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The 2000 U.S. census found that almost 10 million older Americans living in the community need help with activities of daily living (ADLs). In general, about two thirds of people who receive long-term care live in the community, while the other third live in an institutional setting. This means that for every older person living in a nursing home, there are two older people living in the community who may need equal levels of assistance. Most older adults living in the community live in a family setting. A wide range of resources is available to individuals in the community. These resources address many concerns, which can be needed for the short- or long-term. Forms of payment vary–some are supported by insurance (including Medicare and Medicaid), but many are available only by using personal finances.
Home Care For a large number of older adults, home care has the potential to improve quality of life and to prevent or delay having to move into an institution. The number of people receiving home-care grew rapidly in the 1980s and 1990s, because of changes in healthcare financing that favored discharging patients sooner from hospitals. New technologies also created the possibility of providing treatments in the home that used to be available only in hospitals or nursing homes. However, these changes resulted in a huge increase in costs for home care, and Congress set limits on Medicare spending in the late 1990s. The result was decreased payments for home-care services, followed by a 20% decrease in both the number of people receiving home-care services and the number of home-care visits per person. Hundreds of home-care agencies could not adjust and closed because of financial pressures. Rural agencies closed at a higher rate than urban ones. Like other parts of our health care system, home-care agencies now have to develop ways to continue to provide high-quality care despite less reimbursement. Another major challenge facing home-care agencies is recruiting and retaining qualified nurses and aides. The physician’s role in home care Your physician is the center of an interdisciplinary health care team that may include nurses, therapists (eg, speech, physical, occupational, and respiratory), social workers, personal care aides, home medical equipment suppliers, and most importantly, informal caregivers (eg, family members). Although all team members are important, the physician is legally responsible for determining the older person’s health care needs. Physicians also develop, certify, and recertify the plan of care. Physicians should talk regularly with other team members to discuss patient care issues and to handle documentation and other administrative matters. Documentation and administration is especially important given changes in health care financing rules. These changes make it even more critical for the physician to certify the services needed and to ensure that the appropriate quantity and quality of services are being provided. Physicians should also be sensitive to potential conflicts of interest. Specifically, federal legislation prohibits physicians from receiving financial benefit, compensation, or rebate for referring a patient to a home-care provider. Further, physicians may not refer patients to home-care companies in which the physician or the physician’s family has a financial interest of 5% or more. Current regulations allow physicians, nurse practitioners, and physician assistants to provide house call services. House calls can add to the health care provider’s knowledge of the circumstances and home environment of the older person, and may allow them to identify and address problems that cannot be seen during an office visit. For example, there may be barriers (eg, cluttered hallways, no railings) that prevent the older person from functioning as well as he or she could. A home visit may also reveal caregiver burnout, elder mistreatment, or the use of additional medications that may be interfering with management or treatment of the disease. House calls also benefit older adults who may have difficulty getting around outside of the home because they do not have to travel. Changes in Medicare have increased payments for home visits, making homecare more affordable. There are no specific restrictions on the number of home visits, as long as sufficient justification is documented. Who should have home-based health care? To qualify for Medicare home-care benefits, a person must prove their homebound status. Eligibility for benefits depends on whether the person fits the following description:
House calls are especially useful for patients who have one or more of the following characteristics:
House calls are needed for some patients for a limited amount of time, but others require house visits on an ongoing basis. Home assessment Homebound patients often have health problems or disabilities in one or more areas of their health and functioning. Comprehensive geriatric assessment is particularly valuable in this situation (see Assessment). A comprehensive assessment can be used to establish the initial level of health and functioning, monitor the course of illness, and evaluate effects of treatments. Also, assessment in the home has some important advantages over office-based assessment. Advantages of Home Assessment:
In many respects, family caregivers are the most important part of the homecare team. They provide most of the care received by older adults living in the community. In the United States, three out of four caregivers are women, usually wives or daughters. Care giving is often intense, time consuming, and stressful. The physical and emotional health of the caregiver may be affected, resulting in depression and a worsening of his or her own health problems. Attention to caregiver support and issues are therefore vital to making sure that older adults continue to receive care. Caregiver support groups may be particularly helpful. For discussions of specific issues concerning care giving, see Psychological and Social Issues,Problems with Thinking, Understanding, and Remembering, Elder Mistreatment, and Depression. Limitations of home care Most older adults prefer to remain in their own home. However, situations and conditions may come up that make institutional care more appropriate. For example, caregivers may not be available to adequately address the needs of the older person. Similarly, caregiver burnout and stress may prevent continued safe care for the older person in the home. Some serious medical situations that require frequent laboratory testing, respiratory treatments, or intravenous medications also may make institutional care a better choice than home care. In some cases, the home environment itself may be a barrier to continuing home care. Unsafe neighborhoods, household disruptions from alcohol or drug use, and inadequate room for equipment or environmental modifications may make home care a poor or risky option. Finally, home care is not always the least expensive choice, and out-of-pocket expenses may make ongoing home care unaffordable. Insurance coverage is more likely to cover care that is given in a nursing facility or other institutional setting. Ethics and decisions about institutionalization While it is quite natural for people to want to remain at home, conflict arises when a person (or their caregiver) insists on remaining at home even though medical care or personal safety is less than it should be. Caregivers and healthcare providers alike often find it difficult to balance respect for personal choice and independence with the need to prevent substandard care. It is important for healthcare providers, patients, and caregivers to discuss these issues openly and to explore all the options available. It may be that some type of assisted-living arrangement can allow the older adult to have some independence and privacy, while ensuring safety and high-quality care. For terminal conditions, a hospice referral may help provide both additional services in the home and support for both the patient and family. Community-based Services A variety of health care options let people stay at home, while still providing important healthcare support. Adult day care Adult day care is a community-based option that has become more common. It provides a wide range of social and support services in a group setting. Most adult day care centers are either in churches or community centers. Adult day care is commonly used to care for people who need supervision and assistance with activities of daily living (eg, patients with dementia) while primary caregivers are at work. It may also serve as a form of respite for caregivers. Providers of adult day care may offer a variety of services, ranging from simple non-skilled custodial care to more advanced skilled services. For example, a registered nurse may be available for on-site health services, clinical assessment and monitoring, and assistance with medication management. In general, custodial adult day care is not covered by Medicare, although some costs may be covered by Medicaid or other insurers. Day hospitals Day hospitals provide a broad range of skilled-nursing services, including injections, chemotherapy, and intensive rehabilitation. Most day hospital programs are housed in chronic-care hospitals or rehabilitation centers. This allows the health care provider to take advantage of in-house professional expertise and resources, while allowing the patient to return home for the evening. Services are covered under Medicare, with requirements similar to those of home health care. Day hospitals are most often used for two groups of patients: those needing rehabilitation in multiple areas and those with psychiatric illnesses. A systematic review of day-hospital care found that day hospitals compared favorably with other sources of care for many traditional health outcomes (eg, death, disability, etc.). In fact, those receiving care in day hospitals tend to have less functional decline and less hospital and institutional care. Program of all-inclusive care for the elderly (PACE) The Program of All-inclusive Care for the Elderly (PACE) is a relatively new program that pools funds from Medicare and Medicaid (in participating states) to provide acute and long-term care to frail older people. (See also Insurance, Financing, and Costs of Health Care.) This coordinated financing allows PACE to provide traditional coverage of acute, rehabilitative, home, and institutional care. However, participants in the PACE program must meet state-defined requirements regarding their need for a nursing-home level of care. As of November 2004, there were 29 PACE programs in 17 states. Fifty more PACE programs are in various stages of development, and it is thought that the program will continue to expand. The goal of PACE is to keep participants in the community for as long as it is medically, socially, and financially feasible. The system uses a team of health care providers who know the patient and caregivers well and who can provide complete care whether the patient is at home or in the hospital, an alternative living situation, or an institution. It also allows for adult day care, respite care, transportation, medication coverage, rehabilitation (including maintenance physical and occupational therapy), hearing aids, eyeglasses, and a variety of other benefits. The program also has the flexibility to pay for non-medical costs in unusual circumstances (eg, paying a person’s electric or gas bill). Care by the health care team provides for the complex social needs as well as the medical needs of older adults. The PACE system has been described as one of the few truly integrated systems of care in the United States. Although the effectiveness of PACE has not been directly tested by a scientific trial, PACE appears to provide high-quality care, albeit with significant site-to-site variation. Telemedicine Telemedicine involves the transmission of medical data, so that a health care provider can receive needed information to evaluate and make decisions regarding the patient’s health care. Telemedicine systems vary considerably. Some are relatively specific for particular diseases, such as automated blood pressure cuffs and heart rate monitors for people who have congestive heart failure. More elaborate telemedicine systems are set up for audio and video two-way communication. These include distance electrocardiography; on-site stethoscopes that can transmit breath, heart, and abdominal sounds; and camera lenses that allow for detailed examination of the skin and eyes. Telemedicine has particular applicability in rural settings or other areas where access to physicians and other health care providers is often limited. Unfortunately, the growth in telemedicine has not kept up with electronic technology, which has become more available and more affordable. Although telemedicine has been used successfully in radiology (ie, x-rays), it has not been used much in other areas of medicine. Telemedicine has been used in health care programs in some prisons and mental health centers. Some home-health agencies are beginning to use telemedicine for patient monitoring, primarily because of changes in health care financing that provide financial incentives for limiting the number of patient visits. Costs for telemedicine systems vary considerably, from approximately $1500 for simple systems to up to $20,000 or more. These systems are likely to become more affordable and useful in the future, especially as broadband allows for quicker, cheaper data transmission. Telemedicine is sometimes reimbursable by Medicare in rural areas, and some states provide coverage through Medicaid. Home hospitals The home hospital focuses on providing more complex care at home to people who would otherwise have to be hospitalized for a sudden problem. Patients receiving home-hospital care have access to nurses and physicians on a regular basis, and access to an on-call system that allows a flare up to be addressed promptly. Studies conducted outside of the United States suggest that care is comparable for selected patients. and that patient satisfaction is high. Community-based Services Requiring a Change of Residence Other community-based programs require older adults to move from their current home to an alternative one (eg, assisted-living arrangement). However, the goal is still to protect independence and privacy for as long as possible. Assisted living There has been tremendous growth in the number of assisted-living facilities (ALFs) during the late 1990s. State governments regulate and monitor ALFs, which have a variety of names, including adult care, residential care, and assistive living facilities. More than 500,000 people live in ALFs, and this number is expected to grow rapidly as our population ages. Even though these facilities are based on a social (not medical) model, they are caring for more frail people with significant medical needs. ALFs often provide home-health skilled care. The boundary between ALFs and skilled nursing facilities often becomes blurred. Older adults have a variety of choices in ALFs, ranging from smaller, simple home-like environments, to larger, more elaborate (and even luxurious) accommodations. This tremendous variability in types of ALFs allows people to choose a home that best suits their needs, tastes, and financial situation. Special-care units that focus on Alzheimer’s disease and other forms of dementia are also becoming more common. ALFs are required to provide a variety of services, including the following:
Other services vary considerably from state to state. For example, depending on licensing requirements, medication administration and management may be directed by unskilled, skilled, or fully licensed nursing staff. Most older adults must pay for assisted living themselves, although some states now provide funding through Medicaid. Generally, care in an ALF is less expensive than in a nursing home. Part of this difference in cost is because ALFs provide less service and have less overhead. In addition, ALFs generally have fewer regulations to observe (at least for now) and are therefore able to operate more economically. Group homes Group homes are houses or apartments in which two or more unrelated people live together. These include domiciliary care, single-room occupancy residences, board-and-care homes, and some congregate living situations. Group homes vary in the types of residents that live there. For example, many can accommodate people with chronic mental illness or dementia. Most group homes are run as for-profit businesses, and some states require licensing. Residents share a living room, dining room, and kitchen but usually have their own bedrooms. Advantages of this arrangement include a lower cost of living and ability to socialize with peers. Independence and ability to function are supported through the interdependence and relationships of the residents. Opportunities for socialization are increased, reducing social isolation. Resident-to-staff ratios may also be higher than in other supported-living environments. Adult foster care Foster care homes generally provide room, board, and some assistance with activities of daily living. This is provided by the sponsoring family or other paid caregivers, who usually live on the premises. Adult foster care has the advantages of maintaining frail older adults in a more home-like environment. Regulations for foster care vary by state, and some states require licensing. Some states provide coverage of adult foster care through their Medicaid programs. Perhaps the longest experience with adult foster care is in the state of Oregon, where it is used as an alternative to long-term care and institutional living. Sheltered housing Sheltered housing is often in a home that offers personal-care assistance, housekeeping services, and meals. Social work services and activity coordination can be added to these programs. Charges to clients are based on a sliding scale, which may cost up to 30% of income. Continuing-care retirement communities Some older adults may choose a continuing-care retirement community (CCRC). These communities usually have a variety of living options, ranging from apartments or condominiums, to assisted living, to skilled nursing-home care. Often, residents enter the CCRC in the more independent living areas and then progress through the assisted living and skilled care areas as they age. Health care in CCRCs is generally provided using three financial models:
Most CCRCs require an entry fee, which may or may not be refundable, plus a variable monthly fee to pay for rent and supportive services. Monthly fees vary, depending on the level of care being provided. Older adults generally pay to live in these communities, though some facilities have beds for skilled care that are funded by Medicare or Medicaid. See also Insurance, Financing, and Costs of Health Care. |
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Published: 3/15/2005