

Certain key pieces of legislation passed during the last 50 years have significantly impacted the provision of long-term care

In Summary... Long-term care has grown from almshouses

to state mental hospitals to voluntary homes for the aged to nursing homes and other more contemporary settings

The SSA (1935) played an important role in expanding the demand for proprietary and voluntary nursing homes by providing aged individuals, who qualified under a means test, with income through OAA that could be used for personal and nursing care

In Summary...Since then, a variety of legislation has

alternately:increased the demand for nursing homesincreased the number of nursing homesincreased reimbursement to nursing homesplaced controls on nursing home careregulated nursing home carecreated a confusing array of services, eligibility

requirements, and reimbursement services which frequently create barriers to care