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Historical considerations: the evolution of institutional long-term care
American hospitals and nursing facilities have a common progenitor: the colonial period almshouse. The eighteenth-century almshouses received dependent persons who lacked the financial or family resources to maintain themselves in the general community, including the aged, orphaned, debilitated, and mentally or physically ill. The almshouses served a general welfare function by providing substitute households for the poor and infirmed.[1]
The Philadelphia Almshouse was founded in 1732 and provided the first government-sponsored care of the poor in the colonies. It subsequently evolved into Philadelphia General Hospital.[2] The first American public hospital started as a six-bed infirmary ward in the New York City Almshouse, founded in 1736. It subsequently evolved into Bellevue Hospital.[3] The Baltimore City Almshouse, founded in 1774, evolved into the Baltimore City Hospitals.[4]
In 1751, the Pennsylvania Hospital in Philadelphia opened its doors as the first voluntary hospital in America, built with private donations specifically to care for the sick.[5] Other early voluntary hospitals included New York Hospital opening in 1791 and the Massachusetts General Hospital opening in Boston in 1821.[6] Although these institutions were built with private donations for the purpose of taking care of the sick, there was little that medicine had to offer in that era. Hospitals took care of the ill and dying who had no home and family to care for them. Hospitals were viewed as “houses of death” and were considered “unhappy necessities.”[1] The preferred site of medical care, including any surgery and childbirth, was in the family home. It was not until the late nineteenth century, with the adoption of principles of antisepsis, use of anesthesia for surgery, availability of x-rays to improve diagnosis, and the emergence of professionally trained nurses, that hospitals evolved into places to care for people of all socio-economic classes suffering from acute illness.[1]
In the early nineteenth century, women’s and church groups began to establish shelters for “worthy individuals of their own ethnic or religious background,” to keep formerly respectable individuals from being relegated to the almshouse.[7] The Philadelphia Indigent Widows’ and Single Women’s Society founded one of the earliest “old age homes” in 1823, but an applicant had to provide a “certificate of good character.”[7] Many similar institutions had entrance fees, so impoverished individuals still found the almshouse as their last refuge in old age.[7]
As American hospitals began curing episodes of illness, rather than caring for indigent people who were infirm or dying, the average length of stay in the hospitals dropped from the pre-1880 level of more than 4 weeks to 18 days by 1900. By 1923, the average length of stay per hospital episode was 12.5 days.[1] Those who were chronically debilitated were sent to the almshouses, if they lacked family or resources to continue their care at home. During this period, private voluntary charitable institutions arose to care for the convalescing and “the incurable.”[8, 9]
The Social Security Act of 1935 had a provision that persons residing in public institutions were ineligible to receive benefits. This provision, though later rescinded, is credited with the rise of the for-profit nursing home industry. Those aged persons who required daily assistance, but lacked family to care for them at home, could use their Social Security income to pay for domiciliary care in a private setting.
Passed in 1946, the Hill-Burton Act promoted the expansion of institutional health care in the United States in the post–World War II era. Federal grants and loans helped hospitals and nursing facilities with new construction and modernization. In return, the health-care institutions agreed to provide a reasonable volume of services to those unable to pay. Although the Hill-Burton Act funds were no longer available after 1997, there are 170 health-care institutions in the United States that remain obligated, as recipients of Hill-Burton funding, to provide free or reduced-cost care.[10]
The health-care landscape changed dramatically with the passage of the Medicare and Medicaid legislation in 1965. Medicare fueled the growth and dominance of hospital medicine. The growth of the nursing home industry in the 1970s was fueled by the Medicaid program, since Medicaid covered the cost of nursing care in the institutional setting for disabled persons who were unable to pay privately.
In the late 1970s, containment of hospital costs became a priority for the Medicare program. The prospective payment system (PPS) based upon diagnosis-related groups (DGRs) was introduced in 1980 as a novel approach to paying hospitals. This system incentivized hospitals financially to discharge patients at or below the average length of stay for their diagnostic group. Hospitals were noted to discharge patients “quicker and sicker.” Nursing facilities stepped up to assist in this transition by admitting patients under the institutional Medicare Part A skilled nursing benefit for short-term post-acute care.[11] Post-acute care has become the major focus of many nursing facilities because it generates higher revenue than the traditional long-term care (LTC) programs, which have decreased in census due to the increasing numbers of community-based options now available.
The governmental funding bias toward institutional care can be traced back to the early nineteenth century, when in 1828 it was noted that “the government hoped to restrict expenditures for public assistance by making the almshouse the only source of government assistance to the poor.”[1] Today, the modern nursing facility has replaced some functions of the almshouse, as the refuge of last resort for those whose care needs exceed the capacity of their families and communities. Despite the fact that most nursing facilities are owned and operated by private corporations, most of their revenue comes from governmental sources, such as Medicaid, Medicare, and individuals’ Social Security checks.
In the 1970s, advocacy groups began grass roots campaigns to try to expand community-based options for disabled persons of all ages. The 1999 Supreme Court Olmstead decision required states to create more community options for Medicaid recipients. Many states offered “Medicaid wavier” slots to help move lower-acuity indigent residents out of the nursing facilities into assisted-living facilities (ALFs). Medicaid waiver programs also provided funds for expanded services in the person’s own home, at times paying family caregivers, to allow nursing home residents to move back into the community. The private market expansion of ALFs starting in the 1990s allowed those older persons with financial resources and ADL dependencies to find care outside of nursing facilities. The nursing facilities were then left with the highest medical acuity, most behaviorally disturbed, and most dependent indigent residents.
In summary, both modern American hospitals and nursing facilities can trace their origins to the colonial period almshouses. As hospitals evolved in their ability to diagnose, treat, and cure acute illness, medical and surgical care left the private family home and moved into the hospital. Nursing facilities assumed the residential care of chronically ill and dependent persons, whose long-term needs exceeded the capacity of their families. As more chronic care now is moving back into community settings, nursing facilities are focusing on post-acute, short-term care. Although programs such as the Eden Alternative and the Pioneer Network continue to try to assist nursing facilities in developing more homelike LTC environments,[12, 13] the emphasis on post-acute care and preventing hospitalization demands ongoing evolution of nursing facilities into more sophisticated medical facilities.
Current post-acute and long-term care programs
Short-stay residents/patients in the nursing facility
Post-acute care
Although the American nursing facility is considered a site for “institutional long-term care,” short-stay, short-term care programs continue to grow and are increasingly dominant within nursing facilities. Most nursing facilities provide rehabilitation services for patients after stroke, joint replacement, and fracture repair, as well as for reconditioning and strengthening after an acute medical illness or surgery. Medicare Part A includes a benefit that pays 100% for the first 20 days of skilled nursing facility care, if indicated by the patient’s needs and progress. This benefit is only activated if the patient has a three-night qualifying stay in an acute care hospital prior to nursing facility admission. With the increased use of “observation status” rather than actual hospital admission, some Medicare enrollees may not be eligible for the skilled nursing benefit. After the first 20 days, there is a daily co-payment for the care provided on days 21–100. Some, but not all, Medi-gap, secondary insurance policies will pay this copayment. After 100 days total, the Medicare benefit is exhausted and the patient converts to private pay if ongoing institutional skilled care or long-term care is required.[11] People who are enrolled in Medicare managed care programs will have different rules and requirements governing their eligibility for skilled nursing facility rehabilitation and post-acute services. The three-night hospital stay is typically waived for skilled benefit eligibility.
A major focus in the care of the post-acute population has been on the readmission rate back to the acute care setting within the first 30 days after nursing facility admission. Since the Medicare program penalizes the hospital through nonpayment for selected readmissions, hospitals and post-acute facilities have started to work together to analyze and improve the process of transitions of care. Improvements in the clinical capacities of the nursing facility staff, the care rendered by the medical staff, and improved hand-offs from the hospital team have helped decrease the rate of readmission nationwide. Programs such as INERACT have helped facilities focus on improving the care and reducing the readmissions.[14] The emphasis on reducing unnecessary readmissions has pushed the nursing facility into an increasingly medical model, trying to provide acute medical care in addition to the traditional residential long-term and short-term rehabilitative care.
In order to monitor the post-acute care patients adequately, medical visits typically need to be made at least weekly, or more often if patients are experiencing medical complications or setbacks in their rehabilitation progress. Some medical practices are experiencing Medicare audits claiming that this frequency of visits is medically unnecessary, since the historic requirement for Medicare payment for nursing facility visits was once every 30 days for the first 90 days, followed by once every 60 days thereafter. Although good documentation of the medical necessity of the visit should stand up against an audit, this added threat and burden is making some physicians question their ongoing participation in this arena of care. Although Centers for Medicare and Medicaid Services (CMS) is penalizing hospitals for excessive readmissions, it may be simultaneously challenging the work of the nursing facility medical staff to help realize the lower readmission rate through the provision of more frequent, attentive, and expert medical care.
Respite care residents/patients
Another group of people who may be short-term residents/patients of nursing facilities are those who are admitted for respite care. These people generally pay the daily rate out of pocket, unless they have a respite care benefit with a long-term care insurance policy or a Veterans Administration benefit, or they are enrolled in Medicare Home Hospice. A typical respite care scenario would be the short-term admission of a person with dementia who requires 24-hour supervision at home, so that the family caregiver could take a trip, attend to his or her own personal health issues such as the need for elective surgery, or just have a rest. Respite care residents/patients are expected to return to their homes in a matter of days or weeks.
Terminal care/hospice care in the nursing facility
End-of-life care has become part of the scope of practice of US nursing facilities. A decade or more ago, many nursing facilities transferred back to the hospital any resident/patient who was dying, for fear that a death in the facility might lead to a charge of negligence. With greater acceptance of advance directives and advance care planning, residents and their families may have greater autonomy in deciding how they want the end of life to be approached. For those who recognize that repeated hospitalizations as death approaches and attempts at cardiopulmonary resuscitation for people with end-stage conditions are rarely useful and often traumatic to the dying person, hospice-type care in the nursing facility is increasingly accepted. With the strong emphasis on avoiding unnecessary hospital readmissions from nursing facilities, determining prognosis and transitioning dying patients to a palliative care plan has become a critically important aspect of nursing facility medicine.
Although the Medicare Hospice benefit may be applied within the nursing facility, it cannot be implemented along with the Medicare Part A skilled nursing benefit. Because the Medicare Hospice benefit does not pay for the room-and-board aspect of nursing home care, those who qualify for the Medicare Part A skilled nursing benefit would have an increase in their out-of-pocket expenses by signing on to Medicare Hospice. Under these circumstances, hospice-type care may be employed without invoking the Medicare Hospice benefit per se. The Medicare payment for a nursing facility resident enrolled in hospice goes to the hospice organization, and the nursing facility must bill the hospice for its daily rate. This bureaucratic detail inhibits many nursing facilities from enthusiastically referring their end-of-life residents to hospice organizations. Hospice benefits and services for nursing facility residents have also been an active area of Medicare fraud and abuse investigations, inhibiting many hospice organizations from enthusiastically pursuing service in such settings. Despite these concerns, the hospice team often makes a huge difference in helping the nursing facility staff control a resident’s end-of-life symptoms. The hospice benefit also provides additional support to families struggling with a loved one’s death in a nursing facility. Moreover, the hospice benefit provides bereavement care for the surviving family member after the loved one’s death.
Long-stay residents in the nursing facility
Typically, more than half of the long-term care residents in a nursing facility suffer from dementia. Over the last decade, in response to the market demand for higher-amenity, more homelike environments, the assisted-living industry has built thousands of facilities that provide care in the community for frail elders who have dementia. This trend has left the more medically complex, functionally and behaviorally impaired residents with dementia in the nursing facility. It has also made lack of resources a distinguishing feature between those persons with dementia who can afford to enter assisted-living facilities versus those who cannot and are admitted to a nursing facility with Medicaid payment.
Disabled younger persons must resort to living within a nursing facility, when community options are inadequate for their care needs. The social needs of younger, physically impaired persons are dramatically different from the needs of frail elders with dementia, and often the nursing facility struggles with meeting those needs. Although the preadmission screening and referral process (PASAR) is mandated by federal law and requires nursing facilities to identify persons with developmental disabilities and chronic mental illness to promote community placement, it is rare that the preadmission screening and referral process actually results in an alternative site of care for these specialized populations. Specialized facilities and better community options are necessary to meet the needs of younger persons with functional deficits, including those with developmental disabilities and chronic mental illness. Despite the Olmstead decision, it has been challenging to overturn centuries of institutional bias. The nursing facility often remains the community resource and refuge of last resort.
Structure of nursing facility medical practice
Primary care practitioner, continuity of care model
It may be desirable from a continuity of care perspective for a primary care physician to continue to care for his or her own patients once they enter a nursing facility. The long-established doctor–patient relationship can help the nursing home staff understand the new resident within a historical context. The physician can help the patient and family adjust to the strange, new environment and serve as a patient advocate within the facility. It was not long ago that primary care physicians followed their patients across any site of care in which they found themselves. Today, however, emergency room visits are usually managed by the emergency medicine physician, hospital admissions are managed by the hospital-based inpatient team hospitalist physician, and when intensive care is required, the ICU attending is often an intensivist. Likewise, when nursing facility care is needed, the care is often provided by a physician and nurse practitioner team devoting all of their time to nursing facility practice.
The ideal of continuity of care that was taught to twentieth-century medical students as a hallmark and pillar of quality primary care has fallen victim to the demand for efficiency, productivity, and the industrialization of medical care delivery in twenty-first-century America. Physicians today are more likely to define their practice by a particular site of care, rather than by wherever the physician’s patient may be located.
Post-acute/LTC practitioner, unassigned admissions
Some physicians in private practice will accept patients under their care within the nursing facility when the patients’ own attending physicians do not attend there. These patients are termed “unassigned admissions,” as opposed to the patients who are assigned to their community physicians who are on staff at the facility. The physicians accepting unassigned admissions typically make visits on site at the nursing home several days each week and are responsive to the nursing staff calls when they are not on site. Often new physicians in a community will find it advantageous to work with the local nursing facility early in their career to build a caseload while the office-based practice is growing. Once the office practice has grown and is demanding more time, the physician may take him- or herself off of the unassigned admissions roster or may leave the nursing facility practice entirely.
Medical practices employing physicians, nurse practitioners (NPs), and physician assistant (PAs) to work exclusively in nursing facilities are increasingly common. Some of these practices are multistate in scope. Some of these large practices are forcing the independent practitioners out of business, when the nursing facility decides to preferentially give all of the unassigned patients and residents to one group. Sub-specialists who previously were never seen within a nursing facility, are now rounding regularly in many settings to assist facilities with congestive heart failure programs, infection control, post-operative follow-up, physiatry-guided rehabilitation, and others. The landscape of medical practice in nursing facilities is rapidly changing as nursing facilities continue to evolve into a more medically focused site of care.
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