Let's Collaborate.

Bundled payments are here to stay—at least that’s the conclusion one may come to given some recent analyses of the topic. And if the powers that be at CMS read the latest Harvard Business Review, they would find some compelling arguments for making bundled payments a permanent fixture in the agency’s efforts to move Medicare into alternative payment models.

The article, “How to Pay for Health Care,” was particularly helpful in explaining why this model could be very successful in achieving the triple aim the agency aspires to. Authored by noted Harvard Professors Michael Porter and Robert Kaplan, the article offers some persuasive opinions about the potential that bundled payment models have in improving health care, reducing costs, and providing individualized care.

Within the context of long-term and post-acute care, there are two demonstrations under way that impact providers: the Comprehensive Care for Joint Replacement (CJR) model and the Bundled Payments for Care Improvement (BPCI) initiative.

In a bundled payment model providers are paid for the care of a patient’s entire care cycle—such as all services, procedures, tests, drugs, and devices used to treat a patient with a condition such as heart failure or a hip replacement, for example. 

Bundled payments represent one component of CMS’ effort to boost value-based reimbursement, with capitation being the other. But Porter and Kaplan note that under capitation a provider must meet all the needs of a patient population with a fixed payment (per year, per covered life).

As the authors compare and contrast capitation and bundled payments, they are convinced that the solution to improving individualized health care and creating efficiencies will come with the latter. They liken bundled payments to a consumer’s experience purchasing products and services, where a single price is paid for a whole package that meets their needs—such as a car. With the purchase of a car, they argue, the consumer does not buy the motor from one supplier and the brakes from another—they buy a complete product from a single entity.

Bundled payments, they say, simply “draw on an approach long used in virtually every other industry.”

Among the arguments made against capitation is that it creates competition at the wrong level and on the wrong things, “rather than on what really matters to patients and to the healthcare system overall,” the authors state, noting that this is similar to how FFS models have traditionally worked. “Capitation rewards improvement at population level but not at individual level.” It is also not aligned with better or efficient care for each patient’s particular condition.

Another downside to capitation models: The risk factors are complex, which leads to an incentive for health systems to claim as many comorbidities as possible to bolster their revenue and profitability, they contend.

Porter and Kaplan conclude that capitation is wrong because it is a “top-down approach that achieves some cost savings by targeting low-hanging fruit such as readmission rates, expensive drugs, and better management of post-acute care.” The problem with this, they add, is that it doesn’t change how health care is delivered and neither does it hold providers accountable for efficiency and outcomes when it comes to patients and the treatment of their conditions. In short, it restricts patient choice and inhibits provider competition.

A recent analysis by consulting firm Avalere Health asserts that the increase in bundled payment models will impact LTPAC providers in several ways. Among them, will be fewer FFS patients, shorter lengths of stay, fewer readmissions, and a decreased use of costly settings

Avalere also has some predictions about bundled payments for the coming year and beyond: a reopening of the BPCI demonstration for new participants, a potential for new models, and an expansion of mandatory bundles like CJR.

Porter and Kaplan also state that bundled payments “will be the catalyst that finally motivates provider teams to work together to understand the actual costs of each step in the entire care process, learn how to do things better, and get care right the first time.”

These arguments could have a significant impact on healthcare delivery and LTPAC in particular. It’s worth the read. 

Wouldn’t it be great if all long-term and post-acute care providers had an electronic health record (EHR) adoption blueprint that guides them through the process, step by step, to implementation? That’s exactly what LeadingAge’s Center for Aging Services Technology (CAST) has done.

CAST announced very recently that it has updated resources on EHRs to include something called a 7-Stage Adoption Model. Developed by CAST for the following LTPAC entities:

• Adult day care
• Attending physicians
• Assisted living
• Acute rehab facilities
• Home health/home care
• Hospice
• Life plan communities
• Long-term acute care hospitals
• Long-term care rehab facilities
• Skilled nursing facilities
• Intermediate care facilitites
• Intellectual disabilities/developmental disability facilities
• Programs for All-inclusive Care for the Elderly (PACE)

The resources also include an updated EHR Selection Portfolio, an interactive online guide, and a new case study that outlines one provider’s journey through EHR adoption. According to a statement from CAST, previous EHR adoption models focused primarily on inpatient settings like hospitals and nursing homes.

This model, however, is aimed at helping all aging services organization in “choosing an EHR system that fits the needs of the organization, its providers, and its consumers, patients, and clients.”

In my opinion, it’s refreshing to see a tool more reflective of where the industry is headed—a more integrated care model that is more about the patient and the care, not driven by the setting.

According to Majd Alwan, CAST executive director, “the CAST EHR Selection Portfolio’s new 7-Stage Adoption Model was tailored to help long-term care providers not only improve efficiency, but also quality of care for their residents.” He also said that he hopes the model will make it easier for more and more providers to integrate advanced EHR functionalities into their operations, and use them to continuously improve care quality.

The 7-Stage model provides a framework to assess the level of adoption and sophistication of use, as opposed to just the overall rate of adoption, of EHRs in long-term and post-acute care. The model also draws from the HIMSS 7-Stage EMR Adoption Model, PointClickCare’s 7-Stage LTC EHR Adoption Model, and Gutkind-Savage’s 10-Stage International EHR Adoption Model.  

No, this isn’t a post about recent high school graduates—it’s actually about their parents, or more specifically, Americans 40 years and older. I am among that group, and we are, for the most part, unprepared to pay for long-term care (something many of us will need in the second half of our lives), uninformed about how it will or can be paid for, and reluctant to go anywhere else but to our own bedrooms to be cared for if or when we need that care.

How do I know this? Here are some stats: A recent survey of Americans 40 and older further illuminates the problem that most of us are woefully ill equipped for the likely inevitability of needing long-term services and supports (LTSS). The survey found that 77 percent of this cohort would prefer to receive long-term care in their own homes, with far fewer choosing to receive care in a senior living community (11 percent) or a nursing home (4 percent)—no surprise here. Released by the Associated Press-NORC Center for Public Affairs, the survey also asked this same group about their preparations for long-term care, and one-third say they’ve done no planning at all for their own care needs.

Moreover, a majority (64 percent) have little confidence that they will be able to pay for it, and just 13 percent are “very sure” they have long-term care insurance, while 4 out of 10 mistakenly believe that Medicare will pay for their care.

Making matters worse, the cost of long-term care is getting more and more expensive and more and more out of reach for a majority of Americans. The Genworth 2016 Cost of Care Survey found that the price tag for long-term care has risen steadily over the past five years. The average hourly rate for a home health aide is $20, a rate that has risen by only about 1.28 percent in the last five years. Assisted living care, at $3,628 per month on average for 2016, has grown by 2.16 percent in the last five years.

Nursing home care—at $225 per day—has made the largest jump in cost, of 3.12 percent in the last five years. No matter how you look at, the cost of long-term care is high—staggering in some cases--and there is no indication that any of these costs will decline in the coming years.

There is a very cool calculator on the Genworth website that helps you figure out what your future costs of long-term care will be, right down to the closest major city. I decided to find out what the price tag will be for me 15 years from now in my fair city of Cleveland, and the numbers are sobering: In 2031, the average annual cost for a home health aide will be about $72,184; an assisted living community will set me back $74,315; and a private room in a nursing home will be $142,165 per year.

If you’re skeptical about whether or not you will need this type of care one day, here’s another stat: Seventy percent of people who turn age 65 can expect to use some form of long-term care during their lives.

What can be done about it? Back in February, a group known as the Convergence Center for Policy Resolutions released a set of recommendations for long-term care financing reform. The framework was developed over the last three years by a group of policy experts and senior-level decision makers representing a “wide range of interests and ideological views,” known as the Long-Term Care Financing Collaborative. Members of the group include Howard Gleckman of the Urban Institute, Jennie Chin Hansen, immediate-past CEO of the American Geriatrics Society, and Gail Wilensky of Project HOPE. Here are some of their recommendations:

• A universal catastrophic insurance program aimed at providing financial support to those with high levels of care needs over a long period of time.
• Private sector initiatives and public policies that will revitalize the long-term care insurance market to help address non-catastrophic LTSS risk.
• Efforts to encourage retirement savings and develop more efficient and innovative use of home equity to assist middle- and upper-income families finance LTSS needs for those risks that are not covered by catastrophic insurance benefits.
• A modernized Medicaid LTSS safety net for those with limited lifetime incomes who are not able to save for these care needs, as well as for those who deplete their assets paying for medical and long-term care costs, including more flexible public programs that can deliver care in the setting most appropriate to the needs of individuals.
• Stronger support for families and communities that are the bedrock for people receiving care at home.
• Better integration of medical treatment and personal assistance.

Although the group acknowledged that many details are yet to be worked out and many questions remain unanswered regarding LTSS financing, they call for more research and “better support stakeholder agreement and informed policy making.”

Not surprisingly, support for policies to help caregivers face the costs of providing long-term care is widespread. Seventy-two percent of those surveyed for the NORC study said they support state programs to provide paid family leave, 83 percent support tax breaks for caregivers, and 73 percent support a Social Security earnings credit for caregivers taking time out from the workforce to provide care.

Just as the cost of college tuition looms for many of us 40-plus Americans, so too does the specter of shelling out thousounds for long-term care. This cohort needs to be educated about what kind of care they will need as they grow older and the reality of how much it will cost.

As these issues are worked through over the coming months (and years), it is wise to look for opportunities for your organization to inform the conversation. Explore solutions you might offer to meet the needs of a cohort with widely varying levels of need, extremely high expectations … and limited resources.

Humans are living much longer than any other time in history, and according to a recent study this phenomenon will translate into a tremendous boon of volunteerism and charity—to the tune of an $8 trillion dollar windfall—for American society.

Aging guru Ken Dychtwald, PhD, and his colleagues presented the study’s findings in his keynote last month at the American Society on Aging’s annual meeting. Released late last year, the report reveals some remarkable findings about the generosity of older Americans. Titled Giving in Retirement: America’s Longevity Bonus, the study offers some food for thought for anyone who serves elders and plans to serve baby boomers.

The study found that over the next two decades there will be a surge in giving by retirees, leading to what Dychtwald describes as America’s $8 trillion “longevity bonus.” Behind this phenomenon, he says, are three factors: the wave of baby boomers moving into retirement (or something that may or may not resemble retirement), the rise in longevity, and the rather high rates of giving among this cohort.

So what’s the evidence behind his premise? Older Americans have more time, money and skills to contribute to causes they care about than younger adults. For instance, more people age 65-plus donate money or goods than any other age group, and they give the greatest amount—more than double that of younger adults.

The research also found volunteers over age 65 volunteer an average of 133 hours per year, compared to those ages 25-34 and 35-44 who volunteer an average 55 and 58 hours per year, respectively.

In addition, retired women—the predominant gender living in seniors housing—are even more likely than men to say retirement is the best time to give back (68 percent vs. 62 percent). More retired women donate (81 percent of women retirees vs. 71 percent of men retirees) and volunteer (29 percent of retired women retirees vs. 22 percent of men retirees) to charitable causes.

According to Dychtwald, those in the aging services field have a “unique opportunity to harness the wealth of talents, skills, and experiences of the boomer generation as they enter retirement and seek to make a difference.”

Dychtwald is right, and long-term and post-acute care providers are in a unique position to harness this moment in history. Consider the fact that living in a nursing home or assisted living community doesn’t mean you cannot give as a volunteer, as a mentor, or in another capacity. In fact, some providers already offer programs that engage their residents in very successful and purposeful volunteer programs, such as creating items to give to local underserved families, serving as mentors for nearby school children, or making crafts to sell at the community farmers market. It’s also good for you—physically and mentally.

The longevity bonus is also ripe fodder for innovators in the field who may be interested in developing solutions that further enable volunteerism for elders, as well as for providers.

What's more, there can be little downside to activities that have been shown to reduce depression and diminish chronic pain.

Sometimes the best solutions for improving quality care and reducing risk are decidedly low tech. Food for thought indeed.

Seventy-two billion dollars is a substantial sum of money for any industry. But did you know that this figure represents the projected revenue from markets created by senior caregiver spending in 2020? That’s what a recent report from AARP and Park Associates reveals: “Caregiving Innovation Frontiers: A universal need, a growing opportunity—leveraging technology to transform the future.”

Here’s another staggering stat: $42.9 billion. That’s the expected profits from six market segments affiliated with caregiver spending this year alone. If you’re paying close attention, you’ll note that the difference between these two numbers represents the expected growth in these combined markets in the next four years: $29.3 billion.

Yes, that’s a sizable and respectful figure, and it represents an opportunity that providers of aging services may want to consider seizing—as the day is close at hand.

The figures are derived from survey data detailing consumer needs, interests, and behaviors, as well as an examination of services already in the marketplace, says AARP. The report also provides detailed descriptions of the six market segments that will produce the aforementioned revenue and are ripe for opportunity now:

1. Daily Essential Activities: Meals, home and personal care, home repair, delivery, transportation services.
2. Health and Safety Awareness: Health vital alerts, diet and nutrition, medication management, personal safety monitoring, telehealth.
3. Care Coordination: Care planning, care professional engagement, records and benefits management, recovery support.
4. Caregiver Quality of Life: Respite and backup care, social support, health and wellness, financial/job security.
5. Social Well-Being: Digital inclusion, life enrichment and empowerment, community networking, life companions.
6. Transition Support: Home retrofit services, long-term care insurance planning, long-term care provider referral, legal assistance, hospice/funeral planning.

In addition to breaking down revenue forecasts for each of the segments, the report is packed with details about companies already offering similar services in each submarket segment and littered with relevant factoids that bring the opportunities into context for providers. For example, did you know that 67 percent of caregivers want to monitor their care recipients’ health and safety but only one-tenth of them are currently doing so?   

If you’re looking for opportunities to expand or diversify your services into the community—or if you simply need to market a technology or service you already offer—I would suggest reading this report ASAP, as it offers an insightful and very helpful examination of the near future for aging services providers. How will you seize the moment?

In addition to becoming more densely populated with the likes of both Millenials and Baby Boomers, U.S. cities of the future will be centers of open innovation, according to a panelist at last month’s Housing for Tomorrow forum sponsored by The Atlantic. The forum, which took place in Washington, D.C., included a number of luminaries in the field of housing, including Vice President and Founding Director of the Metropolitan Policy Program at The Brookings Institution, Bruce Katz, who made the prediction about urban density.

Katz posits that urban areas of the United States are experiencing a “remarkable revaluing” thanks to the interplay of what Millennials and Baby Boomers want and what companies need. He described it as a restructuring of the U.S. economy from what has been a “closed innovation economy, where you had to be out in the middle of nowhere in science parks to keep your secrets secret, to an open innovation, network economy where proximity, density, vibrancy, vitality gets revalued by innovative companies.”

Katz clarified further: “Where once there were major farming companies that had their R & D facilities in the middle of nowhere, they are now moving back into cores of cities, next to MIT,” for example.

Companies want to be near advanced research institutions and hospital complexes, where ideas are being generated and there is speed-to-market, he says.

Innovation Districts

“It’s almost a collapse back into an innovation economy, where talented workers and innovative firms are going to the cores of metropolitan areas.” This, he asserts, will create “a radical change in the spacial geography of innovation.”

This idea seemed very well thought out to me, so I Googled the term “spacial geography of innovation” and found that, indeed, Katz and a colleague had authored a white paper titled, “The Rise of Innovation Districts,” which describes his concept in much more detail.

“America’s family structure has been altered by the simultaneous aging of the population and the tendency of young adults to delay marriage and have fewer children,” the report states.

What’s more, research shows that 70 percent of Americans place a high priority on walkability, proximity to health care, entertainment, recreation, work and school, and social contacts. “Older Americans are increasingly seeking smaller homes and apartments, as well as places with easy access to medical services, shopping, and other daily necessities,” the report states. “Meanwhile, middle-aged couples, whose children have ‘left the nest,’ show greater receptivity to urban neighborhoods, cultural amenities, and shorter commutes.”

MegaCities and the Death of Distance

Related to the Brookings report is a futures study from the Industrial Research Institute that examines, among other things, a scenario titled “Death of Distance vs. MegaCities,” which dovetails with the Brookings concept in that it advances the idea of an “open innovation framework,” similar to Katz’s assertion.

The study alleges that by 2038 cities will become major political forces in countries due to their embrace of smart technologies to manage transportation, energy, and waste.” But IRI’s crystal ball also finds that technology and connectivity will “make distance irrelevant” and enable scientists to work and teach at the “level of entire corporations or universities of the past.”

What does any of this have to do with aging or long term and post-acute care? For senior housing professionals, it’s valuable information about where future customers will choose to live, where their Millienial caregivers will also live and work, and where the innovation and technology to care for Baby Boomers will be generated.

If you happen to disagree with these predictions, all from highly regarded organizations, then at least consider it food for thought.

Hospitals are out and community alternatives are in, according to Bill Thomas, MD, aging guru and Harvard-trained geriatrician, who was at University of Maryland Baltimore County recently to share his opinions on long term care, ageism, and the word “continuum,” among other things.

After declaring himself a nursing home abolitionist, Thomas was quick to note that he bears no ill will toward owners, operators, or others who work in such places—he simply wants to abolish institutional models of care.

This assertion is not a new one for Thomas, who had just finished his Age of Disruption tour of 35 U.S. cities. He began his career as a nursing home medical director in New York some 30 years ago, where he encountered poorly run facilities and painfully lonely and isolated residents. Since then, he has founded the Eden Alternative and Green House models of long term care, which eschew models that adhere to institutional dictates.

However you may feel about Thomas' views, he is a force to be reckoned with when it comes to holding sway among long term care professionals. His standing as an aging influencer (a title bestowed upon him by both www.NextAvenue.org and The Wall Street Journal) is undeniable. He is credited by most to be the founder of the culture change movement in nursing homes, and his many followers (nearly 7,000 on twitter and thousands between his Facebook page, blogs, and books) believe him to be a bit of a savior in the field of aging services.

The informal gathering enabled Thomas to wax extemporaneously from his “notebooks of thought” on topics such as aging, grief, and hospital care. Yes, that’s hospital care. The good doctor believes that the law responsible for Obamacare is doing a fine job of steering money away from hospital beds and toward outcomes.

How so? For one, he says the Affordable Care Act (ACA) is creating, slowly and imperfectly, “a movement away from a system where the money follows the bed to one where money follows the risk,” he says. What’s emerging, he adds, are populations of people that become enrolled in an organization or system that takes responsibility for those people and those outcomes (a la accountable care organizations).

“All of the sudden,” says Thomas, “heads in beds is not a winning strategy.” He confessed that he spent years of his career doing the best he could to make a flawed nursing home model work. “But now, provisions of the ACA are changing that far more than I ever did."

Connected to this issue, Thomas noted, is something known as post-hospital syndrome—when someone goes into a hospital and comes out much worse off due to a lack of movement resulting in loss of balance and muscle mass, among other things. 

“What happens in a hospital,” Thomas said, “is they treat a presenting complaint and when it’s been adequately treated, you are discharged. They don’t help you heal; the docs treat the numbers, and not the person.”

So, what is the antidote to this? Thomas posits the following: Move Eat Sleep and Heal, or MESH. He believes that hospitals and the entire health care system have been doing it wrong by focusing on chief complaints and diagnoses when they really need to focus on MESH.

“We spend billions of dollars where it’s virtually guaranteed that Medicare patients will not heal,” he says. “The slope [of decline] is of our own creation. We manufacture disability, frailty, weakness, and we create it on a massive scale.”

In short, Thomas says he would like to “free America’s elders from its hospitals.” The real conversation, he adds, is with the payers and with the people who will set up new and different networks that keep people out of hospitals.

The corollary to this, Thomas notes, is to “create a rich set of community-based alternatives that work for people. Get the people who are in hospitals out of hospitals, don’t put them in the nursing home, put them in a place in a neighborhood in a community where they can get MESH care,” such as their homes.

A future post will examine why Thomas wants to wage war on the word “continuum.”

Dementia Care Specialists (DCS) offers an award-winning memory care program, the Warchol Best Abilities Care Model^SM, to providers of senior care.  Those adopting it are transforming the way memory care is delivered, resulting in extraordinary levels of person-centered care. 

The Warchol Best Abilities Care Model accelerates a positive, abilities-based, congruent approach among all staff.  Dementia-capable care partners gain skills to simplify a resident’s world, find the just-right level of challenge, reduce fear and anxiety, and enable vitality. Positive outcomes include improvement in levels of independence, reduction in challenging behaviors, decreased staff turnover, reduction in weight loss, and increased participation in meaningful life activities.

With 60-80% of consumers making purchase decisions long before “the tour,” resources are needed to sway prospects earlier than ever in the sales cycle.  Dementia Care Specialists turned to Quantum Age Collaborative to develop a kit of resources for providers to use over the course of the entire sales cycle, including:

• Awareness.  For consumers in the earliest stages of the cycle, these tools help them answer questions like “what are the signs we need help?”  “How do I cope at home right now?”
• Research.  For consumers knowing they need help, these tools help them explore the differences between services, ways to finance services, and stories of families with similar experiences. 
• Compare.  For consumers actively shopping, these tools help them ask the right questions and compare providers.
• Buy.  For consumers on the tipping point, these tools help with a clean close.
• Delight. Post-close, these tools help consumers feel great about their decision – affirming they’ve made the right choice.

The goal of this program is to make it easy and cost-effective for the provider to leverage prospecting tools over all five phases of the buying cycle, thereby building momentum for the Warchol Model with strong, consistent branding--everywhere it is sold. 

Teams at Quantum Age look forward to collaborating with DCS on this win/win opportunity:  to differentiate a strong marketing mix for the Warchol Model to drive census (for the provider) and thought leadership (for DCS)! 

Quantum Age's CC Andrews moderated a panel of industry leaders at Connect 2015, the National Quality Innovation Conference, held in St. Louis, MO, June 7-9. 

What we learned:

While there are riches in the niches, you must validate your claim of being a specialist to prove you deserve the revenue.  Innovation, differentiation, and revenue are now intertwined with analytics.

For example:

• If you have a heart program to drive referrals, can you measure your performance in real time? 
• How are you driving improvements over time...backed by data to prove it? 
• Can you show how your results compare with others competing for the same business in your region?
• Are you transparent with your weaknesses and what you’re doing about them?  

The bottom line: 

It’s imperative you know your data like your life depends on it, and be prepared to speak to it. 

Long-term care (LTC) delivery is no longer relegated exclusively to the nursing home. Today, these long-term services and supports (LTSS) are delivered with increasing frequency in settings ranging from assisted living and senior living communities to individuals’ personal residences.

The LTC trade association LeadingAge, for example, reports that 61% of its Top 100 constituents have already diversified their service lines to include home and community based services.[i] Recent developments with accountable and managed care organizations indicate that the trend of providing care and services in less institutional settings will continue for the foreseeable future. These models’ value-based payment strategies have made effective care coordination and care transitions top priorities.

Hmmm...are we really a "long-term" industry?

Each setting within the LT-PAC network has its own distinct characteristics.  Traditional nursing homes, while in the process of evolving into other service lines, are still prominent players in the care continuum. Finding specialty areas and expanding into including short-stay rehab, is becoming increasingly important to this sector. An area of significant growth in LT-PAC is short-stay rehab. For those operators, outcomes are the primary emphasis.

Assisted living (AL) is another sector undergoing significant change. Its traditional consumer base is increasingly receiving AL services in their homes, causing providers to offer new services lines, often memory care. For AL, sales and marketing technology is critical. Memory care is a hot area—the prevalence of Alzheimer’s Disease and other forms of dementia assure demand for these services well into the future. Demonstrating outcomes and interfacing with applied technologies are of interest to this sector. Finally, home and community based services (HCBS) including home health, hospice and adult day are increasingly a part of the LT-PAC system.

Nursing Homes

Skilled nursing and intermediate care properties specialize in providing intensive personal and/or healthcare services. According to the Centers for Medicare and Medicaid (CMS), there are 15,681 certified nursing facilities in the US. Of these properties:

• 55% are controlled by multi-facility organizations; 45% are independent

• 69% are for-profit; 25% are nonprofit; and 6% are government facilities

• 6% are dedicated special care units (Alzheimer’s, Rehab, Ventilator, Hospice, Aids, Other)[ii]

Traditionally the “bread and butter” segment of the continuing care spectrum, skilled nursing has been undergoing a process of “right sizing” over the course of the last decade. The number of skilled nursing facilities has been on a steady, but gradual decline. However the number of skilled nursing units overall—as well as the number of residents—has remained constant. Smaller facilities are being replaced with larger, more cost-effective plants.

This segment of the market is now on the brink of a more significant transformation. Due to such factors as demographic shifts, consumer demand and expectations, new Federal health policies and a changing state payor landscape, the standard “nursing home” is changing its focus to chronic, medically complex care and/or short stay rehabilitation services. Both consumers and payors (Medicare/Medicaid and private insurers alike) are pushing care delivery back into Home and Community Based Services (HCBS) for clients whose needs can suitably be delivered outside of a facility setting. Far from its “old folks’ home” roots, the skilled nursing facility is being challenged to care for those patients who are not ready to return home (or to lower levels of care acuity). With progressive frequency, medically complex cases requiring more intensive care and patients recovering from acute events (rehabbing from strokes, cardiac procedures, hip replacement, etc.) are the new nursing home patient.

[i] LeadingAge. Ziegler. “LeadingAge Ziegler 100.” (2013): 4

[ii] American Health Care Association. “LTC Stats: Nursing Facility Operational Characteristic Report.” (2013): March

Short-Stay Rehabilitation

Approximately one-third of hospital patients are discharged into post-acute care. The most common setting for the delivery of this care is the skilled nursing facility specializing in short-stay rehabilitation, making it one of the fastest growing service lines in the LT-PAC spectrum. Facilities providing short-stay rehabilitation offer services to patients who need additional support while recuperating after a hospital discharge.[i]

Services provided might include:

• Physical therapy

• Occupational therapy

• Respiratory therapy

• Speech therapy

• Wound management

• Cardiac rehabilitation

• Pain management

• Ventilation care

There is a determined course of treatment, often involving a therapy regimen. Typically, these services are in place to improve a patient’s transition from hospital to the community. Rehabilitation measures are taken to promote optimum attainable levels of physical, cognitive, psychological, social, emotional and economic usefulness so that an individual can maintain maximum functionality.

The emphasis of short-stay rehabilitation is on results. Payment sources for this service line (primarily Medicare, managed care and/or private insurance) demand both optimal clinical outcomes and cost-effectiveness. Having the data to demonstrate efficacy in both areas is imperative.

Assisted Living

Since each state has its own terminology and standards for this service line, there is no uniform definition for assisted living (AL) across the US. Generally speaking, however, AL supports people who have restricted functionality, due to advanced age and/or disability. Residents are in need of help with activities of daily living (ADLs) like eating, bathing, toileting or ambulating, but are encouraged to live with the highest degree of independence possible.[ii] The current service model is directed at an average resident who is 85, has one or more chronic health conditions, and requires assistance with three or more ADLs (activities of daily living). 42 per cent of AL residents have been diagnosed with some form of dementia. [iii] Services typically include prepared meals, security, organized social activities, laundry and transportation. Assisted living communities are increasingly providing clinical services such as medication management, ointment and light dressing application, and therapies to keep strength and daily function as high as possible.

AL is an extremely diverse market segment. Far from homogenous, this sector ranges from the very small to extra-large. For example, of the 31,100 AL communities accounted for by the Centers for Disease Control and Prevention (CDC):

• 50% are considered small (4-10 beds)

• 28% are categorized as large (26-100 beds)

• 7% are classified as extra-large (more than 100 beds)

Large AL communities (26 or more beds) make up 35 per cent of all AL communities, yet house a full 81 per cent of all AL residents.  Conversely, small to medium sized communities significantly outnumber larger communities, but account for only 19 per cent of all residents. [iv]

The sector is more homogenous in other demographic characteristics:[v]

• 82% of AL communities are privately owned for profits

• The remaining 18 percent (about one in six) are nonprofit or owned by state, city, or local government

• 62% are owned by independent operators (particularly smaller communities)

• Approximately 38 percent of facilities are chain-affiliated

The same trends causing skilled nursing to change its service and operational model will have a significant impact on assisted living as well. The services provided by assisted living are more readily transferred to less congregate settings. The sector is beginning to respond by converting traditional assisted living units into memory care units. In fact, complete memory care wings—and entire communities—are beginning to emerge as a major trend within the long-term care continuum.

Memory Care

An emerging sector in long-term care and senior living is memory care.  Typically housed within a skilled nursing or assisted living community, memory care units cater to consumers with Alzheimer’s disease (AD) and other forms of dementia.  The statistics are staggering.  One in nine people age 65 and older are afflicted with AD and about one-third of people age 85 and older have the disease. As life expectancy increases and the population ages (more rapidly, now that Baby Boomers have begun turning 65), the sheer number of Alzheimer’s cases alone is expected to mushroom.  By 2025, the number of people 65 and older with Alzheimer’s disease is expected to increase by 30 per cent.  Some project the number of AD cases to triple within one generation.[vi]

Upward trends in life expectancy and the aging of the US population are what make the memory care offering so popular.  Assistance with ADLs and care management of chronic conditions are services more easily transferred to HCBS.  Cognitive impairment, however, poses unique challenges and risks—and is often more easily addressed in a congregate setting.  While this sector is small, compared to the other service sectors, the growth change for memory care surpasses all other sectors.

Home and Community Based Services

Home and Community Based Services (HCBS) is a term used to describe an array of non-institutional care alternatives. When describing HCBS, the word “community” is used in a broader sense which can include a person’s home as well as other locations within the general community. Development of HCBS remains a priority for many public healthcare programs. In addition to the cost savings these programs are expected to generate, it is also the desire of most consumers to receive care and services in the least institutional setting possible. For the purposes of LT-PAC delivery, those service lines include home health, hospice/palliative and adult day care.

Home Health Care

As the name implies, home health care services are provided in a person’s place of residence. The home may be a single family home, apartment, or senior living community. Home health services are frequently provided after a hospitalization or short-term rehab stay to assist in a patient’s transition back home. Home health care encompasses such services as assessments, provision of care, treatment, counseling and/or monitoring of clinical status. These services are delivered by a host of professionals including nurses, physical therapists, occupational therapists, speech therapists, audiologists, dentists, social workers, dieticians, and more. Home health care is usually provided when a person requires intermittent care (a few hours per day/a few days per week), rather than full-time.[vii] If more regular, round-the-clock care is required, a facility-based model of care is usually recommended for cost-effectiveness.

Hospice Care

Often referred to as “end-of-life care,” hospice services are provided to individuals diagnosed with terminal illnesses who have a limited life expectancy (usually defined as six months or less). Care provision departs from the traditional model of clinical treatment and instead focuses on the palliative management of pain and other symptoms. Meeting a person’s emotional, psychosocial and spiritual needs is a primary focus, as is assisting the family to cope with the loss of a loved one.  

Adult Day Care

A form of long-term care, adult day care provides interim (less than 24-hour) assistance for individuals who require supervision or assistance, but not round-the-clock nursing care. These community-based programs are designed to provide a safe setting for the provision of social and health services. They also provide a respite for caregivers in need of a break from the demands of their caregiving role. There are several popular models of adult day care services.  The social model provides meals and supervised activities. A more medical approach focuses primarily on the delivery of health care. Specialty models have developed as well, offering services for those with dementia, brain injuries, and other chronic conditions.[viii]

Summary

What was once a safety net for our nation’s elderly has evolved into an ever-more-complex and interwoven system of long-term services and supports for a broad population of Americans. The medical model of old has evolved into a person-centered paradigm, wherein the money follows the patient. Today’s long-term/post-acute care now encompasses skilled nursing, short-stay rehab, assisted living, memory care, and an array of home and community-based services. Consumer demand and the advent of ACOs and MCOs are driving significant change. Fee-for-service is being replaced by value-based payment. LT-PAC providers must demonstrate their outcomes and cost-effectiveness just to survive.

[i] Pratt, John R. Long-Term Care: Managing Across the Continuum. 3^rd Edition. Sudbury, Mass.: Jones and Bartlett Publishers, 2010.

[ii]   McSweeney-Feld, Mary Helen. Oetjen, Reid. (Eds.) Dimensions of Long-Term Care Management, An Introduction. Chicago: HealthAdministration Press, 2012.

[iii] Mollica, Robert. Houser, Ari. Ujvari, Kathleen. “Assisted Living and Residential Care in the States in 2010.” AARP Public Policy Institute, 2010.

[iv] Ibid

[v] Ibid

[vi] Alzheimer’s Association. 2012 Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia. Volume 8, Issue 2

[vii] Pratt, John R. Long-Term Care: Managing Across the Continuum. 3^rd Edition. Sudbury, Mass.: Jones and Bartlett Publishers, 2010R.

[viii] McSweeney-Feld, Mary Helen. Oetjen, Reid. (Eds.) Dimensions of Long-Term Care Management, An Introduction. Chicago: Health Administration Press, 2012.