Term paper on nursing

Publicado em Agosto 2017

Population have some "activity limitation" as a result of a chronic disease or condition. 38 The use of age, and particularly age 65 as a criterion for long-term care benefits is increasingly being challenged. E. As before she was over a department and had to only worry about the Emergency room and the processes in that department. (For persons in the community, but not in nursing homes; income levels can extend up to 133 percent of the state's AFDC grant adjusted for family size. "Preventing or reducing inappropriate institutional care by providing for community-based care" is a national goal, stated as an objective of Title XX of the Social Security Act. Detailed projections of the supply and demand for selected occupations through 1985 have been canpiled by the Bureau of Labor Statistics in conjunction with AoA. The projects were primarily new construction, single buildings of medium to high rise, averaging 170 units, predominantly efficiency apartments. As another example, both persons who are and those who are not chronically disabled obtain funding for health services from the Medicare and Medicaid programs. Mental retardation is a diagnostic classification which includes all individuals who have significantly below average intellectual functioning as measured by standardized tests. Rather, it is the abnormal patterning of daily life, which is in large part a function of the organization of services, and to some extent a function of architecture. In some states without medically needy programs, special-needs caps have been established to assist individuals whose incomes are too high for Medicaid eligibility but too low to pay the full cost of institutional care. 89-97) As part of broad health insurance benefits made available to those over 65 years of age through Medicare, provided an "extended care" facility benefit. " 28 Projects often had a homogenous group of white, middle class, mostly female tenants. Yet, the results of this analysis illustrate that some health planning agencies determine whether their areas are overbedded or underbedded and develop formal goals to correct the imbalance. The Old Age and Survivors Insurance Program (Title II of the Social Security Act) is the retirement insurance benefit program established in 1935 under the Social Security Act. The growing cost of nursing have care has prompted studies of the costs and cost-effectiveness of care delivered in alternative settings. (See discussion below of HUD's Congregate Housing Services Program. Table III compares the functional dependency of the non-institutionalized long-term care population to the nursing home population. Graphics were executed by Ray Shapiro and Vijaya Sonti. The availability of family and friends to help appears to be a critical distinguishing factor. Finally, the extent to which the patterns of expenditure are appropriate is difficult to judge without more detailed analyses of population needs and service effectiveness. " The relationship between any of these factors and staff turnover is poorly understood. While this is true, relatively few nursing have residents need nursing services or therapeutic services that can only be provided in an institutional setting. 71 A recent study by Weissert examined the costs of homemaker and adult day care services compared with the costs of nursing home care in a randomized experiment. Government, business, labor, and insurers participate as do representatives of different population groups. In addition to providing expanded coverage for nursing home care, the Medicare and Medicaid programs extended funding for have health services. This could be as many as 100,000 persons in need of congregate services to enable them to remain in their own homes. Critics claim that coordination between the two agencies was slow initially and is more cumbersome than if the loan and rental assistance programs were run by the same department. Table I presents estimates of the size of this population according to various levels of disability. Population is both the most predictable element in future projections and the fact with the most dramatic implications for long-term care. Critics claim the program was attractive to speculators and did not promote continuous, service-oriented management. Similarly disabled men would normally be included in this level. Coordination of Long-Term Care Programs Since no single program funds a comprehensive array of long-term care services, the effectiveness of coordination across programs is a central issue in the consideration of policy change. Federal programs passed in the 1960s encouraged the development of facilities called "nursing homes", but did not in the early years have stringent definitions of what constituted a "nursing home. She believes there should be processes written out for everything we do for the patient. The system responded predictably. 44 Another area of debate has focused on the income levels which are most appropriate in determining income-based eligibility. The Vocational Rehabilitation Program, established under the Rehabilitation Act of 1973, provides rehabilitation services to physically and mentally disabled persons in order to prepare them for work. One of the penalties for disregarding CON law is loss or refusal of an operating license. Barring major breakthroughs, however, continued incremental improvements in the management of chronic conditions and further reductions in general mortality are likely to increase the size of the long-term care population. The Task Force has begun to examine these and other issues related to eligibility standards, eligibility determinations and the treatment of income and assets. As stated, our CNO is a democratic leader, in her prior position, in Nevada she was the Director of Nursing over the Emergency Room department. Growth Rate of the Elderly Nursing Home Population by Type of Facility 1960-1970 Medical Assistance to the Aged (MAA), or the Kerr-Mills Act, was passed in 1960 and provided for payments for "skilled nursing home services. Private payments for nursing home care were 65 percent of all payments in 1965. Empirically there are only very tenuous links between physical characteristics (a missing leg), physical functioning (ability to walk), and social functioning (ability to get and keep a job); it is difficult to predict any one characteristic, knowing another. 7 These factors are important: when two people have similar conditions and needs for help, the person with a spouse is less likely to be institutionalized. G. " In 1956, this program of social insurance benefits term paper on nursing was extended to severely disabled workers and adult disabled children of deceased and retired workers. In addition, supplemental rental assistance was provided for up to 40 percent of the tenants in a project with incomes too low to afford the reduced rent. Medical schools offered courses in geriatrics, gerontology, or both to medical students. The National Task Force for the Definition of Developmental Disabilities estimated that there are approximately 2. The majority of elderly persons (88%) reported no unmet needs. The tenant contributes between 15 and 25 percent of his or her income toward the rent and the housing assistance payment makes up the difference between that and the established rent paid to the owner. L. The appropriate federal role in this is open to question. 13 A particularly interesting finding of the California study was that only 8% of the residents of skilled nursing facilities for the "mentally disordered" received any "psychological therapy" beyond that provided on an ad hoc basis by the nursing staff. The provision of day care reduced the use of both SNFs and hospitals but total costs increased because the cost of the day care itself was much higher than the reduction in institutional costs. Eligibility for services is extended to all those with physical or mental impairments who have reasonable expectation of obtaining employment as a result of vocational rehabilitation. The rapid proliferation of private "nursing homes" not known to provide nursing may be a result of the lack of federal definition of a nursing facility. This inflation in the nursing home sector (along with even more rapid inflation in home health services) has serious implications for the public and private role in financing long-term care. TABLE II. It is estimated that in 1976, the number of adults needing congregate housing, personal care homes and other sheltered living arrangements exceeded the number actually residing in such facilities by more than 1. Proportion of the Elderly in Institutions and Group Quarters by Age Cohort: 1950-1970 Distribution Among Types of Institutions: While the proportion of the elderly in institutions and group quarters of all types has grown only slightly in recent years, changes in the distribution of the institutionalized have been rather dramatic. It examines the planning and regulatory options open to the agencies and ways in which they have been used to affect long-term care. Current evidence is inadequate to conclude that there is currently a national surplus or shortage of nursing have beds and other long-term care services and settings. 54 Among the social services studied were transportation, personal care, housekeeping, social activities, emergency assistance, food shopping, and food preparation. These arguments are not necessarily inconsistent since many factors can generate excessive demand, for example: 1) the lack of appropriate alternatives, 2) public subsidization of nursing home care, lowering its price to the Medicaid or Medicare consumer, 3) absence of or insufficient public support for alternatives to nursing homes. Current understanding is very limited. Similarly, many who are dependent on others for help with the most basic elements of daily life are yet quite capable The National Health Interview Survey and other sources of national data based on household samples under-represent the number of disabled people in board and care facilities and other group settings not classified as institutions. The answers to these questions are critical in evaluating the role of CC and planning in long-term care. " 40 As the House Select Committee on Aging has noted: It is our contention that if this country attempts to serve all seniors equally through its fragile Aging Network, it will actually be able to serve only a few, and not very well at that. Further, there is considerable variation among people in the severity, responsiveness to treatment, and so forth of any one condition. Section 236E, Housing and Urban Development Act of 1968: From 1968 until its suspension in 1973, this program was a major source of funds for construction of rental and cooperative housing for low and moderate income families and the elderly. Substantial contributions were made by John Grana. They found that "using the most conservative criteria that include functional dependency, need for nursing services, and the presence of other physical impairments, the estimated number of elderly for whom long-term care placement appears unnecessary approaches 100,000 persons. Understanding the caps with government reimbursements, and providing healthcare services to an aging population that relies on Medicare for their healthcare needs (Weil, 2007). Although the particular combination of services required by members of each of these groups may differ, the general nature of their conditions and resulting overall service requirements appear to be similar enough to warrant efforts to integrate the development of overall program policy to the extent possible. Medicare home health benefits include part-time or intermittent nursing care; physical, occupational or speech therapy; medical social services; part-time or intermittent home health aide services; medical supplies; and in some cases hospital-based medical services. These provisions allow the agencies some leverage in affecting the number and location of long-term care facilities and beds and related services. For Level III, the relative proportions are 9 percent of those over 65 years and . G. The geographic distribution was not even, with 71 projects in Florida and California and most of the remaining ones in large metropolitan areas in the Northeast and Midwest, and did not reflect the distribution of the elderly. This analysis implies that a high degree of consistency may exist. These plans define the effective and efficient health systems they hope to achieve. For persons in nursing homes, income levels can be set up to 300 percent of the SSI payment standard. A review of selected plans from approximately 100 HSA's shows that long-term care is a primary concern of these agencies. As a further example, more federal money was spent in 1978 on Disability Insurance than on nursing home care ( robert b parker phd thesis Table I). The types of services to be reviewed, capital limit or other review trigger, criteria, review and appeals processes, and penalties vary from state to state. They raise additional questions. The program provided a subsidy to the mortgage that reduced the effective interest rate paid by the mortgagor to 1 percent and required low rents. It is not possible to isolate the extent of long-term care spending from these data. Now she was over a system and had to look at system approaches in the hospital. Initially, a renewable 4-year program of 3-5 year grants was authorized at $120,000,000. "At first glance at least, the experience of European dissertation concurrence et prix countries in reducing use of nursing homes through the ready availability of home based services does not appear encouraging. 82 Because a systematic analysis of the impact of planning agencies on long-term care has not been done, there is not yet reliable nationwide evidence to support either view. Blindness is the most prevalent condition, followed by paralysis and impairments of the back and spine. In all, about 50,000 units under Section 221(d) (3) and (4) went to the elderly. In many states, Medicaid programs apply the same eligibility requirements. Ultimately we would like to have a comprehensive picture of the availability, use, efficacy, costs, sources of funding and so forth of each service set. Yet, the results of this analysis illustrate that some health planning agencies determine whether their areas are overbedded or underbedded and develop formal goals to correct the imbalance. A five-year study comparing residents to "matched controls" on the waiting list found that: Although congregate housing has been found to be less costly than nursing home care for some chronically impaired elderly, very little is known about the cost-effectiveness of congregate housing in preventing institutionalization compared to home-based services alone or to other forms of domiciliary care. The Under Secretary's Long-Term Care Task Force: Members and Program Participants Nathan J. Are beds being added or dropped in the right places? Recent changes in long-term care on a national as well as a State level are related to health planning activities. Furthermore, projected growth rates are greatest among the "old-old" who are the most vulnerable. Eighty percent of personal care services for the elderly and chronically disabled are provided by family members. Nursing homes, formerly homes for the aged, have only recently become the predominant institution providing shelter and long-term care to the chronically ill and functionally dependent. 5 million non institutionalized chronically ill and functionally dependent do not need assistance with ADL's. 1 million. Research to date is very limited and inconclusive. (A single nursing home facility, over a period of time, could have more than one Hill Burton project. For example, total federal expenditures for nursing home care were over ten times the expenditures for home health in 1978. Most of the assistance, $38,957,086 went as loan guarantees to 24 private projects for 2,675 beds. There is widespread agreement that long-term care service "needs" are more closely related to functional disability than to chronic disease or condition, per se. Small, scattered site projects, such as group homes for 12 or fewer chronically mentally ill individuals or independent living complexes of 6-10 apartment units for no more than 20 individuals are the norm. Particular services available in given communities depend on funding available and locally determined service priorities. " 2 An additional 900,000 people in institutions are counted in the CMI target population. Backlog appears to be a local, not a national, issue. Among the more important for this discussion were the original prohibitions against payments to persons in non-medical public institutions and to persons in public mental or turberculosis hospitals. The indexed plans covered areas in almost all States, except for the District of Columbia, Rhode Island, Utah, New Mexico, and New Hampshire. Available studies appear to indicate that for slightly impaired people, alternatives are more economical than nursing homes; for severely impaired people the opposite is true. Carefully executed studies to date provide only mixed, partial, and largely indirect findings with respect to the impact of home-based care provision on rates of institutionalization for the dependent aged population". With regard to eligibility for nursing have services, it is argued that eligibility policies in the Medicaid and SSI programs create financial incentives for persons to enter nursing homes rather than remain within the community. Some argue that despite the apparent medical orientation of public long-term care programs, the health care needs of the chronically ill, particularly the elderly, are often severely neglected, particularly in nursing homes. How much of the nursing have bill should then be attributed to "social service" expenditures? As can be seen, from 1950 to 1970, the proportion of the population aged 65-79 in institutions and group quarters has remained virtually constant. Research, demonstrations, and training programs constitute a major part of the federal effort. This provision requires state approval of capital expenditures over a certain limit, $100,000 at present. While the program also has the potential of facilitating repairs for elderly homeowners, who have relatively old homes, perhaps the financial burden is still too great for many to benefit. The projected increase in the number of elderly above the age of 75; the longer life expectancy of the disabled; and the inflation of nursing home, home health care, and personal care costs make it increasingly difficult to maintain the security of those in need of long-term care services. The National Center for Health Statistics, for the purposes of the Health Interview Survey, uses two criteria to distinguish chronic from acute illness. No comprehensive analysis of what health planning has accomplished in long-term care exists. Standards for ECFs required extensive professional and supportive staffs, and such facilities never comprised a large segment of nursing homes. Eligibility is also extended to the dependents of workers found to be disabled. Economic Papers on Nursing The Chief Nursing Officer (CNO) at my current hospital has been a nurse for 25 years, her leadership in nursing started about 17 years ago where she became a manager of a nursing unit. Federal, state, and local programs must be organized to use resources as efficiently as possible to assure the quality of care and quality of life of the long-term care population - both in the institution and in the community. What is not known is the break-even point, and how to determine for which individuals which particular services and settings are cost-effective. Barbara Manard served as the principal author and editor of these papers. The second report describes the services, staffing arrangements, and charges of the individual facilities in its area. 62, 63, 64, 65, 66, 67 According to a recent critique of these reviews, because of the difficulty of comparing the costs of have and institutional care, more recent reviews of empirical studies conclude that little is reliably known and that more careful research is necessary. , nursing homes), while individually tailored service packages are difficult to organize in any setting. Analysis of areawide health plans reveals that states with high nursing have bed-population ratios tend to have plans that call for reductions in the ratios, and states with low bed-population ratios call for increases in the ratios through increases in the supply of beds. Based on a number of assumptions regarding the extent of delegation to nurse practitioners and physician's assistants, and the age of the population dealt with (75 and older), the report makes a summary estimate that the country will require between 7000 and 10,300 geriatricians by 1990, with the best intermediate estimate being about 8000. 47 There are various ways in which an individual can become eligible for Medicaid benefits in nursing homes while not being eligible for these benefits in the community: A second major area of concern pertains to eligibility standards for home health services. Recent federal programs also appear to have influenced the development of particular types of nursing homes and other "near" institutions. A review of the financing of long-term care is further complicated by the fact that many of the federal programs which fund the provision of long-term care services have not been exclusively designed to support services for the chronically disabled, apart from other needy population groups. Combined Medicare "extended-care" facilities and Medicaid "skilled nursing" homes into a single service category -- the skilled nursing facility. The projects average about 35-45 units each. To comply with Departmental guidelines, all of these plans were supposed to address long-term care concerns. Actual appropriations in FY 79 and FY 80 were $10,000,000 each. All health planning agencies are not represented in the AHPA data. S. , Old Age Institutions, D. Emphasis is placed on the planning, coordination and development of services. Even though Section 502 has been a large program with over 800,000 loans made through FY 78, less than 3 percent of them have gone to the elderly. Since that time, the "old-old" have comprised an increasingly larger segment. Nevertheless, the conclusions commonly drawn from such isolated facts cannot be easily substantiated. The Congress, government officials at all levels, consumers, and providers generally agree that the present programs often fail to promote desired objectives: The Department of Health and Human Services administers most of the major federal programs which serve the chronically disabled. 34 Since the range of services which provide assistance to the chronically disabled is broad, it is difficult to isolate how much is actually spent on long-term care from all sources. " "Expert medical opinion" need not be rendered by a physician; further, need may not be limited to medical needs, but may encompass psychological and social needs as well. Of those impaired, 56 percent were receiving services from family or friends. In fact, many projects were "retirement centers," including many life-supporting services such as meals, housekeeping, hobby rooms, and full medical care of a nursing home level. As of July 1980, all states except Louisiana have some type of CON legislation. A. Moreover, there appears to be a serious shortage of nursing home beds, with perhaps as many as 30 percent of hospital beds occupied by long-term patients. However, the more detailed data available now make clear that a very large proportion (nearly half) of the nursing home population is so debilitated that few with similar conditions -- regardless of their social situation -- manage in a community setting. Increased demand for nursing home care is expected to be particularly great among persons 85 years and older ( Figure IV). Nevertheless, it is useful to consider estimates of the numbers of people in the long-term care population with different degrees and types of functional disability, broadly defined. The services required by the most extremely impaired elderly, about 10% of the population over 65, could be delivered more economically in nursing homes. It is clear, however, that the lack of diversification in living arrangements for the long-term care population is a problem. Scales were constructed which measured various dimensions of functional health, excluding direct indicators of cognitive ability and emotional stability for which data were not available. TITLE XX (Office of Human Development Services, DHHS) Services are provided to veterans directly through the VA or through contract in hospitals, nursing homes, psychiatric and domiciliary facilities. In contrast, the proportion of the population aged 80 and older experienced over 50% increases in their rates of institutionalization over the two decades. Staff turnover in hospitals, however, is not much lower for comparable personnel than in nursing homes. The Disability Insurance Program (Title II of the Social Security Act) began in 1957 as a Federal program of cash benefits for totally disabled workers. This estimate is based on a very broad conception of "chronic mental illness" as it includes all people who have any chronic mental condition, including "senility," and all of those regardless of whether the condition is the primary reason for admission to an institution or a secondary diagnosis. There are at least 80 Federal programs which benefit the disabled (and able) elderly, either directly or indirectly through cash assistance, in-kind transfers, or the direct provision of goods and services; Another source lists 150 programs which assist the handicapped by providing health, education, rehabilitation, income and housing. Amendments to the Social Security Act in 1950 repealed the prohibition against payments to residents of public institutions, and also permitted direct payments (called vendor payments) to providers of nursing care, in addition to beneficiary payments. The decline of the proportion in group quarters (boarding houses, retirement hotels, and the like) has been equally dramatic: from 41% in 1940, to 12% in 1970. At the same time, depending on the mortality assumptions employed, the nursing home population is projected to increase by 28 to 56 percent over the next ten years if current patterns of use are continued. It authorized HUD to make 3-5 year grants to Public Housing Agencies and Section 202 borrowers under which they can then fund a package of services, including meals, personal assistance and housekeeping, for their eligible elderly and handicapped residents. "In accordance with its intent, the program served basically a middle income elderly group. " 30 Public Housing: Low rent public housing is the oldest (since 1937) and by far the largest program providing housing to poor families and the elderly. Some current and proposed demonstrations address these questions. In addition, there has been a substantial public role since the colonial era, though the nature and scope has changed over time. Farmers Home Administration in coordination with the Administration on Aging is supporting congregate housing demonstration at 10 diverse sites. As a new CNO learning to maintain and help implement the regulatory processes within the hospital has been challenging over these past six months, we have had Florida Agency for Health Care Administration (AHCA), and within the next six months we should have our Joint Commission inspection. Under this legislation, a network of area-wide agencies on aging has responsibility for planning and funding the provision of a broad range of social services. The development of a coordinated comprehensive long-term care policy requires a different approach. 5 million are in institutions, primarily nursing homes, though the proportion who will ever become institutionalized is considerably higher. In general, each successively higher level of disability is a subset of the previous level. Although information on CON is scarce, a small data "window" exists for the period July - December 1979, which casts some light on the CON activity of states which consider themselves overbedded or underbedded: It is important to note that the health planning process does not take place in a vacuum, but within a complex health care system. The incidence of having one or more unmet needs increases with age, from 6% for the 65-69 age group to 28% for those 85 years and over. The "family setting" is have for nearly 90% of all people unable to perform major activity. 5 million for 3 years. C. Survivor benefits are also provided to dependents of deceased workers. Presumably the recipients spent much of this on "basic living services. Some information on health plans was available from a computerized topic index developed by the Bureau of Health Planning, Health Resources Administration. Of those who are, many probably rely on the social security insurance benefits to purchase certain long-term care services. Although older people (particularly those over 85) are more likely than others to need personal care services, at every level of ADL dependency, there are more people who need personal care services under age 75 than over. The following definitions serve to clarify the distinction between need and utilization, and the important concept of demand: Need: As generally defined by professional judgement other than that of the recipient, need is "that quantity of services which expert medical opinion believes ought to be consumed over a relevant time period in order for individuals to remain or become as 'healthy' as is permitted by medical knowledge. Traditionally this group has included those who are blind, deaf, paralyzed, and otherwise "visibly" physically handicapped. , 1976. 48-55. 76 A related way to regulate service supply is provided by S. These quality assurance elements are part of the Conditions of Participation and by regulation, phd thesis anupam have been made common to both Medicare and Medicaid. Section 8, Housing and Community Development Act of 1974: Section 8 provides a rent subsidy to lower and very low income tenants in leased housing. First, more rapid inflation in nursing home services than in the general economy means fewer people can pay for services privately, placing increasing pressure on public budgets. What Do I Do Now? Since the range of services which provide assistance to the chronically disabled is broad, it is difficult to isolate how much is actually spent on long-term care from all sources, public and private. The Medicare and Medicaid program (Titles XVIII and XIX of the Social Security Act), established in 1965, provided health insurance to aged and low income individuals for a broad range of health-oriented long-term care services in a variety of institutional and noninstitutional settings. For the mental conditions specified on the NHIS condition list, 853,000 individuals in 1978 reported being unable to conduct their major activity (Level II). Eligibility for Medicaid benefits extends at a minimum to all persons receiving cash assistance under various welfare programs (Aid to Families with Dependent Children and, with certain exceptions, Supplementary Security Income). Rapidly increasing costs increase the rates at which individuals exhaust private resources and increase the probability that Medicaid will have to pay the nursing home bill. "A survey by the International Center for Social Gerontology of 182 Housing Authorities with developments for the elderly built before 1970 revealed that 12. Of those, an estimated 1 million were mentally retarded. Working Paper #5: Dynamics of the Current System The long-term care system is extraordinarily complex, encompassing issues in the areas of health, housing, transportation, social services, income security and jobs. 6 million people) refers to those who report needing help with personal care and hygiene, that is, "activities of daily living": eating, dressing, bathing, and using the toilet. The tenants reflected the neighborhoods in which the projects were located and the sponsors, often relatively well-established religious, occupational and fraternal organizations. 79 In some States bed removals are also reviewed. the best college essays The Task Force incorporated other related activities underway such as the implementation of the National Long-Term Care Demonstration Program, and established staff working groups to review research, budget, and analytical issues. The first, the State Health Planning and Development Agency (SHPDA) is a part of State government; the second, the Statewide Health Coordinating Council (SHCC) is an advisory committee made of representatives of the States' HSAs and State government. This Section is being used for the FmHA congregate housing program. The goals and other parts of the health systems plans are published and disseminated throughout the area. Interim Medicaid standards adopted in 1967 relied on existing state standards, developed under the Kerr-Mills program. Population, according to the 1977 National Health Interview Survey, have some "activity limitation" as a result of a chronic disease or condition. Dramatic growth in vendor payments to nursing homes occurred in 1960 as a result of the Kerr-Mills program, with payments increasing almost ten times by 1965. Both the young and the old disabled alike have lower incomes than their peers. The Supply of Long-Term Care Services and Settings Need, Demand and Utilization The relationship between need and actual resource use is not straightforward. Without 1122 approval, Medicare reimbursement for the institution is cut to exclude the costs of capital involved in the specific project. The relationship between age and functional status was discussed briefly in Working Paper #2. Eligibility procedures and the scope of in-home services under Title XX vary by state. This authority was to be used to pay for dining facilities and equipment in low-rent public housing projects. Further, the entire federal share of Title XX, including the costs of all social programs, was only about half of the federal share of nursing home costs in the same year. As a nurse leader our CNO needs to be able to respond to an ever-changing healthcare environment, including organizational expectations and changes to local and national policy (Middleton, n. APPENDIX 4-A. In addition, the Assistant Secretary for Planning and Evaluation and each principal operating component in the Department established a long-term care organizational unit or function to signal its commitment to this key policy area and to ensure permanent staff capacity for these activities. Since the elderly comprise the largest segment of the long-term care population, discussion is focused on that group. Medicaid, as an expanded version of the Kerr-Mills program, continued the provision of federal matching funds on a vendor-payment basis for skilled nursing services to cash assistance recipients and, in some states, to the medically indigent. S. Regulation The most direct way in which HSAs and SHPDAs influence long-term care bed supply is through COIN and 1122 decisions. Previous research has stressed the importance of social factors such as living arrangements and marital status in determining institutionalization. As a measure of functional impairment it works better for adult men than for adult women. G. The translation of functional disabilities into service needs is attenuated by personal circumstance and is highly subjective. Some argue that the regulatory methods emphasized to date are inappropriate approaches to quality assurance and that other methods -- including market strategies -- need to be tried. Detailed evidence on the family situation of individuals with different levels of impairment is not currently available. Coverage and Coordination of LTC Programs The categories incorporate less skilled assistance provided in the bane as well as formally organized services offered in specialized settings. To some, long-term care services are be entitled and which public financing programs should be expanded to cover, wholly or on a sliding fee basis. 12 Similarly, a recent study of 87 California SNF's found that only 10% of the residents received physical therapy, though staff believed half needed it. Payment patterns to institutions under the matching grants for old age assistance and aid to the blind have changed over the years as well. The long-term care population is extremely diverse in its functional disabilities, illness, needs, desires, personal resources and living arrangements. 3 million. The HSAs and SHPDAs that address these types of programs clearly have a comprehensive concept of the health care needs of their populations. Introduction Whereas individuals with similar long-term care needs may experience similar outcomes from the same services delivered in different settings, the cost of the provision of those services in different settings may be entirely different. Colonial American communities, for example, appropriated substantial funds for the foster care of disabled persons without families or resources. This group includes those most "at risk" for institutionalization and is discussed in greater detail in Working Paper #3. For example, "basic living" always includes food, but meals may also be part of a highly complex therapeutic plan. Given a pattern of needs, utilization or demand, supply may or may not be adequate to meet it. With regard to nursing have beds, reports of overuse and misplacement (indications of possible surpluses) are to be contrasted with reports of long queues of people waiting to enter nursing homes (possibly indicating bed shortages). Further, the use of any particular age as a criterion for service eligibility is arbitrary since at any age there will be, needy persons who will be too young to qualify for benefits. Shows that the state is making satisfactory progress toward developing and implementing a comprehensive mental health program, including provision for utilization of community health centers, nursing homes, and other alternatives to care in public institutions for mental disease". " 29 For the first time, the 1978 amendments authorized HUD to enter into contracts with local public housing agencies and project sponsors to provide congregate services to eligible project residents. The major disagreement between Vladeck and Feder and Scanlon is that Vladeck believes nursing homes should be cut in order to motivate the growth of new alternative services, while Feder and Scanlon feel that nursing homes supply should not be cut until alternatives take hold and we are certain that patients are receiving the levels of care they need. Older people are particularly vulnerable to chronic illness and accompanying functional disabilities. 50 Under current Medicare law, eligibility for home health services is extended only to individuals who are homebound, who have a primary need for "skilled" nursing care and who require these services on a part time or intermittent basis. 22 Quality Assurance The Federal government has played an active role in efforts to upgrade the quality of care for the LTC population for over a century, though the extent of that role has changed as a result of both growing federal financial responsibility and changing notions about effective ways of influencing quality. Tenants pay no more than 25 percent of their adjusted income for rent and at least 20 percent of each project must be occupied by very low income tenants, those with incomes 50 percent or less of the area's median. The most recent reliable data on State supply of long-term care beds is the 1976 Master Facility Inventory, compiled by the National Center for Health Statistics. 92-603) Extended coverage under Medicare to the disabled. About 12 percent of the more than 450,000 units produced were occupied by the elderly. Rapidly increasing costs increase the probability that Medicaid will have to pay the nursing have bill. Estimates of the Size of the Long-Term Care Population The Non-Institutional Population: Levels of Functional Disability Approximately 30 million people, or more than 13% of the total U. They are described in Appendix 3-B. The most apparent distinction involves a subtle shading of ideological emphasis. While federal regulations define the basic tenets and minimum requirements of acceptable CON programs, each State has developed a unique program. 43 Others argue that for the most part, public funding for long-term care services should be reserved for those who are least able to obtain these services because of low income. 1 million people) is 65 years and older. TITLE III. These studies have became the basis for several comparative' reviews. By this estimate, 58% of the nursing home population is included in the CMI target group. The additional and exceptional demands of chronic disabling conditions complicate the ordinary process of living. We are presently ill-equipped to capture simultaneous changes and dynamics of the long-term care system as a whole. And Paul W. Therefore, there may be no other place to put an "inappropriately" placed individual if "appropriateness" is determined according to medical criteria. But with that we are learning how to develop processes from the ground up. Data on the CON and 1122 decisions by State for the six months period of July through December 1979 has been developed by the Health Resources Administration and used in this analysis. The Medicaid Program (Title XIX of the Social Security Act) began in 1966 as a joint Federal-state program to provide medical assistance to persons with low income, including the aged, blind and disabled. S. Eligibility for services under term paper on nursing the Act is extended to all persons 60 or over, without regard to income. Further, the states can extend the spend-down provisions only to those who could be considered categorically needy if state standards were as liberal as allowed (option 209 b) or to a broader range of persons whose incomes place them above eligibility standards for categorical assistance. Rather, an attempt has been made to include material from those planning efforts in these Working Papers. The program was very popular among sponsors and tenants and was well received by the surrounding communities. Others have argued that rather than substitute for informal care, formal benefits can supplement family efforts and keep even the client who would eventually be institutionalized in the community longer before institutionalization becomes inevitable. In comparison, only 16% of all individuals and 39% of all elderly were similarly poor. The proportion of the elderly population in institutions grew only slightly over the first half of this century; recent, more rapid growth has resulted mainly from large recent increases in the relative numbers of "old-old" (over 75 years) and increasing rates of instititutionalization of this group. These aspects of federal policy appear to be reflected in Table III. 2% in 1890 to 1. Required payment to skilled nursing facilities and intermediate care facilities under Medicaid on a reasonable cost related basis. It appears that the pattern of the 1960s has been reversed, and that "homes for the aged and dependent" are increasingly medically-oriented nursing homes. The gradual increase over that period, seen in Figure I, is largely accounted for by changes in the age structure of the elderly. Our policy must realize that those truly in need--the 75+ population -- have first rights and must be the focus of future aging policy. Such alternate patterns may require larger numbers of community health specialists such as geriatric nurse specialists, as well as requiring professionals to initiate mechanisms to assure quality care under such alternative arrangements. In 1927, the Bureau of Labor Statistics undertook a complete survey of conditions in all almshouses and homes for the aged. Funds for modernization of older projects can also be used to add congregate facilities. To describe facilities certified for Medicare participation. The long-term care population is extremely diverse in its functional disabilities, illnesses, needs, desires, personal resources and living arrangements. This diminution of private ability to finance LTC services is a matter of serious concern; to the extent that the public nursing have bill absorbs additional resources, it will be more difficult to target funds on alternatives to nursing have care and other possible system changes. Many people who want to enter a nursing home bed at existing prices can't get in. ) - a nationally representative sample of long-term care facilities. First, a chronic condition is one which was noticed more than three months before the interview. PSROs have primarily been involved in reviewing care setting. 8%) of non-institutionalized chronically ill and functionally dependent population need help in bathing, 1. "Potential sponsors have expressed a need to coordinate the funding of Section 202 housing with that of supportive services provided in those projects. They are based on the work of the Department Task Force on Long-Term Care up to January, 1981 and contain data that have not been available before. According to these estimates, a long-term care target population of 6 million persons in 1980 could increase to 7. To date, however, none of these proposals has been adopted for program funding related to long-term care services, with the exception of the Supplemental Security Income program. The overall effect of all this activity is difficult to assess. In 1971, funding for ICF care was transferred to Medicaid. The interest rate on the loan is generally below the market rate, but low income homeowners may be eligible for an extra interest subsidy. It can also be part of the services automatically provided in group homes or nursing homes. Based on these projections, the Task Force has estimated that the target long-term care population could increase between 25 and 50 percent over the next decade, since this target population includes a large number of older and highly dependent members of the more general population. ) From 1972-1976, direct loans were available to public sponsors and guaranteed loans to private, non-profit sponsors. Within this broad definition, states set their own standards for services eligibility. 1 percent of nursing home residents had a primary diagnosis of mental retardation. The agencies are provided with certain tools to achieve these purposes. These same services can be provided in a nursing home for $450. Nevertheless, functional needs alone do not determine whether or not an individual is cared for at home or in an institution. Some, however, argue that it is more appropriate to focus the education of health practitioners on the needs of the chronically ill, particularly the elderly. 4%, in 1970 with the greatest increase beginning in 1950. Alone, these data don' t show whether CON and the planning program have a real impact on the supply of long-term care beds and other related services. This group would increase by 2. There is some basis for questioning whether these patterns are the most accurate models to use to project future needs. Or a straight grant can be given to an elderly person if warranted economically. Taken together, these programs represent a major commitment to financing long-term care. Thus, as a greater proportion of those over age 65 are "old-old" (75 and older), the greater will be the proportion of all elderly in institutions. Fur the most part services are provided to non-elderly adults. Heath, Lexington, Mass. Table II shows this relationship in greater detail and indicates score potential problems with an age-based long-term care strategy. Many people in the long-term care population have low incomes and this seriously compounds their problems. Analysis The analysis centered on those States with very high and very low ratios. First, more rapid inflation in nursing home services than in the general economy means fewer people can pay for services privately, placing increasing pressure on public budgets. For those workers who have sufficient quarters in covered employment, eligibility for benefits is based on inability to engage in any substantial gainful activity, as determined by the monetary level of income earned. APPENDIX 5-A. Number and Percent of Non-Institutionalized Chronically Ill and Functionally Dependent Persons Who Receive ADL Assistance by Who Provides HelpUnited States, 1977 (thousands) Section 202, Housing Act of 1959: "was designed to provide 'independent living' for elderly and handicapped individuals whose incomes are above the public housing income limits but below the level to afford standard private sector housing. Project sponsors include individuals, consumer cooperatives, State or local public agencies, limited partnerships and profit or nonprofit corporations. 6 million people) refers to people reporting a need for help getting around the house, neighborhood, or community ("mobility assistance"). 7% in 1890 to 5. Moreover, backlog may be more related to adequacy of financing than to supply. Obviously, the type of long-term care required by schizophrenics differs from that required by diabetics. On the other hand, some fear that public subsidies for community-based services may encourage the substitution of formal for informal services. Now, as in the distant past, families and friends provide most of the care received by the chronically disabled. This represents 113 percent of the 713 beds requested to be removed. The Medicaid definition of facilities offering this level of care called for the provision of health related care to individuals who did not require hospital or skilled nursing services, but who required care which could only be made available through institutional services. There is no assumption that the planning agencies have caused specific changes in the supply of long-term care beds. C. Similarly, a Texas study found that therapeutic services were generally unavailable to mental patients in nursing homes. Staff turnover has been variously attributed to such factors as "sex, age, marital status, education, salary and benefits, hours and working conditions, local demographics, length of employment, personnel practices, morale, adequacy of training, attitude towards patients and families. LEVEL IV: (1. The 1970 Housing and Urban Development Act provided authority for congregate housing. Working Paper #3: Services and Settings People in the long-term care population suffer from a wide variety of physical and mental conditions and often have multiple conditions and multiple service requirements. 6%) of the 28. Thus, simply knowing the number of people with various types of chronic diseases is not very useful to discussions of long-term care services. Because the framework used for Task Force analysis departs from the way public programs have been structured, reliable national data are not available. National data on the results of CON and 1122 reviews are incomplete; State level data are even more fragmented. Stated briefly, the definition is as follows: For Task Force purposes, then, the long-term care population encompasses several important subgroups: those elderly disabled by chronic conditions, the physically handicapped, the developmentally disabled, the chronically mentally ill and the mentally retarded. The potential demand for congregate housing is even more difficult to estimate. By 1985, it is estimated that unmet need will approach 1. The federal government has little authority over board and care facilities. In the past, similarly dependent people were cared for in a greater variety of different types of institutions and congregate living arrangements. Additional Federal' funds are available to rehabilitate beneficiaries of DI and SSI. Thus, as one observer of the Swedish scene has suggested, whether availability of home-based supportive services in that country reduces institutionalization remains an unanswered question. Most of this growth is projected to occur in the older age groups ( Figure III). B. Adult Physically Disabled There is no one commonly agreed on definition of the adult physically disabled. Benefit levels range from a monthly average of $322 for the DI program to $357 for families ($238 for individuals) in the SSI program (including optional state supplementation). The exact magnitude of that commitment, however, cannot be determined at this time. With the rapidly changing healthcare system, regulations and guidelines have been changing. Most observers agree, however, that a substantial proportion of the institutionalized population has problems associated with chronic alcoholism. Subcommittee on Human Services of the Select Committee on Aging, Future Directions for Aging Policy: A Human Service Mode, Washington: U. Evaluation of local health plans indicates there are perceived shortages in some states and surpluses in others, perceptions being highly correlated with current availability of beds. In these particular States, the bed-related goals specified in areawide plans seem to be coming to pass. In real terms, Medicaid payments grew 48 percent over this period, relative to real growth in private expenditures of only 10 percent over the same period. There have been very few attempts to assess the quality of nursing homes over time and to relate these changes to government activities. Data on the institutionalized population are relatively comparable from 1940 to 1970. Many plans discuss the need for other alternatives to nursing homes, including meals-on-wheels, case management programs for the elderly, and congregate living arrangements. 81 He argues that CON should be used stringently to do so, while congregate housing and other services for the elderly are increased. Farmers Home Administration Housing Programs Farmers Home Administration, Section 502: As shown above, the HUD programs have been less successful in rural areas than in metropolitan areas. The other 1. As indicated in Table II, Medicaid expenditures for nursing have care more than doubled in the four years between 1973 and 1977. The areawide and state health plans are often instrumental in analyzing the need for the proposed project. Facilities already qualified under the 1967 code or state codes did not lose their eligibility to participate in the programs. These goals, approved by the agency's board of consumers and providers, show the directions in which the community wishes to move. Nursing Home Programs Hill Burton: Unlike the HUD program to finance nursing homes, the HEW program provided grants as well as loans, but only to nonprofit and public sponsors. TABLE II. In the absence of uniform standards, some states restricted participation to professionally-staffed facilities, while others certified non-professionally-staffed residential facilities. For moderate and higher income families unable to obtain a reasonable private loan there is a Guaranteed Loan Program. As in the Disability Insurance program, disabled persons are defined as those unable to engage in any substantial gainful activity by reason of any medically determinable impairment. In order to understand reasonably well the potential impact of programmatic changes one would ideally like to understand the dynamics of the system -- how the elements interact. It was stated over and over that the only other alternative was eviction and general reliance on the nursing home. Congress used the phrase "extended care facility" (ECF). Intermediate care facilities (ICFs) were designed as a less costly alternative. Also, available data indicate that although nursing have care costs per resident were approximately $8,011 in 1975, average per capita income for those over 65 was only $5,349. " But monies were expressly prohibited for payments to or care on behalf of any individual who is an inmate of a public institution, except as a patient in a medical institution". Efforts of reformers to close the almshouses and later to reduce the population of mental institutions led to federal programs which provided financial incentives for states and communities to accomplish those goals. 4 Some, but not all people classified as mentally retarded (because they score low on an I. While the importance of family, community networks, and informal services in long-term care cannot be overly stressed, little is known about the relationship between these and formal services or public programs. These goals, approved by the agency's board of consumers and providers, show the directions in which the community wishes to move. The purpose of the programs funded under this legislation has been to enable older persons to live in their own homes as independently as possible. Conclusion The long-term care system is extraordinarily complex, encompassing issues in the areas of health, housing, transportation, social services, income security and employment. Between 1960 and 1970, the number of elderly nursing home residents more than doubled. In addition to these beneficiaries, eligibility for Mediare benefits now includes persons who are permanently disabled (receiving disability insurance benefits), dependents of the permanently disabled and persons suffering from end-stage renal disease. TABLE IV. The program insured loans made to profit and nonprofit sponsors. Evidence of hospital backlogs used to suport the shortage theory is problematic. 3 million (1. Test) are also classified as being developmentally disabled (because they are functionally limited). The Task Force agreed that as an initial step we need a common ground of understanding for the Department as a whole. The physical facilities as well as accompanying services are to be designed specifically to meet the needs of the handicapped. Prior to 1935, however, government support was largely a state and local matter. But the most visible and controversial activities relate to the certification and regulation of nursing homes. A. These needs range from social to medical, from basic living services to highly skilled technical ones needed to diagnose, test, treat, and manage chronic or acute illness. 72 Weissert found home services to be an addition to, not a substitute for existing Medicare SNF (post hospital) benefits and that costs were $3,442 per year higher for experimentals than controls. These distinctions have found their way into federal legislation dealing with congregate housing for the elderly (for example, 1970 and 1974 housing legislation authorized congregate living arrangements in public housing), but the language is restrictive and almost solely concerned with provision for group dining facilities. Further, some conditions are always classified as chronic, including: allergy; diabetes; hemorrhoids; hernia; mental illness; missing fingers, hand, arm, toes, foot, or leg; speech defect; stomach ulcer; tuberculosis; and trouble with varicose veins. The older a person is, the greater the risk of institutionalization. " 26 HUD provided a direct loan to the sponsor rather than the mortgage guarantee used in most other HUD programs. This rental assistance enabled projects to serve a wider economic range than did the original Section 202 program. More than half of the new construction developed in conjunction with Section 8 rental assistance has been for the elderly. Sweden, for example, which employs more home aides per 1,000 elderly population than any other country - and where in Stockholm, have aides may be utilized by one-third of the elderly population - has an overall institutionalization rate at least as high as in this country. 8 million people with developmental disabilities. Then we have something to follow as a guide in the future. Services provided are comprehensive including evaluation, counseling, placement, training, physical and mental restoration services and transportation. " B. Relatively few elderly were housed under Section 221(d)(3) until 1964 when eligibility was expanded to include single elderly individuals. P. Additional benefits are provided to the dependents of retired workers. She is also a democratic leader, she is a leader that encourages open communication and team participation in decisions. She then turned Long-term care is a complex policy area which involves many of the programs of the Department of Health and Human Services. Section 515: Initially this program was exclusively for the elderly, but legislation in 1966 included families, also. House of Representatives Ninety-Sixth Congress, May, 1980; Federal Council on Aging, Public Policy and the Frail Elderly, Washington: U. I. Further, recent research indicates that nursing homes provide very few rehabilitative services and that nursing home patients have remarkably little contact with skilled medical personnel. By this line of reasoning, cross-sectional studies may under-estimate the degree of inappropriate institutionalization. Although it is popularly believed that public financing of long-term care is a relatively recent phenomenon, there has always been a significant public role in supporting care of the chronically disabled. Provided on this informal basis were transportation (60%), "checking" (stopping by to look in on) (44%), homemaking (20%), administrative and legal (15%), meal preparation (13%), housing services (12%), coordination (8%), groceries and food stamps (7%), continuous supervision (6%), nursing care (3%), and general financial help (2%). They are summarized below. 58 Over the past decade, however, standards of participation have been considerably augmented. More important, adequate means for solving the problems have not been established, though a variety of proposals have been put forward. This long-term care population is varied one: varied in age, source of limitation, degree of disability and dependence on others, and in the capacity to obtain assistance on their own, through either personal or public financial resources or from families and friends. Service Expenditures for Selected Federal ProgramsFY 1978 (in millions of dollars) However, it is possible to identify some significant trends in the relationship between Federal programs and private expenditures for long-term care by examining the case of nursing homes. This inflation in the nursing home sector (along with even more rapid inflation in home health services) has serious implications for the public and private role in financing long-term care. G. Feder and Scanlon write that alternative long-term care services that might substitute for a bed shortage have not been sufficiently developed or financed. The Future Size of the Long-Term Care Population The number of people who will need long-term care services in the future depends on an enormous array of factors including economic conditions, demographic changes, and patterns of family organization. Distribution of the Known Institutionalized Population, Aged 65+(One-Day Census) By Type of Institution: 1890-1970 As can be seen, in 1890 approximately 14% of the institutionalized elderly were in mental hospitals, over half were in almshouses, and less than a quarter were in "homes for children and adults. Often the loans arid grants are used for adding cooking or toilet facilities. Increasing attention has been focused in recent years on those with "hidden" handicaps such as epilepsy and alcoholism. 5 to 3 million persons. 18 Since there is no one commonly agreed upon definition of congregate housing, it is not easy to distinguish between congregate housing and other forms of group living environments (e. HUD establishes fair market rents and the local housing agency administers the program for existing housing units. Common space for socialization is included in this concept, and most proponents see the provision of apartments with some kitchen facilities, rather than single rooms, as being essential to maintaining the personal independence of residents. Certificate of Need (CON) laws, first enacted in New York in 1964, require State approval for large capital expenditures or significant changes in institutional health services. Of those who did have a person who would be available, 89% named a family member. Determining the types of services being provided under these programs is a separate issue. Some evidence supports this contention. If the bed supply is affected, are the changes beneficial? " The results of federal efforts to encourage and ensure quality within the long-term care system reflect those inherent difficulties. The Task Force was headed by the Under Secretary and the Assistant Secretary for Planning and Evaluation and composed of senior officials at the level of Deputy Assistant Secretary from principal operating components and staff offices. Planning agencies can influence the supply of institutional health services through regulation of capital expenditures. Types of Services Basic Living Services At a minimum the long-term care population needs what everyone needs: food, shelter, clothing, transportation, companionship, and assistance in time of crisis. The scope of its responsibilities was considerably broader and the orientation of its activities significantly different from term paper on nursing existing Departmental efforts involving long-term care issues. The Working Papers were prepared by staff of the Division of Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, under the direction of Maureen Baltay. 35 Given these constraints, the following pages focus on those aspects of long-term care financing considered most salient by the Task Force: the relative roles of the public and private sectors in funding of services; the types of services covered and their coordination under major federal funding programs; and eligibility for Federally-financed long-term care services. 1122 of the Social Security Act. While the majority of nursing home patients initially use private funds, a substantial proportion convert to public sources of payment after exhausting personal resources during the first year. 11 TABLE III. That part of the Section 8 program used for existing units has the advantage of permitting an elderly renting household to remain in its own apartment, to maintain its community contacts but to receive assistance in making the rent payments. Eligibility Standards for Specific Target Groups for Titles III, XVIII, XIX, XX, and SSI, OMHC Programs Not only do the different Federal programs provide funding for a varying scope of long-term care services, and for different types of particular services, but eligibility requirements vary so that the same individual may have access to one needed service and not another. It should be noted, however, that informal supports may be especially lacking in Sweden. In order to begin focusing on the complexities of system dynamics, however, the Task Force examined two related topics: (1) the supply of selected services and settings and (2) the "cost effectiveness" of selected "alternatives. This program reached a peak in service to the elderly in FY 77 with nearly two thirds of all commitments for housing assistance for elderly units. Approximately 22% have been diverted, at least temporarily, to community care. Two prominent examples are "I think I Need a Nursing Home. The same survey shows that 809 beds were approved for removal. Monitoring, as another example, can include sitter services, respite care or check-in systems. A wide array of social, recreational, and health services is available. Poverty in some cases is a result of chronic illness and in all cases severely complicates the lives of those afflicted. 19 in nursing homes. Agencies can try to coordinate different organizations and interests and act as a catalyst in the community's health care system. Specifically: It is important to note that the health planning process does not take place in a vacuum but within a complex health care system. The primary purpose of the health and safety survey is to determine whether the facility has met the Conditions of Participation and therefore has the capacity for providing safe, quality care. Other federal programs provide funding for long-term care services both directly and indirectly. Generally, treatment of chronic illness is considered to require continuing management to reduce acute flare-ups, minimize complications, maximize periods of remission and maximize maintenance of functional capabilities. The final decision is made at the state level. There is no assumption that the planning agencies have caused specific changes in long-term care beds. This is, however, a recent development. Once viewed principally as a moral flaw, alcoholism and other forms of substance abuse have been variously defined and redefined over the years as forms of criminal behavior, evidence of "mental illness" and -- some would argue -- essay writter reviews "physical handicaps" with a substantially biological etiological component. For instance, the Veterans Administration supports a comprehensive program of long-term care benefits for veterans, and the, Department of Housing and Urban Development operates programs which provide housing assistance to the elderly and the disabled. It is not surprising that our understanding of the system is rudimentary: our data are poor, our methods crude, our analytical instruments inadequate. Some agencies have written and published consumer guides to nursing home and other institutional and non-institutional long-term care services in their areas. Funding may also be provided for hospitalization, convalescent or nursing home care, prosthetic, orthotic or other assistance devices, education, attendance services, interpreter services for the deaf, and specially outfitted vehicles. However, the greatest rate of growth during that period was in facilities which the Census described as those "not known to have nursing care. Limited information on CON decisions has also been gathered. The program produced 335 projects with a total of about 45,000 units before it was phased out in 1969. Much of the current public discussion of long-term care service organization focuses on this distinction between community and institutional settings. Very low income homeowners are eligible. ). Table V presents examples of variation in eligibility standards among selected. The network consists of State agencies and areawide Health Systems Agencies (HSAs), mandated by National Health Planning and Resources Development Act of 1974, P. Half of the loan authority will be used for demonstration (see discussion below). Elements of a UC program include utilization review, physician certification and recertification of the need for patient services, and individual patient care plans. Funding is also provided for the direct delivery of services such as meals, chore services, home repair and transportation. 17 Housing with Services Providing care "in the least restrictive environment" is not just an issue of "institutional" versus "home" care. Higher income standards for eligibility extended to persons in nursing homes cannot exceed 300 percent of the SSI standard payment amount. The social and mental functioning of recipients was unaffected although contentment increased. One of the biggest challenges for her is understanding all the changes that are happening with Medicare and Medicaid. Figure II illustrates changes in the age structure of the elderly population from 1890 to 1980. The Farmers Home Administration is better structured administratively to deal with rural areas, but its programs are not focused exclusively on the elderly. As Dunlop has written: "Although common sense suggests that some families would retain their dependent elderly at home longer if certain formal support services were made available to them, there appears to be no hard, unbiased evidence to support this notion. 1979 CON and 1122 decisions seem to be consistent with the goals defined in 1978 plans. 5% in 1970 largely reflects changes in Census procedures and in the age structure of the population over age 65. TABLE V. The report is five years old, however, and some of the studies on which the CBO estimates were based date from the 1960's. About 7% had unmet transportation needs and considered it a big problem, another 24% were somewhat restricted or had some problems with transportation, and the remaining 69% were generally self-sufficient and unrestricted. However people with such conditions are classified, to the extent to which they experience functional limitations over a long period of time, they are included in the long-term care population. No HUD funds are available for those services. Table III indicates that: These findings indicate that the need for personal care services is a greater factor in institutionalization than has been thought. Both means of eligibility determination are currently used in Federal programs. Among the most recent studies is the work of Beth Soldo and her colleagues. 6%) need help in dressing, 0. Q. Health planning statutes require CON and 1122 decisions to be consistent with the health systems plans. Some argue that the key factor is inadequate salaries. Federal Programs Which Fund Long-Term Care Services One problem is that the indirect use of public dollars provided through the social security program for long-term care services in institutional or community settings cannot be calculated. This housing was intended to be an alternative to institutionalization in a hospital or nursing home. She has since evolved her leadership skills and became our CNO of our hospital last year. Some studies indicate that some alternatives tend to became additions to, not substitutes for, existing services, with very costly implications: additional costs tend to outweigh savings from reduced institutionalization. These patterns of funding and organization are mirrored at every level of public responsibility: federal, state, and local. In 1965, was designed to encourage the development of comprehensive and coordinated social service systems for the elderly. Quality of care objectives are more difficult to achieve than custodial goals because the elements of quality care are so poorly understood and there is no well-defined technology for either producing or evaluating quality care in long-term care settings. Also, available data indicate that although nursing home care costs per resident were approximately $8,011 in 1975, average per capita income for those over 65 was only $5,349. Patients in ECFs were not originally eligible for Medicaid. As a consequence, in addition to ongoing work on individual segments of the system, there is need for work to begin on modeling the long-term care system, across all segments, and over time. Practical experience in a number of areas and demonstration projects do indicate that where people can be linked to appropriate alternative services, a significant proportion can be maintained in the community, though it is unknown for how long. Total System Costs Even if a particular service provided in the home is cost-effective, the issue of who pays becomes relevant. The State CON and 1122 decisions for the 1979 six month period were also studied and compared to the plan goals. For either existing or new housing, the private owner is responsible for managing the unit. Approximately 1% of the total long-term care beds can be identified as serving "drug abusers or alcoholics" ( Figure II). 52 Until further evidence is available, therefore, the Task Force concludes that the issue whether there is a nursing home bed supply shortage or surplus is a state-specific and probably a local issue. These working groups were organized around eleven long-term care issues. About 63 percent for the units have been for the elderly. PSROs are groups of physicians in 192 areas throughout the country who are organized to assure that health care services for Medicare and Medicaid patients are of a quality that meets professionally recognized standards of care, are medically necessary, and are appropriately provided in the most economical setting. Comparisons of the Dependency Levels of Nursing Home and Non-Institutionalized Populations by AgePercent (N=X1,000) Some local studies also emphasize scanty contact with health professionals. NUMBER AND PERCENT OF NON-INSTITUTIONAL CHRONICALLY ILL AND FUNCTIONALLY DEPENDENT BY WHO PROVIDES HELP, LIVING ARRANGEMENT, INCOME AND MARITAL STATUS TABLE A3-I. , Title XX) support health care services, health care programs support social services (Medicaid), some sets of services are "pre-packaged" in settings (e. There are many determinants of utilization other than functional disability, such as individual choice, the availability of services, and costs. The rate of growth of this segment peaked in 1960; however, this growth rate has continued to surpass that of other age segments. Public and Private Expenditures Table I summarizes the total expenditures under the major federal programs which finance long-term care services. Section 231, Housing Act of 1959: This program was designed to provide unsubsidized rental housing for frail but mobile elderly. One of the few careful examinations of what nursing homes really do is Gottesman and Burestom's study of activities in forty "elite" skilled nursing homes in Detroit (1974). 8 percent had health or life insurance. Intermediate care (under Title XI) was initially defined by the states to include facilities providing more than room and board, but less than skilled nursing care. Nevertheless, some problems are striking and require redress: high rates of staff turnover in LTC facilities; repeated, if anecdotal, evidence of abuse; inadequate recognition that LTC facilities -- unlike hospitals -- are places where people live for long periods and hence should be designed, run, and financed accordingly -- as places for living. An additional component of the evolving federal role related to funding of long-term care services is the Title XX program. Much of their work is incorporated in these Working Papers (See Appendix 1-A for a complete list of Task Force members and staff). The Supplemental Security Income Program (Title XVI of the Social Security Act) was initiated in 1974 as an income and resource-tested income maintenance program for the needy aged, blind and disabled. " For example, money spent on nursing home care pays for food and housing as well as nursing. Federal involvement in the care of the frail and dependent dates largely from the passage of the Social Security Act in 1935, prompted in part by widespread dissatisfaction with state and muncipal almshouses housing indigent disabled and elderly people. Public housing for the elderly is so popular because it is easier to manage than family projects and local communities prefer it to family projects. Here, for example, is the definition adopted by a 1976 national conference on congregate housing for the elderly. To check the consistency of these figures with NHIS data, figures on activity limitation by cause from the NHIS were examined. The areawide agencies develop Health Systems Plans (HSPs) and Annual Implementation Plans (AIPs), while the SHPIIA combines the major points of these plans, adds State health priorities and policy considerations, and produces a State Health Plan, reviewed by the SHCC and the Governor. The phenomenon is further illustrated in Figure III, which shows the dramatic rate of growth of the oldest segment -- those over age 85. This is illustrated in Table II. SELECTED HIGHLIGHTS OF LEGISLATIVE ACTIVITY RELATED TO LONG-TERM CARE 1935 MEDICARE - MEDICAID PROGRAMS (P. Numerous studies have shown that clear differences in services utilization can be seen between eligible and non-eligible groups of individuals. They are listed in the appendix to Working Paper #1. Table IV presents data from a decade of MFI surveys. Over the same time period, another third of this population growth would occur among those persons currently living in the community who are potential candidates for institutional services due to disability and limited resources. Once goals and objectives are determined, the HSA and State agencies can advocate their adoption. The vast majority (95. For example, among those who require some but not many personal care services (about 30% of the LTC population), for every one person in an institution, there are approximately three with similar needs functioning in the community. By contrast, the proportion in homes for the aged rose from 23. F. MEDICARE (Health Care Financing Administration, DHHS) The Medicare Program (Tile XVIII of the Social Security Act) began in 1966 as a Federal health insurance program for Social Security beneficiaries who are 65 years of age and older. While the actual review processes for 1122 and CON vary from state to state, in most states the HSA does the initial review and develops recommendations. The gradual increase from 1. For example, Virginia has a mandatory prescreening program for all Medicaid clients who apply for admission to nursing homes. Craig, J. About 45 percent of the 1,200,000 units are occupied by the elderly and most new construction in the last 10 years has been in projects for the elderly. Proportionally, 17 percent of all elderly persons living in the community are disabled enough to fit within Level II, compared with only 2 percent of all persons under 65 years of age. Such efforts should yield, at the very least, perspectives on the more important problem areas, and identification of the critical leverage points in the system. A recent Department study concludes that an increase in nursing home beds would not reduce backlog since providers still would perceive reimbursement for the heavy care patients "backed up" as inadequate. The elderly, however, are substantially more likely to be disabled. In practice, preventing unnecessary institutionalization has largely meant working to keep the elderly out of nursing homes and other mentally and physically handicapped people out of large state institutions. Agency actions should be considered in relation to other parts of the health care system, the supply of acute care and alternative types of long-term care services, reimbursement policies and practices, and the political and economic environment. The proportion in prisons and jails has gradually declined from 2. 15 The right to care in "the least restrictive environment" is increasingly sanctioned by courts. It stems from the HSA status as a community organization, comprised of health care consumers and providers who are representative of the area's population and organizations. Further, it is difficult to define "levels" of functional disability because "disability" is less an individual characteristic than a characteristic of individual and environmental interaction: blind men may be less "disabled" in the dark than the sighted. 9% in 1890 to 72. FmHA provides direct loans for the construction, purchase or improvement of rental or cooperative housing to be occupied by low to moderate income rural families and elderly persons. 41 More general discussions have focused on the issue of universal entitlement with sliding fees (based on age or other criteria) vs. Even less is known about the adequacy of non-institutional services. 5 million (1. The index includes one or more areas of the other States; no attempt was made to index plans from all sections of any single State. The growing cost of nursing have care has prompted studies of the cost and cost effectiveness of care delivered in alternative settings. These inspection teams are composed of State employed professionals who are required to review the care being provided, the adequacy of the services available to meet current health needs, the necessity of continued placement, and the feasibility of alternate care arrangements. As one might expect, most people who need help with personal care (Level IV) also need help getting around the neighborhood (Level III), and are also unable to conduct their major activity (Level II). C. Our CNO also believes that building relationships are important while focusing on quality improvement of systems and processes. To those meeting specified income criteria, offered skilled nursing have services through Medicaid. 45 Proposals have been made to establish minimum "floors" to which all states must adhere. Newacheck, "Health and Social Factors Relevant to Long-Term Care Policy," Paper prepared for the LTC Symposium, Williamsburg, Virginia; Health Policy Program, University of California, San Francisco, 1980. Indexed plans from Health Systems Agencies in these States were examined to note differences in their long-term care goals. By law, in-home services under Title XX are directed more to social service needs than to health needs. Federal, state, and local governments fund a number of long-term care services. 9 It often involves a great deal of trial and error, multiple pharmacological and dietary approaches, and a great deal of supportive nursing. Reliable data on the nation's nursing home bed supply are available only up to 1976; measurement of recent trends is impossible. Most of those women who are not employed -- in part because of chronic conditions -- but who are able to do housework are not counted in Level II. 33 Another source lists 150 federal programs which assist the handicapped by providing health, education, rehabilitation, income and housing. Students who need to write an economic term paper about nursing can find a number of options just by flipping on their television. This figure is remarkably close to the 800,000 estimate used in the National Plan. In addition to selecting residents, States are expected to coordinate implementation of the program with sponsors and appropriate State and local supportive services. Formal social service agencies were infrequently mentioned. For additional ideas, students can use the following list of economic nursing topics to get started. Therefore, these studies are to be interpreted and used only with great caution. As late as 1976, the Senate Special Committee on Aging found that only 3 of 87 schools responding to their survey had established geriatrics as a specialty within the curriculm. About half of the states have opted to provide benefits to other low-income persons such as the "medically needy," those whose incomes are too high to qualify then for welfare, but too low to cover their medical expenses. In fact, since the subsidy only applied to the mortgage payments, rapidly rising operating costs meant that rental income was often insufficient to cover both debt service and necessary maintenance. " 73 A common problem with studies looking at the cost effectiveness of particular LTC services and settings or the impact of additional services on total systems costs is that they do not allow the time necessary for the structural changes in the delivery system to be commonly accepted so that a new "normal" routine of care can be properly evaluated. HUD has identified 22,500 units which provide full meal service at a minimum, but there are no reliable data on supply of non-federally subsidized congregate housing. 74 The Act mandated Health Systems Agencies (HSAs) to do local or areawide planning and two State agencies to do statewide planning. In 1965, another law was passed which provided for public funding of long-term care services, the Older Americans Act. Such problems generally increase as the disabled person grows older. Cirtics claim Section 231 has a high default or foreclosure rate and that it served a relatively high income, low priority population. Established Professional Standards Review Organizations. One major criticism of current program definitions of home health services eligibility is that they do not realistically cover the situations under which many individuals require such services. 57 Although few states took full advantage of Kerr-Mills, and hence its effect may have been relatively marginal, certain provisions of MAA were incorporated into Medicare and Medicaid which replaced MAA in 1966. One of the penalties for disregarding CON law is loss of or refusal of operating license. The program is federally financed and locally operated through some 3000 public housing agencies authorized to acquire, construct, develop or lease real property suitable for low income housing. Continued work will be necessary to resolve questions of cost, appropriateness, and equity. This has been a challenge for her, as she has to control her attempt of taking control of the nursing departments when they are having issues instead of leaving the current manager to deal with the issues and process of the department. 56 Note the change from the original Social Security Act, which prohibited payments to persons in any public institution. The mortgage subsidy required the sponsor to charge rents below the market rate. The agencies use their regulatory and advocacy roles to implement the plans. Section 504: Direct loans of up to $5,000 are made for home repairs necessary to remove health hazards and to make the hate safe and sanitary. Vladeck, on the ocher hand seems to assure that CON has not really restrained bed supply. D. These services have traditionally been provided by family, friends, community and private sector providers, at relatively little public expense and with little public oversight. 36 Title II of the original Social Security Act established the program of social insurance retirement benefits based on employee and employer contributions, now commonly referred to as "social security. D. Congregate housing is one mode of providing services in a large-scale "non-institutional" setting to people for whoa complete independence is inappropriate, undesirable, or too costly. The incremental development of the current long-term care "system" has resulted in a complicated pattern where public social services programs (e. For workers with sufficient quarters of coverage, full retirement benefits are paid at age 65, or at the worker's option, permanently reduced benefits may begin at age 62. 80 They believe CON may impede the accessibility of the old and the poor to nursing home beds. Difficulties were experienced in developing these estimates. Disability must be caused by a medically determinable physical or mental impairment that has lasted or is expected to last at least 12 months or to result in death. The combination of wide variation in the ratio of beds to population across the States and no accepted standard of adequacy suggests the issue of a nursing home bed supply shortage or surplus is a state specific issue. The controversy is in large part over the appropriate locus for authority and public financing in long-term care; whether long-term care should be developed as an extension of "medical" programs, social service programs, or an all together new program. Whether there is a shortage of congregate and other sheltered facilities cannot be determined with certainty. States for similar services. This may be partly the result of more experience in using assessment tools and the greater prevalence of nursing home screening programs. During the latter part of the 19th century, the Bureau of the Census -- as part of its responsibility to enumerate the numbers of inmates of institutions for the blind and "feeble minded" -- conducted a series of surveys, the results of which spurred the deinstitutionalization of the blind and the establishment of community workshops. Table I illustrates directly the relationship between the age structure of the elderly population and rates of institutionalization. Amendments in 1960 and 1967 broadened the definitions of disability and the conditions under which an individual can became eligible for disability insurance benefits. " By 1940, the aged mental hospital population had increased to one-quarter of the institutionalized aged; by 1970 it had declined to 12% -- approximately the same as in 1890. Two percent of the elderly but less than one percent of all younger people have incomes below $6,000 and need personal care services (See Appendix 2-A). The final decision is made at the State level. Operating funds even for this service are not authorized. D. Consequently, assessing the comparability of levels of disability between the population under and over 65 is difficult when the "major activity" criteria is used. On a national basis, an American Health Planning Association survey discovered that approximately 75 percent of proposed nursing home capital expenditures, or $1. The distinctions between "medical treatment" and social support became blurred with chronic illness. The original Section 202 program benefited a select group of the elderly. Under Medicaid, states have the option of extending benefits to the medically needy: those whose incomes are above the standards for public assistance but not high enough to cover their medical expenses. Other program design requirements may, also have adverse consequences for access to services. In brief, it appears that more attention has been, given to specialized training of health care practitioners than to training and education for community social service workers. Income-based services eligibility. Further, all such projections are based upon current patterns of care provision and care providers. Considerable problems, however, appear to remain in the assurance of quality care. " Seventy-five percent of those identified by the Task Force as the core long-term care population live in various "community" settings, from skid raw flop houses to Palm Beach condominiums. Eligibility for SSI benefits includes all persons who are aged, blind or disabled who meet the standard for low income. " 61 It is impossible now to say with any precision what should be the approximate mix of congregate housing, nursing homes, and other types of service-enriched living arrangements. Projects are under development now and will begin to open for occupancy shortly. Further, some services financed under health care programs are actually "basic living services. By June 1979, a total of 61 U. 4 million more very old people than there are today. This experience is apparently replicated in Europe, where the ready availability of have based services does little to displace institutionalization. Owing to the complexity of the task, analysis has focused on small segments of the system rather than taken the broad view. This may reflect a shift of the oldest patients out of general hospitals or family settings into nursing homes. The attractiveness of the program was enhanced by the coordinated use of the Rent Supplement Program, which was operated similarly to Section 8, but was phased out in 1973. Numerous proposals have been put forth to expand the criteria for have health services eligibility. 23 Improvements over time have been noted in the provision of clean and safe physical environments. This paper considers the role of health planning in long-term care. The difference in her style of leadership as CNO is the approach. According to the Series II Census projections, the population aged 65 and over is expected to increase by 26% between 1980 and 1999. Estimating the extent of inappropriate institutionalization is difficult and depends on the instrument used, the weight given to medical versus social factors in placement, and different judgments about what level of disability requires institutionalization. Nevertheless, the conclusions commonly drawn from such isolated facts cannot be substantiated for total public and private spending. The Congressional Budget office's estimates of inappropriate institutionalization of the elderly (10-40%) are often cited. LONG-TERM CARE, HEALTH PLANNING, AND CERTIFICATE OF NEED Introduction A national network of health planning agencies analyzes, plans, and regulates long-term care and other health services. For new developments and Section 202 projects HUD contracts directly with the developer. 21 Similar results have been reported elsewhere. For example, only 9. They reanalyzed data on persons age 60 and over from the 1976 Survey of Institutionalized Persons (S. Transportation was the type of service most frequently cited as a problem . " 60 "Recent research studies, however, have estimated current need for the elderly in public housing and Section 202 housing alone as perhaps 15 percent of the elderly individuals in residence. 6 Children within and outside of the household were the next helping source. Although a greater proportion of elderly persons compared to other age groups require long-term care services, there are more young people than elderly in the long-term care population. " 16 While this is a substantial number of people, it is less than 10% of the institutionalized elderly. The elderly -- and hence the potential long-term care population -- are a rapidly growing segment of the population. Some evidence can be cited in support of those conclusions. "The program was suspended in 1973, amid charges that the assistance was not great enough to serve very low income people, the program was too expensive and default rates were unacceptably high. Costs were $2,692 per year higher for experimentals than controls. Nor is it possible with existing data to substantiate some widely held beliefs, namely, that spending for health services is much greater then spending for social services, and that spending for nursing home care is substantially larger than spending for non-institutional care. Usually the agency owns and operates its projects. The terms are 1 percent interest for up to 20 years. This was due in part to an average annual increase in payments per recipient of over 15 percent. While these programs are designed to cover basic living expenses, they are not intended to cover the special service requirements of the long-term care population. Although there is some indication that previous estimates of the degree of inappropriate nursing home use may not reflect the current situation, it is incorrect to assume that "the problem has been solved. In addition, Medicare law requires that the appropriate services delivered to patients and quality care be assured through a utilization review (UR) committee within a skilled nursing facility. Men age 75 is used as the cut-off point, there are more young people than elderly in the long-term care population. As long-term care services are extended into different community settings, quality assurance will become even more complex. The Task Force Working Papers represent one effort toward that goal. However, federal standards for ICFs were not issued until January, 1974. The rate of increase among those 85 and over, however, will be twice that: in 1999 there will be 1. 3 percent of the present residents needed basic services. APPENDIX 3-A. The Adequacy of Supply of Non-institutional Long-Term Care Services All caveats concerning studies of need and unmet need for institutional services also apply to such studies for non-institutional services: assessment instruments are imperfect; their application involves great subjectivity; needs are determined by many factors in addition to functional disabilities. They found that only 2% of the resident's time was spent receiving "skilled nursing. The Impact of Public Programs on the Distribution of Settings: Institutional types follow the public money. The main exception is the relative decline of total industry employment expected for professional and technical workers (from 13. Hence the Task Force adopted a framework for analysis which characterizes the long-term care population according to different levels or types of functional disability. , board and care homes, adult foster care). At a minimum the project must provide: full or partial meal service, housekeeping and personal care services, transportation, and social and recreational activities. Eighty-five percent of the nursing home population (approximately 1. This provision requires State approval of capital expenditures over a certain limit, $100,000 at present. The remaining population increase would occur among those persons living in the community with resources sufficient enough to make institutionalization unlikely. Approximately 100 plans, almost all Health Systems Plans produced by HSAs in 1978, were abstracted and contained in the index. Some of the challenges that our CNO discussed with me is surviving all the changes that are happening in healthcare today. Originally an optional benefit under Medicaid, home health services became a required benefit in 1970. The current federal activities in long-term care quality assurance are largely variations on these two historical approaches: (1) conducting and supporting research and (2) establishing standards for the receipt of public benefits. HUD Program for Deinstitutionalization of the Chronically Mentally Ill This program was initiated in 1978 and is now operating in 39 States. ) The Older Americans Act, initially passed. These services, however, were defined primarily as health rather than custodial care. Thus the substitution (if it occurs) will both increase the total proportion of GNP devoted to LTC, if the total volume of services rendered remains constant, as well as increase the size of the government budget. This is in contrast to score 629 physicians who reported geriatrics as their primary, secondary, or tertiary specialty in 1977. Thus, "major activity" does not necessarily refer to a person's own perception of his or her usual, desirable, or most important activity. The broader concept of developmental disabilities is a functional classification, including individuals with severe chronic disabilities occurring before age 22, attributable to physical or mental impairments, and causing limitations in three or more major life activities such as self-care, learning, and economic sufficiency. As shown in Table II, the private proportion of nursing home care costs in relation to public expenditures declined steadily until the mid-70's, but has remained relatively stable at 42-43 percent in recent years. The discussion in this paper represents a preliminary exploration. This is consistent with the trend to allocate routine tasks to auxiliary workers. Under Medicare and term paper on nursing Medicaid, vendor payments provided with federal matching funds were made available to facilities offering extended care (Medicare) and skilled nursing services (Medicaid). As she became CNO she realized that she needed to look at things differently. Even more obscure is the relationship between any of these and the need for particular services. The adequacy of nursing home services was discussed above. Introduction A full discussion of current long-term care financing would have to take into account a very wide variety of public and private sources of funding for services to the chronically disabled; by one count, there are at least 80 Federal programs which benefit all elderly (both disabled and non-disabled) either directly or indirectly through cash assistance, in-kind transfers, or the direct provision of goods and services. Because of the nature of the medical management of chronic illness, it is very difficult to determine the relative importance of "health care" to other services in long-term care. The model facilities carbine Section 515 loans with Section 8 rental assistance and AOA non-renewable grants of $2. There are many determinants of nursing home use other than functional disability, such as the lack of family and friends to care for even a mildly impaired person at home. Acute conditions, by contrast, are those which entail single episodes of fairly short duration. With the 4 ADL measures, a 5-level index can be specified ( Table I). Evaluating local perceptions indicates that generalizing about the total supply of beds on a national scale simply is not appropriate: there are shortages in some states, surpluses in others. The analysis of systems dynamics, the interaction of the supply of one service on the supply of other services, and the interaction of different financing options on the availability of each is therefore critical in formulating future policy in this area. Seven percent of the elderly living with their spouse had one or more unmet needs, compared to 17% for those who lived alone, and 22% who lived with their children. The areawide and State health plans are often instrumental in analyzing the need for the proposed project. For example, the figures in Table I show that the Old Age and Survivors Insurance (OASI) program represents the largest category of Federal expenditures compared with the other programs shown. These difficulties stem in part from the complexity of the long-term care mission. TABLE I. Available evidence on the extent of substitution is limited. ) described above. Between 1973 and 1977, the Medicaid program has accounted for between 78-85 percent of all public expenditures for nursing have care. Services made available vary by state and include a number of home-based and community services. " As a generic term, however, it most often designates a broader concept. " Surveys of those currently in institutions do not accurately reflect the conditions of people at the point of entry, when they may be less disabled. Moreover, under MAA, states were allowed to support the aged in public mental institutions, but only "if the State plan ... In addition to changing coverage, many media sites have discussed the shortage of nurses and health care professionals in the United States. Many states simply licensed as ICFs those facilities which failed to meet the standards for skilled care. In other situations, the result may be an unmet need for particular types of long-term care. Under Medicare, payments were to be made only for a period of post hospital convalescence, provided that skilled nursing services were required. TABLE OF CONTENTS WORKING PAPER #1: OVERVIEW AND SUMMARY The Population Services and Settings Programs and Financing for Long-Term Care Dynamics of the Current System Appendix 1-A: The Under Secretary's Task Force on Long-Term Care, Members and Participants WORKING PAPER #2: THE LONG-TERM CARE POPULATION Introduction Chronic Conditions, Functional Disability, and Service Requirements Estimates of the Size of the Long-Term Care Population Estimating the Size of Subgroups in the Long-Term Care Population The Age and Income of the Long-Term Care Population The Future Size of the Long-Term Care Population Appendix 2-A: Distribution of Non-Institutionalized Population WORKING PAPER #3: SERVICES AND SETTINGS Introduction Types of Services Settings: Selected Issues Cross-Cutting Issues Appendix 3-A: Number and Percent of Non-Institutional Chronically Ill and Functionally Dependent by Who Provides Help, Living Arrangement, Income and Marital Status Appendix 3-B: An Overview of Federal Housing Programs Benefitting the Elderly and Handicapped WORKING PAPER #4: PROGRAMS AND FINANCING FOR LONG-TERM CARE SERVICES Introduction Public and Private Roles in Long-Term Care Financing Coverage and Coordination of Long-Term Care Programs Eligibility Appendix 4-A: Selected Highlights of Legislative Activity Related to Long-Term Care Appendix 4-B: Selected Federal Programs Serving the Long-Term Care Population WORKING PAPER #5: DYNAMICS OF THE CURRENT SYSTEM Introduction The Supply of Long-Term Care Services and Settings The Cost of Different Long-Term Care Services and Settings Conclusion Appendix 5-A: Long-Term Care, Health Planning, and Certificate of Need NOTES LIST OF TABLES Working Paper #2 Long-term care refers to the services required by people who have functional limitations as a result of or in conjunction with chronic illness or conditions. The chief virtue of the typology for Task Force purposes is that it emphasizes the distinctions among services, settings, and programs. The Age and Income of the Long-Term Care Population As can be seen in Table I, there are only slightly more people over age 65 than under among the non-institutionalized at Levels II and IV. To make the situation even more complicated, eligibility for certain services can differ by state or community within single programs; for example, in some states, counties determine service eligibility criteria for the Title XX program, and eligibility for Medicaid varies greatly from state to state. According to the 1977 National Nursing Home Survey, however, almost 80,000 or 6. This diminution of private ability to finance LTC services is a matter of serious concern; to the extent that the public nursing home bill absorbs additional resources, it will be more difficult to target funds on alternatives to nursing home care and other possible system changes. This development has occured at the expense of other types of institutions and "near-institutions," especially once-important "group quarters. Determinations of disability are made on the basis of the medical severity of the impairment as indicated by clinical and laboratory findings. In their analysis of CON and long-term care, Feder and Scanlon assure that CON has constrained supply. B. Appropriate long-term care services are fundamentally cross-cutting, involving both medical care and social support, with the line between them often blurred. This has meant standing back from specific program issues and attempting to define and understand basic elements of the current long-term care system and how they interact. 72 to $20. Services provided by families, although not costless, are usually less expensive than those purchased in a formal market. The boundaries of these categories are imprecise. Instead, it refers to pre-determined categories of activity. 78 Preliminary results of a DHHS survey reported that of 13,138 beds proposed to be added in the last six months of 1979, 86 percent, 11,290 beds, were approved. At least one study indicates that the elderly in Sweden have the least contact with children of any western society. 31 per day for alternatives compared to $19. These pension programs for the elderly and blind provided many with the means to purchase room, board and services in private boarding homes, rest homes and homes for the aged. In addition, states may provide supplementary payments for various types of special living arrangements, including congregate care or personal care. Alternatively, some programs limit services to specific settings; Medicaid does pay for housing, meals, and housekeeping in nursing homes, but does not reimburse these services for individuals living in the community. 4 million (4. Interrelation Among The Levels Of Disability Figure I illustrates the relationships among the various levels of disability. The Highland Heights Experiment - 1977 20: Highland Heights is a specially designed 14-story apartment house for low-income physically impaired and elderly persons. 7 billion from July 1976 through December 1978, was approved by planning agencies. FmHA preferred to use HUD's Section 8 program. There are, however, a number of significant and interesting exceptions to this pattern. The regulations were recently revised to permit loans for the addition of separate, independent living unit to be added onto the family dwelling for senior relatives. PSROs stress physician and provider education as the means to improve quality of care. By contrast, the 1978 Congregate Housing Services Act emphasizes basic services within the congregate setting for the express purpose of prolonging independence and preventing premature institutionalization, and authorizes funds for basic services when third-party funds cannot be obtained. Et al. The Social Security Act and subsequent amendments established a complex patchwork of programs variously targeted by age, income, condition and largely organized along functional lines -- income support, social services, and medical care. 4 to 10. The demonstration uses direct loan authority reserved under Section 202 in conjuction with a set aside of Section 8 funds to cover 100 percent of the approximately 2,000 units to be constructed or rehabilitated. 0 million (3. No subsidy was provided to cover the costs of the meals and other services. Although important to our understanding of individual components, such analysis misses the critical implications of the interactions among all facets of long-term care. AMENDMENTS TO THE SOCIAL SECURITY ACT (P. Anecdotal evidence suggests that even minimum physical standards have not been achieved in that segment of the long-term care system. If government provided benefits replace services that are currently provided informally by family and friends, the total bill may increase even if services are being provided more efficiently. The State can apply to HHS for Section 1115 waivers on behalf of project sponsors to permit a more flexible use of supportive services. Proportional spending for various types of services can be obtained, but relative spending for services directed specifically towards the long-term care population is not known. 39 At the same time, some believe that more efficient targeting of services within older age groups is essential. The DHHS data include preliminary data from 48 States. DHEW, (79-20959), December, 1978. Two of the major public programs which serve the long-term care population (Medicare and Medicaid) are fundamentally health care programs. Further, some services financed under health care programs are actually "basic living services. Stark, ChairmanUnder Secretary The Long-Term Care Task Force adopted a broad rather than narrow definition of the long-term care population, including individuals of all ages, not just the elderly, and all persons disabled by chronic conditions, whether these conditions are physical or mental in origin. Planning and Advocacy Another widespread topic was home health care, often considered an alternative to nursing home services. The National Nursing Home Survey used a six point ADL scale, while the Health Interview Survey used a five point scale, so comparable levels of dependency can only be approximated. Eligible residents include individuals 18 years or older with severe and persistent emotional or mental disorders which limit their functional capacities, but could be improved by more suitable housing conditions. When these elderly were asked if someone were available if they were sick or disabled, 87% answered "yes". In 1961 a Below Market Interest Rate subsidy program was added to this section, but was dropped during the housing moratorium in 1973. The program has 463 projects with about 63,000 units, but has fallen into disuse because sponsors prefer other forms of mortgage assistance. Without help from family, friends, or formal community services, many people at Level III would be unable to maintain an independent household. The quality of long-term care institutions continues to be problemmatic. In the absence of clearly defined goals and well-understood means of achieving them, it is difficult for institutions, largely staffed by semi-skilled workers, to evaluate successes and failures and to "improve. " For example, money spent on nursing home care pays for food and housing as well as nursing. The HSA and the SHCC provide a forum to discuss and design health care policy. TABLE III. 2 percent in 1970. However, as the cost of Medicaid rapidly escalated, it was asserted that many of the publicly-supported patients in SNFs required fewer professional services. To broaden the types of facilities eligible for reimbursement in states participating in Medicaid, vendor payments for a lower skilled level of care within intermediate care facilities (ICF) were initiated in 1967 under Title XI of the Social Security Act. As of July 1980, minimum guaranteed incomes under SSI are $238 a month for an individual and $357 a month for a couple, assuming SSI program requirements are met. MEDICARE DEADLINE AMENDMENTS (P. 68 The studies are commonly faulted on several grounds: patient characteristics or outcome measures are not controlled; sampling methods were thought to be inadequate; samples were too small; cost data were not sufficiently detailed; patients were followed for too short a time; questions of objectivity were raised by provider involvement in the evaluations. Of these, 4 now mandate a clerkship in geriatric medicine or psychiatry and an additional 4 include geriatrics as part of a major clinical clerkship. If the trends shown in the 1979 CON and 1122 review information continue, high bed States may become less overbedded while low bed States gain beds. One of the most difficult research questions is the extent to which the availability of formal support services retards institutionalization without destroying the fabric of the informal support network and its willingness to provide care. This has led to the conclusion that public efforts represent an "over-medicalization" of long-term care. By contrast, nearly all registered nurses in hospitals had paid vacations, health insurance and retirement and most had shift differential pay and paid overtime. Since the Department of Health and Human Services already had underway two planning efforts focusing particularly on the chronically mentally ill and the mentally retarded, the Task Force has not initiated separate analyses pertaining to these subgroups. 24 Quality of care objectives are more difficult to achieve than custodial goals because there is no well defined technology for either producing or evaluating quality care in long-term care settings. (See Appendix 3-B for a description of federal housing programs, some of which include services for the disabled). TABLE II. Creative solutions to providing and financing long-term care must be developed, which acknowledge the desire of people to be independent and productive for as long as possible. Our discussion of cost will be divided into two parts: (1) the comparison of particular services and settings; e. Two recent reports have recommended that the focus of long-term care service delivery should center around those who are 75 and over, the so-called "frail elderly. The Medicaid utilization control program additionally calls for a periodic medical review (MR) team in skilled nursing facilities and an independent professional review (IPR) team in intermediate care facilities to survey a facility at least annually. Developed as part of the 1975 amendments to the Social Security Act, Title XX consolidates funding for social service programs from various titles within the Social Security Act. Individual program service definitions, design of benefits, and interrelationships between eligibility requirements, all have implications for the appropriateness of services to individuals and cost-effectiveness of a long-term care system. B. Thus, nursing homes are currently an important source of personal care services for people without families able or willing to provide these services, without the financial resources to purchase them in the community, or with personal care requirements which might be most efficiently provided in an institutional setting. It is true that there are differences between salaries and benefits in hospitals and nursing homes. The philosophy of long-term care increasingly has been shifting from institutional and custodial management of patients to an emphasis on the care of patients in their homes. 9 percent of the total). WORKING PAPER #4: PROGRAMS AND FINANCING FOR LONG-TERM CARE SERVICES A. While planning itself is not explicitly mentioned, the literature suggests two alternative theories of the impact of CON. These different eligibility criteria reflect basic strategies and purposes inherent in the various Federal programs. Public almshouses -- by that name at least -- have disappeared. As a consequence of such disparities, an individual who is eligible for long-term care social services under Title XX may not qualify for long-term care health benefits under Medicaid. In addition, there are supplemental income programs such as Disability Insurance (DI) and Supplemental Security Income (SSI) which provide income to people too disabled to work and to the very low income elderly. The total supply of congregate housing facilities is not known. TABLE I: Number (Percent) of People at Different "Levels" of Disability Due to Chronic ConditionsNational Health Interview Survey (NCHS), 1977 Non-Institutional Population 1 LEVEL III: (3. S. Mile federal regulations define the basic tenets and minimum requirements of acceptable CON programs, each state has developed a unique program. We do know that family and friends provide most of the basic help: A GAO study of services for the elderly in Cleveland (1977 preliminary report) showed that 23 percent of the sample were assessed as impaired. After more than fifteen years of direct federal efforts to upgrade nursing homes -- largely through a process of standards, certification, and inspections -- some progress has been made in the provision of clean and safe physical environments. As we discussed informal and formal power within our organization she felt that her management skills are built on informal power, her definition of informal power is transparent and how imperative it is to be successful as a team and collaborate with each other’s to meet at one common goal. TABLE IV. Direct services provided under the Act are, in-home services, congregate meals, residential repair and renovation, legal services, transportation, information and referral, escort and outreach services. Butler, Lewis H. The SSI program replaced and consolidated earlier Federal matching grant adult assistance programs. The report of that survey, which found that conditions varied considerably but that the worst were found in large public almshouses, directly contributed to the decision to prohibit Social Security payments to inmates of public institutions. 9 million people) have levels of functional disability so high that they require direct personal assistance in performing even the most basic activities of daily living. Section 502 provides direct loans to rural low and moderate income families for construction, rehabilitation, repairs or the purchase of existing housing. There were very few projects in rural areas because of a lack of qualified sponsors and high rents relative to median income. Alcohol and drug addicts are not included. I would consider this CNO a mentor, she is a teacher, supporter, coach, facilitator, assessor, and role model to our nursing team. Congregate Housing is an assisted independent group living environment that offers the elderly who are functionally impaired or socially deprived, but otherwise in good health, the residential accommodations and supporting services they need to maintain or return to a semi-independent life style and prevent premature or unnecessary institutionalization as they grow older. The rents required under this program, even with the interest subsidy, would be more than 25 percent of income for most elderly renters, so Congress in 1974 authorized special rental assistance payments. Overall, it is expected that the percentage of persons with activity limitation due to chronic conditions will increase by 13 to 23 per cent by 1990 (the growth rates depend on different mortality assumptions). In fact, discussions of the financing problems in long-term care frequently center on the inability of current programs, as they are presently organized, to meet the particular needs of individuals with chronic disabilities. Funding for nursing home services incorporated many of the features of the Kerr-Mills program. Only about one-third of this group are currently in institutions and the remainder are able to remain outside of institutions because services are provided by an informal network of family and friends. A major focus of the program is the planning and coordination of services, including health, housing, labor, transportation, and social services. A definition of the skilled nursing services benefit was not included in the original Medicaid legislation. TABLE I. Introduction Other Working Papers in this series deal with separate elements of the long-term care "system". Subsequent legislative action has further refined the definition of skilled and intermediate levels of care and the conditions under which these services should be offered. We know very little about how most such people manage -- particularly those who never come to the attention of social service agencies -- though such information term paper on nursing would be enormously useful. In order to promote more new construction in rural areas, the Section 8 program is being coordinated with the Farmers Home Administration's Section 515 program (see discussion below). Debate has centered around expanding the role of one or the other method for financing particular services or services delivered in particular settings. National and State level data on CON and 1122 programs provide further evidence of this. As can be seen from Figure II, the "old-old" remained a relatively constant proportion of the elderly population until 1940. Scientific advances are certain to have an impact, though in ways which are unpredictable. If the proportions of the long-term care population cared for in various settings remain constant, roughly a third of this projected increase would occur within the institutionalized population, with 2. 9%) need help in going to the toilet, and 0. S. Health Planning Activities Related to Long-Term Care Their legislative mandate requires HSAs and SHPDAs to plan for and regulate long-term care services as well as other facets of the health care system. The advocacy role of the planning agencies is more amorphous than their regulatory responsibilities. 10 Similarly, national surveys indicate that nursing have residents see physicians an average of seven times a year -- only slightly more than the non-institutionalized elderly. The Cost of Different Long-Term Care Services and Settings The previous section considered issues of supply independently of issues of costs. Background: The Health Planning Network P. A related way to regulate service supply is provided by Section 1122 of the Social Security Act. In 55 of the 61 schools, elective courses are offered; most of then are clinical clerkships of one kind or another. The loan can be combined with a grant for an applicant 62 years old or more with insufficient income to repay the full cost of the needed repair. As of July 1980 all States except Louisiana have some type of CON legislation. As healthcare providers must comply with federal and state laws, they have to operate a complex regulatory environment in which federal health care laws intersect, and often overlap with, a variety of state-specific legislation, including state health regulations, insurance laws, antitrust laws, consumer protection laws, and other statutes (Weil, 2007). For example, the variability in income standards employed by different states for Medicaid demonstrates that there is no clear consensus on the level of income below which public assistance should be provided. Created the Supplemental Security Income (SSI) program to provide cash assistance to the aged, blind and disabled. It is logical to conclude that the factor most responsible for this has been the large sums of public money available under Medicaid for this particular type of group facility. In the field of medicine, there has already been some movement toward incorporating geriatrics into medical school curricula, according to the Rand study on geriatrics. Furthermore, the distribution of beds within an area, may be as important as term paper on nursing the supply of beds and cannot be analyzed with these data. Supplementing the basic level of care raises the costs of alternatives, and increases are particularly dramatic when the basic service of the nursing home (24 hour surveillance) is needed. Poor data and rudimentary analytical methods limit our understanding of long-term care to isolated segments of the system and to short time periods. Costs of Services in Different Settings In addition to the service characteristics of most nursing homes (hotel services, food services, nursing services, personal care services, patient activities, medical treatment, and physical and occupational therapy), additional services (checking, transportation, respite care) might be needed to provide comparable care in alternative settings. Family and friends provide equivalent services of $673 per month and agencies supply an additional $172 for a total of $845. "Congregate" housing is both a programmatic and a generic term. 5 or 9 million by 1990. Further, while the fastest growing segment was in non-medical private nursing homes, public facilities with nursing grew faster than public facilities without nursing. Also, the need for congregate housing cannot be estimated with any degree of precision. It is even more difficult to assign a dollar figure to total private spending for LTC than to public support, for two reasons: existing data collection systems are oriented towards Federal and State programs rather than private sources and a significant source of long-term care is services provided to disabled individuals by friends and family, the costs of which are usually hidden because they are not translated into money transactions. " by the Metropolitan Council of Saint Paul, Minnesota and "Making Choices: Guidebook to Long-Term Care Facilities and Home Health Services" by the Illinois Central Health System Agency. The characteristics of the population to be considered, the services which should be included, the overlap between services and settings, the definition of need, and the assessment of the extent to which it is currently being met have all been dealt with in fundamentally different ways at different times. The types of services to be addressed, capital limit or other review threshold, specific review criteria, appeals procedures, and penalties vary from State to State. It is argued that most families institutionalize relatives reluctantly term paper on nursing as a last resort and only after considerable personal sacrifice, and after various alternative solutions have been attempted. The Institutional Population: The analysis of unpublished data from the Health Interview Survey allowed the Task Force to examine the relationship between ADL dependency and institutionalization on a national scale. " As a consequence, the spectrum of non-medical settings available to the elderly has narrowed. As can be seen, there was a 105% increase in the elderly nursing home population, swelled with elderly people both discharged and diverted from state institutions. , is home health a cost-effective alternative to nursing homes; and (2) the impact on total LTC systems costs of expanding services and settings. Distribution of Nursing Home Beds by Type of Care The growth of nursing homes may also be affected by another Federal program, the National Health Planning and Resources Development Act of 1974, which provides for a national network of state and local planning agencies which can influence the supply of institutional health services through regulation of capital expenditures. The congregate housing concept emphasizes maximum independence through supportive services; more traditional forms emphasize the protective care of sheltered group living. Eligibility for Medicaid begins when the individual in paying for medical expenses has spent down to the State's income eligibility level. Without 1122 approval, Medicare reimbursement for the institution is cut to exclude the costs of capital involved in the specific project. In order to understand recent trends in institutional supply and use, it is useful to consider their development from a longer historical perspective. This is the Rand study on Geriatrics in the United States: Manpower Projections and Training Considerations (May 1980). Nursing homes, congregate homes, and shall group or domiciliary care homes provide the settings for the provision of supportive services when the family support mechanism collapses. These critics argue that nursing home residents are as isolated from high quality medical care as they are from community social life. In 1977, 41% of the non-institutionalized functionally disabled had incomes less than $6,000; 46% of the functionally disabled age 65 and older had incomes less than $6,000. 5 In 1977, a national probability sample revealed that the primary caretaker of the bedfast elderly was the spouse: 38% of the housework was done by spouse, 44% of the meal preparation, and 30% of the shopping. At the basic level of care, the estimates range from $13. C. Personal Care Services The Non-Institutional Population: About 1. 53 Not only is it home, but family members act as the primary help sources, regardless of the disability. Health care has been a hot topic in the news for several years. L. In these situations, Medicaid pays the difference between the individuals' available income and the cost of nursing home care. Approximately 4% of the elderly living outside of institutions (approximately 0. Manard, Barbara B. Because benefit payments under these programs were forbidden to "inmates of public institutions," a pattern was established under which beneficiaries of public funding programs purchased services primarily from private providers. 2 percent of registered nurses in nursing homes in 1977 had paid vacations and sick leave, only 11 percent had retirement programs, and only 10. The category "skilled nursing facility" was devised to provide a somewhat lower level of care at lower costs for long term convalescent and terminal patients. Although most of the disabled live with others, who can help them, some 20% live alone and therefore must make arrangements to secure services -- services which are often accessible only in institutional settings. There were few minority group sponsors. 94-182) Required skilled nursing facilities participating in the Medicare and Medicaid program to meet the 1973 Life Safety Code as opposed to the 1967 Life Safety Code. In addition to these 8, term paper on nursing another 21 intersperse didactic material in geriatrics or gerontology through the pre-clinical and clinical years as part of other courses. People who are too poor to purchase adequate services and whose family and friends are unable to help sufficiently find it difficult to maintain an independent existence in the community. Studies based on more recent data, including the previously unpublished data in this paper, indicate that the degree of inappropriate nursing have use is probably lower than had been thought. Table II presents estimates from the National Health Interview Survey of those who are limited in their major activity (Level II) because of such conditions. Their planning responsibilities require agencies to identify major problems of health status and the health system, goals and objectives to correct these problems, and strategies to implement the goals. " Staff Recruitment and Retention: One personnel issue of particular concern is the difficulty experienced by nursing homes in attracting and keeping staff. 5 to 3 million persons in these facilities by 1990 (provided there is a commensurate increase in the supply of institutional beds). While the actual review processes for 1122 and CON vary from State to State, in most States the HSA does the initial review and develops recommendations. , "Cost Issues in Home Health Care," in Marie Callender and Judy LaVor, Home Health Development, Problems, and Potential, Washington: Disability and Long-Term Care Study, Office of the Assistant Secretary for Planning Evaluation, Department of Health, Education and Welfare, April, 1975, pp. The Proportion of the Elderly in Institutions: Figure I shows the proportion of the elderly enumerated in institutions and group quarters on the day of the Census from 1890 to 1970. There has been little development of congregate facilities under this program because: Section 221(d)(3): This program operated from 1954 until 1968 and provided mortgage insurance for nonprofit, cooperative and limited dividend sponsors to develop multifamily rental projects for low and moderate income families. A relatively early study of nursing homes in three states found that few facilities provided more than personal care services. Loan terms include: an interest subsidy which can reduce the effective interest rate of 1 percent for nonprofit sponsors, the regular FmHA interest rate for profit-oriented sponsors, and a repayment period of 40 years or 50 years for projects specially designed for the elderly. It is officially defined in federal legislation as "low income housing which has an available central dining facility where meals can be served to residents. On the other hand, measurement of "appropriateness" of placement is still in the early stages of development, and is highly subjective; there are many determinants of nursing home need and use other than functional disability which are not captured by existing assessment methods. Their responsibilities can be grouped in three categories: planning, advocacy, and regulation. Evidence does appear to indicate that the choices of living arrangements available to the elderly have narrowed in the past 50 years. Even if the formal service were proven to be much more cost-effective than an equivalent volume of services provided by family and friends, these potential financing shifts might make the change undesirable. A total of thirty projects supported the construction, addition or modernization of 2,992 long-term care beds, either in free-standing nursing homes or in long-term care facilities attached to general hospitals. Considerable problems remain in the assurance of quality care, regardless of setting. Further, different settings may alter the requirement for services, thereby altering the cost of services for similarly affected individuals. Because the underlying mechanisms of chronic disease are so poorly understood, medical management involves what Lewis Thomas calls a "halfway technology". Some evidence can be cited in support of those conclusions. Expenditures for Nursing Home Care (millions of dollars) Growth in public expenditures has occurred both because of an increase in the number of persons receiving benefits under public programs, and because of increases in payments per recipient. Generally the financing is for multifamily units and may include appropriate recreational and service facilities. Early HUD evaluation data show nearly 90 percent of funds for Section 8 existing housing has gone to the elderly. D. APPENDIX 1-A. " Finally, the extent to which the patterns of expenditure are appropriate is difficult to judge without more detailed analyses of population needs and service effectiveness. BLS felt that no reliable supply estimates could be made for those occupations for which on-the-job training provides many of the entrants such as nurse aides and other support personnel. Cross-Cutting Issues Personnel Very little change is expected in the occupational distribution of nursing home industry employment between 1976 and 1985. The increasing importance of these settings in long-term care has been recognized and plans for future national surveys address the problem of obtaining more accurate data. Further, without a more specific delineation of the services which should be considered long-term care, financing issues are not easily addressed in a comprehensive manner. What we do not yet know is exactly where the breakeven point occurs, and how to determine for which individuals and subpopulations which particular services and settings are cost-effective. 93-641. L. Number and Percent of Non-Institutionalized Chronically Ill and Functionally Dependent* According to Levels of Dependence for Activities of Daily Living by AgeUnited States, 1977 The therapeutic goals and types of health services interventions required to manage chronic illness are different from those appropriate for acute illnesses; even the management of acute episodes of illness differs for patients with chronic diseases since their recovery from the acute problem means return to the chronic illness and not full health. Medicaid law specifies a utilization control (UC) program to assure quality care. These Working Papers describe the current state of knowledge about long-term care in the United States, and serve as a knowledge base for the difficult analytic tasks that lie ahead. It is important to note that both surveys are incomplete. It has been argued that the development of respite care, adult day care, and similar services may relieve some stress on families of the disabled and enhance their ability and willingness to continue caring for the aged and dependent. Consequently, useful information in this area is rare. The Core Population The National Plan for the Chronically Mentally Ill defines the chronically mentally ill population as encompassing: "those persons who suffer certain mental or emotional disorders that erode or prevent the development of their functional capacities in relation to three or more of such primary aspects of daily life as personal hygiene and self-care, self-direction, interpersonal relationships, social transactions, learning and recreation and that erode or prevent the development of their economic self-sufficiency. The purpose of the grant is to support a project director at each site who will seek community support for necessary services and to ensure their continuation beyond the grant period, provide outreach to the community, and help match the project design with the housing and service needs of the local elderly. 8 percent for those under 65 ( Appendix 2-A). Included in this group are those who may require such basic living services as transportation, help with meal preparation, and chore services. One study concluded that the most important effect has been the "standardization" of facilities, which has an uncertain effect on quality. Numerous staff of the Department were responsible for much of the data, analysis, and documents on which these papers were based. The other challenge that she mentioned was the trials and tribulations of keeping the doors open to the hospital, it’s been a learning experience for all of us to open the doors to a brand new hospital last year. On one hand, it may become possible to prevent or cure certain chronic conditions and hence reduce the number needing long-term care, as did the conquest of polio. Exceptions were Florida agencies which stressed the need to control the number of home health care agencies as these agencies have proliferated in the past few years. 1%) need help in eating. The Adequacy of Settings Loss of care-givers, reduction in the capacity of a care-giver, rapid depletion of income and other family resources, and physical and mental deterioration of the disabled person weaken the ability of the family to continue as the primary setting in which the disabled receive long-term care services. NOTES The estimate in the National Plan of the noninstitutionalized population with chronic mental illness was obtained from the 1973 Comprehensive Needs Survey done by the Urban Institute and from the 1966 Survey of Disabled Adults done by the Social Security Administration. 46 Given current data, however, it is not possible to determine the full extent to which appropriate levels of long-term care services utilization have been reduced by present eligibility standards. This decline is expected to be accompanied by an increase in the total percentage of clerical workers required for the detailed paperwork required by the growing amount of government reimbursement. 59 Certificate of Need (CON) laws, first enacted in New York in 1964, require state approval for large capital expenditures or significant changes in institutional health services. Expansion of the scope of Federal responsibility for the aged and disabled dates from the establishment of Federal matching grants to the States for Old Age Assistance and Aid to the Blind in Titles I and X, respectively, of the Social Security Act of 1935. One of the most reliable studies to date on the unmet needs for social services of the non-institutionalized elderly indicates that the great majority of the elderly feel their needs for assistance in basic activities are being met. The Impact of Planning on Nursing Home Supply Aggregate information on plans and CON or 1122 decisions is difficult to interpret. " This appears to have encouraged the pattern observed in Table III. ) Another significant revision in 1978 set aside $50 million for Section 202 housing for non-elderly handicapped individuals. TABLE II: Estimates of the Prevalence of Physical Handicapping Conditions Resulting in Limitation of Major Acivity (Level II)National Health Interview Survey (NCHS), 1978 The aging of the U. Not all OASI beneficiaries, however, are disabled by chronic conditions. While the majority of nursing have patients initially use private funds, a substantial proportion convert to public sources of payment after exhausting personal resources during the first year. Congregate Housing Program HUD's Congregate Housing Services Programs: In 1978 Congress recognized the limitations in HUD's bricks and mortar approach to meeting the housing needs of the elderly and the lack of coordination between the housing programs and essential social services. L. There were six direct loans totalling $5,355,000 for 317 beds. 1 B. Available studies seem to indicate that for slightly impaired people, alternatives are more economical than nursing homes; for severely impaired people the opposite is true. Most states fund services which are similar to those provided under Medicare, although specific criteria for service eligibility are slightly broader. WORKING PAPER #5: DYNAMICS OF THE CURRENT SYSTEM A. Death rates were reduced slightly but dependency, contentment, and mental and social functioning were only minimally affected. She delegates and gives responsibility, accountability, and feedback regarding their performances. Further, the entire federal share of Title XX, including the costs of all social programs, was only about half of the federal share of nursing home costs in the same year. For example, a paraplegic may need help with bathing or dressing (Level IV), and may yet report no need for help getting around the house (Level III) because special aids, devices, and architectural features transform the environment, reducing the functional importance of a physical disability. As the data are reviewed in the following sections, two important caveats should be kept in mind: People who are more disabled in some sense than others may need fewer services, depending on a variety of factors. Current data do not permit classification of these populations by the levels of functional disability (Level II, III, etc. Escalating program costs, anticipated growth in the number of the aged and disabled, and increasing awareness of unsatisfactory aspects of the current system prompted Secretary Patricia Roberts Harris to establish the 1980 Task Force on long-term care. Moreover, the problem of finding a bed for particular subpopulations such as Medicaid clients is often severe, creating a particular problem for the Department even if analysis concludes there is not a general shortage of beds. Program funds went almost exclusively to urban areas. S. Meals, for example, can be delivered to community residences or can be provided in congregate dining facilities. Categories of States According to Level of Nursing Home Beds The analysis, summarized in Table 2, revealed that States with high bed-population ratios seem to set different types of long-term care goals and approve different levels of beds than States with low ratios. Different levels of beds are applied for in States with varying bed supplies. One problem is that the indirect use of public dollars provided through the Social Security program for long-term care services in institutional or community settings cannot be calculated. For example, total federal expenditures specifically allocated for nursing home care were over ten times the expenditures specifically allocated for have health in 1978. A recent California study found that the turnover rate among nursing home personnel exceeded 100 percent. National perspective on this issue is not very useful for policy purposes. " Contact with any staff member filled only 10% of the residents' time -- about half of this was personal care services. The income disparity is far more pronounced for the working age disabled than for the elderly, as would be expected, though the aged are more likely to be both disabled and poor. Old age, poverty, and chronic illness can be, quite literally, a deadly combination. Agency actions should be considered in relation to other parts of the health care system, the supply of acute care alternative types of long-term care services, reimbursement policies practices, and the political and economic environment. Specific services provided include inpatient care, skilled and intermediate nursing care, psychiatric services, domiciliary care, social services and rehabilitation. L. Long-term care institutions have been expected to rehabilitate the chronically ill, shelter the homeless, entertain the bored, and provide for the total psychosocial needs of people living and dying among strangers. One recent study focuses strictly on projecting the need for physician personnel to provide care for the elderly over the next 50 years. Brenda Thorne typed the several drafts and was assisted by Jewell Griffin. The majority of plans urged increased availability of home health services including, in some cases, more flexible reimbursement for these services. 25 The problems which remain with quality assurance in institutional settings are sure to be compounded as long-term care services are expanded in the community. TABLE A5-I. The program operates as a grant-in-aid program under which states are able to provide a range of social services to population groups determined to be eligible under federal and state criteria. For example, since Medicare requires that have health agencies provide skilled nursing care and at least one other therapeutic service, home health agencies in certain rural areas which are not able to recruit specialized personnel are not able to receive Medicare funding. On the other hand, analysts who look at demand for nursing have beds conclude that there is a shortage. However, public policy must also take into account costs, and consider whether services and settings are cost-effective while meeting needs or satisfying demand. 93-641 created a national network for the planning and regulation of the health care system. It is clear that, presently, we are less equipped than is desirable to capture the simultaneous interactions among all facets of long-term care and the dynamics of the long-term care system as a whole. Most projects include design features to meet the special needs of the elderly, but do not accommodate the handicapped. 55 Nursing homes today are the principal type of institution providing shelter and long-term care to the chronically ill and functionally dependent. Limited home health services were also made available under Medicare for posthospital homebound patients. Both conditions, of course, may exist at the same time: Individuals may demand care who do not need it because of the lack of alternatives, or because of incentives to enter an institution owing to distorted price signals obtained from the public reimbursement mechanism. Working Paper #2: The Population Approximately 30 million people or more than 13% of the total U. Some states have also begun to reform their policies in this area. From 1956-1976, the Hill Burton programs contributed $209,708,178 in grants for 606 nursing home projects which provided 43,120 beds. " As can be seen in Table III, while the elderly population in facilities "known to have nursing care" increased by 49%, that in other facilities increased by 150%. These architectural design features distinguish current views of congregate housing from the older domiciliary care concept as much as does the emphasis on a service package which promotes independence rather than mere protection of chronically impaired residents. Training and Evaluation: The Federal government supports a variety of programs which train long-term care personnel. 14 Most people with functional dependencies due to chronic illness live "in the community. Problems are also encountered when the concept of major activity limitation is applied to the elderly since most of them are likely to be retired. The states set the income standards used for eligibility determinations. For newly constructed or rehabilitated units for the elderly an extra 5 percent above the established fair market rent is granted to the owner. State social service agencies select appropriate residents. There is no legislative definition of home health services in the Medicaid legislation. At each Census since 1950, there has been over a 50% increase in the oldest segment, compared to the previous decades' population. The characteristic which makes institutional life objectionable to so many is not the intensity of available services nor neccessarily the size of a facility, nor the fact that many people live in the same building. Title XIX and Title XX Comparison of Income Eligibility Levels (as of January 1979)* In some cases, the fact that some are eligible for public funding for certain services and not for others may present no difficulties because these individuals may be able to pay for services on their own. Chronic Conditions, Functional Disability, and Service Requirements Chronic conditions are defined as those in which nonreversible pathological alterations or congenital deficits cause residual disability which requires habilitation or rehabilitation, supervision and care over a long period of time. Need for State Level Analysis The lack of up-to-date information on nursing home beds, discussed in detail in Working Paper #5, coupled with the scarcity of information on CON and 1122 decisions, influenced the scope of the analysis. Long-Term Care System Analysis A major problem which has confronted this Department and others in developing policy recommendations in long-term care has been the absence of a consistent and generally accepted definition of the issue. Based on more recent data, the Rand study concludes that: "...