Running Head: EXPLORING THE LONG-TERM CARE DELIVERY SYSTEM

Exploring the Long-Term Care Delivery System Rebecca King and Sarah Thomasson Auburn University School of Nursing

EXPLORING THE LONG-TERM CARE DELIVERY SYSTEM Abstract

The purpose of this paper is to examine the long-term care delivery system, including the function, cost, and current issues and to evaluate the care of a particular patient through a focused case study. Long-term care acts as a living facility for those unable to care for themselves. It can also function as a short-term facility for brief times of recovery and rehabilitation. The demand for long-term care is great as the elderly population and chronic illnesses are rapidly increasing. Despite the increasing demand, many insurance companies, particularly Medicaid, have reduced reimbursement rates below the level of the cost of care. In response, many facilities have down sized services, as well as staff, leading to a decrease in the quality of care. This care delivery system is not considered sustainable due to the increasing demand from the aging population, shortages of professional staff, and diminishing financial resources. Keywords: Long-term care, Interprofessional teams, Medicaid

EXPLORING THE LONG-TERM CARE DELIVERY SYSTEM Exploring the Long-Term Care Delivery System

The demand for long-term care facilities in the United States is already high, but it is expected to dramatically increase over the next 30 years due to the aging population (Roberts, Miller, & Hokenstad, 2012). The purpose of this paper is to discuss the function of the long-term care facility, the extent of the need for this care delivery system, the costs associated with the plan of care for a patient suffering from dementia and depression, and the methods of payment for this type of care. This paper also seeks to address the sustainability of this care delivery system during this time of economic instability. Long Term Care Description Long-term care acts as a living facility for those who find themselves in poor health and unable to care for themselves at home, as well as a short-term service for those needing a brief period of recovery (Centers for Medicare and Medicaid Services, n.d.). Currently there are over 1.6 million patients admitted to nursing homes and over 18,000 facilities in the United States with an average occupancy of 87 percent (Brune, 2011). A majority of these patients require assistance with multiple activities of daily living, or basic personal task such as bathing, dressing, using the toilet, transferring, and eating. Over 42 percent of patients admitted to long-term care are diagnosed with dementia, seeing as many of these patients are in the later stages of dementia and are no longer able to perform self care tasks (Brune, 2011). Many alternatives to long-term care exist, but their services may not be the most beneficial for the patient and the patients family. The least expensive alternative for care is an unpaid family member or friend. Unpaid caregivers encompass about 80 percent of elderly care in the United

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States. Most people can live at home for many years with help from friends or family; however, many times the patients needs begin to exceed the familys abilities to support the patient. Other options for long-term care include care from a home health aid or adult day care services. These services are similar to nursing homes but do not operate 24 hours a day. Instead, they can provide relief to the patient or normal care givers during the day when the most assistance is typically required. Assisted living is another step down from a nursing home and includes 24-hour care but care is not as thorough as in a nursing home (U.S. Department of Health and Human Services, n.d.). Today there are over 10 million Americans in need of long-term care services and that number is expected to more than double over the next 30 years as the baby boomer generation ages. The worlds population is aging rapidly with an increase in longevity as well as an increase in chronic illness. In fact, roughly 80 percent of adults 65 and older have one or more chronic illnesses and nearly two-thirds of health care costs are committed to the treatment of these chronic illnesses (Roberts et al., 2012). In addition to the great increase in the number of patients, there is also a nursing shortage in the long-term care sector. Although a substantial amount of research shows the critical role of the registered nurse in the nursing home setting on improving the quality of care, most of the nurses employed in these facilities take on higher level management positions rather than direct patient care (Harahan, 2010). While federal regulations require one licensed nurse on duty in a nursing facility at all times, this regulation does not differentiate registered nurses from licensed practical nurses. The Institute of Medicine recognizes the importance of higher levels of staffing and wrote three separate reports on its importance in the nursing home sector. However, nursing

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home staff levels have remained relatively the same since 1994 (Harrington, Swan, & Carrillo, 2007). Like most businesses, the health industry, including long-term care, has been designed to be efficient, standardized, and cost-driven (Brune, 2011). Due to this drive for efficiency, effectiveness and quality of care can be lost. A study by Castle & Engberg (2007) found that for-profit institutions as well as high bed size facilities were associated with low quality of care. In addition, many facilities take on too many patients without the appropriate number of staff in an attempt to increase profit even though this is known to dramatically decrease quality. It has been shown that low nurse aid staffing levels can lead to resident weight loss and ungroomed residents. Similarly, high registered nurse turnover is identified with lower functional improvement, while high registered nurse stability is more commonly associated with low prevalence of pressure ulcers (Castle & Engberg, 2007). Unfortunately, nurse stability in long-term care is not very common with turnover of registered nurses ranging form 38 to 50 percent (Harahan, 2010). Another issue that impacts long-term care is the inaccessibility due to costs. Roberts et al. (2012) states that monetary difficulties are the most important predictor of unmet care needs in the long-term setting. These two issues are interrelated as companies face the choice to either hire the appropriate personnel and face a cost increase for potential clients, or limit the number of employees and keep the cost low to attract new clients. Within the long-term care setting there are many professionals working together to care for the patients many needs. Registered nurses play a significant role in these long-term care facilities. Not only are they responsible for the care of the patients by

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assessing their health and preparing a plan of care, but also they are responsible for delegating and supervising the work of nursing aids who assist patients with their daily needs and activities. In addition, nurses perform medication administration and patient education. Any nursing home reimbursed by Medicare or Medicaid is also required to have a physician on staff to supervise and contribute to planning the care of residents. Social workers are an important aspect to long-term care facilities as well since they are able to provide an array of services such as psychological, legal, and end of life planning. Since most of these facilities operate under a case management model, these positions are typically overseen by the nursing home administration, who manage staff and coordinate care while insuring that the facility complies with state regulations (Harahan, 2010). Many other positions such as physical therapists, occupational therapists, and speech pathologist may be employed depending on the size and care provided for the nursing home. Interprofessional teamwork among these members is vital to attain improved patient care and outcomes. Interprofessional teams are groups of diverse health professionals who work together to accomplish specific goals using a mutually dependent and collaborative effort. For the team to achieve these goals, effective communication and a clear understanding of each others roles is important (Sargeant, Loney, & Murphy, 2008). Focused Case Study E.B. is a 71-year-old Caucasian female admitted to the facility for exhaustion, lack of appetite, and changing levels of consciousness. Her diagnoses upon admission were depression and dementia. She also has Type II Diabetes Mellitus, weighs 135 pounds and has 10 decubitus ulcers on various parts of her body, including her sacrum,

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right elbow, left heel, right hip, posterior right leg, right upper back, left hip, right inner knee, and right outer fifth pedal digit. Upon assessment, the patient indicates that she has pain all over almost constantly, and that this pain has interfered with her activities of daily living and her sleep schedule. The patient does not give a numerical pain rating, but does state that the worst pain she has experienced over the last five days is of moderate intensity. The patients balance is unsteady, and she requ ires assistance with transfers. She uses a wheelchair for transportation within the facility. Staff members assist the patient with transfers and activities of daily living (ADLs) and ensure that she is safely transported to the common area to socialize and promote cognitive function. To help combat the effects of dementia and prevent confusion, the staff orient the patient every day and post visual aides that indicate the season and upcoming holidays. To encourage autonomy, the staff ensure that materials for ADLs are available to the patient, but encourage her to do as much for herself as possible. Because the patient has difficulty ambulating and is occasionally incontinent of bowel, staff monitor her for incontinence every two hours, looking for wet or dirty skin and cleaning her as needed to prevent skin breakdown and infection. The patient has a foam wedge to help with positioning, and staff assist her to turn or reposition every two hours while she is lying in bed or sitting in her wheelchair. She is encouraged to consume at least 50 to 75 percent of her meals and to drink fluids with her meals in order to ensure adequate nutrition and prevent hypovolemia. She receives Glucerna three times a day to provide supplemental nutrition without greatly increasing her blood glucose levels. The patient is encouraged to perform mouth care every day and to participate in the social activities that the facility offers. In order to care for the patients

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psychological needs and mange her depression, the patient is encouraged to express her thoughts and feelings. The patient has agreed to use various therapeutic mechanisms such as breath awareness, reframing to focus on her successes, modeling appropriate behaviors combined with positive reinforcement, and reflective listening and reassurance. The patient is prescribed Promod, zinc, vitamin C, and a multivitamin to promote the healing of her decubitus ulcers. She is also taking Boniva 150 mg daily to prevent bone resorption and to decrease her risk for falls; Hydrocodone 5/325 daily to manage her pain; Vitamin D to promote bone mineralization; and Trazodone 50 mg at bedtime to manage depression. Medications can have adverse effects on the patient, and the nurse is responsible for monitoring the patient for these undesirable signs and symptoms. Effects caused by hydrocodone include respiratory depression, dizziness, constipation, and drowsiness. The patient is at increased risk for falls while taking this medication. The sedating effects of the medicine could also be contributing to the patients feelings of exhaustion and changes in level of consciousness (LOC). Trazodone can cause effects such as dry mouth, somnolence, dizziness, fatigue, constipation, and hypotension, and could also be contributing to the patients changes in LOC. The patients laboratory values are within normal range. Because this patient is at an increased risk for falls due to her poor balance and the medications she is prescribed, it is vital for the nurse to maintain patient safety during E.B.s stay at the facility. This includes educating the patient on medication effects, keeping the patients floor free from clutter and cords, keeping the call light easily accessible, ensuring that she is wearing shoes or non-skid socks before each

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transfer, and assisting the patient with transfers and ADLs as needed (Centers for Disease Control and Prevention, 2013). Pain management is also of high priority, as this promotes the patients ability to sleep and to engage in social activities, both of which can be beneficial in managing the patients depression (National Institute of Mental Health, n.d.). In a study of other long-term care facilities, residents indicated that they value social interaction and self-care activities (Popham & Orrell, 2012). These results suggest that promoting autonomy and encouraging social interaction are nursing priorities for this patient. These can be accomplished by encouraging her to perform as many of her ADLs by herself as possible, as well as to participate in social gatherings at the facility. Therapeutic communication was also noted as being important to long-term care residents (Popham & Orrell, 2012). It is especially vital for the nurse in this case to listen to the patient and encourage her to express her emotions in order to assess for suicidal ideations and help manage her depression. To promote the health of E.B., one of the staffs biggest priorities is to ensure that she receives adequate nutrition. To do this, staff encourages her to eat 50 to 75 percent of her meals in addition to three Glucerna drinks each day and vitamin C, Zinc, Promod (a protein supplement), and a multivitamin. Good nutrition combined with excellent skin care is essential to the wound healing process, and this is especially important in providing care for the patients multiple decubitus ulcers (Wound Care Centers, 2013). Because the patient is not very mobile and already has many decubitus ulcers, she must be turned at least every two hours to prevent further skin breakdown. This can be frightening and confusing to a patient with dementia, and can often painful as well. The nurse educates the patient and her daughter about the turning

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schedule and why it is necessary, and informs the patient of what she is going to do each time she enters the room to turn E.B. The patient is also prescribed Effexor XR each morning to treat her depression. Although it is an antidepressant, this medication has the potential to increase the symptoms of depression and to cause suicidal ideations. The nurse monitors the patient for these adverse effects and notifies the physician if they occur. To combat the effects of dementia, the nurse reorients the client whenever she is caring for the patient, including addressing the patient by her name, talking to her, and posting information that indicates the season in her bedroom. Patient goals include developing strategies to cope with grief and manage depression; eat at least 50 to 75 percent of each meal; engage in social activities offered by the facility; prevent further skin breakdown; maintain patient safety in the facility; and, ultimately, regain ability to perform ADLs so she can be discharged. Family goals include educating the daughter about the correlation between the patients depression and lack of appetite so that she can recognize when the patient needs help. Because the daughter is sickly, it is also important to identify another person who will be able to help care for the patient once she returns home. The patient was admitted to this long-term facility because of lack of appetite, most likely related to her unresolved grief and depression. The health professionals in this care delivery system include physicians, nurses, nurses aides, social workers, physical and occupational therapists, and Adult Protective Services (APS) workers. The physicians role is to oversee patient care by writing orders and ensuring that they are followed. The nurses deliver medications and whatever treatments the patients require. Nurses aides are responsible for tasks such as bathing, dressing, changing, and

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ambulating the patients. Physical therapists help the patients regain strength and coordination, while occupational therapists work with the patients on developing independence with ADLs. APS workers collaborate with social workers to formulate a plan to ensure that older adults are receiving the care that they need and to prevent them from maltreatment (Department of Human Resources). These professionals function as a multidisciplinary team, each meeting with the patients separately, creating their own care plans, and then communicating the plans to the other health professionals. While studies indicate that interprofessional teams are correlated to better patient outcomes such as decreased distress and pain (Chapman & Toseland, 2007), the multidisciplinary team at this facility displays some key traits of an effective interprofessional team, including an understanding of and respect for each others professional roles, and the ability to communicate patient information to one another (Sargeant et al., 2008). However, the members of the team are not interested in sharing each others responsibilities, but strictly adhere to their own patient care assignments. The ultimate goal for this patient is being discharged and returning home. The nurses notes on October 8, 2013 state that the patient and her daughter have requested an order for discharge and that the patient is excited about going home. Providing mental stimulation through group activities and social interaction is one of the most important aspects of care to be provided in a nursing home (Popham & Orell, 2012). Nurses notes from September 20, 2013 state that the patient attends at least five group outings per week, such as bingo, book club, fun and fitness, and special parties. She also offers to help the staff and other residents when she can, especially

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with bingo. This statement suggests that the patient has improved dramatically from her state at admission, at which point she was anorexic, drowsy, and barely able to answer the nurses questions. The expected outcomes for E.B. were a stabilized mood and emotional resolution. The nurses note on September 25, 2013 states, Resident is very upbeat and enjoys talking. Resident has progressed very well. This indicates that the patient is expected to meet her outcomes of stabilized mood and emotional resolution. An earlier social workers note from September eighteenth reinforces this expectation, stating the resident is very amenable to using the approach of breath awareness, role playing, reframing, and reflective listening and reassurance to manage her depression. The patient will be visited by an APS worker after she arrives at home, and the APS worker will collaborate with a social worker to ensure that E.B. is in a safe environment and is receiving the care she needs. The patients daughter will help with her care, but her ability to do this is limited by her own poor health. Before discharge, the nurse will review with the patient fall risks at home, side effects of her medications, positive methods of coping with grief, and community resources that may be beneficial. The nurse will also help the patient identify someone besides her daughter that she can contact in case of emergency. Cost of Care In 2011, the average cost for nursing home care in a private room was $77,745. In 2009 the average cost per day was $219 for a private room and $198 for a semiprivate room, making it the majority of the cost of care (Roberts et al., 2012). The average length of stay was 892 days (Brune, 2011). In 2002, the bill for the United

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States as a whole for nursing home care totaled $103 billion dollars. Of that cost, Medicaid and other public payers paid for 51 percent, Medicare paid for 12.5 percent, and private insurance paid for 7 percent (Harrington et al., 2007). Because of the large amount of patients in nursing homes with Medicaid insurance coverage, their policies and reimbursement rates have a great effect on the way nursing homes operate. Since Medicaid reimbursement rates are determined by the state policy makers on the basis of facility cost, including nurse staffing, higher staffing should result in a higher reimbursement and the ability to accept residents with higher case-levels (Roberts et al., 2012). Nursing care is not charged as a separate entity, but rather it is included in the cost of the nursing home room. One study found that a $10 increase in Medicaid reimbursement rates would increase registered nurse hours by 0.01 hours per resident day. Therefore, to increase nursing hours by 0.09 hours to the recommended level, Medicaid would need to reimburse an extra $90 per resident day. However, efforts by the state to contain the cost of long-term care have led to a substantially lower Medicaid reimbursement rate of around $115 per day (Harrington et al., 2007). The resulting gap between the amount Medicaid is willing to pay and the actual cost of care has led to many facilities decreasing services and only providing basic care or restricting care for those who can pay privately. Although countless studies have shown that higher Medicaid reimbursements rates encourage better nursing care, nursing homes primarily funded by Medicaid continue to demonstrate a decreased quality of care due to their unwillingness or inability to increase reimbursement (Roberts et al., 2012). Another policy that affects cost and quality of care includes the Patient Protection and Affordable Care Act implemented by the Obama administration. This act includes

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the Community Living Assistance Services and Supports Act, which allows for a voluntary insurance program in which employed adults can contribute a premium toward future long-term care services in exchange for a cash benefit if these services are needed. This program has many benefits over private insurance because an individual cannot be excluded from enrolling based on pre-existing conditions. In addition, there are no benefits limitations and the money for services is provided directly to the enrollee, rather than going through a separate agency (Roberts et al., 2012). Patients diagnosed with dementia who are living in a long-term care facility are charged an average of $4,270 per month. The majority of dementia patients in longterm care live there for the remainder of their lives, and the goal is to promote the best quality of life for them as possible as they approach death (Simmons, 2011). Because E.B. was admitted for symptoms of depression and not due to of her dementia, her length of stay was only 94 days. The patients total cost for her months stay in September is $4782.60, $4,500 of which covered the cost of her room and nursing care. Medical-surgical supplies used in her treatment cost $48.20, physical therapy cost $77.20, occupational therapy cost $77.20, and a speech pathology evaluation cost $80.00. There is not a separate category for nursing care fees because they are combined with the cost of the room. To decrease the cost, the facility could work to ensure that each nurse is assigned patients with varying levels of care needs, thus decreasing nurse workload. A study of nursing homes in Austria indicates that increasing the size of the facility or distributing the patients according to the level of care they need would decrease the cost by making nursing care more efficient and less demanding on the nurses (Hoess, Bachler, Ostermann, & Staudinger, 2009).

EXPLORING THE LONG-TERM CARE DELIVERY SYSTEM Increasing a facilitys capacity, however, is correlated with lower quality of care.

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Individual facilities must ensure that their increase in capacity is within the limits of what is safe for both the staff and the patients (Roberts et al. 2012). The patients outcome was appropriate to the cost, because she achieved her goals while at the facility and was able to be discharged to live at home. She progressed from being drowsy, anorexic, and barely able to communicate to being social, active, and in good spirits. The patients bill was paid for entirely by Medicaid. Medicaid is funded by the federal and state governments, with each states per capita income determining what percent of program costs the federal government will reimburse them. Medicaid covers the care of patients living in long-term care facilities, referring to their care requirements as institutional benefits. To qualify as an institutional benefit that Medicaid will cover, the institution providing the care must be residential, offer complete patient care including room and board, be licensed by the state, and be open to inspection to maintain certification. The costs of care are added together and paid for as one bill by Medicaid (Centers for Medicare and Medicaid Services, n.d.). The patients daily cost of $150.00 was comparable to the average cost of a semi-private room in nursing homes, which is $6,235.00 per month or $205.00 per day (U.S. Department of Health and Human Services, n.d.). Summary The increasing demand for long-term care in the United States is accompanied by increasing costs of care, a shortage of staff, and decreasing reimbursement rates of insurance companies such as Medicaid. Long-term care facilities are faced with the option to decrease costs and quality of care by lowering staff numbers or to maintain

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high staff levels and pursue high-quality care at the risk of losing business due to higher costs. While interprofessional care teams have been shown to improve patient outcomes, the staff at the facility described in this paper function more as a multidisciplinary team, with each member working independently from the others. The patient whose care is described in this paper receives holistic care at the facility, with treatments ranging from nutritional supplements, to physical therapy and grief counseling. The majority of her bill, however, covers the cost of her room and nursing care. She has met her goals and shown enough progression to be discharged. The Obama administration has implemented the Patient Protection and Affordable Care Act in an effort to help working adults plan for future healthcare needs. This act allows working adults to contribute to a voluntary insurance program that helps ensure that they will have the financial means to pay for long-term care services in the future. Although costs of nursing home care are increasing, insurance companies are lowering their reimbursement rates, making it more difficult for long-term care facilities to maintain a high level of care and the recommended number of staff. With dwindling financial resources available, the long-term care delivery system in its current state is not sustainable. As with most fields in health care, long-term care must aid in orienting the community towards health promotion and disease prevention. With the large influx of older adults and chronic illnesses it is important to educate the public on ways to prevent these problems by implementing lifestyle changes such as proper nutrition, exercise, and regular screenings.

EXPLORING THE LONG-TERM CARE DELIVERY SYSTEM References

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Alabama Department of Human Resources. (n.d.). List of services provided. Retrieved from http://dhr.alabama.gov/services/Adult_Protective_Services/Svcs_Provided.aspx Brune, K. (2011). Culture Change in Long Term Care Services: Eden-GreenhouseAging in the Community. Educational Gerontology, 37(6), 506-525. doi:10.1080/03601277.2011.570206 Castle, N. G., & Engberg, J. (2007). The Influence of Staffing Characteristics on Quality of Care in Nursing Homes. Health Services Research, 42(5), 1822-1847. doi:10.1111/j.1475-6773.2007.00704.x Centers for Disease Control and Prevention. (2013, September 23). Preventing falls among older adults. Retrieved from http://www.cdc.gov/features/OlderAmericans/ Centers for Medicare & Medicaid Services. (n.d.) Long-term services and support. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Long-Term-Services-and-Support/Long-Term-Services-and-Support.html Chapman, D. G., & Toseland, R. W. (2007). Effectiveness of Advanced Illness Care Teams for Nursing Home Residents with Dementia. Social Work, 52(4), 321-329. Harahan, M. F. (2010). A Critical Look at the Looming Long-Term-Care Workforce Crisis. Generations, 34(4), 20-26. Harrington, C., Swan, J. H., & Carrillo, H. (2007). Nurse Staffing Levels and Medicaid Reimbursement Rates in Nursing Facilities. Health Services Research, 42(3P1), 1105-1129. doi:10.1111/j.1475-6773.2006.00641.x

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Hoess, V., Bachler, A., Ostermann, H., & Staudinger, R. (2009). Cost Control in Nursing Homes by Means of Economies of Scale and Care Profile Optimization. Nursing Economic$, 27(1), 45-63. National Institute of Mental Health. (n.d.). Depression and chronic pain. Retrieved from http://www.nimh.nih.gov/health/publications/depression-and-chronicpain/index.shtml Popham, C., & Orrell, M. (2012). What matters for people with dementia in care homes?. Aging & Mental Health, 16(2), doi: 10.1080/13607863.2011.62897. Roberts, A., Miller, D. B., & Hokenstad JR., M. (2012). Long Term Care Insurance Beyond the CLASS Program. Journal Of Sociology & Social Welfare, 39(3), 85109. Sargeant, J., Loney, E., & Murphy, G. (2008). Effective interprofessional teams: Contact is not enough to build a team. Journal Of Continuing Education In The Health Professions, 28(4), 228-234. doi:10.10020chp.189 Simmons, D. (2011). Sustainable Living In Long-term Care: For People with Dementia/Alzheimer's. Educational Gerontology, 37(6), 526-547. doi:10.1080/03601277.2011.570208 U.S. Department of Health and Human Services. (n.d.). Long term care information. Retrieved from http://longtermcare.gov/the-basics/who-needs-care/ Wound Care Centers. (2013). How your diet can aid in wound healing. Retrieved from http://www.woundcarecenters.org/living-with-wounds/how-your-diet-can-aid-inwound-healing.html

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