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Introduction
Community-based long-term care encompasses a wide array of medical and nonmedical diagnostic, preventive, therapeutic, rehabilitative, personal, social, supportive, and palliative services in a variety of settings for individuals who have lost some capacity for self-care because of a chronic illness or physical, cognitive, or emotional impairment. Some support services allow the patient to remain at home (including adult day care, home health services, home medical care, and telemedicine), whereas other services require a change of residence (such as assisted-living, adult-care homes, and continuing-care retirement communities). The goal of care is to build on interprofessional expertise and teamwork to promote the optimally independent level of physical, social, and psychological functioning in the least restrictive environment.
Older adults are high users of health care. In 2012, 23% of those aged 75 and older had 10 or more medical visits in the last year as compared to 14% of those aged 45–64.[1] Most older adults with chronic health problems prefer to remain at home or in a homelike setting.[2] A minority of older adults (3.5% of all 65+ and 10% of those 85+) live in nursing homes, and there has been a trend toward community-based services to provide support.
Community-based long-term care services focus on the older adult’s medical and psychosocial needs and aim to maintain function, prevent acute exacerbations of chronic illness, and avoid unnecessary and costly emergency room visits and hospitalizations. Services include assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). In addition, this care seeks to maintain the patient’s safety and provide comfort and assurance. It may entail hands-on or supervisory human assistance, assistive devices, and technology such as computerized medication reminders and emergency alert systems.[3]
Comprehensive geriatric assessment, a multidimensional and interdisciplinary process, embodies a formal approach to match the patient’s needs with available resources to provide safe, effective, and high-quality care.[4, 5] Case/care managers are often the point of entry to in-home and community-based services; they are responsible for the determination of the patient’s needs. Case management is often provided by a nurse, social worker, or private consultant. A key component of such management involves a review of an individual’s socioeconomic, environmental, psychological, and physical health challenges, and the development of a care plan for services or treatment.
The role of the physician in long-term care is vital because, by definition, these patients are often medically complex with restricted ability to manage their own care, and are therefore very vulnerable to further insults to their health. The primary care physician caring for patients who need long-term care will most likely be responsible for authorizing and supervising complex medical plans of care, advocating for the patient, and promoting a collaborative interdisciplinary team effort. Physicians certify patient eligibility for Medicare-funded home health care (HHC), including nursing care, rehabilitative therapies, and hospice care. Medicare has assigned billing codes specifically for physicians who coordinate long-term-care services under Medicare. Physicians also provide a critical consultative function for community-based services funded by other sources.
Community-based care enables the older adult with disabilities to live more independently and may reduce the probability of institutionalization; however, sometimes the challenges posed by limited availability, access, and affordability of services prohibit continued care in the community.
Home care
Home care is defined by the American Medical Association (AMA) as “the provision of equipment and services to the patient in the home for the purpose of restoring and maintaining his or her maximal level of comfort, function and health … and is a collaborative effort of the patient, family, and professionals.”[6] Home care includes a wide array of services: home health care, medical house calls, special programs, home hospice, and long-term supportive care, such as caregiving and home-delivered meals.[7]
Home health care
Medicare skilled home health care (HHC) was designed to provide acute and post-acute care following hospitalization, but it is also useful for the provision of episodic skilled care for the older patient who has difficulty coming to office appointments. HHC includes skilled nursing care, health monitoring, dispensing of medications, psychiatric care, physical and other rehabilitative therapies, personal care, homemaker services, and health education of patients, family members, and caregivers. With technological advances, HHC diagnostic and therapeutic procedures may include intravenous antibiotics, transfusions, chemotherapy, dialysis, enteral and parenteral nutrition, and mechanical ventilation. The use of telemonitoring systems offers the options of telehome care and “electronic house calls” to assist with chronic disease management programs.
The older patient in need of HHC often has complex medical problems and functional impairments. In order to receive HHC through Medicare, assessments are required to determine medical necessity, including the acuity of the problem, underlying comorbidities, the severity of the patient’s functional disability and homebound status, and potential interventions. This process includes a determination of the appropriate level of care and services, and the patient and/or caregiver’s ability to implement the plan of care. Most primary care physicians will be involved in ordering, certifying, and overseeing complex home-care plans for their homebound patients, including documentation of a face-to-face evaluation. The details of the care plan are often generated by nurses and therapists who then implement them. This process should be collaborative and include the expertise of all interdisciplinary team members.[8]
Medicare and Medicaid pay for most of HHC, though other reimbursement programs include private insurance, managed care, the Older Americans Act, and self-pay. In 2010, there were over 10,000 Medicare-certified home health agencies, and an additional unknown number of agencies not certified.[9] Medicare-covered services are part-time, intermittent, skilled services that are limited to homebound patients. This care must be ordered by a physician; administered by a core provider such as a nurse, physical therapist, or speech therapist; and must be appropriate to the patient’s illness and/or injury. As skilled care is provided only temporarily, it is critical that the patient and caregiver learn and carry out tasks such as the use and maintenance of tubes and catheters and the changing of dressings. Other services, such as those provided by a social worker or home health aide, may be reimbursed but only when the patient is receiving care from one of the three core skilled services. Reimbursement models other than Medicare may include considerations of cost-effectiveness, patient prognosis, and the opportunity to achieve certain outcomes of care. This may include care for patients who are not homebound, but who require services such as infusion therapy.
The website Home Health Compare, sponsored by the Centers for Medicare and Medicaid Services (CMS), an agency of the US Department of Health and Human Services (DHHS) – www.medicare.gov/homehealthcompare/search.html – can help providers, patients, and families assess quality measures of Medicare-certified home health agencies.
Medical house calls
There are a significant number of homebound older adults who have difficulty accessing primary medical care, and their care is disproportionately managed in the emergency room or the acute care setting.[10] In fact, it has been suggested that with focus on acute inpatient care, we are actually neglecting the care of those at home.[11] The vulnerable, elderly, homebound patients may receive care at home through home visits or “house calls.” House calls are now more financially feasible for clinicians through modestly higher reimbursement from Medicare, as well as innovative business models based on potential cost savings for health plans, commercial insurers, and other payors from reductions in unnecessary utilization. As a result, the number of house calls performed has grown significantly. However, there are still many office-based primary care providers who – owing to perceived poor reimbursement; time-inefficiencies; concerns about safety, liability, and legal issues; lack of equipment; and perhaps lack of training do – not see patients at home.
Medical house calls are provided by physicians, physician’s assistants, and nurse practitioners in the home as part of an ongoing office-based practice, a hospital-based program, a free-standing practice, special programs such as the Veteran’s Administration (VA), or specialty programs through academic medical centers. Models range from single providers to team-based care that can include social workers, nurses, and others. House calls can provide longitudinal primary care as well as assessment and management of acute/sub-acute care. Programs frequently coordinate with home health agencies and community-based organizations, such as home-delivered meals, to support patients in their homes. The growth and positive published outcomes of many specialized house call/home-care programs are encouraging. Positive outcomes of these programs include optimization of home safety, enhancement of patient and family education, identification of common geriatric issues that would otherwise go unrecognized,[12] increased likelihood of dying in a location of choice,[13] decreased hospital admissions,[14] and reduced health-care costs.[15]
The VA’s Home Based Primary Care (HBPC) program for frail veterans has led the country as a model for comprehensive, interdisciplinary home care. The HBPC program targets patients for whom clinic-based care is not effective, and covers clinician visits, skilled nursing care, and nonskilled care as well as case management. The VA’s HBPC program has demonstrated significantly lower total costs (without shifting costs to Medicare) and reduced hospital and nursing home use.[16, 17]
Another established model of care, the Care Transitions Intervention (www.caretransitons.org), developed by Eric Coleman, focuses on the critical transition of medical care of the patient from hospital to home. The model is operationalized by transition coaches (usually nurse practitioners), and has repeatedly shown that it can decrease hospital readmissions and decrease costs.[18, 19]
Other programs across the country caring for large numbers of chronically ill patients have demonstrated very remarkable reductions in emergency room visits, hospitalizations, length of stay in hospital, and cost savings through a primary care, home-based team approach.[20] In addition, there are specialty home-care programs designed for targeted care of specific medical problems, such as heart failure.
Independence at Home, a Medicare demonstration program supported by the Affordable Care Act and modeled on the demonstrated successes of the VA’s HBPC program, began in 2012 and aims to enroll 10,000 home-limited Medicare patients with multiple chronic medical problems. In this three-year, shared-savings program, patients are provided longitudinal primary care and care coordination services in the home for medical and social service needs by teams headed by physicians or nurse practitioners. Quality, patient satisfaction, and cost savings will be measured.[21]
Importantly, a comprehensive set of evidence-based process quality indicators for homebound seniors developed by the Home-based Primary Care Quality Initiative provides a quality framework to evaluate home-based primary medical care.[22]
Residential care facilities
The landscape is changing in regards to the array of residential facilities available for the older adult. The variety of facilities and what they offer can be daunting. Independent-living and assisted-living (AL) facilities, as well as residential or personal care homes, adult board and care, domiciliary care, and congregate living homes are examples of residential care facilities (RCFs). RCFs were designed as less expensive, and often more appropriate, alternatives to nursing home placement for older persons with chronic care needs. There is still much variability ranging from the definition of facilities, to services provided, to regulation. Consequently, RCFs blur the line between community and institutionally based long-term care.
In addition, continuing care retirement communities (CCRCs) are designed to cross the spectrum for individuals with increasing care needs over time.
In 2010, the National Survey of Residential Care Facilities reported 31,100 RCFs with a capacity for 971,900 residents. About 50% of RCFs were small facilities (4–10 residents), 16% had 11–25 residents, 28% had 26–100 residents, and 7% had capacity for more than 100. Larger RCFs are more likely to be affiliated with a chain and offer services such as physical and occupational therapy and case management.
Although both nursing homes and RCFs provide housing and care to elders with disabilities, a number of important characteristics differentiate them, including the foundation of how care is provided, what care is provided, regulation, and payment.
Whereas nursing homes were developed on a medical model where physicians direct and order care and nurses are the primary providers of care, RCFs were developed more on a residential model where medical care is not central. In fact, most RCFs do not have physicians on site and there are fewer nursing staff.
Just as RCFs were designed to be different from nursing homes, their regulation was also designed differently. Unlike nursing homes, where the CMS sets the standards that qualify a facility for federal Medicare/Medicaid funding, states are the primary regulators of RCFs. Across states, there are no generally agreed upon standards for care and no consensus about which RCFs should be licensed. States establish their own requirements and may provide little oversight or protection for residents. This has resulted in large numbers of disabled older adults receiving care in what is a largely unregulated industry.
Generally, RCF costs are not covered by Medicare, Medicaid, or private insurance; however, resources vary from state to state, and more facilities have been receiving Medicaid support in recent years.[23] Residency can be costly, and the average monthly rate in 2010 was $3,165 for AL facilities.[24]
Assisted living is one example of an RCF. AL facilities originally were designed to serve those who needed intermediate care – between independent living and a nursing home. ALs may offer individual houses, townhouses, condominiums, or apartments that often incorporate disability features and assistive technology. They can be located in freestanding facilities or on a campus with other facilities.
Assisted living traditionally has provided meals; housekeeping; recreational, social, and educational activities; transportation; emergency help; and only limited assistance with ADLs and personal care. However, more and more ALs are offering many levels of care as individuals decline in function and are reluctant to move to a nursing home. Services offered vary from facility to facility, including assistance with medication administration, ADLs, and other nursing care. The National Center for Assisted Living (NCAL) has been leading a quality initiative and encouraging standards and evaluation in assisted living.[25]
Dependencies and comorbidities vary among residents. More than half (54%) of residents in AL are over 85 years old. In 2010, 72% of residents received assistance with bathing, 52% received assistance with dressing, 36% received assistance with toileting, 25% received assistance with transferring, and 22% received assistance with eating. Dementia is common among residents (42%), and 17% of facilities have dementia special care units. These units include special features for the care of residents with dementia, such as dementia-specific activities and programming (91%), doors with alarms (90%), specially trained staff (88%), and locked exit doors (76%).[26]
Other RCFs such as adult board and care, or personal care homes, may not be exclusive to older adults; they may also serve those who require supervision and some personal care with few onsite medical services. They are privately operated and are often converted single-family homes. State law and local zoning regulations determine the exact number of residents allowed (approximately 2–20).
Facilities such as board and care homes typically provide a basic room (may be shared), meals, some assistance with daily activities, custodial help (including reminders to take medications, laundry, housekeeping, transportation), and supervision. Depending on licensing, the home may provide assistance with ADLs (such as bathing and grooming), dispensing of medications, dementia care, basic nursing care, and social, recreational, and spiritual activities. Many board and care homes are unlicensed, and states may only infrequently monitor the licensed homes.
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