CHAPTER 10
Long-Term Care
INTRODUCTION
• To put it simply, long-term care (LTC) includes a variety of services for clients of any
age who have dependencies because of functional deficits. Reasons: chronic conditions,
comorbidities, serious illness or injuries, and cognitive impairment may lead to functional
decline.
THE NATURE OF LONG-TERM CARE
Main dimensions of LTC:
2. Individualized services: Assessment, plan of care, customized interventions.
4. Maintenance of Residual Function: Maintain whatever function still remains and prevent
further decline. However, some patients are totally dependent.
5. Extended period of care: Short duration LTC lasts less than 90 days. Most patients need
6. Holistic care: A patient’s physical, mental, social, and spiritual needs and preferences
should be incorporated into the delivery of LTC services.
7. Quality of life: Quality of life take added significance in LTC because (1) a loss of self-
worth often accompanies disability, and (2) patients remain in LTC settings for relatively
long periods with little hope of full recovery in most instances.
Five facets of Quality of Life:
a. Lifestyle pursuits for personal enrichment
8. Use of technology: Examples—personal emergency response system (PERS), fall
9. Use of evidence-based practices: Studies show reduction in falls, prevention of pressure
ulcers, and increased satisfaction among nurses.
LONG-TERM CARE SERVICES
An array of services can include a combination of the following:
1. Medical care, nursing, and rehabilitation: Services are provided under the direction of a
2. Mental health services and dementia care: mental health disorders are frequently comorbid
3. Social support: Needed to help cope with adverse life events; adaptation to new
4. Preventive and therapeutic LTC: delaying institutionalization through appropriate
community-based care that emphasizes nutrition and enables access to routine medical care.
5. Informal and formal care: Most LTC is unpaid; it is delivered by family, friends, and
surrogates. Men, minorities, married individuals, and those with less education are more
6. Respite Care: Respite care provides temporary relief to informal caregivers. Services can
include adult day care, home health care, or temporary institutionalization.
7. Community-based and institutional services: home- and community-based services
(HCBS) enable many people to live independently. Functional deficits in 3 or more ADLs
dramatically raise the probability for institutional care.
(b) Supplement or substitute informal caregiving. (c) Respite care. (d) Delay or prevent
institutionalization.
7. Housing: Independent living facilities and retirement living centers/communities. Must
8. End-of-life care: Prevent needless pain and distress for the terminally ill; dignity and
comfort are emphasized; hospice services.
THE CLIENTS OF LONG-TERM CARE
• Older adults
– Demographic trends have serious implications for financing and delivery of LTC
– Elderly in the lowest socioeconomic status are at the greatest risk of need for
• Children and adolescents
– Birth-related disorders (cerebral palsy, autism, etc.)
– Adults with IDD (MR/DD): 1999 US Supreme Court ruling in Olmstead v. L.C.:
states must provide community-based services when appropriate
• People with HIV/AIDS
– Now a chronic condition thanks to antiretroviral therapy
– High prevalence of HIV infection among people over 50
LEVEL OF CARE CONTINUUM
Personal care—basic ADL assistance (e.g., bathing); informal care or care provided by
paraprofessionals
Custodial care—nonmedical care to support and maintain function
HOME- AND COMMUNITY-BASED SERVICES
Funding sources: private out-of-pocket payments, private long-term care insurance, Medicaid,
Medicare, Older Americans Act of 1965, Home and Community Based Waivers (HCBW)—
Services Program. The ACA of 2010 offers limited financial incentives to states to enhance their
HCBS programs for Medicaid beneficiaries.
Services:
• Home health care: A community- or hospital-based home health agency sends health care
professionals and paraprofessionals to patients’ homes. Services must be approved by a
funding are Medicaid (1915c waivers) and private out-of-pocket payments. Medicare does
not pay for ADC but may cover rehabilitation services under Part B.
• Adult foster care: Family environment in small community-based dwellings; services
primarily focus on room and board, supervision, and light ADL assistance; funding for
1. Brokerage model—Case managers are freestanding agents who assess client
3. Integrated care model—PACE is an example of this model. PACE focuses on
clients who have already been certified for nursing home placement. The goal is
to prevent or delay institutionalization.
INSTITUTIONAL LTC CONTINUUM
Because of overlap in services brought about by the philosophy of aging in place, facility labels
do not always clearly define the level of care. Distinguishing characteristics are defined by the
level and extent of services, particularly nursing care given by licensed nurses and rehabilitation
services by licensed therapists. There are four main categories within the institutional continuum
of LTC:
1. Residential or personal care facilities: These facilities provide physically supportive dwelling
2. Assisted living facilities: These facilities provide personal care; 24-hour supervision; social
services, recreational activities, some nursing and rehabilitation services, and
Alzheimer’s/dementia care. Accommodations are generally private, and most people pay out of
private funds or through private LTC insurance. All states require licensing of these facilities.
3. Skilled nursing facilities: These are the typical nursing homes. Incontinence, depression, and
Alzheimer’s-type dementia are the most common conditions. The prevalence of psychiatric
4. Subacute care facilities
• Three types of institutions: LTCHs (certified as acute care hospitals); transitional care
units in hospitals: SNF certification; skilled care nursing homes: SNF certification
SPECIALIZED FACILITIES
Facilities that provide special services for individuals with distinct medical needs: ventilator
care, wound care, intensive rehabilitation, closed head trauma care, or Alzheimer’s/dementia
care.
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) –
formerly ICF/MR: Separate federal certification; financed by Medicaid; must provide nursing
Alzheimer’s facilities: specialized facilities for those who have severe dementia or comorbid
conditions. They have small-group living arrangements, copious use of natural lighting,
CONTINUING CARE RETIREMENT COMMUNITY (CCRC)
• Integrates and coordinates independent living with institutional services, all located on one
campus: Independent living cottages or apartments(with or without support services),
INSTITUTIONAL TRENDS, UTILIZATION, AND COSTS
• The number of nursing homes and beds have declined over time. The ratio of nursing home
beds per 1,000 people age 65 and over has dropped for 11 years in a row. Nursing home
utilization has also trended downward, which is likely attributable to aging in place.
• The hospital industry has drastically cut back on the number of SNFs it operates.
PRIVATE LONG-TERM CARE INSURANCE
Private policies cover both institutional and HCBS care. Premiums depend on the amount of
daily benefit, waiting period, number of years over which benefits will be paid, and inflation
TERMINOLOGY
• Adult day care (ADC)—A daytime group program that is designed to meet the needs of
functionally and/or cognitively impaired adults and to provide partial respite to family
caregivers.
oversight, and personal care to nonrelated adults.
• Aging-in-place—Older people’s preference and expectation to stay in one place for as long as
possible, and to delay or avoid transfer to an institution where the acuity level of patients is
higher.
• Brokerage model—A model of LTC case management in which patients’ needs are
independently assessed by a freestanding case manager who then arranges services through other
providers.
• CCRC—Continuing care retirement community. A CCRC integrates and coordinates
independent living and institutional components of the LTC continuum. As a convenience factor,
different levels of services are all located on one campus. Secondly, CCRCs guarantee delivery
• Dementia— A general term for progressive and irreversible decline in cognition, thinking, and
memory.
• Developmental disability—A physical incapacity that generally accompanies mental
retardation. It often arises at birth or in early childhood.
• Distinct part—A section of a nursing home that is distinctly certified from the rest of the
facility. It generally refers to an SNF distinct part.
• Dual certification—Both SNF and NF certifications. Dual certification allows a facility to