Continuum of Long-term Healthcare

How is senior housing financed?

1. Age restricted communities - They can be expensive high- end communities to government subsidized senior housing. The subsidized one are financed by local communities or non-profit organizations. 2. Independent living - the rental cost of these units generally depends on the region of country, size of living unit and services that include monthly fee and amenities provided. The fee ranges from $1,500 to $3,500 per month. 3. Congregate housing - The living cost at these facilities ranges from $500 per month to more than $4,000 per month. The size of living unit varies according to the cost. Private, nonsubsidized apartment begin at around $1,500 per month. 4. Continuing Care Retirement Communities - they are the most expensive long-term care solution. They are generally not affordable to lower or moderate-income group. The entrance fee as well as monthly charges at these facilities are hefty ranging from $100,000 to $1 million. Monthly charges range from $3,000 to $5,000, and increase according to services availed.

Who provides the various types of senior housing?

1. Age restricted communities are under two heads one is for profit ownership and other is publicly owned. Many of these are owned by for -profit investors. Other are subsidized by municipalities to cater elderly needs. 2. Independent living - these are also provided by for profit investors, but there are also vast number of not-for-profit senior housing providers. 3. Continuing Care Retirement Communities - These are also provided by both profit and non profit investors. They can be religious, fraternal and community organizations, universities and hospitals. Some companies also involve in operation of senior living communities.

What are some of the legal and ethical issues facing community-based services providers and consumers?

1. Patient Noncompliance - though providers give lot of freedom t patient in making care related decision however clash do happen whenever there is difference of opinion over patient's choice. The patients often not conform with the treatment plan. Then it has to be dealt with education, bit of scolding. Adult day care however, has onsite supervision and hence noncompliance is not an issue. 2. Patient's safety - There are situation when staffs suspects that patient is in unsafe situation in home or might be subjected to neglect or abuse by family members. If their suspicion is true than it must be legally and ethically obliged to report the matter to appropriate authorities. Then authorities provide staffs, legal counsel to review the matter. 3. Patients' right - The patient right is of utmost importance and community-based providers have to be contingent of these and other legal and ethical issues. 4. The decision to accept Hospice care - issue regarding denial of hospice care is very common. Patients find it hard to accept that they are terminally ill. The patients eligible for hospice care must accept that death is somewhere around the corner. It is important that the patient, family members as well as the health care professional must understand the benefits of hospice care and does not delay the admission. 5. Inequitable access - There is different patterns of admission in hospice services that varies from state to state, urban to rural areas and even geographically. The extent to which how right is the access to appropriate community based services is an ethical issue.

Who uses long-term care services, and why do they use them?

1.) Elderly people- Mostly elderly people of the society of age above 65 years are the users of long-term care. They need this care for different reasons and their numbers are growing pretty fast. 2) Elderly as a political source- The growth of the elderly people in numbers and in their need for long-term services has resulted from their increased economic and political powers. Compared to their previous generations, the elderly people nowadays are better informed and can protest for their concerns. For this they are getting support from well-organized advocacy organizations. 3) Nonelderly long-term users- Although majority of the long-term care users are the aged or elderly people, nowadays, young consumers are also observed in this system. Elderly people of age 65 years or more make up 63% of the total long-term care populations and the rest are of age 64 or younger. These consumers may include people of any age suffering from critical longterm injuries, children with different disabilities or congenital illnesses, AIDS patients, and people with mental disorder or with disabling disease. Similar to the elderly patients, they also require assistance with normal functions of everyday life. 4) Physically handicapped- This special group of consumers need long-term complicated and intensive care because of various physical disabilities. They are functionally independent and even require mental and emotional assistance. Handicapped children requiring extended care all time due to debilitating diseases such as cerebral palsy, spina bifida, muscular dystrophy also fall in this category. 5) Mentally ill/retarded- These consumers are less visible; however they require long-term care due to mental illness or mental retardation. They can suffer this illness from birth or early age of their life and need intensive long-term care for prolonged period of time.

What is meant by uniform assessment?

A uniform assessment is "...an assessment that is comprehensive and detailed. It requires an assessment that addresses all of the individual's needs, including medical, social, and financial...it must focus on the whole person, rather than the parts that make up that whole" (Pratt, 69). To successfully use this assessment, all parts of the system have to work together to share information.

What types of professional and paraprofessional staff work in nursing facilities?

According to American Health Care Association, the skilled nursing centers are supposed to appoint registered nurses (RNs), licensed practical nurses (LPNs), nurse practitioners, certified nursing assistants (CNAs), therapists, housekeeping staffs, dietary staff, social service workers, and administrative staff to take care of the residents. The most important professional staff in nursing facility is the nursing staff, including registered nurses and licensed practical nurses. Government regulations, especially Omnibus Budget Reconcilation Act of 1987 (OBRA) and Medicare have indicated the numbers of staff on duty in each work shift and also mentioned that a mix of professional categories should make up the workforce. Certified nurse aides are nonlicensed paraprofessionals who provide most of the hands-on care. The CNAs are the primary component of staffing in nursing facilities. The CNAs are supposed to have minimum amount of training and certification otherwise they are judged by their competence.

What regulations govern the operation of nursing facilities? Who does the regulating?

Another federal legislation that affects nursing facilities greatly is the Omnibus Budget Reconcilation Act of 1987 (OBRA), which is otherwise known as the Nursing Home Reform Act. This law has elevated staffing requirements and developed several resident rights, such as rights to be free from mistreatment, abuse, and neglect. Regulations affecting residents- OBRA, Medicare, Medicaid, and state licensing regulations recommend the types and extent of care to be provided, the types and numbers of professional staff required, the layout and the condition of the facility, and many other specific details of the ways of providing care. The Older American Acts and ADA are the other regulations that directly affect the nursing facility residents. Regulations impacting employees- There are numerous regulations for the staffs and employees of nursing facilities, which are linked with different laws and regulatory organizations, such as the Occupational Safety and Health Administration Department of Labor Wage and Hour Division, the Equal Employment Opportunity Commission, the ADA, state worker's compensation acts, the Fair Law Act, the Family medical leave Act, and many others. Regulations affecting building construction and safety- Nursing facilities must follow the Life Safety Code, the Occupational Safety and Health Administration, and local building codes to confirm the safety and comfort of the residents. Regulations for environmental safety should be obeyed by nursing facility

What are some of the ethical and legal issues affecting assisted living?

Assisted living facilities face similar legal and ethical issues to other long-term care facilities. "Their focus on resident independence can create some difficult situations for them" (Pratt, 166). Autonomy and Decision Making: Assisted living facilities deal with the issue of the level of autonomy that is acceptable and safe for a patient/resident. There needs to be a balance and boundary line to how much independence is given to the patient while also the facility's responsibility to protect and provide the care they need to. While a patient wants to be independent, the facility needs to be aware of when to step in and cut back on the independence given to the patient. An example that is seen in assisted living facilities is the act of taking medications. In assisted living facilities, patients are responsible for taking their medications. This is to allow them to feel like they have independence and to feel as if they are living in their own home. The job of the assisted living facility staff is to supervise and manage patients' medications. The staff is responsible for keeping records of each patient's medications and when they are consumed. Based on the patient this can go many ways, a patient may be trusted to take the medication out of the container themselves or the medication is split up and distributed to them in a different way. Other forms of medication that require serious measures like insulin are taken into account. These are highly supervised and when needed administrated by a staff member. Aging in Place: Aging in Place is a concept of bringing the services to a patient rather than them moving to other facilities to receive those services. Many patients can grow out of the care they are receiving. Meaning that they may need more hands-on and controlled care. Most of the time, the patient is moved to a new facility to receive that care. This can cause a lot of emotional stress for the patient. There have been many issues regarding this, many believe that if a patient needs care that they should receive it in whatever facility they're currently in regardless of availability, cost, etc. It is the facilities responsibility to give the care needed instead of trying to send them elsewhere.

What is assisted living, and how does it differ from nursing facility care?

Assisted living is a type of long-term care facility for individuals who need assistance with activities of daily living (ADL) including meals, bathing, changing dress, assistance with medication management, and also transportation. Assisted living is actually an intermediate between home care and nursing home care. Assisted living is suitable for people, who need some sort of assistance without which they can't survive independently. However, they don't require intense care and are somewhat functionally independent. The main difference between assisted living and nursing home is the degree of medical care provided by both of them.

What services are usually included in assisted living?

Assisted living normally provides following services: • Personal care services • Different healthcare services • Management with medication • Monitoring persons with cognitive disabilities • Social services • Social and religious activities • Arrangements of transportation • Exercise and educational activities • Laundry and linen service • Housekeeping and maintenance In addition to these services, assisted living facilities provide three meals a day and snacks in a group dining room and 24-hour supervision. Although majority of assisted living facilities (ALFs) provide these services, it is not necessary to take all these services by an individual. Beyond basic housing, all other services are optional and selected by the individual according to the need.

What is meant by bundling?

Bundling' refers to a new mode of payments developed by ACA as a Care Improvement initiative. Financial and performance accountability for the period of care are the part of the arrangements. In Bundled Payments, the payment is paid to a single entity for distinct period of care, which included following services: inpatient hospital, outpatient therapy, physician, and postacute care services. The episode of care should begin with hospitalization and continue till 30 days following discharge.

What are the provisions of the Affordable Care Act that directly impact long-term care providers?

Community First Choice Option- This option provides a 6% increase in federal Medicaid matching funds to states for community-based attendant services and supports within their Medicaid program. The main goal of this option is to make people receive services from the community rather than from a hospital or nursing home. Balancing Incentive Payments Program- This is another ACA provision meant to keep long-term care consumers away from costly institutions and getting care in people's homes and communities. Money Follows the Person Program- This program also attempted to keep long-term care consumers away from costly institutions. For this program, the ACA included a number of Medicaid home and community-based service options. Spousal Impoverishment Protections- Compulsory spousal impoverishment protection was provided to the spouses of people receiving home and community-based services. No Wrong Door System- Aging and Disability Resource Centers- This system supports state efforts to offer easy and simple accessibility to long-term care services for the individuals with disabilities. This system was developed in such a way that it would be available to every community across the country, so that people of all ages, incomes, and disabilities get health care related information and receive one-on-one person centered counseling. Health Homes- were designed to be person-centered systems of care and provide complete primary and acute physical health services, behavioral health care, and long-term communitybased services and supports.

What are community-based services?

Community-Based Long-Term care offer an alternative to institutional services for many longterm care consumers. The various community-based services are home health care, hospice care and adult day care thought are separate, yet closely knitted services that can delay or even prevent institutionalization. This is facility that is provided in home setting as long as possible. Case manager arrange and coordinate Meals on Wheels, medical care, home health aides, and companion services. This means a higher quality of life and lower cost of care.

What is meant by a consumer-driven long-term care system?

Consumer Driven- The consumers are the individuals using the services of long-term care system and they deserve to be treated with dignity and respect. Since the consumers are extremely dependent on LTC, the system must operate in such a way that it provides best possible service to them. The consumers must be the center of focus of the LTC; they should be given the power to determine the services to access and when to access them. Therefore, the long-term care system should be consumer-driven.

What are some of the ethical issues faced in nursing facilities?

Day-to-Day Quality-of-Life Issues- The most important aspect and issue that faces residents in nursing facilities is personal autonomy. Even when living in a nursing facility, residents seek and deserve to have control over their own lives. Personal autonomy can differ from patient to patient. Whether it is making everyday decisions or it is refusing treatment. For nursing staff, personal autonomy also affects their work environments and the way they provide for their patients. They have to try and work with the patient to meet their personal expectations while also providing the right and most effective quality of care. The issue of individual choice and group choice is another issue that arises in nursing facilities. In a group setting, an individual may not be able to have their expectations met if it negatively affects the other individuals living in that environment. Another issue is center day-to-day activities such as meals, activities, entertainment, and visitors. These activities are all closely monitored and may be hard to change and adjust to everyone's needs. End-of-Life Issues- Nursing facilities have to face and deal with residents' deaths. Many residents come into a nursing facility for the rest of their lives. Nursing facilities need to focus more on the quality of life those residents are receiving rather than the extension of their lives. It is important to meet the desires of each patients' needs and allow for a comfortable environment for them to live in. Residents should be able to make decisions about the care they receive and to make their desires known.

What factors have led to the development of the long-term care system as it currently exists?

During the 19th century and even much of the 20th century, the long-term care to the old, sick, needy individuals was provided by the informal caregivers, such as family members and friends, or religious institutions, or some community groups. Mostly the long-term care was provided at home in the past. Only the individual without any support or family was provided home by institutional care system. This home was in the form of almshouses or poor farms and was meant to care for people having different needs. They didn't distinguish between the people requiring food and shelter with those requiring support, supervision, and functional assistance. The elderly, homeless, unemployed, and also people, who cannot take care of themselves, were kept in these houses and they received almost same care.

What is the hospital readmissions reduction program (HRRP), and how does it affect long-term care organizations?

HRRP charge penalties from hospitals having high rates of readmission of patients with specific medical conditions.

What are the patient services most commonly provided by each of the services discussed herein (home health care, hospice care, adult day care)?

Home Health Care - Home healthcare services provide both skilled healthcare professional, under the direction of physician as well as supportive community services, including support for instrumental activities of daily living and personal care. The nurse and the client act as a team where nurse trains and counsels the client about effective self-management techniques. Hospice Care - Hospice agencies supports an individual at end journey of his life by providing supportive and palliative care. These agencies are not curative rather it focusses on quality of life and comfort. It focusses on easing the pain of patient and assist the patient and families in their difficult times. The services vary from physician services, nursing services, social services, counseling, provide medical equipment and medication to relief symptoms, therapies, personal care and assistance with housework. Adult Day Care - Adult day care centers are generally divided into two categories: social day care and health day care. A third form is dementia day care. Social day care provide relief from loneliness, depression and boredom. It provides interaction between the elderly. It focusses on socialization as well as recreational activities.

What types of services are provided by nursing facilities? Who uses them?

In general, nursing facility provides the following services: nursing care, physical therapy, medical services, dental services, occupational therapy, speech therapy, medications, as well as laboratory and X-ray services as needed. Few nursing homes provide adult day care services, open for the nursing home residents or the members of the community. Some provide adult day care services exclusively to nursing home residents and some provide this service to only the members of the neighborhood community. 65 and up

What is and has been the role of informal caregivers in the long-term care system?

Informal caregivers refer to unpaid individual who assist the needy people with their daily activities or with the medical tasks. Informal caregivers can be spouse, partner, family member, friend, or neighbor. They provide care to the elderly, diseased, and functionally inactive individuals at home, when the individual is unable to pay for the formal long-term health care services. They provide physical and emotional support, cook meal, and supervise the needy people. Informal caregivers usually are not considered as an integral part of the formal long-term care system. Moreover, they do not receive enough support financially; sometimes it becomes difficult for them to maintain employment.

What is an integrated health network?

Integrated health network (IHN) is a term used to describe integrated systems. This is one of the terminologies used to describe healthcare integration. The other being integrated health system, integrated care system, integrated care network, integrated delivery system, integrated delivery network, community care network, integrated healthcare organizations.

What is an integrated health system?

Integrated health system (IHS) is a term used to describe integrated systems. This is one of the terminologies used to describe healthcare integration. The other being integrated health network, integrated care system, integrated care network, integrated delivery system, integrated delivery network, community care network, integrated healthcare organizations.

Why has the long-term care field not been subject to strong competition in the past? Why has that changed?

Long term care field has not been subjected to strong competition in the past because it worked in a benevolent environment. They were the sole provider of services in the community or nearby communities. There was less consumer of long-term care and was unknown to many as there were not much marketing of the services. Now the operating environment has changed tremendously in field of long-term care. The reason for the growing competition in this field is owed to the developments taking place every day. The number of older people is also growing that is affecting the long-term care.

What is a continuum of care, and where do long-term care services fit in that continuum?

Long-term care and its providers are interrelated as a continuum of care. The term continuum of care means the overall system or a specific subsystem serving a defined geographic area, or a particular service population. The elements of a continuum remain the same. It is client oriented, comprehensive, and integrated. Client/consumer-oriented continuum - Long-term care and other health and social services provide service to the consumers. Clientoriented service is the ideal long-term care service and it should not force the consumers to revolve around the service that is it should not be payer-oriented. The client should be the principal component of this service. Comprehensive continuum - A long-term care system, in order to be true continuum should provide all of the services required by its consumers throughout the USA. Different services must include the following: health promotion/illness prevention, ambulatory care, residential long-term care, impatient acute care, community-based care, and housing. The consumers may need any one or more than one of the services, or even all the services at one time or another. A continuum must include more than the services normally related to long-term care. Integrated continuum- Continuum of care is an integrated system of care. Majority of individuals using long-term may shift from one level of need to another randomly, which is quite unpredictable. Long-term care was once considered to be a one-way street that goes from one level of need to another. Often in some elderly patients, periodic episodes of acute illness occur. Long-term care is a dynamic process since one individual can shift from one mode of care delivery to other, and back again over a period of years.

What are some of the rights and responsibilities of long-term care consumers?

Long-term care consumers and families of those consumers should be able to participate in designing plans of care. They should also be the only ones able to make health-related decisions. They should be more involved in the process and be able to understand any process they may go through. Consumers should be held accountable and responsible for their everyday life decisions and how they may affect their health. Life decisions that could affect the health care process could be not eating right, endangering oneself, etc. Not only should they be responsible for those everyday decisions, but they should also be responsible for "subordinating their personal needs and desires to the interests of the larger group" (Pratt, 61). Last, consumers need to be held responsible for their financial costs like co-payments and insurance.What are some of the rights and responsibilities of long-term care consumers?

How did nursing facilities develop?

Many of the aged people were not at all satisfied with the care provided and didn't show much improvement in their health. Thus, they were reluctant to go the nursing homes. The negative image about nursing homes also came from several instances of inadequate care, management, fraud, and resident abuse. Many of the residents were found to be abused physically and financially. The blame of the poor care and inadequate management partly went for incompetent and unscrupulous nursing home administrators who were more interested in making money and partly went for the reluctance of the whole industry. The nursing home industry was not at all properly regulated. Unlike the hospitals, the nursing homes were initially operated on their own. They mostly didn't have responsible governing boards. There was little or no incentive to provide free care for needy people. The patients requiring acute care and sometimes even suffering from life-threatening conditions requiring immediate care are admitted to the hospital, whereas the nursing homes take patients who require long-term, postacute care, which is not as urgent as hospital care.

How are each of the community-based services financed?

Medicare are the sole largest payer of home healthcare services. It is very volatile. The rates of Medicare fluctuate, addition of new beneficiaries, change of payment method impacts home health care considerably. The current payment system, pays home health and hospice providers for each 60-day episode of care. The rate of payment is standard based on type and intensity of care given. Medicare is sole payer of hospice reimbursement however, it does not include treatment designed to cure terminal illness, treatment that are not related to comfort, care from another hospice provider etc. Medicaid is program designed for covering healthcare of medically indigent people, who have very low income and can't afford to pay for care, and have no health insurance. It is state run under the national guidelines and the cost is divided among state and national government. They include nursing services, home care aide services and medical equipment and resources. They do not include services covered under Medicare. Private Health Insurance and Managed Care also provide coverage to community-based care. The traditional insurance did not cover it but the insurance policies that have been specially designed for long term care include it. The main objective of this private health insurance is to improve cost effectiveness. The MCO are slower in covering adult day care, but slowly they are getting interested in it. Private, out-of-pocket financing is the amount referred to that which is paid by the patients as well as the family members personally. The reason or such payment is that they might not under the umbrella of any insurance, or either they do not qualify for other programs. Though there are other sources of financing, but it is so fragmented that families and caregivers have to come up with their own funds.

Who provides assisted living?

Most of the assisted living facilities (ALFs) are owned and maintained by for-profit-organizations.

Who provides community-based services?

Non profit community based, long term care services are owned and operated by religious organizations, community organizations that is set up with that purpose, or non-profit hospitals or healthcare systems. For profit community based, long term care services are generally affiliated with a healthcare organization or independent. Some of these are free hold type without any ownership, while some are part of chain of similar agencies or chain of multilevel that includes several healthcare services. Government operated community based, long term care services includes local healthcare departments and state agencies. Since, now they are reimbursement facility available from Medicare or Medicaid, these agencies are not needed much, and some are disbanded. Many of these have become independent, or now are run by private organizations.

What is a nursing facility? How does the name nursing home relate to it?

Nursing facility is a part of the continuum of long-term care units. Nursing facility is a comparatively new term and is chiefly a regulatory term. Nursing facility includes state licensed facilities that offer room, board, nursing care, and certain therapies. In fact, nursing facility is one of the many settings of long-term care that involves services and supports outside an institution and receives support or certification from Medicare. Skilled nursing facilities (SNFs) and intermediate care facilities are included within nursing facility and these two facilities mainly differ in the level of provided care. The term nursing home was commonly used in the past and was synonymous to the 'long-term care'. A nursing home is referred to as a facility that provides room, meals, personal care, nursing care, and other medical services to the residents.

What are some incentives that might encourage consumers to use the long-term care system more effectively and efficiently

One such type of incentive can be public/private partnerships, where they can pass on some of their assets for purchasing insurance that would cover their LTC cost. In this way, the consumers are motivated to buy private insurance, instead of using public funded Medicare and Medicaid. Another form of incentive to the consumers of LTC to buy private insurance is tax deduction. Several states offer different tax incentives, such as credits, deductions, or both for purchasing private health insurance for LTC. The financial support for family caregivers is another form of incentive.

What is pay-for-performance (P4P), and how does it improve quality?

Pay-forperformance (P4P). P4P is a broad term for programs intended to enhance the quality, efficiency, and overall health care value. P4P provides incentives to physicians, hospitals, and other health care providers to improve and to attain best outcomes for patients.

What are postacute and subacute care?

Postacute care is a type of care designed to improve the transition from hospital to the community. Postacute care comes immediately after acute care in the hospital. It provides service to those patients who require extra support after getting discharged from the hospital. Postacute care helps with recuperation, rehabilitation, and nursing services to the patients following acute care. Postacute care settings include skilled nursing facilities (SNFs), long-term care hospitals (LTCH), inpatient rehabilitation facilities (IRFs), outpatient rehabilitation providers, and home health agencies (HHAs). Subacute care is a type of care required by those patients who do not need hospital acute care, but need more serious nursing care than that is provided in any SNFs. Subacute care is a comprehensive and cost-effective inpatient level of care for patients with acute injury or illness. In addition to medical care, subacute care provides nursing and psychosocial care. Sometime, after subacute care the patient can be provided with postacute care as follow-up to inpatient subacute care. Subacute care is a fast-growing concept in the healthcare industry.

What are some incentives that might be provided to encourage providers to operate more effectively and efficiently?

Provide incentives to providers to develop cost-effective measures- The providers of LTC system can improve the quality of care in cost-effective manner if they are provided incentives. The LTC should be more flexible about innovative ideas of their providers. Incentives for providers to operate more efficiently include: allowing the providers actually share their ideas about cost savings and also giving them more freedom to be creative without reprimanding them. Development of payment mechanism that allows efficient providers to compensate staff- The providers can work effectively if they get reimbursed in a manner that motivates them to employ well-qualified and properly trained staff. It does not mean to increase reimbursement. However, the providers those are efficient enough to hire skillful staff, should be given some flexibility in their payment scheme. This would allow the providers to apply some of their cost savings to provide sufficient payment to their staffs

How and why did subacute care develop?

Subacute care actually found its niche during 1980s and 1990s, when the healthcare industry was forced to be much more cost-effective, recommended to give higher importance for consumer choice, and faced competition amongst different providers. The subacute care can be best described as post-acute services for people who are recovering from acute illness/injury or from major surgery. These individuals may face some complications during the process and need more medical and nursing interventions than that are normally provided in skilled nursing care facility. The patients in subacute care are generally medically unstable and require special services including tracheotomy therapy, inhalation therapy, cardiac recovery, intravenous tube feeding, complex wound management, orthopedic rehabilitation etc.

What regulations apply to subacute care?

Subacute care is known to be in between hospital care and nursing facility care; therefore, regulations differ. One regulation that applies to subacute care is Medicare certification. This regulation covers staffing, length of stay, organizational form, patients' rights, and other required services. While this regulation is in place, subacute care providers have a hard time complying with them due to differences between providers. Subacute providers are also affected by Medicaid regulations. The regulations could vary from state to state, and crossovers could occur between Medicare and Medicaid. Another regulation that applies to subacute care is a regulation associated with the Omnibus Budget Reconciliation Act of 1987 (OBRA), which is also known as the Nursing Home Reform Act. OBRA focuses on facility design, staffing patterns, care plans, and services provided. This could apply to not only subacute care facilities but hospitals and all SNFs certified by Medicare. Subacute care providers are also affected by the certificate of need (CON) regulations. "The purpose of the law is to limit healthcare spending by limiting expansions of services or the building of healthcare facilities" (Pratt, 135). In the states that still enforce CON regulations, subacute providers a dragged through a lengthy and expensive process to get approval for a new subacute care service. Other regulations that affect subacute care are regulations of employment, treatment of staff, building construction and safety. Subacute care regulations need to be closely examined and established. Subacute care needs to be addressed directly.

What types of services are included in subacute care?

Subacute care provides different types of services based on the type of the patient served. The services offered by subacute care are as follows: • Physical and occupational therapy • Respiratory therapy • Cardiac rehabilitation • Speech therapy • Chemotherapy • Complex medical care • Pain management • Wound management • Ventilation care • Other specialty care • Rehabilitation •Total parenteral nutrition (tube feeding)

What factors led to passage of the Affordable Care Act?

The Affordable Care Act (ACA) proposed by Barrack Obama gained a remarkable victory after he became the president. However, the act was highly controversial. Three main objectives of ACA were i) increase quality, ii) affordability of health insurance to every American; every individual should be covered by health insurance, and iii) to reduce the health care costs for the individual and the government.

What is the CLASS Act, and why was it suspended?

The Community Living Assistance Services and Supports (CLASS) Act is referred to as a voluntary employment-based public long-term care insurance program aimed to provide a financial support privately for disability-linked services and to support in both working years and old age. The long-term care needs via ACA can be addressed by the CLASS Act. It was decided that an individual has to pay for the CLASS program for 5 years and only after that he/she can avail this. In this way, the Program will be able to build up a fund before being utilized. However, the long-run sustainability of the CLASS program was highly scrutinized. Thus, this program was suspended indefinitely on October 14, 2011 by the Obama administration.

What is long-term care?

The Long-Term Care system is defined as the system providing extended care to the needy individuals over a prolonged period of time, often throughout the life of the individuals with temporary breaks for a shorter period of time. The long-term care is provided to the individual, who needs physical and emotional assistance for a long period of time from someone.

How are nursing facilities financed?

The financing of nursing facilities come from various sources. A major portion of the funding comes from government Medicare and Medicaid, with Medicaid funding about two thirds of the consumers of nursing facilities.

What effect have government regulations had on the financing of long-term care?

The government involvement in the long-term care was very less even in the first 2 decades of the 20th century. Only when private resources were not found, then government was involved. From 1930s, the situation started to change. Due to Great Depression, many people failed to take care of themselves. In 1935, Social Security Act was passed and also other related programs and with these the government became more involved in taking care of the society, especially, for the aged, disabled, blind, and homeless people. With the passage of the groundbreaking Medicare and Medicaid amendments in 1960, the funding started to come for hospital medical care for aged and for those people, who were unable to pay for medical expenses. For the hospital, this funding indicated a new source of revenue, a decreased need of giving free care, more demands for their services, and also more rules and regulations. Moreover, this led to the development of nursing home industry. Medicare covered certain limited types of long-term care including skilled nursing facilities (SNF), which provide good nursing home care. Medicare was meant to serve the elderly, the blind, and some groups of permanently disabled people, unable to pay for care. Medicare coverage is quite limited in terms of coverage and duration of coverage. In contrast, Medicaid provides more extensive coverage and meant for the medically needy people, who are not capable to pay their own health care. These differences between Medicare and Medicaid had a remarkable influence on long-term care. Since, the coverage of Medicare is limited; it often stops paying for the care, even when prolonged care is needed. Medicare is federally funded program and is funded by a combination of federal and state taxes. The Medicaid Act provided certain levels of coverage below which states cannot go. Some states provide more coverage than others leading to inequities in coverage, moving of consumers from one state to another, and difficulty for some states in funding the programs. The Medicaid is the principal source of payment for long-term services and supports (LTSS) along with out-of-pocket payments by individuals or families. Besides Medicare and Medicaid amendments, the Older American Act affected financing of longterm care by the government. This act was meant for people of age above 60 years. This act helped these people to maintain independence at home and communities and received proper services and also to promote continuum of care for the susceptible adults. This Act is the major breakthrough in government financing for long-term care since before this, the federal and state government only provided a limited social services and LTSS to the aged people.

What types of services make up institutional and noninstitutional care?

The institutional care refers to the care provided in the facilities developed for that purpose. Nursing care, assisted living care, subacute care, and housing services fall under this category. The noninstitutional care or community-based care refers to the care provided in the consumer's home, for e.g. home care, adult day care, and hospice care.

Under what circumstances might a long-term care organization choose to join an integrated system? An integrated network?

The long-term care involves with either integrated health system or integrated health network with the need and desire to strengthen its position by joining other organizational entities in long term care field.

What is the role of education in creating a long-term care system that closely approximates the ideal?

The long-term care system should include community education, education for providers and educating young people to prepare them for future illnesses. Community Education- Many don't know how the long-term care system works and the services provided through the system. The public is simply uneducated about the resources that may be available to them. "One of the most striking characteristics of the current system is the general lack of understanding about what the long-term care system offers, how it is accessed, who is eligible, and what is covered" (Pratt, 80). The public must receive information and education regarding medical decisions that they may have to make in the future. Education for Providers- Providers like physicians and other specialty doctors need to learn the difference between caring for an elderly patient and a young patient. There are different needs, limitations, and expectations. Educate young people to prepare for future illnesses- The long-term care system should start educating younger people to prepare for future illnesses. Prevention is key for this education. Prevention will allow for better health in the future. If younger people are taught about the risks that over every day, they can take steps to prevent future illnesses.

How is subacute care financed?

The main financers of subacute nursing home care are Medicare and private insurance companies. Medicare pays about 68% of the cost whereas private insurance and individual selfpay account for 22%. The rest of the finances come from other sources including the Medicaid (10%) and patient or his or her family (8%).

What is an Accountable Care Organization (ACO), and how does it work?

The main objective of ACOs is to lower hospital readmissions, decrease quality differences, and to manage risk. ACOs work under bundled payment method. In general, the ACOs have to make an agreement with the long-term care providers for postacute care and the ACOs will be considered to be responsible for the type of outcomes linked with that care. An ACO can be composed of a group of physicians, hospitals, and other suppliers of services. Nonetheless, ACOs affecting long-term care are usually hospital-based organizations

What is senior housing, and how does it differ from other types of long-term care?

The senior housing is basically incorporated to provide the seniors services and assistance they need while maintain their independence. The main motto behind this is to help them lead a free and self-sufficient life. Senior housing is the institutions for senior living accommodations that meet their functional and personal needs. The various types of senior housing are age restricted housing, reverse mortgage, age restricted retirement communities, senior apartments, independent livings, congregate housing, continuing care retirement community, life care community etc. Senior housing differs from other types of long-term care as long-term care services aid with activities of daily living such as dressing, grooming, feeding, bathing etc. Long term care includes a wide array of services related to health, personal care, psycho-emotional, and social needs of person who face difficulty in self-management. The senior housing is age restricted and is only open for seniors unlike other types of long-term care.

What services are usually included in the various types of senior housing?

The services provided in various senior housing are: 1. Age restricted communities whether on ownership or rental, they provide minimal amount of services. Some of these provide different kind of services for people residing there like meals, transportation, social activities etc 2. Independent living - they usually accommodate more lively and active seniors. They offer amenities, activities and services. The independent living provides a much independent lifestyles to elderly and provide benefit of full-service community. They provide meals in a restaurant setting, housekeeping, transportation and other social activities. Recreational activities like arts and crafts, holidays gathering are also included. 3. Congregate housing - they provide services same as that of senior retirement apartment complexes. Some of these provide different kind of services for people residing there like shared meals, transportation, social activities, housekeeping, secure building, full time staffs to assist residents etc. with an extra fee they also provide laundry services, health monitoring, assisted daily living, help in taking medication etc. 4. Continuing Care Retirement Communities - they provided wide array of services and housing package that allow path to independent living, assisted living, and skilled nursing facilities. They provide freedom to resident to move between the available housing environment as one's need change. They provide services that include housing, healthcare, social activities, health programs, nursing facilities 5. Life care community - This is a form of Continuing Care Retirement Communities that provide insurance type of contract and provides all level of care by paying monthly fee. This includes acute care and also visits of physicians.

How is assisted living financed?

There are several different forms of financing of assisted living. Financing of assisted living consists of the ways in which consumers are being charged and also the form of reimbursement to the providers of assisted living. The basic fee normally covers two or three meals daily in a communal dining room. Some of the residents can prepare extra meals in their kitchens, if they are capable to cook. Otherwise, they can arrange for additional meals in their own dining room and pay extra for that. Reimbursement - The largest source of reimbursement for ALF comes from the residents' personal funds. This is not under the coverage of Medicare, although there is some coverage under Social Security's Supplemental Security Income. Another growing source of reimbursement is Medicaid, although its coverage is small. In fact, in 2010 about 4 in 10 served residents received long-term care services paid by Medicaid. In total, approximately 43% of ALFs had at least one resident having majority of long-term care services paid by Medicaid

What is the role of illness in prevention in long-term care?

There is a great deal of prevention that can be acted upon in everyday life. That is to eat right, don't smoke, and exercise. While not every disease is preventable, getting treatment when needed will help prevent other health problems from continuing to exist. With receiving treatment, one is preventing their health from getting worse which could impact decrease the demand for long-term care. "Illness prevention efforts and the degree to which they are successful will play a role in shaping the future of the long-term care system" (Pratt, 70).

Who are baby boomers, and what is their impact on the long-term care system?

This new group of consumers is known as the 'baby boomers'. The name was given to those individuals born during the period of World War II from 1946 to 1964. Around 40 million Americans were 65 and above, when the first of these people started to retire approximately in 2011. The Federal Interagency Forum on Aging-Related Statistics in 2013 forecasted that by 2030, their number will be twice as large as their counterparts in 2000 and will represent only 20% of the entire population. With the increase in the number of the elderly, the growth of the chronically ill or disabled people requiring long-term care will also increase consistently. According to one source, about 12 million Americans are thought to require long-term care by 2020. Moreover, these people will be better educated and will demand more from the system. Thus, they will have major impact on the long-term care system

What are the components of accessibility to long-term care services?

Universal accessibility- In ideal situation the services should be provided to all needy individuals and not restricted to certain groups based on financial condition, insurance coverage, political connection, and other criteria. The functionally disabled individual requiring assistance with activities of daily living (ADLs) should be definitely eligible for this type of care, irrespective of the insurance type or if without coverage. LTC must be user friendly- LTC should be easily accessible to the consumers and must have strong philosophy of customer service. To provide good customer service, proper understanding of the care plan, customer needs, and overall understanding of the system are essential. There should be minimal paperwork and must be understandable to majority of the consumers. Moreover, there should be assistance, if necessary for completing paperwork. Care must be provided in the least restrictive environment - The care should be provided in such a manner that best combination of proper care and quality of life can be provided to each consumer in a cost-effective manner. Each consumer must be provided with best possible degree of independence and freedom. This will allow all the participants of LTC in understanding that the least restrictive environment is different for each person. Encouragement towards single-site care availability - It is important that all necessary services in LTC are provided to the consumers at single site instead of making them to go to multiple sites or to different providers. Single site is quite convenient for the consumers making the service more accessible to them. Single site availability of needed services has other benefits, such as allowing spouses to remain together, or nearby, allowing the consumers to receive care in known surroundings etc

What is the difference between cooperation and integration?

When stimulated by competition, cooperation among health care or long-term care provider organizations, usually require to have informal liaison that give advantage to all involved. Whereas, Integration is more formal, where the organizations become a part of large organizations through the process of merger, contracts or through other forms of affiliation. The difference between cooperation and integration is matter of degree and structure. So basically, whenever healthcare providers move from informal to formal organizational interaction, they basically cross the distinct line between cooperation and integration. As the pressure increases, they move towards more formal integration.

What is the difference between care management and case management?

care management deals with the type and quality of care received in subacute care facility. It includes evaluation of each patient's needs, designing a care plan to fulfill these needs, constantly monitoring the care, and adjusting accordingly. Care management is the best way to provide subacute care. Case management is different from care management and it deals with the cost-effectiveness. The case managers emphasize mostly on the degree of efficiency with which care is given and also manage the resource utilizations and expenses involved in giving appropriate care. There are internal case managers and sometimes external case manager appointed by payers.

What are some of the weaknesses of the current long-term care system?

i) Reimbursement-Driven system- Providers are more interested about the reimbursement and are not much interested to provide services to those, who are unable to pay, or for whom reimbursement is limited, thus providing reduced services to many of the consumers with limited insurance coverage. ii) Fragmented system- This system is fragmented and comprises of many parts, such as different payers, nature of providers, types of reimbursement etc. and they are not integrated. iii) Multiple entry points- Because of the fragmented and unintegrated nature, it is difficult to access the services of the long-term care system. There are many different points of entry into the system along with different steps. iv) Overshadowed by the acute (hospital) system- This is another drawback of the long-term system. v) Include both health and social services- This system is a mix of health-related elements and social services, which include taking care of the health and functional need of the disabled person and also their housing, transportation, meal etc. for a long term. vi) Not enough support to the informal caregivers- who are mostly providing care to the consumers vii) Poor public image of the long-term care system- mostly because nursing homes, which are the principal providers of long-term care became the center for bad publicity.

What are some of the strengths of the current long-term care system?

i) Response to changing needs- In order to cope with the changing environment, new delivery methods has been invented to respond to the needs of the consumers. One major example is care provided for the patients of Alzheimer's disease. The needs for the consumers of this disease are quite different and not known previously; however, new mode is used to deliver good care for them. ii) The dedication of caregivers- Extreme hard work of different people working in this system, particularly the caregivers, benefits the consumers. The dedication and ingenuity of the caregivers for those, whom they take care has allowed the system to survive in the toughest days. iii) Development of innovative types of care- In order to provide better service and survive in the competitive market, new types of care have been developed. This included the following: aging in place, multilevel facilities, adult day care, and pediatric day care. v) Integration efforts- Integration of services is one of the most remarkable and promising innovation of the long-term care system. This effort indicates a significant advancement of longterm care system to provide true care.

What are the provisions of the Affordable Care Act that benefit consumers?

i) The mandates need individuals to have insurance coverage regardless of any medical condition- Every individual should be covered by health insurance either purchased individually or obtained through employment. The businesses with over 50 full-time employees are required to provide coverage for all the employees or otherwise need to pay penalty. ii) Health insurance exchanges- Each state was planned to develop health insurance exchanges- online marketplaces for health insurance. Under this provision, small businesses and individual are able to buy insurance from competing private healthcare providers (with government subsidy, if eligible). Moreover, according to the law the insurance companies must provide coverage to every applicant within new minimum standards. The companies should not charge different rate for insurance policies due to pre-existing condition or gender. iii) People under 26 should be covered by their parent's insurance.

Where is subacute care provided, and by whom?

the hospital where the patient was admitted may provide subacute care, or freestanding nursing facilities provide this sort of care. Both these groups have become a part of integrated healthcare networks. Subacute care units when affiliated with hospitals or nursing home facilities are normally considered as Skilled nursing facilities (SNFs) by Medicare for the purpose of reimbursement. A large proportion of subacute care unit is being owned and operated by either national or regional corporate chains and mostly become part of integrated health networks.

What are special care units (SCUs) in nursing facilities? Why do they exist?

the special care unit (SCU). The SCUs are built to meet the specific requirements of residents who need special care due to a particular health condition or disease. The care provided by SCUs is normally different from the care provided to the general residents. SCUs in nursing facilities have several benefits, which are as follows: • The ability of staff to become efficient in taking care of special needs • Creating support groups for the residents • Grouping residents with common care needs