HESC/Gero 450 ONLINE, Fall 2018
TEXT/TRANSCRIPT OF LECTURE CH 10, LONG TERM CARE, PALLIATIVE CARE, END-OF-LIFE CARE
Long Term Care
· What is Long Term Care?
· Personal care and assistance needed on a chronic basis due to disability and/or illness limiting ability to function independently
· Needs may be due to cognitive impairment, physical impairment, or both
· Long Term Care Services, Settings, Personnel
· In-home
Unpaid/informal caregivers
· Home and community-based services
· Public
· Private
· LTC institutional facilities
· SNF
· nursing home
· ALF
TISNADO: Long term care services and supports (LTSS) vary and may be delivered in a number of settings…many in the home. Most of needed services are provided by unpaid or informal caregivers – family such as spouses, siblings, adult children, or other loved ones.
Other public services include things such as transportation services, food assistance such as Meal on Wheels, senior centers which provide opportunities for socialization and also for meals. There are services that provide adult day care that may be totally privately financed or that are partially supported by Medicaid or other state or local public programs. These types of services all tend to account for small amounts of public spending. The bulk of public spending tends to go towards institution-based care.
SNFs: Skilled nursing facilities or SNFs are institutions set up to provide nursing and rehabilitation services immediately following an acute-care stay (ie a hospitalization). SNFs do not provide long term nursing home care. SNF care may generally be reimbursed by Medicare if it meets the criteria of being needed after a hospitalization for a limited amount of time.
Nursing home care: nursing homes are institutions that provide room, board, 24-hour nursing care in a medical setting on a long term basis. Note: this type of nursing home care is NOT reimbursed by Medicare; it is generally paid for privately or by Medicaid.
Assisted living facilities or ALFs are facilities that care for individuals with less intensive needs for professional assistance but who perhaps no longer feel able to live completely independently. These facilities are less costly and less regulated than nursing homes, and have been serving increasing numbers of clients as compared with nursing homes. However, it is important to remember that most individuals’ preferences are to remain in their own homes for as long as possible.
· Long Term Care Financing
· Who pays?
· For home-based services?
· For institution-based services?
· Medicaid
· PACE models
· CLASS Act
TISNADO: The majority of spending for long term care services is out-of-pocket (ie, individuals pay cash for the services themselves). Medicaid, not Medicare, is the largest public payor of long term care services. Individuals often “spend down” or pay out of pocket until their wealth dwindles to the level at which they can quality for Medicaid. Many elders then wind up as so-called “Medi-Medi” patients with both Medicare and Medicaid. Such patients used to be attractive to health care providers because they had relatively good insurance coverage. However, the cost to government, especially state governments, is enormous.
It has long been the case that about 70% of all Medicaid spending is spent on long term care services. Not surprisingly many efforts have been made to find more efficient and affordable models of delivering the long term and supportive care services that many older adults need while trying to shift the financial incentives from institutional care to care that may assist older adults to stay and be cared for in the community, while ideally preventing hospitalizations and long term institutionalization. The PACE models of care are one such type of model. PACE stands for Programs of All-inclusive Care for the Elderly, and they are an integrated insurance and healthcare services model for older adults who might be eligible for nursing home care but who could be able to stay in the community with the right level of supportive services. PACE takes advantage of Medicare and Medicaid dollars to provide comprehensive community-based services including preventive care and even environmental upgrades to make the home safer such as ramps and grab bars, and adult day healthcare centers with both day care and clinical care services offered. PACE programs may achieve cost savings by preventing institutionalizations but they require states to take an active role in directing Medicaid funds towards the program which some states with smaller Medicaid programs are not willing to do.
The so called Community Living Assistance Services or CLASS Act legislation was passed as part of the Affordable Care Act to create an affordable, optional public insurance plan that aimed to make long term care insurance available and affordable to American employees, but it was quickly deemed unworkable and was repealed in Jan 2013.
· Issues of Quality
Issues to be aware of
· Financial incentives
· Regulatory environment
· Increasing patient acuity means need for more highly trained & skilled clinical & managerial staff than in the past!
· Clinical skills to address physical needs, dementia issues, social needs
TISNADO: Nursing home quality of care has long been a concern and investigations in the past have found scandalous conditions in some nursing homes that were essentially taking patients’ Medicaid funding and then in turn providing care as cheaply as possible. This has led to a heavily regulated nursing home environment. Even so, many concerns regarding quality of care exist. Concerns include the training of staff: are nursing aides and other staff adequately trained in interacting with patients with dementia? With providing psychosocial support – emotional support and comfort? Psychological, social, and cognitive stimulation? Are the kitchen staff adequately trained in providing appropriate nutrition, including for special dietary needs for diabetics, those with sodium-sensitive issues such as high blood pressure and congestive heart failure? Are the physical therapy staff adequately trained in working with the physical rehab and maintenance needs of older adults?
Even if they are trained is the staffing adequate to allow adequate time for staff to do their jobs well? Can we work to create better more actionable quality metrics and create financial incentives for institutions that can demonstrate exemplary performance on those quality metrics? Many different state initiatives are exploring these questions and looking for ways to improve this system of care.
III. Palliative and End of life Care
· What are Palliative Care and Hospice?
Palliative Care
· an approach that improves quality of life of patients and families facing problems associated with life-limiting illness, through prevention and relief of suffering by means of early identification, assessment and treatment of pain and other problems including psychological, social, and spiritual needs.
TISNADO: Palliative care should not be thought of as replacing curative care, but as complementing it. Many practitioners refer to palliative care as an “extra layer of support.” Palliative care team may include a physician, nurse, social worker, physical and/or occupational therapy, and chaplain (although many teams do not necessarily include all of these disciplines). Sometimes the physician involved is a general internist, but may also be specially board certified in palliative care or in pain management.
· What are Palliative Care and Hospice?
Hospice Care
· a type of care and philosophy of care that focuses on the palliation (attempt to relieve) of a chronically ill, terminally ill or seriously ill patient’s pain and symptoms, and attending to their emotional and spiritual needs
· Hospice usually pertinent to care close to the end of life, whereas palliative care should not be thought of only as end-of-life care
· What is Involved?
· Pain relief
· Relief of other symptoms: e.g., shortness of breath, rashes/sores, bowel problems
· Maintenance of nutrition
· Social support, helping family and patient cope with distress, articulate values, establish goals and preferences
· Spiritual care
· What is Advance Care Planning?
· Process of considering values, goals, and preferences for treatment options, considering goals such as extending life, maximizing quality of life as defined by the individual
· Ideally done in ADVANCE of any health crisis, and involving loved ones and providers
· Much better to think about before a crisis hits
· Crucial to involve others; your wishes are not actionable if others don’t know them!
· Advance Directives, POLST
· Advance care planning is the process mentioned on the previous slide
· Advance Directive: a document that might result from that process, noting preferences for or against listed medical interventions
· Actual care is often inconsistent with advance directives (or “ADs”) – in other words even when people have an advance directive, the care people get often does NOT match what their Advance Directive says
· POLST: Physicians Order for Life Sustaining Treatment
· For patients with very serious/ life-limiting illness
· Posted in the home, directs EMT personnel
· “Prepare for Your Care”
· Now an assignment! I want you to go to the “PREPARE for your care” online tool to get a feel for an excellent model of advance care planning!
· Work through the interactive version
· Note the examples of discussions amongst family and healthcare professionals
· Note the many excellent examples of informed and shared decision-making
· Prepare for Your Care
· https://www.prepareforyourcare.org/
TISNADO: This (above) is the website for the Prepare for your care tool. I will put the link on Titanium as well.