Long Term Care

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Long Term Care

• Nancy L. Wilson-Baylor College of Medicine
• Huffington Center on Aging-Department of Medicine
• Presentation to Citizens Health Care Working
  Group
• Houston Hearing
• July 26, 2005

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• Mission Statement To improve long-term care and
  supportive services provided to vulnerable older
  adults and family caregivers in Harris County
  through collaborative problem solving and
  strategic planning that involves consumers,
  providers, funding organizations, and other major
  stakeholders of the long-term care system.
• www.careforelders.org
• RWJ Community Partnership Program for Older
  Adults

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Key Issues and Strategies

• Access to Needed Services
• Availability of Affordable Services
• Quality of Care Major Workforce Issues
• Preparedness for Aging
• Individual/Personal
• Organizational
• Community

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Todays Presentation

• Population concerned with long-term care is very
  diverse in terms of age and level of disability
  physical, mental,
• My Expertise and Experience Focused on Older
  Adults (60-63)
• Who I think about
• My brother in-law who has managed with
  functional limitations due to encephalitis
  fiercely independent in his own apartment with an
  electric wheelchair and dependent on daily
  assistance
• My neighbors Mrs. H, 81 who has congestive heart
  failure and COPD as well as a closed head injury
  sustained from a fall. She would like to remain
  at home with her husband for the duration of her
  illness.
• My niece who is 22-years-old who has mental
  retardation as a result of
• complications during birth and has been
  diagnosed with autism. Her family would like her
  to live at home indefinitely , but they need help
  with her care, particularly with a program of
  supervised daily activities.
• Think about the heroic families who support these
  individuals and the workplaces who make
  accommodations for these families

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Definition and Examples

• LTC is difficult to define boundaries among
  primary, acute, and long-term care have blurred.
  
• medication management for elders with chronic
  disabilities ?
• Settings of care are confounded with services
• Nursing homes provide acute care
• Home Health Care delivers medical treatment

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• Long-term care is primarily concerned with
  maintaining or improving the ability of elderly
  people with disabilities to function as
  independently as possible for as long as
  possible.
• Long-term care also encompasses social and
  environmental needs and is therefore broader than
  the medical model that dominates acute care.
• Long-term care is primarily low-tech, although it
  has become more complicated as elderly persons
  with complex medical needs are discharged to, or
  remain in, traditional long-term care settings,
  including their own homes.
• Services and housing are both essential to the
  development of long-term care policy and systems.
  
• R. Stone (2000) Milbank Memorial Fund

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Key Issue Chronic Disease and Disability

• 43.5 of Harris County elders report disability
• 55.5 report two or more disabilities
• 63,400 need help with basic daily living tasks

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Key Issue Disability and Long Term Care

• Not Just Nursing Homes
• A range of services to address functional
  needs and support independence
• Everything from a home delivered meal to
  institutionally based care
• Escalating costs
• National expenditures in long term care
  expected to triple to 346 billion/year by 2040

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Long-Term Care Risk

• The risk of nursing home placement increases with
  age - 31 of those who are severely impaired and
  between the ages of 65 and 70 receive care in a
  nursing home compared to 61 of those age 85 and
  older.
• Most people with long-term care needs (83
  percent) live in their own home among those
  living at home, the majority (78 percent) does
  not hire any help and only 8 depend only on paid
  help

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Long-Term Care is Expensive

• In 2002, the average annual cost for a nursing
  home was 51,000 for a semi-private room and
  61,000 for a private room.
• Four hours of home care daily costs 26,000 a
  year. (national average)
• The cost of assisted living can range from less
  than 10,000 a year to well more than 50,000 a
  year (depending on the kind of assisted living
  facility and type of services an older person
  chooses.) (DHHSAdministration on Aging, 2003))

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The value of the services family caregivers
provide for "free" is estimated to be 257
billion a year.
BILLIONS OF DOLLARS
Source Expenditure data from HCFA, Office of the
Actuary, Levit K. et all, Health Affairs
200221.
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Economic reality

• You can save for collegebut most of us cant
  save for long-term care
• Need to Consider how to approach the individual
  and social risk
• Physical, emotional, and social burdens that
  providing care impose on the caregiver and its
  economic costs to the caregiver and to society.
• Caregiving can conflict with caregivers
  employment, creating economic losses for
  caregivers and society.
• Individuals suffer from inadequate attention to
  basic needs

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Best Practice Approaches with Potential to Reduce
LTC Costs

• Integration of care for long-term care
  recipients
• PACE Program of All-Inclusive Care for the
  Elderly (55 Medicare/Medicaid population)
• EverCare nursing home managed care (Use of NPs
  and PAs to deliver medical care)
• Consumer-Directed Services Cash and Counseling
  Demonstration
• Public Policy Support of Private Insurance Plans
  and Consumer Education

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Other Approaches

• Incorporating Geriatric and Prevention Approaches
  to Chronic Illness

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A Geriatric PerspectiveFinding the Appropriate
Balance and the Right Plan
A
B
C
D
ProlongingLife
Optimizing Qualityof Life
Increasing age and frailty
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Examples of promising complements to primary care
of senior populations

• Brief GEM/disability prevention with attention to
  primary care adherence in community (HEP, Stuck)
  or clinic
• Chronic Disease Self-management and other proven
  self-management support programs
• Post-hospital transition care
• Linkage to community Alzheimers services and
  supports
• Problem-solving therapy for depression
• Post-prescription drug monitoring
• Senior oriented physical activity
• (Ed Wagner, Seattle 2005)

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Threats to Health and Quality of Life

• Physical inactivity
• Poor diet and nutrition, obesity
• Falls
• Alcohol and substance abuse
• Depression
• Smoking
• Infection (flu and pneumonia)
• Inability to self-manage chronic conditions
• Inattention to clinical preventive services
• Social isolation

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Underlying Risk Factors The Actual Causes of
Death

• Behavior of deaths, 2000
• Smoking 18
• Poor diet nutrition/ 17
• Physical inactivity
• Alcohol 4
• Infections, pneumonia 3
• Racial, ethnic, economic ?
• disparities
• Mokdad et al., Actual causes of death in the
  United States, 2000, JAMA, March 10, 2004.

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Threats to Health and Well-being Among Seniors

• 37 women 33 men aged 65 74 report no
  physical activity
• 24 - obese
• 33 - fall each year
• 34 - no flu shot
• 45 - no pneumococcal shot
• 47 - no mammogram
• 88 - at least one chronic condition
• 37 experience some activity limitation

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Evidence Based Health Promotion Programs

• Administration on Aging and National Council on
  the Aging (www.healthyagingprograms.org)
• Evidence Based Disease Self-Management National
  Demonstration Program
• 3 of 13 projects in Texas

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• Houston
• Care for Elders/Sheltering Arms
• Depression intervention
• Neighborhood Centers, Inc. St. Josephs
• Physical activity intervention
• San Antonio and Other Projects Nationally
• Chronic disease self management
• Diabetes
• Heart disease
• Nutrition and diet
• Falls prevention
• Medication management

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Contact Information

• Nancy L. Wilson
• Huffington Center on Aging
• Baylor College of Medicine
• One Baylor Plaza M-320
• Houston, TX. 77030-3498
• 713.798-3850
• nwilson_at_bcm.edu

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Key Issue Long Term Care and Funding
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Access to Needed Services
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Access to Needed Services Advocacy Message

• Support efforts that promote coordination
• Between state and local levels
• Between public and private sectors

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Availability of Affordable Services

• Inadequate supply to meet the demand
• Transportation
• Home and personal care assistance
• Affordable housing and home repair
• Respite
• Mental health services

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Availability of Affordable Services Advocacy
Messages

• Redirect Medicaid funding away from
• institutionally based care and toward home
• and community-based long-term care
• Support efforts that expand services
  through integration of existing services

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Quality of Care
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Quality of Care Advocacy Messages

• Require higher standards for orientation and
  training of direct care workforce
• Increase wages for direct care workers

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Preparedness for Aging

• Individual knowledge and action to prepare for a
  healthy old age
• Family readiness to assume elder care
  responsibilities
• Provider preparedness for the growing number and
  diversity of older adults
• Community elder-friendliness