- prior to 1930s: almost nonexistent

- prior to 1950s: policy response to LTC was small

- 1950-1970s: creation of Medicare & Medicaid, new sources for funding cause a growth of institutional LTC

- 1970-1990: addressing provider abuse, alternatives to nursing home

- 1990-2010: market reform, move to comm-based alternatives

- Olmstead decision: person w disabilities have right to integrated, comm-based services

- each level of care provides diff services @ diff costs, complex sys to navigate

- unequal access to care & an inability to finance care

- racial & socioeconomic segregation of LTC facilities a diff in quality in the care has been documented

1. Informal : consists of of the care provided by the family

2. Formal care: begins w services to supplement the family (HHC), extends services that replace informal (SNF)

- foundation of LTC is the fam

- 12% of US pop living in comm has a disability

- avg person older than 75 female, lives alone or w spouse, rate health as fair or poor, needs help w IADLs or 1-2 basic ADLs

- study on fam caregivers of dementia:

*if fam costs were considered it would be more costly than SNF care

- concerns when considering informal vs formal:

*cost, stress to fam, personal preference, & premorbid attitudes about level of care

- typically falls on female spouse & the adult female children of aging relatives, 10-40 hrs/wk of informal services on avg

- 90% of nations 3 million ppl w dev disabilities are cared for by fam members

*^ anxiety & responsibility

- challenges to use of informal care:

*fam not always available

*stress of caregiving

- fam utilizing voluntary agencies

- important for OT/PT to be involved in these organizations

- vital to meet needs of those w chronic illness & disability

- each year 23% of americans provide informal care to other persons

- 71% do not live w recipient of care

- 2007: informal caregivers provided $375 billion worth of care (more than Medicaid spending)

- economic & social value of informal care is enormous:

*formal care based on the need to assist informal caregivers

- important for OTs to involve fam caregivers in tx plans, goals, caregiver edu

- mix of residential & professional sites & types of care

- Residential: supervision & Min A (ALF) to providing multiple medical & rehab treatments (SNF)

- 2 types: Residential vs nonresidential

Nonresidential:

- home health agencies, hospice & adult day services

- informal care is support & supplemented w targeted interventions based on client & caregiver needs

Residential:

- provides a place to live along w services, replace informal care services

- both provide skilled & non-skilled services

*skilled: those w comlex nursing or rehab need that cannot be provided in another env (ex/ not in home health or ALF)

>services provided: nursing, rehab, personal care, residential services, medical care

*Nonskilled: dietary, laundry, activities, CNA

>important to understand the extent of services & needs of pts for appropriate referrals & d/c

- HHC: formal regulated program of care offering medical, therapeutic & nonmedical services by a variety of professionals in the pt's home

*pt medically stable but unable to access other community resources

- 1.4 mil Americans receive home care, 7.2 mil d/c from HHA annually, avg LOS is 70 days

- Pt demographics: white elderly female, w multiple med dx & fxnl limitations (circulatory disease, musculoskeletal connective d/o, falls)

- 4 in 10 received PT, 1 in 10 receive OT, 1/2 use self care aid

- best for those who need comprehensive care, desire to live @ home, & have some social supports

- must be homebound: unable to leave homes w/o exceptional effort, may leave for med or religious reasons

- provided by non-profit, for-profit, & gov agencies that are free-standing or components of an integrated health care system

- CDC: 12,400 (2014), proportion of agencies w for-profit ownership (80%) 2014

- Health care delivered by RN & rehab professionals under the medical supervision of an MD

 - skilled services in HHC

- nonskilled services in HHC

- comprehensive eval occurs to determine the need for skilled & nonskilled services for smooth transition into the comm

- those w more disability are more responsive to therapy services

2. Nonresidential Formal Care: Hospice

-       Services for those w terminal illness & their support sys/family during and after the dying process

-       First hospice= in US was New Haven, CT in 1974

-       CDC:

o   # of hospice care agencies: 4,000 (2014)

o   # of pt: 1.3 million (2013)

o   proportion of hospice care agencies w for-profit ownership: 60.2% (2014)

-       Hospice is about “dying well”

-       To qualify: pt must be terminally ill w 6 mo or less to live, stop life prolonging treatments

-       Common complaints of those on hospice: pain, fatigue, anorexia, dyspnea, nausea, confusion, depression

-       Role of rehab has ^

-       Allows for respite from the stress of informal/fam caregiving

-       CDC:

o   # of adult day services centers: 4,800 (2014

o   % of adult day service centers w for-profit ownership: 44.2%

o   # of participant on any given day: 282,200

-       What services provided?: transportation, meals, social services, personal care, occasional nursing, occasional rehab, activities (1/2 offer OT or PT)

-       Typically white elderly lady w spouse, cog impairments

-       Variation in adult day services: Program for All Inclusive Care (PACE)

o   Services those @ risk of nursing home placements, attempts to keep them functioning within the community longer

o   Eligible: 55 y/o, live in PACE service area, be able to live safely in community

o   Proven Effective: reduce hospital admissions & ER visits – reduce nursing home admissions, and have higher 5 yr survival rate

-       Provides housing/support services to those who cannot independently but generally do not require a skilled level of care

-       Ideal for those who need supervision or non-skilled services on a reg basis

-       Typical resident: 80 y/o female who is ambulatory, needs assistance w 2 ADLs, assistance for transportation/shopping/meal prep/housework/med mgmt./money mgmt.

-       Services provided: 3 meals/day, transportation, social activities, assistance with ADLs, med mgmt., security services

-       may be free standing building or part of SNF

-       avg monthly cost $3,477, paid by private funding

-       goal: allow residents to “age in place”

-       PT & OT offered by nearly all ALFs often through contract relationships

-       Service 2 types of residents: post-acute & chronic

-       CDC

o   # of nursing homes: 15,600

o   Proportion of nursing homes w for-profit ownership: 69.8%

o   # of licensed beds: 1.7 million

o   # of residents: 1.4 million

-       Avg daily care is $239/day – Federal Medicare/Medicaid programs funds about 7 in 10 residents

-       Services: skilled care, assistance w at least 3 ADLs, 3/4^th have cog problems, complex needs but are often medically stable

o   4 basic services: nursing, rehab, personal care, residential services & medical care (24 hour care)

-       OT/PT provided eval & interventions

-       concerns regarding quality of care in SNF: employee turnover, absenteeism, declines through the years, RAI MDS (used to improve quality of care in SNF)

-       Restorative care!!!

-       Comprehensive inpatient care for those w acute illness/injury/exacerbation

-       After or instead of acute hospitalization to provide medically complex tx

-       Step down from acute hospitalization intended for short-term recuperation

-       Can be found in SNF or hospitals

o   Hospitals sometimes call it the swing bed unit

o   Often organized around pt type: medically complex, vent, post surgical, stroke, ortho

-       Lower intensity of RN & physician care

o   Physicians once a week not every day like in acute

-       OT/PT daily but less than 3 hours/day

o   Goal is to move to less intensive env: home or LTC

- independent stand-alone or dedicated unit in hospital, fixed rate

- provide care in preparation to return to community

- often treat most complex pts: TBI, SCI

- pt need to tolerate 3 hours of therapy/day (Medicare guidelines)

- services: OT, PT, SLP, recreation therapy, nursing, counseling, psychiatry

Next Few flash cards based on Article!!

Article:
Coming to Terms with the
IMPACT act of 2014

- The improving Medicare Post-Acute Transformation Act of 2014 (IMPACT)

*Act focused on dev & implementation of post-acute quality measures w a specific timetable for each of the 4 post acute settings

- Changes in health care:

*gradual move from fee for service to bundled fee

*move away from prestige & risk & move towards price & quality

* this will req 2 sets of reform:

>pricing & payment reform

> quality & outcome metrics

- ACA makes Medicare place of transformation of delivery & finance

- IMPACT: focus on quality metric track, secondarily on the payment reform, picks up where the ACA leaves off

1. Patient Assessment Data:

- all post-acute providers must report data from following CARE item set domains:

*Diagnoses including comorbidities

*Impairments

*functional status

*cog function & mental status

* services & treatment req

2. Quality Measures:

- req to report 5 sets of quality data:

*physical & cog function & changes in function

*skin integrity

* med reconcilliation

*incidence of major falls

*d/c plan

3. Resource use measures:

- req to report 3 main measures:

*Total Medicare spending per beneficiary

*whether pt was d/c to the comm

*all-cause-risk-adjusted preventable hospital readmission rates

1.     Data collection, reporting, and analysis

2.     Feedback to providers

3.     Public reporting

- CMS moved so that this data collection could begin Oct 1 of 2016

- Risk adjustment:

* IMPACT Act provides risk adjustment to ensure that those facilities that specialize in more diff pts are not penalized

- Larger Quality Metric Selection Ecosystem:

* CMS must seek the national quality forum endorsement when selecting quality measures

- CMS must work w MedPAC to dev a prototype prospective cross-setting, site-neutral payment sys

*report this sys due Oct 1 2021, by June 2022 report to operationalize the new payment sys

- Act mainly ratified changes already underway w the ACA, but timeline was new

o   Move towards value-based care, episode-based mgmt., & bundled payment

o   Ensure that OT is included in health benefits packages, CPT has acceptable OT related codes, functional assessment instruments include domain that reflect OT

o   Move towards how OT’s timing, type of interventions & intensity adds value to patients

o   OTs need to make sure that episode & pop based payment will be tied to more outcomes that OTs can contribute to

-       Conclusion:

o   Change how OTs will add value for all stakeholders

o   Willingness to shed old ways of thinking, learn new tech, & embrace new ways of delivering managing care