1. THE UNITED STATES HEALTH CARE SYSTEM Combining Business, Health, and Delivery CHAPTER Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Tertiary Care: The Long-Term Care Continuum 8

2. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Objectives Describe the continuum of long term care (LTC). Describe who uses LTC. Explain the various ways LTC is provided. Describe how LTC is financed. Discuss ethical and political issues in LTC.

3. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Introduction Long-term is one of the fastest growing sectors –Aging of baby boomers  67 million people will be over 65 by 2030  Double the number in 2000 –The number of people 85+ will also double –The ability to treat diseases that would have killed in this age group will add significantly to the 65+ population

4. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Introduction (cont.) Long-Term Care Means providing health care services to an individual for more than 90 days. Facilities include: –Hospitals/Nursing homes –Assisted living/Community based residential facilities –Adult day care/Adult foster homes –Respite care/Hospice care

5. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Introduction (cont.) Long-Term Care (cont.) Means providing health care services to an individual for more than 90 days. Facilities include: (cont.) –Rehabilitation centers/Mental health facilities –Children’s chronic care facilities/Care provided by family and friends

6. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Needs Long-Term Care? Anyone with a chronic condition requiring assistance for more than 90 days. The time needing assistance may range from 90 days to many years.

7. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Needs Long-Term Care? (cont.) Need is determined by assessing the ability to perform: –ADLs (activities of daily living)  Bathing, dressing, toileting, transferring, continence control, and eating –IADLs (instrumental activities of daily living)  Managing money, telephoning, grocery and personal shopping, using transportation, housekeeping, chores, and managing medication

8. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Needs Long-Term Care? (cont.) ADLs and IADLs are assessed using 4 categories –Totally independent –Requiring mechanical assistance only  Hearing aid, cane, special utensils –Requiring assistance from another person –Unable to do the activity at all

9. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Needs Long-Term Care? (cont.) If a person can manage most of the ADLs/IADLs even though they may have considerable disability, they do not need LTC.

10. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Needs Long-Term Care? (cont.) Continuum of Care A philosophy that emphasizes the physical needs of the person, also the social, mental, and financial support. It is a holistic and wellness model rather than the medical or illness model used now.

11. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Needs Long-Term Care? (cont.) Continuum of Care (cont.) Currently a person may need to interact with 80 or more agencies to get the help they need.

12. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Uses LTC? People of all ages Largest group is age 65+ representing 80% of all LTC usage 1 in every 8, or 12.8% (39 million), of the population is an older American

13. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Uses LTC? (cont.) 7% of people 65+ report a need for outside assistance for either ADLs or IADLs 20% in the 85+ age group need outside assistance 5.5% of these are nursing home residents

14. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Uses LTC? (cont.) Primary Diseases that Affect Older Adults –Arthritis –Complications of high blood pressure (e.g., stroke, heart) –Diabetes –Pulmonary disease –Cancers –Fractures –Cognitive impairment from Alzheimer’s or other dementias

15. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Uses LTC? (cont.) Demographic trend questions: –Who will be available to care for an aging population? –How we will fund that care? Median income of older persons in 2008 was $25,503.

16. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Uses LTC? (cont.) Sources of income: Social Security (87%), income from assets (52%), private pensions (28%), earnings (25%), and government employee pensions (13%) 17% of school-age children with chronic disease use LTC services.

17. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Uses LTC? (cont.) Non-institutionalized people with disabilities represent about 19% of the population. 50% of men over the age of 65 are veterans. Department of Veteran Affairs (DVA) LTC facilities cares for over 100,000 veterans a year.

18. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? Largest group is unpaid caregivers –Provide 70% of all care to ages 18-64 –11% are cared for by a combination of paid and unpaid –Only 9% totally rely on paid care

19. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Largest group is unpaid caregivers (cont.) –65+ rely heavily on companion/spousal care and adult children, usually daughters –Families provide 91% of care –Friends and community provide the other 9% of unpaid care

20. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Home Health Care –Fastest growing segment of LTC –Since 1880s has been a part of LTC –Decreased hospital stays since the 1980s have dramatically increased the demand –High-tech therapies available in the home have further pushed the demand

21. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Home Health Care (cont.) –Diseases of the heart and vascular system top the diagnosis list for visits –Funded by combination of federal, state, local, and personal funds

22. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Adult day care centers provide care for part of each day –50% of clients have cognitive impairment –40% have 3 or more ADL deficits –Patient’s average age is 76 and is a woman

23. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Respite care –Allows the caregiver to have scheduled times to shop, care for their own health, and to socialize with healthy friends and relatives –Provided by adult day care centers, hospitals, and nursing homes –This segment of LTC is growing because of the aging of America

24. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Hospitals offer different types of LTC –Home health –Respite care –Skilled nursing beds –Clinical pharmacy and respiratory care –Case management

25. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Hospitals offer different types of LTC (cont.) –Geriatric and geriatric psychiatric assessments –Adult day care –Hospice –Assisted living and retirement housing

26. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Nursing Home A facility with 3 or more beds licensed to provide medical care. Rapidly changing part of the spectrum. –Historically small and family owned –Currently large multilevel facilities owned by corporations 1.5 million people live in nursing homes. 88.3% are 65+ and 71% are women.

27. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Nursing Home (cont.) The 16,000 nursing homes in the U.S. are classified by ownership and level of care. –Two thirds are proprietary for profit –Rest are not-for-profit or government sponsored

28. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Nursing Home (cont.) Level of care categories –ECF: Extended care facilities –ICF: Intermediate care facilities –ICF-MR: Intermediate care for mentally retarded –SNF: Skilled nursing facility

29. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Assisted living facilities (ALFs) Not a medical model–a social/cognitive model. 36,000 facilities nationwide. 910,000 residents. Average age: 84. Female-to-male ratio: 5 women to 1 man. Each unit is a full living unit.

30. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Assisted living facilities (ALFs) (cont.) Eat one meal in congregate dining room. May get some assistance, but remaining functional and choice is the goal. Cost: $1,800 to $2,200 a month. Independent living is an apartment specially adapted so the resident can live without assistance.

31. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Who Provides LTC Services? (cont.) Paying for LTC Services Financing of nursing home care is primarily by Medicaid and private individuals and families. Medicare only pays for skilled nursing. ICF costs from $5000 to $8000 per month.

32. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle How Do We Pay for LTC Services? A combination of government programs (Medicare and Medicaid); private funding (personal insurance and out-of-pocket payments). A great deal of LTC is unpaid assistance by family and friends.

33. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle How Do We Pay for LTC Services? (cont.) Medicare does not pay for LTC. Medicaid will pay for nursing homes; however, the patient must meet Medicaid’s income tests.

34. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Ethical and Political Issues in LTC Political To what extent should the government finance, regulate, and deliver LTC services?

35. Copyright ©2012 by Pearson Education, Inc. All rights reserved. The United States Health Care System: Combining Business, Health, and Delivery, Second Edition Anne Austin Victoria Wetle Ethical and Political Issues in LTC (cont.) Political and Ethical –Resource allocation between generations –Guardianship and medical powers of attorney –End-of-life care and decisions How we treat the chronically ill is a measure of our values as a country.