Health Care Delivery Chapters 9 and 10 pc

The age, diagnosis, and ability to perform personal self-care and the sites of care delivery vary widely for recipients of this type of care. Thus, this requires diversified, yet coordinated, services and flexibility within the service system to respond t

long-term care

The ideal system that provides participants with comprehensive personal, social, and medical care services.

health care delivery

increase due to medical advances that increase longevity; changes in social structures that preclude home/informal care

Long-term care needs

almshouses started by charitable colonists who purchased private homes for communal residences

Colonial era

city, county-operated homes & infirmaries for impoverished older adults; professional home care began as response to living conditions of immigrants (e.g. VNA) & expanded to education about hygiene, nutrition

19th-early 20th century

private citizens boarded older adults for financial benefit; many quality of care issues. Operating small private nursing homes became attractive to people in financial danger of losing their homes to mortgage foreclosure because taking in outsiders and p

Great Depression (1929)

enabled older adults and those with certain disabilities to avoid reliance on charity, could supplement retirement income

Social Security (1935):

government loans aided not-for-profit nursing home development


___________ lending programs available to not-for-profit organizations beginning in the 1950s spurred the development of nursing homes in this sector; major growth in the proprietary sector did not occur until after the passage of Medicare and Medicaid le

Centers for Medicare & Medicaid Services

Medicare and Medicaid passage had profound effects on the LTC - Long Term Care industry


Stimulated nursing home industry development as a profitable businesses
Required minimum standards of care for reimbursement
Attracted scrupulous & unscrupulous operators

Medicare & Medicaid

1970s public exposes': Congressional hearings on inhumane treatment, by Ralph Nader, others, e.g.
- Untrained, inadequate staff
- Hazardous, unsanitary conditions
- Over, under-medication
- Discrimination against minorities
- Thefts of belongings


The long-term care industry came under increasing scrutiny in the early 1970s during congressional hearings on the nursing home industry, after several hundred expos�s published in newspapers and additional publications such as the Nader Report and Mary A

Tender Loving Greed.

The litany of nursing home _____ and _____ that were exposed during that period included the following:
Care that did not recognize the right to human dignity
A lack of activities for residents Untrained and inadequate staff, including untrained administr

corruption and abuses

Medicare and Medicaid certification
State nursing home & home care licensing
Appropriate staff credentialing
Laws for elder abuse reporting
Regulations on restraints
Nursing home residents' "bill of rights"
Ombudsman programs



skilled nursing facilities

A facility that is Medicare and Medicaid certified is defined as "a facility, or distinct part of one, primarily engaged in providing skilled nursing care and related services for people requiring medical or nursing care, or rehabilitation services."

Skilled Nursing Facility

Appropriate for people not requiring skilled nursing services whose needs lie in the custodial and supportive realm: "a program that provides and/or arranges for daily meals, personal and other supportive services, health care and 24-hour oversight to per

Assisted Living Facilities

Community-based care provided in private residences; long-term for chronically ill; short-term for rehabilitation after illness or hospitalization

Home Care

expanded its scope of services in response to demographic, economic, and legislative changes that include:
An increase in the number of older persons and their expressed desire to remain in their own homes for care whenever possible
Decreased numbers of i

The home care industry

Eligibility for _______ reimbursement of home care services originally included four criteria:
1. Home care must include the provision of skilled nursing care; physical, occupational, and speech therapies; and medical social services as warranted by the p


Under the _____, in April 2011, Congress added more criteria for eligibility for Medicare reimbursement for home care to those listed above. Additional criteria included a requirement for Medicare beneficiaries receiving home care to have a face-to-face o


is a philosophy supporting a coordinated program of care for the terminally ill. The most common criterion for admission into this is that the applicant has a diagnosis of a terminal illness with a limited life expectancy of 6 months or less. Aggressive m


The term "____ ____" often is used synonymously with hospice care. It is care or treatment given to relieve the symptoms of a disease rather than attempting to cure the disease. Pain, nausea, malaise, and emotional distress caused by feelings of fear and

palliative care

Family caregivers continue to be a key factor in providing care for many long-term care recipients in their communities, rather than placing them in institutions. Providing care up to 24 hours a day can place enormous physical and emotional stress on fami

Respite care

care may be offered in a variety of settings: the home; a day care situation; or institutions with overnight care, such as hospitals, nursing homes, or group homes. Respite-care auspices may include private, public, and voluntary not-for-profit agencies.

respite care

include: Alzheimer's disease care on an inpatient basis with admissions lasting for several weeks
Community-based, adult day care centers that offer nursing, therapeutic, and social services
In-home assistance, where visiting homecare or personal care aid

Respite models

One of the major barriers to responsive changes in reimbursement for ____ _____ has been that funding mechanisms have viewed respite care as meeting a social need but not an acute medical care need.

respite care

may provide a supervised program of social activities and custodial care (social model), medical and rehabilitative care through skilled nursing (medical model), or specialized services for patients with Alzheimer's disease or other forms of dementia.

An adult day care center

Most people prefer to remain actively engaged in their own support and care, in their own residence, and within the context of their own family.
Research indicates enhanced quality of life and longevity when older adults are able to remain in their own re

Aging in Place

are available for those Americans who do not wish to stay in their own homes as they get older yet are essentially well enough to avoid institutionalization.

Continuing care retirement communities (CCRCs)

There are three types of CCRCs:
Life care or extended contract/continuing life care community (CLCC): This is the most expensive option. It offers unlimited assisted living, medical treatment, and skilled nursing care without any additional charges as the

Continuing care retirement communities (CCRCs)


continuing life care community

describe apartment buildings where most residents were 60 years of age or older.

A "naturally occurring retirement community" (NORC)

Advanced technology for intravenous infusions, ventilation, dialysis, parenteral nutrition, chemotherapy available in the home
Specialist home care personnel (nurses, pharmacists, respiratory therapists, etc.)
Cost effective
Preferred by patients

High-technology home care

is one financing option for the various components of long-term care. The earliest policies were first offered in the 1970s and covered only care in nursing homes.
In 2010, the AARP estimated that between 7 and 9 million Americans owned LTCI policies, and

Long-term care insurance (LTCI)

The ACA included a provision to establish a national voluntary long-term care insurance program funded through payroll deductions by persons at least 18 years of age. After 5 years of enrollment, the program would have allowed participants who became func

Community Living Assistance Services and Supports Act (CLASS Act)

The United States will need more and diverse long-term care programs in the future to serve increasing needs, especially of older adults. Some of the causes underlying the intensifying need for diverse long-term care service options are as follows:

Future of Long-Term Care


Long Term Care Insurance


Agency on Ageing


Continuing Care Retirement Community


Continuing Life Care Community


Natural Occurring Retirement community


Community Living Assistance Services and Support

Mental health care" now often called

behavioral health care" with psychiatric care

Patient" replaced by

consumer" or "person/people" with a psychiatric or substance abuse disorder

a psychiatric or substance abuse disorder

mental health issue

Problem-based" diagnosis model replaced with

strength-based" model in "Recovery Movement

mentally ill confined to almshouses, jails, hospitals with no treatment, decrepit conditions

Colonial era to 1800s

1800s: Quakers advocated "____ ______," est. 1814 Philadelphia "______.

moral treatment

WWI: "____ _____" in returning military focused new attention on mental illness

shell shock

1930s: First effective ____ ______ : insulin coma, drug-induced convulsions, electroconvulsive therapy

biological treatments

Post WWII, _____ ______ ______ Act of 1946:
National Institute of Mental Health
Dept. of Veterans' Affairs psychiatric hospitals and clinics

National Mental Health Act of 1946

passing the National Mental Health Act in 1946, which resulted in the establishment of the _____ ______ __ ____ ______. Federal, state, and county public funds were allocated for mental health training, research, and service. The Department of Veterans Af

National Institute of Mental Health (NIMH).

New drugs for schizophrenia, other psychotic disorders allowed

ambulatory treatment

1955: ____ ______ on Mental Illness & Health est. by Congress, the first time a federal body considered resources for the mentally ill

Joint Commission

1960: Medicare, Medicaid, SSI, Social Security Disability & housing subsidies accessible for

mentally ill

Not equal services or payments


Medicaid incentives to move patients from psychiatric hospitals to community boarding and nursing homes; community mental health centers inadequately staffed for severely mentally ill
Large numbers incarcerated, homeless
1950: 77 % inpatient, 23% outpatie

Deinstitutionalization (1970s-1980s)


National Alliance on Mental Illness


National Institute of Mental Health

expanded drug coverage

Medicare Act of 2003



_____ ______ _____ Act of 2008 advanced equitable coverage for mentally ill

Wellstone-Domenici Parity

reinforced insurance parity

ACA of 2010


Disability-adjusted life years

Neuropsychiatric disorders: the leading cause of disability in the U.S. and Canada measured in units encompassing the total burden of disease, defined as "____ ____ ____ ____" (DALYs); contribute 2x DALYS of cardiovascular disease & cancers

Disability-adjusted life years


DALYS - Disability-adjusted life years

the co-existence of two diagnoses; ~1/2 of mentally ill have an additional disorder; e.g. substance abuse of 23-80% with other disorders


provider availability; financial, lack of health insurance; stigma; misunderstandings about treatability; personal & provider attitudes; cultural issues; poorly organized systems of care

Barriers to Care

Four major delivery system Sectors:
*** Essay
Psychiatric and behavioral health
Primary care
Human services
Voluntary support network

The Organization of Psychiatric and Behavioral Health Services


Recovery Oriented Systems of Care

Initiated by Bush's "Freedom Commission on Mental Health." 2004 National Consensus Conference cited "recovery" as most important goal for transforming mental illness care in America.

Recovery Oriented Systems of Care (ROSC)

Funding sources: private health insurance, Medicaid, Medicare, state and county funding, contracts and grants
"Non-parity" existed for many years, denying the chronic nature of mental illness compared with medical conditions; dates to 1950s
Parity: requir

Financing Psychiatric and Behavioral Health Services

Equated aggregate lifetime limits, annual limits with general medical care
Allowed cost-shifting loopholes: e.g., limits on psychiatric inpatient days, prescription drugs, raising co-insurance & deductibles; did not require employers to offer

Mental Health Parity Act, 1996

(built upon 1996 Act)
End health insurance benefit inequity between mental health/substance abuse plans and medical/surgical plans
Equal coverage applicable to all deductibles, copayments, coinsurance and out-of-pocket expenses and all treatment limitatio

Mental Health Parity and Addiction Equity Act, 2008


Managed Behavioral Healthcare Organizations

Managed care systems (public and private) tightly control & monitor services for mentally ill; use subcontractors, "______ _____ _____ _____" (MBHOs) to manage behavioral health patients through "carve-outs;" research indicates that MBHOs successfully fac

Managed Behavioral Healthcare Organizations" (MBHOs)

were established to provide trained nurses to tend to the sick in their homes. Their role quickly expanded to include preventive education regarding hygiene, nutrition, and coordination of social welfare intervention, especially in caring for society's mo

Visiting Nurses Association