16 - Nursing Home Care
Editors: Kane, Robert L.; Ouslander, Joseph G.; Abrass, Itamar B.
Title: Essentials of Clinical Geriatrics, 5th Edition
Copyright 2004 McGraw-Hill
> Table of Contents > Part III - General Management Strategies > Chapter 15 - Health Services
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Chapter 15
Health Services
Geriatrics can be thought of as the intersection of chronic disease care and gerontology. The latter refers largely to the contents of this book: the syndromes associated with aging, the atypical presentations of disease, and the difficulties of managing multiple, simultaneous, interactive problems. Health care for older persons consists largely of addressing the problems associated with chronic illness. However, medical care continues to be practiced as though it consisted of a series of discrete encounters. What is needed is a systematic approach to chronic care that encourages clinicians to recognize the overall course expected for each patient and to manage treatment within those parameters. The clinical glide path approach (described in Chap. 4) is one way to encourage such practice.
Care for frail older persons has been impeded by an artificial dichotomy between medical and social interventions. This separation has been enhanced by the funding policies, such as the auspices of Medicare and Medicaid, but it also reflects the philosophies of the dominant professions. A prerequisite for effective coordination is shared goals. Until the differences in goals are reconciled, there is little hope for integrated care.
Medical practice has been driven by what may be termed a therapeutic model. The basic expectation from medical care is that it will make a difference. The difference may not always be reflected in an improvement in the patient's status. Indeed, for many chronically ill patients decline is inevitable, but good care should at least delay that decline. Because many patients do get worse over time, it may be difficult for clinicians to see the effects of their care.
Appreciating the benefits of good care in the context of decline in function over time may require a comparison between what happens and what would have occurred in the absence of that care. In effect, the yield from good care is the difference between what is observed and what is reasonable to expect; but without the expected value, the benefit may be hard to appreciate. Figure 15-1 provides a theoretical model of these two curves. Both trajectories show decline, but the slope associated with better care is less acute. The area between them represents the effects of good care. Unfortunately, that benefit is invisible unless specific steps are taken to demonstrate the difference between the observed and expected course.
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FIGURE 15-1 Theoretical model of observed versus expected clinical course. The shaded area between the observed and expected outcomes represents the benefits of good care. Thus a patient's condition may deteriorate and still be considered as an indication of good care if the rate of deterioration is less than expected. |
The alternative model, usually associated with social services, is compensatory care. Under this concept, a person is assessed to determine deficits and a plan of care is developed to address the identified deficits. Good care is defined as providing services that meet the profile of dependencies and thereby allows the client
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to enjoy as normal a lifestyle as possible without incurring any adverse consequences. The two approaches should not be incompatible. Providing needed services should enhance functioning or at least slow its decline.
Care for the frail older patient requires a synthesis of medical and social attention. The medical care system has not facilitated that interaction. The new developments in managed care could provide a framework for achieving this coordination, but the track record so far does not suggest that the incentives are yet in place to produce this effect. A few notable programs have been able to merge funding and services for this frail population. Probably the best example of creative integration is seen in the Program of All-inclusive Care of the Elderly (PACE), which uses pooled capitated funding from Medicare and Medicaid to provide integrated health and social services to older persons who are deemed to be eligible for nursing home care but who are still living in the community (Kane, 1999). Another model that shows promise for demonstrating this integration is the second generation of the social health maintenance organization (SHMO) (Kane et al., 1997b). Whether managed care will achieve its potential as a vehicle for improving coordination of care for older persons remains to be seen. In any event, care for older persons will require such integration and eventually some reconciliation about what constitutes the desired goals of such care.
Geriatric care thus implies team care. This concept does not mean that everyone needs to do everything. Rather, it means that some activities can be the purview of other disciplines with special skills and training for such tasks. However, these colleagues must not be expected to operate alone. Good communication and coordination will avoid duplication of effort and lead to a better overall outcome. To play a useful role on the health care team, physicians need to appreciate what other health professions can do and know how and when to call on their skills.
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PUBLIC PROGRAMS
The physician caring for elderly patients must have at least a working acquaintance with the major programs that support older people. We are accustomed to thinking about care of older people in association with Medicare. In fact, at least three parts (called Titles) of the Social Security Act provide important benefits for the elderly: Title XVIII (Medicare), Title XIX (Medicaid), and Social Services Block Grants (formerly Title XX). Medicare was designed to address health care, particularly acute care hospital services. The Medicare program is in flux. Changes in the payment system have been introduced to counter what some saw as abuses (certainly expansions) of the previous system. Medicare was intended to deal with long-term care only to the extent that long-term care can supplant more expensive hospital care, leaving the major funding for long-term care to Medicaid. However, the funding demarcation between acute and long-term care services became blurred. Especially with regard to home health care, Medicare began to cover more care that would be considered long-term. In 1993, approximately 60 percent of home health care visits under Medicare were delivered to persons who have received such care for at least 6 months, well beyond the traditional designation of acute care (Welch et al., 1996). As a result, a new prospective payment system was introduced for home health care under Medicare. This approach caps the amounts paid and links them to patient characteristics. Long bouts of services are discouraged.
This distinction in programmatic responsibility between Medicare and Medicaid is a very important one. Whereas Medicare is an insurance-type program to which persons are entitled after contributing a certain amount, Medicaid is a welfare program, eligibility for which depends on a combination of need and poverty. Thus, to become eligible for Medicaid, a person must not only prove illness but also exhaustion of personal resources hardly a situation conducive to restoring autonomy.
The pattern of coverage is quite different for the various services covered. Figures 15-2 and 15-3 trace spending on health care for elderly persons by Medicare and Medicaid, respectively. Medicare is a major payer of hospital and physician care but pays for only a small portion of nursing home care, whereas just the reverse applies to Medicaid. (Medicare has played a larger role in nursing home and home health care as the role of postacute care grew, but new funding priorities have attempted to reduce that role.)
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FIGURE 15-2 Distribution of Medicare expenditures for the aged, 1995. (From US Department of Health and Human Services, 1997a.) |
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FIGURE 15-3 Distribution of Medicaid expenditures for the aged, 1995. (From US Department of Health and Human Services, 1997b.) |
Medicare
Eligibility for Medicare differs for each of its two major parts. Part A (hospital services insurance) is available to all who are eligible for Social Security, usually
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by virtue of paying the Social Security tax for a sufficient number of quarters. This program is supported by a special payroll tax, which goes into the Medicare Trust Fund. Part B (medical services insurance) is offered for a monthly premium, paid by the individual but heavily subsidized by the government (which pays approximately 70 percent of the cost from general tax revenues). Almost everyone older than age 65 is automatically covered by Part A. (Federal, state, and local government employees are exceptions; until recently they were not covered by Social Security and had their own pension and medical programs.) The introduction of prospective payment for hospitals under Medicare created a new set of complications. Hospitals are paid a fixed amount per admission according to the diagnosis-related group (DRG), to which the patient is assigned on the basis of the admitting diagnosis. The rates for DRGs are, in turn, based on expected lengths of stay and intensity of care for each condition. The incentives in such an approach run almost directly contrary to most of the goals of geriatrics. Whereas geriatrics addresses the functional result of multiple interacting problems, DRGs encourage concentration on a single problem. Extra time required to make an appropriate discharge plan is discouraged. Use of ancillary personnel, such as social workers, is similarly discouraged. As a result of DRGs, hospital lengths of stay have decreased, leading to the phenomenon of quicker and sicker discharges. Many of these former hospital patients are now cared for through home health and nursing homes. In effect, Medicare is paying for care twice: It pays for the hospital stay regardless of length
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and then pays for the posthospital care. The rapid rise in this latter sector has led Medicare to search for solutions. Different types of Medicare prospective payment for the different types of posthospital care have been established. Nursing homes are paid on a per-diem basis, whereas home health agencies and rehabilitation units are paid on a per-episode basis. A more effective solution would be to combine the payment for hospital and posthospital care into a single bundled payment, although some fear that such a step would place too much control in the hands of hospitals. The Balanced Budget Act of 1997 (BBA) included a small step in this direction. For selected DRGs, hospital discharges to postacute care are treated as transfers. Hospitals receive a lower payment than the usual DRG payment if the length of stay is less than the median.
The payment systems now in effect create much confusion for Medicare beneficiaries. Although hospitals are paid a fixed amount per case, the patients continue to pay under a system of deductibles and copayments.
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Managed care is aggressively being pursued as an option to traditional fee-for-service care. Under that arrangement, the managed care organizations receive a fixed monthly payment from Medicare in exchange for providing at least the range of services covered by Medicare. Although many managed care companies were initially attracted to this business because of the generous rates offered, subsequent reductions have made the business less attractive and many are exiting the program, leaving beneficiaries to scramble for alternative coverage, especially for the so-called Medigap policies that pay for deductibles and copayments.
The pricing system used by Medicare basically reflects the prices paid for fee-for-service care in each county. Managed care organizations are paid a fixed amount calculated on the basis of the average amount Medicare paid for its beneficiaries in that county. This adjusted average per capita cost (AAPCC) varies widely from one location to another. The BBA called for a shift to national pricing. In an effort to attract more providers into managed care, the BBA broadened the definition of what kinds of organizations can provide managed care to Medicare beneficiaries, removing many of the restrictions (especially financial surety bonding) that left managed care largely in the hands of insurance companies. Unlike managed care enrollees in the rest of the population, who are locked into health plans for a year, Medicare beneficiaries have the right to disenroll at any time. There is some evidence to suggest that Medicare beneficiaries may move in and out of managed care as they use up available benefits. The future of managed care as a Medicare venue is still unclear. The current administration continues to back this approach despite the number of managed care companies exiting from the market. Managed care participation has fallen from its high in 1998 of approximately 15 percent of Medicare beneficiaries to approximately half that number.
The likelihood of managed care achieving its potential symbiosis with geriatrics appears dim. Ideally, managed care could provide an environment where many of the principles of geriatrics could be implemented to the benefit of all; on the other hand, the performance to date suggests that managed care for Medicare beneficiaries has so far responded more to the incentives from favorable selection (recruiting healthy patients and getting paid average rates), discounted purchasing of services, and barriers to access than to the potential benefits from increased efficiency derived from a geriatric philosophy (Kane, 1998).
Although Medicare does pay for authorized posthospital services in nursing homes and through home health care, the payment for physicians does not encourage their active participation. For example, while a physician would be paid a regular consultation visit fee for daily rounds on a Medicare patient in a hospital, if the patient is discharged to a nursing home the following day, both the rate of physician reimbursement for a visit and the number of visits per week considered customary decrease dramatically. Although physician home visits are still a rarity, payment for these services has increased substantially in recent years. There are now physician groups that have made a business out of nursing home
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care and home health care. An interesting model of Medicare managed care directed specifically at nursing home residents is Evercare, which makes active use of nurse practitioners to increase the primary care attention residents receive. They have shown that it is possible to reduce the use of hospital care by this means (Kane, in press).
Many Medicare beneficiaries have also purchased so-called Medigap insurance. This insurance comes in a variety of forms (federal law now dictates the various components); most of this insurance covers only the gaps up to the ceilings established by Medicare (i.e., it pays deductibles and coinsurance but generally does not cover the difference between billed charges and allowable charges). An increasing number of policies cover at least some drug costs. In some cases, older persons may have purchased multiple Medigap policies under the erroneous assumption they were buying more coverage.
Medicare coverage is important but not sufficient for three basic reasons: (1) To control use, it mandates deductible and copayment charges for both Parts A and B. (2) It sets physician's fees by a complicated formula called the Resource-Based Relative Value Scale (RBRVS). The RBRVS is designed to pay physicians more closely according to the value of their services as determined both within a specialty and across specialties. Theoretically, both the value of the services provided and the investment in training are considered in setting the rates. This new payment approach was intended to increase the payment for primary care relative to surgical specialties, but early reports suggest that, ironically, many geriatric assessment services have been reimbursed at a level lower than before its introduction. Under Medicare Part B physicians are generally paid less than they would usually bill for the service. [Some physicians opt to bill the patient directly for the difference but a number of states have mandated that physicians accept assignment of Medicare fees, i.e., they accept the fee (plus the 20 percent copayment) as payment in full.] (3) The program does not cover several services essential to patient functioning, such as drugs, eyeglasses, hearing aids, and many preventive services (although the benefits for the latter are expanding). Medicare specifically excludes services designed to provide custodial care the very services often most critical to long-term care. (However, as noted above, the boundary between acute and long-term care exclusions seems to be eroding.)
As a result of these three factors, a substantial amount of the medical bill is left to the individual. Today, elderly persons' out-of-pocket costs for health care represent more than 20 percent of their income, a figure comparable to before the passage of Medicare. In general, out-of-pocket costs are less for those in managed care.
Medicaid
Medicaid, in contrast to Medicare, is a welfare program designed to serve the poor. It is a state-run program to which the federal government contributes (50 to
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78 percent of the costs, depending on the state). In some states, persons can be covered as medically indigent even if their income is above the poverty level if their medical expenses would impoverish them. As a welfare program, Medicaid has no deductibles or coinsurance (although current proposals call for modest charges to discourage excess use). It is, however, a welfare program cast in the medical model.
It is important to appreciate that the shape of the Medicaid expenditures for older people is determined largely by the gaps in Medicare. Medicaid serves primarily two distinct groups: mothers and young children under Temporary Assistance to Needy Families (TANF) and elderly persons eligible for Old Age Assistance. The other major route to eligibility for older people is the medically needy program, whereby eligibility is conferred when medical costs usually nursing homes exceed a fixed fraction of a person's income. Medicaid has been described as a universal health program that had a deductible of all of your assets and a copay of all of your income. The numerically larger group made up of mothers and children use less care per capita. They use some hospital care around birth and for the small group of severely ill children. A large portion of the Medicaid dollar goes to the services needed by the elderly enrollees but not covered by Medicare, namely, drugs, nursing home care, and custodial home care. (Most states automatically enroll eligible Medicaid recipients in Medicare Part B.)
Medicaid is the major source of nursing home payments. It requires physicians to certify a patient's physical limitations in order to gain the patient admittance to a nursing home. In some cases physicians may have to invent medical justifications for primarily social reasons (i.e., lack of social supports necessary to remain in the community).
Medicaid is thus important in shaping nursing home policies. It pays about half of the nursing costs but covers almost 70 percent of the residents. The discrepancy is explained by the policies that require residents to expend their own resources first. Thus Social Security payments, private pensions, and the like are used as primary sources of payment, and Medicaid picks up the remainder. However, it does not directly pay for most physician care in the nursing home; that is covered by Medicare. Medicaid would pay the deductibles and copayments and those services not covered under Medicare.
Whereas going on Medicaid was once seen as a great social embarrassment, associated with accepting public charity, there appears to be a growing sense among many older persons that they are entitled to receive Medicaid help when their health care expenses, especially their long-term care costs, are high. The stigma appears to be displaced by the idea that they paid taxes for many years and are now entitled to reap the rewards. As a result of this shift in sentiment, at least in the states with generous levels of Medicaid eligibility, there is a burgeoning industry of financial advisers to assist older persons in preparing to become Medicaid eligible. Because eligibility is usually based on both income and assets,
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such a step necessitates advance planning. Usually state laws require that assets transferred within two or more years of applying for Medicaid funds are considered to still be owned. (The situation is more complicated in the case of a married couple, where provisions have been made to allow the spouse to retain part of the family's assets.) This requirement means that older persons contemplating becoming eligible for Medicaid must be willing to divest themselves of their assets at least several years in advance of the time they expect to need such help. This step places them in a very dependent position, financially and psychologically. Much has been made of the divestiture phenomenon whereby older people scheme to divest themselves of their assets in order to qualify for Medicaid, but there is no good evidence about the scale of the phenomenon.
There is also growing enthusiasm for promoting various forms of private long-term care insurance. This coverage, in effect, protects the assets of those who might otherwise be marginally eligible for Medicaid or who simply want to preserve an inheritance for their heirs. Like any insurance linked to age-related events but to a greater degree, long-term care insurance is quite affordable when purchased at a young age (when the likelihood of needing it is very low) but becomes quite expensive as the buyer reaches age 75 or older. Thus, those most likely to consider buying it would have to pay a premium close to the average cost of long-term care itself. Only a small number of young persons have shown any interest in purchasing such coverage, especially when companies are not anxious to add it to their employee benefit packages as a free benefit. Although economic projections suggest that private long-term care insurance is not likely to save substantial money for the Medicaid program, several states have developed programs to encourage individuals to purchase the insurance by offering linked Medicaid benefits.
Other Programs
The third part of the Social Security legislation pertinent to older persons is Title XX, now administered as Social Services Block Grants. This is also a welfare program targeted especially to those on categorical welfare programs such as Temporary Assistance to Needy Families and, more germane, Supplemental Security Income. The latter is a federal program, which, as the name implies, supplements Social Security benefits to provide a minimum income. Title XX funds are administered through state and local agencies, which have a substantial amount of flexibility in how they allocate the available money across a variety of stipulated services. The state also has the option of broadening the eligibility criteria to include those just above the poverty line.
Another relevant federal program is Title III of the Older Americans Act. This program is available to all persons over age 60 regardless of income. The single largest component goes to support nutrition through congregate meal programs where elderly persons can get a subsidized hot meal, but it also provides
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meals-on-wheels (home-delivered meals) and a wide variety of other services. Some services duplicate or supplement those covered under Social Security programs; others are unique.
Table 15-1 summarizes these four programs and their current scope. It is important to appreciate that this summary attempts to condense and simplify a complex and ever-changing set of rules and regulations. Physicians should be familiar with the broad scope and limitations of these programs but will have to rely on others, especially social workers, who are familiar with the operating details.
TABLE 15-1 SUMMARY OF MAJOR FEDERAL PROGRAMS FOR ELDERLY PATIENTS | ||||||||||||||||||||||||||||
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LONG-TERM CARE
A proportion of older patients require substantial long-term care. There is no uniform definition for long-term care, but the following description of the term highlights the important aspects: A range of services that addresses the health, personal care, and social needs of individuals who lack some capacity for self-care. Services may be continuous or intermittent but are delivered for sustained periods to individuals who have a demonstrated need, usually measured by some index of functional incapacity. This statement emphasizes the common thread of most discussions of long-term care: the dependence of an individual on the services of another for a substantial period. The definition is carefully vague about who provides those services or what they are. Long-term care is certainly not the exclusive purview of the medical profession; in fact, most of the long-term care in this country is not provided by professionals at all, but by a host of individuals loosely referred to as informal support. These persons may be family, friends, or neighbors.
Informal care has been and remains the backbone of long-term care. In many instances, the family (and often nonrelatives) is the first line of support. The ideal program would keep older people at home, relying on family care and bolstering their efforts with more formal assistance to provide professional services and occasional respite care. More than 80 percent of all the care given in the community comes from informal sources. (In truth, the proportion is higher because much of the formal care is made possible by a substrate of informal care.) Surprisingly, this figure seems to remain fairly constant in countries with more generous provision of formal long-term care. Many observers have questioned whether the informal care role, which is largely performed by women, can be sustained as more women enter the labor force and are already managing several roles. Despite dire predictions about its inevitable collapse, there is yet no evidence of serious decline in informal care. It is important to bear in mind that as the age of frailty rises, the children of these frail older people may themselves be in their seventh and eighth decades.
The best estimates suggest that about 15 percent of the elderly population need the help of another person to manage their daily lives. The good news is that
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the prevalence of disability among older persons has declined about 1 percent per year over the last several decades (Cutler, 2001). As shown in Fig. 15-4, the proportion of persons who have difficulty performing one or more activities of daily living (ADL) increases with age, from approximately 8 percent at age 65 to 53 percent after age 85. If only those living in the community are examined, the proportion of persons needing help with one or more ADL in 1991 1992 was 4.1 percent of those age 65 to 74, 9.6 percent of those age 75 to 84, and 22.9 percent of those age 85 and older (Kennedy et al., 1997). Recall that for each person in a nursing home today, there are between one and three equally disabled persons living in the community. Thus, first instincts are not always best. Physicians have been trained to respond to the dependent elderly person by thinking of admission to a nursing home. Nursing home placement should be the last resort, not the first.
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FIGURE 15-4 Prevalence of chronic disability in the United States, 1994. (From Manton et al., 1997.) |
Current practice is trying to shift the balance between institutional care and home and community based services to emphasize use of the latter (Kane et al., 1998). Table 15-2 suggests a wider array of treatment choices for various types of patients. The physician, in conjunction with other health professionals (especially social workers and nurses), can do a great deal to steer patients and their families toward these resources. Although the physicians are not always actively involved in specific placement decisions, they should be. Indeed, the physician's suggestions and opinions about what should be considered can play a pivotal role. Moreover, the physician's medical certification of need is essential for establishing eligibility for long-term care services under several reimbursement programs.
TABLE 15-2 RELATIONSHIP BETWEEN TARGET GROUPS AND POSSIBLE ALTERNATIVES | ||||||||||||||||||||||||||||||
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Why then does our system rely so heavily on the nursing home? Several reasons can be offered. First, nursing homes are available; there are more nursing home beds than acute care hospital beds in this country. Nonetheless, there is usually a waiting list to get in, especially into a relatively good home. (That situation is beginning to change, however. With the growth in alternatives, especially assisted living, we are seeing for the first time substantial numbers of empty nursing home beds.) Second, nursing home care is cheap; it runs around $100 a day in most states, while a hospital day costs at least $1000, and even a good hotel room costs more than $100. Finally, and related to the first two points, the nursing home comes as an already assembled package of services. The programs to cover long-term care services have become a complex maze of eligibility and regulations, which has not encouraged anyone to develop innovative alternatives. The pressure for faster discharge from hospitals has created a new industry of postacute nursing home care. Although changes in Medicare payment have dampened some of the enthusiasm, this sector is still vital.
There have been periodic efforts to develop alternatives to nursing home care. Some were the results of deliberate public policies; others arose as new marketing efforts. For a period of time, great effort was expended trying to find less expensive ways of caring for people needing long-term care in the community. The upshot of these efforts was the recognition that community care is preferable
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in many cases, but not always cheaper. A major difficulty in controlling the cost of this care is the potential for widespread use. Because a large number of dependent older persons live in the community, a dependency-based eligibility system will include many people who would not opt for a nursing home. This need to control entry has stimulated great interest in case management. The continuing need to improve community care has led to some innovations, including Medicaid waiver programs that allow use of nursing home funds for community care if the total long-term care budget is kept constant. As a result, there has been uneven development of community programs in different parts of the country.
The earlier emphasis on seeking community-based alternatives to nursing home care has shifted to some extent to developing other mechanisms for providing the combined housing and service functions. Among these are assisted living and adult foster care. Assisted living, in effect, renders the recipient first and foremost a tenant, who has control over her singly occupied living space (e.g., a lock on the door and determination about waking and retiring times). In addition to single occupancy, the client's autonomy is reenforced by providing modest cooking and refrigeration facilities, which allow the person to function independently without relying exclusively on the services of the institution and even to entertain modestly (Kane, 2001). However, as assisted living became a more desirable product it began to lose its identity. A variety of providers surfaced, many of whom offered very different services under that name. Today, it is hard to know just what one is getting when assisted living is cited.
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Adult foster care homes are usually limited to a small number of clients in any home (usually no more than five). Single rooms are not required; the situation is more analogous to individuals taking clients into their own homes, with small numbers of flexibly deployed nonprofessional staff. Recent trends suggest that the historic growth in nursing home use is changing. The last few years have witnessed a decline in nursing home occupancy. At least some of this effect undoubtedly comes from the growing availability of other residential models, which consumers find more attractive.
At the same time, there is concern that a preoccupation with a search for alternatives to nursing homes may distract efforts from the sorely needed work to improve the quality of nursing home care. Even in the best situation, a substantial number of older persons will continue to need such care. One scenario for the future holds that the form of nursing homes will change. Many of the residents currently cared for in nursing homes will be treated in more flexible situations, like assisted living, which emphasize living arrangements with nursing and other services brought to the residents on a more individualized basis. Those patients needing more intensive care will be treated in more medically oriented facilities.
THE NURSING HOME
The nursing home is an important part of the health care delivery system for frail older persons. Virtually without planning, it has emerged as the touchstone of long-term care. Given its origins as the stepchild of the almshouse and the hospital, it is not surprising that it has enjoyed a poor reputation. Since the passage of the Medicaid legislation in 1965, the nursing home industry has gone through growth and transformation. As a reaction to scandals during the early years, nursing homes are heavily regulated.
Today's nursing homes operate under two different principles, which complicate any attempt to describe them. For one group of clients admitted from hospitals for rehabilitation, they function as Medicare posthospital care providers, responsible for administering rehabilitative and restorative services to get these persons back into community living as soon as possible. For another stream of clients (often supported by Medicaid), they provide long-term care, which may last a lifetime.
Seen from one vantage point, the term nursing home is a misnomer. Although these institutions are better staffed and run than in the past, they remain generally somber places that offer their residents neither a great deal of real nursing care nor a very homelike environment.
Most nursing home residents share their rooms. There is little privacy and few opportunities to retain control over even small parts of one's life. Fire regulations often prevent residents from bringing personal furniture into the homes. The nursing home is not a miniature hospital. Nursing homes are smaller and less well staffed
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than hospitals. Whereas a hospital has a ratio of greater than three staff for each bed, the nursing home has only about a sixth of that number, and most of those staff are aides. Whereas the distinction whereby nursing homes were certified as being capable of caring for patients with different needs based on these levels has been abandoned, the distinction between nursing home care and that provided in purely residential facilities with little or no nursing component has been retained. But even here the boundaries are blurred. Some forms of assisted living seek to serve a population that heavily overlaps the long-term care groups served by nursing homes.
Admission to a nursing home is very much a function of age (Fig. 15-5). There is a sharp rise in the rate of nursing home use with each decade after age 65, such that only about 1 percent of people age 65 to 74 are in nursing homes, but 5 percent of those age 74 to 85 and 20 percent of those age 85 or more are in nursing homes. Because this latter portion of the population is growing rapidly, there is great fear of being inundated with nursing home users.
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FIGURE 15-5 Rate of nursing home use. (From National Center for Health Statistics, 1997.) |
The residents in nursing homes are distinguishable from older persons living in the community on several basic parameters. As shown in Table 15-3, in addition to being older, they are more likely to be white, female, unmarried, and have multiple chronic problems.
TABLE 15-3 COMPARISON OF NURSING HOME RESIDENTS AND THE NONINSTITUTIONALIZED POPULATION AGE 65+, 1995 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Nursing home users appear to have become more disabled in the last several years (Fig. 15-6). Some attribute this change to the impact of DRGs, but the trend had begun well in advance of that change. The contemporary nursing home user is older and more disabled than in the past.
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FIGURE 15-6 Percent of nursing home residents older than 65 years of age who are receiving assistance with activities of daily living. (From Dey, 1997, and Hing et al., 1989.) |
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Any effort to describe the nursing home resident population must recognize that the nursing home plays multiple roles. It caters to a wide variety of clientele. At least five distinct groups of residents can be identified.
Those actively recuperating or being rehabilitated. These are largely persons discharged from hospitals and are expected to have a short course in the nursing home before returning home. This care has been called subacute or transitional. The evidence of the nursing home's capacity to provide effective care of this type is mixed (Kramer et al., 1997; Kane et al., 1996).
Those with substantial physical dependencies. These residents need regular and usually frequent assistance during the day. Their care could be managed in the community with sufficient formal and informal support.
Those with primarily severe cognitive losses. These people present special management problems because of their behavior and their propensity to wander. Some favor separate facilities for them, primarily to remove them from the environment of those who are cognitively intact. There is no evidence of improvement in the outcomes of demented residents from these special care units.
Those receiving terminal care. This hospice care is directed toward making the person as comfortable as possible. Palliative care is provided but no heroic efforts are undertaken.
Those in a permanent vegetative state. This group is distinguished by its inability to relate to the environment. Care is primarily directed toward avoiding complications (e.g., decubitus ulcers).
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For those who are sensitive to their environments and likely to be in the nursing home for some time (i.e., groups 2 and 4), quality-of-life issues will be at least as salient as traditional technical quality-of-care issues.
Especially in the wake of changing hospital practice and the rise of subacute care, great care must be exercised in using nursing home data because of the differences in the characteristics of those entering or leaving and those resident at any point in time. The latter are more likely to have chronic problems such as dementia, whereas the former will have problems that are either rehabilitatable or fatal (e.g., hip fracture and cancer). This distinction makes it tricky to talk about nursing home patients and may explain the often contradictory data presented.
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The problem with data about nursing home residents is made more confusing when different approaches to sampling are used. The characteristics of discharges are different from those of a cross-section of residents. The former have sorter lengths of stay, whereas the latter have a preponderance of dementia.
Payment for nursing home care has been increasingly based on measures that reflect the costs of providing that care. Although this type of payment is often called prospective reimbursement, it is important to recognize that it is quite different from that used with hospitals. Nursing home prospective payment is calculated on a daily rate basis in contrast to the episode basis used for hospitals. Hence as a person's status changes, so does the payment. Medicare payments now use a daily prospective payment rate based on case mix and many states are adapting a corresponding approach for Medicaid payments, although the specific systems may use fewer categories. This form of case-mix reimbursement is largely driven by the costs of the nursing personnel who provide that care. The costs are usually calculated by estimating these costs based on a set of observed times spent by different types of personnel (nurses aides, LPNs, and RNs) for different classes of residents. In some cases, the time spent is self-reported by the staff; in other instances, it is based on observations. These data are then used to construct models that relate the cost of professional time to the characteristics of the clients. This approach has two major problems.
The models generally rely on looking at what kind of care is being given rather than what sort of care is actually needed; the care is not related to outcomes obtained nor is it based on any models of especially good care.
The logic behind this approach to estimating payments is inherently perverse. If carried to its logical extreme, this system of payment rewards nursing homes for residents becoming more dependent instead of more independent.
The most commonly used case-mix system is the Resource Utilization Groups (RUGS). Since its development for use in New York, it has been revised several times and is now linked to a form of the Minimum Data Set (MDS), which is the mandated assessment approach for nursing home care. Figure 15-7 illustrates the RUGS-III approach to classifying nursing home residents according to groups that imply different levels of staffing needs. This approach has been used by some Medicaid programs and is the basis for Medicare skilled nursing facility payments.
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FIGURE 15-7 The Resource Utilization Group (RUG-III) case-mix classification system. RUGs are generated from items in the Minimum Data Set (MDS) and used as a basis for case-mix reimbursement. (Figures supplied by Dr. Brant Fries.) |
The physician's role in nursing home care is discussed in greater detail in Chap. 16. Suffice it to say here that the nursing home has not been an attractive place for physicians to practice. However, conditions are changing. The physician can play a critical role in setting the tone for the care of patients in the nursing home. Physicians' expectations of professional performance and their advocacy of their patients' needs can be very influential in shaping staff behavior.
New types of personnel can be used effectively to deliver primary care to nursing home patients. Nurse practitioners and physician assistants deliver high-quality care in this setting (Kane et al., in press). Medicare regulations covering
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Part B were altered to allow greater use of physician assistants and nurse practitioners. Similarly, clinical pharmacists are very helpful for simplifying drug regimens and avoiding potential drug interactions.
A managed care program directed specifically at nursing home patients points to the art of the possible. Building on the prior successes of using nurse practitioners as key figures to provide primary care to nursing home residents, the Evercare program has developed Medicare managed care risk contracts specifically for long-stay nursing home patients. Under this arrangement, Evercare is responsible for all the residents' Medicare costs (both Part A and Part B) but not their nursing home costs. The underlying concept is that by providing more aggressive primary care they can prevent hospital admissions.
Evercare places nurse practitioners in each participating nursing home to work with the residents' own physicians. The nurse practitioners provide closer follow up and work closely with the nursing home staff to identify problems early. In some cases, Evercare will pay the nursing home extra to increase nursing attention for patients in order to treat that person in the nursing home rather than admitting the patient to a hospital. The theory is that the savings from avoided or shortened hospital stays will offset the added costs of more attentive primary care provided by the nurse practitioners. The apparent success of the Evercare model has spawned similar approaches.
A study by the Institute of Medicine pointed to the need for reforms, many of which were incorporated into Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). The implementation of the OBRA 1987 regulations has produced a number of changes in the way nursing homes are operated. In addition to the standardized assessment mandated in the Minimum Data Set (described in Chap. 16), the emphasis in regulation has shifted more toward addressing the outcomes of patient care; but some increases in process measures have also been introduced. For example, guidelines for the use of psychoactive drugs have been mandated. All residents admitted and already living in the nursing home must be screened to determine if they are there primarily because of chronic mental illness. If so, a specific plan of care must be developed with appropriate participation from mental health professionals. Those residents who do not require skilled care are supposed to be transferred to more appropriate care settings. More training is mandated for nurses' aides and the staffing requirements overall have been upgraded.
Data elements from the MDS have been used to create a series of quality indicators, which are antedated to reflect potential areas of poor care in need of further exploration by state surveyors (Zimmerman et al., 1995). In a move to foster informed consumer choice, some of these quality indicators are now being posted on Web sites to provide consumers and their families with better information about the quality of nursing home care.
New models of nursing home care are being developed despite regulatory constraints on creativity. In some settings, large institutions are being converted into smaller living communities, where residents exert more control over their
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lives. The Eden Alternative has provided a model for how to humanize nursing home care. The Wellspring Movement is trying to pursue a quality improvement agenda by empowering nursing home staff to take greater responsibility for identifying ways to improve care. Although both are attractive concepts, neither has yet been shown to produce dramatic improvements in residents' quality of care or quality of life.
ASSISTED LIVING
A new form of chronic care is emerging. Assisted living describes a form of care for many of those persons who currently require nursing home care. It is designed to provide services to persons as they require them, in a setting that more closely resembles a person's home. In effect, service recipients need not lose their personhood and their autonomy to get care. Residents still live in institutional settings that house many people within the same facility, thus maximizing efficiency of service delivery. They use common facilities, such as a dining room, but they also retain their privacy. Basically, each resident is treated as a tenant and has control over a living unit. At a minimum, each individually occupied dwelling unit contains space for living and sleeping, a bathroom, and at least minimal cooking facilities. (The stove can be disconnected for those for whom it might pose a serious danger.) Each unit can be locked by the occupant.
Under this approach, control is shifted toward empowering the recipient of care. In contrast to the situation in a nursing home, where residents are expected to conform to the norms of the institution, in an assisted living facility individualized care is stressed. As the tenant, the resident has control over the use of her space: care providers must be invited in; care plans must be accepted by the resident. These shifts, while subtle at one level, are fundamental at another. They imply a dramatically altered approach to care, some of which is tangible and some of which is not. The lore of nursing homes is laden with evidence of learned helplessness and enforced dependency. This approach to care is aimed at maximizing a resident's sense of self and independence as much as possible.
Especially for those chronically impaired persons who have retained an appreciation of their environment, such a philosophy of care makes great sense. Examples of such care are becoming more prevalent. Assisted living is able to serve quite disabled persons although most recipients are less impaired. The majority of assisted living exists as a privately paid service. Medicaid in most states has been slow to cover this service, and where it has, it covers only the services component, leaving Social Security and welfare payments to address the room and board costs.
The costs of assisted living are usually much less than comparable nursing home care. One reason that assisted living is less expensive and more flexible is that it has thus far been spared the heavy regulatory mantle laid on nursing homes.
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Staffing patterns are not as intense or as professionally dictated. Staff performs multiple functions. If it is regulated in the same way, it will inevitably come to resemble nursing home care.
Once again, the form of care is determined by society's willingness to accept some risks. At a minimum, those who receive the care should have an opportunity to choose what kind of care they want to get.
At the same time, assisted living has come under criticisms reminiscent of those addressed at nursing homes in years past. With growth has come great variation. It is no longer clear just what is being offered by whom. Some standardized taxonomy is needed to allow consumers to make more informed choices. Concerns about quality are frequently expressed, especially with regard to the management of the more frail and medically complex residents.
HOME CARE
As already noted, we have developed a backward system of long-term care in this country that focuses on the nursing home. We tend to speak of the nursing home and alternatives to it, when we should begin with the premise that elderly people belong at home and want to be cared for at home. Institutional care will be needed in some cases, when the strain on caregivers is too great, but it should not be the resource of first resort. Our system has not evolved that way, and the resources available for home care are meager, but not so underdeveloped as to be ignored. Even today, most communities have at least some home care services, and more are likely to develop.
Home care involves at least two basic types of care: home health services; and homemaking and chore services. As shown in Table 15-4, different programs provide one or both types. Most elderly people treated at home require homemaking more than home health services.
TABLE 15-4 HOME CARE PROVIDED UNDER VARIOUS FEDERAL PROGRAMS | ||||||||||||||||||||
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Sometimes the differences between the two are purely arbitrary. If we consider that the homemaker replaces or supplements a family member, many of the tasks involved are extensions of home nursing (for example, supervising medication or giving baths). The definitions have emerged to fit the regulations governing a particular program. The physician will usually find that the home health agency is familiar with these regulations and how to deal with them.
The major problem at present is getting services. In response to political pressures, Medicare broadened its long-term care benefit (including waiving the former requirement that a person have a prior hospital stay of at least 3 days) and moved the program from Part B to Part A, thereby removing the copayment requirement. The subsequent enormous growth in home health care under Medicare has led to instituting prospective payment and making revisions in coverage that move part of the program back under Part B. (Home health care not related to a
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prior 3-day hospital stay, or visits after the 100th visit if related to a stay, will be covered under Part B.) Medicare covered home health care had been growing annually until the imposition of prospective payment in 1997.
Despite the growth in use, some still maintain that the criteria for eligibility for these services severely restricts their use. To get home health services for a patient, a physician must certify that the patient is homebound and that intermittent skilled care is likely to produce a benefit in a reasonable time. Thus, a large number of dependent older persons who need continuing home nursing but are custodial are ineligible unless the physician misrepresents their situation. Skilled service is defined as a skilled service offered by a nurse, a physical therapist, or a speech therapist.
If one of these establishing services is present, the patient may also receive the skilled services of an occupational therapist or medical social worker and/or the services of a home health aide if required by the plan. Medicare has begun to allow home health agencies to continue to serve clients who need case management, thus permitting some cases to remain open longer than the intermittent rule might otherwise imply. All reimbursed services must be given by a certified home health agency. (To be certified, the agency needs to offer nursing plus at least one of the five other services.) The requirement for using a certified agency greatly increases the costs of the services, although the assumption is that this certification assures at least a minimal level of professional oversight. A recurring question is how much administrative overhead is affordable as the pressure on the long-term care dollar grows.
Medicare-certified home health agencies are required to complete an OASIS (Outcome and Assessment Information Set) form at several stages of care to track outcomes and need for care. This recording burden has proven onerous for many agencies.
Medicaid funds can be used to provide home health care to persons eligible for nursing home care. Until recently, Medicaid funds have not been widely used for home care. In fact, until 1980, one state (New York) accounted for almost 95 percent of the Medicaid moneys spent on home health care. (It is still by far the largest user of Medicaid home care.) Home care under Medicaid must have a physician's authorization, but the patient need not be homebound, and the care need not be skilled. All agencies delivering home care under Medicaid must meet Medicare certification standards, but if no organized home health agencies exist in a region, a registered nurse may be reimbursed for the services. Home care can be provided under two auspices under Medicaid. It is a mandated service and it can be part of a waivered service package (i.e., services authorized in lieu of nursing home care). In practice, states have often modeled their Medicaid home care benefits after the medically oriented Medicare benefit and thus restricted its use. Under Medicaid, the nursing care is a required component of home health services, and the state has the option to provide physical, occupational, and speech therapy; medical social services; and personal-care services. Medicaid allows homemaking assistance on a more generous basis than does Medicare. Personal-care services must be prescribed
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by a physician and supervised by a registered nurse. These services may not be delivered by persons related to the patient.
Recent changes in legislation have broadened the permissible use of Medicaid moneys to support a wide variety of long-term care services in an effort to reduce nursing home costs. A number of states have received waivers to develop this broader package of services in lieu of nursing home care, but most of these waivered services are limited in the numbers of slots they are allowed. The waivers require some evidence of budget neutrality. The assumption is that as more care is provided in the community, fewer people will use nursing homes.
Despite the growth of home care under Medicaid and the growing numbers of alternative waiver programs, the large bulk of Medicaid long-term care funds continue to flow to nursing homes. However, the relative dominance of spending on nursing home care varies widely from state to state. An analysis of 1996 data showed that only 18 percent of Medicaid long-term care expenditures go to home and community-based services; the proportion ranges from 44 percent (Oregon) to 0.05 percent (Pennsylvania). Nationally, total monthly expenditure on home and community-based services per person age 65+ was $247, with a range from $4137 (Alaska) to $16 (Tennessee). Nursing home Medicaid expenditures per person age 65+ likewise varied widely, from $2163 in New York to $343 in Nevada, with a national average of $893 (Ladd et al., 1999).
Additional support for homemaking services comes from Title III and Title XX. Title XX provides at least four methods of payment: local public agencies can provide the service directly; they can contract with agency providers (perhaps using competitive bidding); they can purchase services from agencies at negotiated prices; or they can permit the recipient to enter into agreement with independent providers, who do not work for an agency. It is possible to have all these arrangements operating in the same community.
This provision for independent vendors has prompted controversy because maintaining standards is difficult in the absence of any supervisory system or institutional responsibility. Under Title XX, an employment category known as chore worker has emerged; although performing functions similar to the home health aide and the homemaker, chore workers do not need to be tightly supervised and cannot be reimbursed under Medicare or Medicaid.
Persons eligible for cash assistance from the state, and other persons with low incomes and unmet service needs, are eligible for Title XX as long as 50 percent of a state's annual federal allotment is expended on those receiving cash assistance. Fees are charged to those whose family income exceeds 80 percent of the state's median income for a family of four.
Home services are one of four priority items under Title III of the Older Americans Act. Although the dollar volume is low, this source is important because means testing (whereby eligibility is set by income) is prohibited for programs under the Older Americans Act, making it possible to target a group that
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cannot afford private care but is ineligible for Title XX or Medicaid. Generally speaking, the Area Agency on Aging subcontracts for home care services rather than providing them directly. The usual pattern is that Administration on Aging dollars permit existing agencies to develop or expand a home care component. Services vary from area to area but can include personal care, homemaker service, chore service, and service for heavier jobs (e.g., minor home repairs or renovations, insect eradication, gardening, and painting). The provisions for assistance under the Area Agency on Aging are sharply limited by their constrained budgets and the competing demands for programs.
The extent of services under these several programs is still limited at present, although enthusiasm for in-home care is growing. The total sum of public dollars spent on home care remains only a fraction of that devoted to nursing homes.
OTHER SERVICES
A number of other modes of care can be tapped on behalf of elderly patients. Table 15-5 lists some of these services. However, despite their growing availability, they are still not widely used. The most frequently used service in that set is the senior center, a service designed for the well elderly person.
TABLE 15-5 EXAMPLES OF COMMUNITY LONG-TERM CARE PROGRAMS | ||
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Day care can fulfill a number of needs. Most day care programs provide some combination of recreational and restorative activity. In contrast to senior centers, which are usually sponsored by recreational departments and targeted at the well elderly, day care programs serve persons with limited functional ability. Some are for cognitively impaired persons. The programs provide supervised activities, which may improve basic ADL skills and social skills. At the very least, they provide an important respite for the primary caregiver and thus may make
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the critical difference for allowing an impaired older person to remain at home. To increase efficiency, most programs serve any given client fewer than 5 days a week, usually 2 or 3 days.
Other forms of day care can include a larger medical component. Some areas have developed day hospitals for seniors, where virtually all the services of the hospital are available on an ambulatory basis. Emphasis is usually placed on rehabilitation, especially occupational and physical therapy. The adult day health center is an intermediate model, which combines day care with nursing, physical therapy, and perhaps social work. Such sites can also be used for periodic ambulatory care clinics.
A problem common to all day-care programs is transportation. It is hard to arrange, expensive, and time-consuming. Special vans are usually needed, and, to avoid excessive travel times, services are usually confined to very limited areas.
In many communities, a variety of services exist to help seniors: ombudsmen, peer counselors, mental health clinics, transportation, congregate meal sites, and meals-on-wheels just to name a few. Availability varies greatly from place to place. Good sources of information are the social work department in a hospital and the Area Agency on Aging.
The physician cannot be expected to know all the resources available for geriatric patients and will have to rely on other professionals to make appropriate arrangements to take advantage of them. But a physician should have a good sense of what can be done in general and what needs to be done for any particular patient. Often knowing what is needed but not locally available can lead to its development, particularly if responsible professionals take an active role on behalf of their patients.
Figure 15-7 summarizes the pattern of support for long-term care services to older persons.
CASE MANAGEMENT
The growing interest in the plethora of community long-term care services has sparked some concerns about the need to control use. A frequent answer is case management. This term has been widely and variably used. The basic components of case management are assessment, prescription, authorization, coordination, and monitoring.
These are issues very close to activities of primary care and hence may lead to some concern about role overlap between the case manager and the primary care physician. It is possible for physicians to serve as case managers, but most do not have the interest or the resources to perform this task. It is usually more efficient to look to other disciplines to perform this function but to recognize the important role of the physician in the overall care of the long-term care patient. Where a full range of geriatric services is available, case management is usually included.
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Regardless of discipline, the case manager faces some difficult tasks. There is often a discrepancy between responsibility and authority. It is very different to prescribe, authorize, or mandate.
Case managers may or may not have the purchasing authority to pay for services they feel are necessary. Case managers may easily find themselves in the same bind as physicians. Specifically, they are expected to serve simultaneously as patient advocates and gatekeepers. The two roles are incompatible. For everyone's peace of mind, it is important to clarify at the outset who is the principal client. Because many decisions involve advocating on behalf of one group over another, this distinction is critical. It is very different to work on behalf of a client to obtain all the resources you believe they need than it is to work to distribute a fixed pool of resources to those who will best use them.
Another frequently heard concern about case management is the need to affix responsibility. On the one hand, the easiest way to do this is to give the case manager a budget and expect the case manager to work within it to achieve the most possible. However, some have expressed anxieties that the person charged with authorizing services should be at arm's length from those providing them. Specific concerns are heard about hospital discharge planners' decisions as to when to refer patients to services owned or operated by the hospital. There is a real potential for client skimming. Similarly, if the case manager works for a caregiving agency, there is the risk that that agency may get a disproportionate share of the choicest clients. On the other hand, even when case managers are separated from direct care, they are not immune to pressure from the purveyors, just as the physician is pursued by the drug companies.
Case management has also become a mainstay of managed care. In this context, cases are usually identified on the basis of some risk indicators either a record of heavy use of services or the presence of risk factors that imply such a pattern in the future. While some case management within managed care is patient-centered, operating on the premise that closer care can stave off costly problems, much of it revolves around primarily utilization controls.
Several states have begun experimenting with a program called cash and counseling. Modeled after successful programs in California and Europe, disabled seniors can receive direct cash payments for care, which they can, in turn, use to purchase services, including from relatives. There is still some uneasiness about just how much discretion such programs should allow, many still require limited choices of vendors and evidence that the funds were used for the intended purposes. Nonetheless, these efforts represent a new direction of giving frail older clients more leeway in how to obtain services.
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