Homework answers / question archive / Chapter 10 Long-Term Care Learning Objectives (1 of 2) • • • • Concept and features of long-term care (LTC) Discuss the various types of LTC services Describe who needs long-term care and why Home- and community-based LTC services, and who pays Learning Objectives (2 of 2) • LTC institutions and levels of services provided • Specialized LTC facilities and continuing care retirement communities • Institutional trends, utilization, and costs • Explore the aspects of private LTC insurance Introduction (1 of 2) • Long-term care (LTC) is a complex subsystem

Chapter 10 Long-Term Care Learning Objectives (1 of 2) • • • • Concept and features of long-term care (LTC) Discuss the various types of LTC services Describe who needs long-term care and why Home- and community-based LTC services, and who pays Learning Objectives (2 of 2) • LTC institutions and levels of services provided • Specialized LTC facilities and continuing care retirement communities • Institutional trends, utilization, and costs • Explore the aspects of private LTC insurance Introduction (1 of 2) • Long-term care (LTC) is a complex subsystem

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Chapter 10 Long-Term Care Learning Objectives (1 of 2) • • • • Concept and features of long-term care (LTC) Discuss the various types of LTC services Describe who needs long-term care and why Home- and community-based LTC services, and who pays Learning Objectives (2 of 2) • LTC institutions and levels of services provided • Specialized LTC facilities and continuing care retirement communities • Institutional trends, utilization, and costs • Explore the aspects of private LTC insurance Introduction (1 of 2) • Long-term care (LTC) is a complex subsystem. • Numerous sources of financing. • Community-based services. – More economical and preferred by older people • Individuals may require LTC from functional deficits arising from chronic conditions. Figure 10-1: People with multiple chronic conditions are more likely to have activity limitations. Reproduced from Partnership for Solutions and Johns Hopkins University. 2002. Chronic conditions: Making the case for ongoing care. Baltimore, MD: Johns Hopkins University. p. 12. Introduction (2 of 2) • Cognitive impairment may lead to functional decline. • Two indicators assess functional limitations – Activities of daily living (ADLs) scale – Instrumental activities of daily living (IADLs) Nature of Long-Term Care (1 of 2) • • • • • Variety of services Individualized services Well-coordinated total care Maintenance of residual function Extended period of care Figure 10-3: Key characteristics of a welldesigned long-term care system. Nature of Long-Term Care (2 of 2) • Holistic care • Quality of life – Loss of self-worth accompanies disability. – Patients remain in LTC settings for long periods. • Use of current technology – Personal emergency response system (PERS) • Use of evidence-based practices Long-Term Care Services (1 of 2) • Medical care, nursing, and rehabilitation • Mental health services and dementia care – Caring for dementia patients is a major focus in LTC. • Social support • Preventive and therapeutic long-term care • Informal and formal care Long-Term Care Services (2 of 2) • Respite care • Community-based and institutional services • Housing – Private and public housing • End-of-life care Figure 10-2: Medicare enrollees age 65 and older with functional limitations according to where they live, 2009. Reproduced from Federal Interagency Forum on Aging-Related Statistics. 2012. Older Americans 2012: Key indicators of well-being. Washington, DC: US Government Printing Office. p. 61. Figure 10-4: Range of services for those in need of long-term care. Modified with permission from Taylor & Francis from Singh, D. A. 1997. Nursing home administrators: Their influence on quality of care. New York: Garland Publishing, Inc. p. 15. Users of Long-Term Care • 50% of LTC users are younger than age 65. – Developmental disability (DD) – Intellectual disability (ID) – Patients with HIV/AIDS Figure 10-5: Users of long-term care by age group. Data from Iglehart, J.K. 2016. Future of long-term care and the expanding role of Medicaid managed care. New England Journal of Medicine 374: 182–187. Level of Care Continuum (1 of 2) • Personal care – Paraprofessionals • Custodial care • Restorative care • Skilled nursing care – Rehabilitation is an important component. Level of Care Continuum (2 of 2) • Four categories of subacute care services 1. 2. 3. 4. Extensive care Special Clinically complex care Intensive rehabilitation Home- and Community-Based Services (1 of 4) • Home health care • Adult day care – Medicaid provides funding. • Adult foster care Home- and Community-Based Services (2 of 4) Figure 10-6 Most frequently provided services to home health patients. Data from Jones, A. L., et al. 2012. Characteristics and use of home health care by men and women aged 65 and over. National health statistics reports, No. 52. Hyattsville, MD: National Center for Health Statistics. Figure 10-7 Sources of payment for home health care, 2014. Data from National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 298. Home- and Community-Based Services (3 of 4) • Senior centers • Home-delivered and congregate meals – Elderly nutrition program (ENP) – Meals-on-wheels • Homemaker services • Continuing care at home Home- and Community-Based Services (4 of 4) • Case management – Brokerage model – Managed care/integrated model • Recent policies related to community-based services – Money follows the person – Community first choice Institutional Long-Term Care Continuum • • • • Residential and personal care facilities Assisted living facilities Skilled nursing facilities Subacute care facilities—three main locations – Long-term care hospitals (LTCHs) – Hospital transitional care units certified as SNFs – Freestanding nursing homes Specialized Care Facilities • Intermediate care facilities for individuals with intellectual disabilities – Most patients have disabilities in addition to ID • Alzheimer’s facilities Continuing Care Retirement Communities • Three common types of CCRC contracts – Life care or extended contract – Modified contract – Fee-for-service contract Institutional Trends, Utilization, and Costs • Community-based services and assisted living absorbed much of the nursing home care. • Rising cost of institutional care. • Five nursing home chains operate more than 9% of U.S. nursing homes. Table 10-1: Trends in Number of Long-Term Care Facilities, Beds/Resident Capacity, and Prices, Selected Years Data from Genworth Financial, Inc. 2010. Genworth 2010 cost of care survey. Richmond, VA: Author; Genworth Financial, Inc. 2015. Genworth 2015 cost of care survey. Richmond, VA: Author; Sanofi-Aventis. 2016. Managed care digest series: Public payer digest, 2016. Bridgewater, NJ: Author. Insurance for Long-Term Care • Medicare does not cover most LTC services. • Medicaid requires spending one’s assets to poverty levels to qualify. • Public policy created few incentives to spur LTC insurance growth. • ACA did little to address the LTC dilemma. Summary (1 of 2) • Need for LTC increases – Due to severe chronic condition, multiple illnesses, or cognitive impairment • LTC includes – Medical care, nursing, rehabilitation, social support, and mental health care – Housing alternatives and end-of-life care Summary (2 of 2) • Nursing homes require – SNF certification to admit Medicare patients – NF certification to admit Medicaid patients • Industry has become more competitive. • Medicaid and Medicare expenditures for LTC will be unsustainable in the long term. Chapter 11 Health Services for Special Populations Learning Objectives (1 of 2) • Population groups facing greater challenges and barriers in accessing health care services • Racial and ethnic disparities in health status • Children's health concerns and services • Women's health concerns and services • Rural health challenges and steps to care access Learning Objectives (2 of 2) • Health concerns of the homeless population and migrant workers • Describe the U.S. mental health system • Summarize the AIDS epidemic in the U.S. • ACA benefits for vulnerable groups Introduction (1 of 2) • Certain groups at greater risk of poor physical, psychological, or social health • Terms used – Underserved – Medically underserved – Medically disadvantaged – Underprivileged – American underclasses Introduction (2 of 2) • Population groups – Racial and ethnic minorities – Uninsured children – Women – Rural area residents – Homeless population – Mentally and chronically ill – Disabled – HIV/AIDS Framework to Study Vulnerable Populations • Vulnerability – Predisposing – Enabling – Need characteristics • Three vulnerability model characteristics – Comprehensive – General – Convergence Figure 11-5: U.S. life expectancy at birth, 1970–2014. Data from Health, United States, 2015, p. 93 Figure 11-6: Age-adjusted maternal mortality rates. Data from Health, United States, 2010, p. 231. Centers for Disease Control and Prevention (CDC). 2016. Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html. Figure 11-7: Respondent-assessed health status. Data from Health, United States, 1995, p. 172, Centers for Disease Control and Prevention, National Center for Health Statistics, 1996, Health, United States, 2012, p. 168, and Health, United States, 2015, p. 182. Figure 11-8: Current cigarette smoking by persons 18 years of age and over, age adjusted, 2014. Data from Health, United States, 2015, p. 186, Centers for Disease Control and Prevention, National Center for Health Statistics. Table 11-2: Age-Adjusted Death Rates for Selected Causes of Death, 1970–2014 Data from Health, United States, 2015, Table 17, pp. 99–101, Centers for Disease Control and Prevention, National Center for Health Statistics. Table 11-3: Infant, Neonatal, and Postneonatal Mortality Rates by Mother’s Race (per 1,000 Live Births) Data from Health, United States, 2015, p. 86. Table 11-4: Selected Health Risks Among Persons 20 Years and Older, 2011–2014 Data from Health, United States, 2015, pp. 202, 204, 216 Figure 11-3: Alcohol consumption by persons 18 years of age and older, selected years. Data from Centers for Disease Control and Prevention (CDC). National Health Interview Survey. https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201409_09.pdf. Figure 11-4: Use of mammography by women 40 years of age and older, 2013. Data from National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 246. Table 11-1: Characteristics of U.S. Mothers by Race/Ethnicity Numbers are percentages. 163 *Data from 2008. Source: Data from Health, United States, 2015, p. 74; Health, United States, 2012, p. 144; Health, United States, 2009, pp. 159, Racial/Ethnic Minorities: Asian Americans • In 2015, Asians accounted for only 5.6% of the U.S. population. • Asian Americans constitute one of the fastestgrowing U.S. population segments. Racial/Ethnic Minorities: American Indians and Alaska Natives • Incidence and prevalence of certain diseases in the AIAN population are a prime concern. • Higher death rates from alcoholism, tuberculosis, diabetes, injuries, suicide, and homicide. • Indian Health Care Improvement Act. • Indian Health Service. Uninsured • Ethnic minorities are more likely than whites to lack health insurance. • Most of the uninsured population comprises young workers. • Uninsured persons are in poorer health than the general population. • ACA made progress in reducing the uninsured. Children (1 of 2) • Health insurance is a major determinant of access to and utilization of health care. • Coverage rates vary across races and ethnicities. • Unintentional injuries are the leading cause of death for children and adolescents. • Asthma is a common childhood chronic disease. • Depression has an impact on adolescent development. Children (2 of 2) • Children’s health has certain unique aspects. – Developmental vulnerability and dependency • Children and the U.S. health care system – Programs categorized into three sectors • Personal medical and preventive services • Population-based community health services • Health-related support services Women • Office on Women’s Health – Specific goals that span the spectrum of disease and disability • Women and the U.S. health care system – At a disadvantage in obtaining employer-based health insurance – See Figure 11-10 Rural Health (1 of 2) • National Health Service Corps • Health professional shortage areas – Health Professions Educational Assistance Act – Three types of HPSAs by geographic areas, population groups, and medical facilities Rural Health (2 of 2) • Medically underserved areas – Percentage of population below poverty income levels – Percentage of population 65 years of age and older – Infant mortality rates – Number of primary care practitioners per 1,000 population Migrant Workers • Community and migrant health centers • Rural Health Clinics Act – Concern rural areas could not support a physician – Permitted PAs, NPs, and CNMs with rural clinics to practice without the direct supervision of a physician – Enabled rural health clinics to be reimbursed by Medicare and Medicaid Homeless • Approximately 1 in 200 people became homeless in 2011. – Adult population is 63% men and 37% women. – Estimated 22.8% are children under age 18. – 35.8% are families with children. – 14% are veterans. • Shortage of adequate low-income housing. • Barriers to health care. Mental Health • • • • • Barriers to mental health care Uninsured and mental health Insured and mental health Managed care and mental health Mental health professionals – See Table 11-7 Chronically Ill • Chronic diseases are the leading cause of death in the U.S. – Result in limitations on daily life activities. – Treatment accounts for 86% of U.S. health costs. • Disability – Categorized as mental, physical, or social – Disability tests HIV/AIDS (1 of 3) • Number of AIDS cases reported – Increased between 1987 and 1993 – Decreased between 1994 and 1999 – Increased between 2000 and 2004 – Decreased since 2005 • HIV Infection in rural communities • HIV in children HIV/AIDS (2 of 3) • HIV in women • HIV/AIDS-related issues – Need for research – Public health concerns – Discrimination – Provider training HIV/AIDS (3 of 3) • Cost of HIV/AIDs – See Figure 11-12 • AIDS and the U.S. health care system – AIDS is characterized by a gradual decline in physical, cognitive, and emotional function. – As HIV disease progresses, many people become disabled and rely on public entitlements. Summary • Challenges and barriers in accessing health care services for certain population groups. • Health needs of these population groups vary. • Gaps exist between population groups and the rest of the population. Chapter 12 Cost, Access, and Quality Learning Objectives (1 of 2) • Meaning of health care costs and trend review • Factors that led to past cost escalations • Describe regulatory and market-oriented approaches to contain costs • Why some regulatory cost-containment approaches were unsuccessful • Discuss the access to care framework and various dimensions of access to care Learning Objectives (2 of 2) • Describe access indicators and measurements • The nature, scope, and dimensions of quality • Differentiate between quality assurance and quality assessment • Implications of the ACA for health care costs, access, and quality Introduction (1 of 2) • Three cornerstones of health care delivery – Cost – Access – Quality • Expansion of access will increase health care expenditures. Introduction (2 of 2) • Costs of health care from a macro and micro perspective. • Equal access to high quality care. • Cost is important in the evaluation of quality. • Quality – Up-to-date capabilities, evidence-based processes, and measuring outcomes Cost of Health Care • Trends in national health expenditures • Should health care costs be contained? – Three sources to assess if spending too much 1. International comparisons 2. Rise in private sector health insurance premiums 3. Government spending on health care for beneficiaries Reasons for Cost Escalation (1 of 3) • • • • • Third-party payment Imperfect market Growth of technology Increase in the elderly population Medical model of health care delivery Reasons for Cost Escalation (2 of 3) Figure 12-5 Life expectancy of Americans at birth, age 65, and age 75, 1900–2014 (selected years). Data from National Center for Health Statistics (NCHS). 2002. Health, United States, 2002. Hyattsville, MD: U.S. Department of Health and Human Services. p. 116; National Center for Health Statistics (NCHS). 2010. Health, United States, 2009. Hyattsville, MD: U.S. Department of Health and Human Services. p. 187; National Center for Health Statistics (NCHS). 2016b. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 95. Figure 12-6 Change in U.S. population mix between 1970 and 2014, and projections for 2030. Data from National Center for Health Statistics (NCHS). 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 45; U.S. Census Bureau. 2000. Projections of the total resident population by 5-year age groups, and sex with special age categories: middle series, 2025 to 2045. Available at: https://www.census.gov/population/projections/files/natproj/summary/np-t3-f.pdf. Accessed April 2017. Reasons for Cost Escalation (3 of 3) • Multipayer system and administrative costs • Defensive medicine • Fraud and abuse – Upcoding – Anti-kickback statute • Practice variations – Small area variations (SAV) Cost Containment: Regulatory Approaches • Health planning – Health planning experiments in the U.S. – Certificate-of-need statutes (CON) • Price controls • Peer review Figure 12-7: Increase in U.S. per capita Medicare spending, selected years, 1970– 2014. Data from Health, United States, 2015, p. 327; National Center for Health Statistics. Cost Containment: Competitive Approaches • Competition refers to rivalry among sellers for customers. – Technical quality, amenities, access or others • • • • Demand-side incentives. Supply-side regulation. Payer-driven price competition. Utilization controls. Cost Containment under Health Reform • Medicare payment cuts to providers. • New taxes imposed. • Reforms contributed to a health care spending slowdown. – Tightening provider payment rates – Providing incentives to reduce costs • Medicare projected to spend $1 trillion less by 2020. Access to Care (1 of 2) • Key implications of access for health and health care delivery – Access to medical care, along with environment, lifestyle, and heredity factors. – Access is a benchmark in assessing the effectiveness of the delivery system. – Measures of access reflect if delivery is equitable. – Access is linked to quality of care and efficient use. Access to Care (2 of 2) • Framework of access • Five dimensions of access – – – – – Availability Accessibility Accommodation Affordability Acceptability Figure 12-8 Framework for access in the managed care context. Reproduced from E.R. Docteur, D.C. Colby, and M. Gold, “Shifting the Paradigm,” Health Care Financing Review 17, no. 4 (1996): p. 12. Four Main Types of Access • • • • Potential access Realized access Equitable or inequitable access Effective and efficient access Measurement and Current Status of Access • Measurement of access – Using conceptual models access is measured at three levels 1. Individual 2. Health plan 3. Delivery system • Current status of access Current State of Access Data from US Census Bureau. Statistical Abstracts of the United States, 2015, Washington, DC, p. 265. Data from Health, United States, 2015, pp. 235, National Center for Health Statistics, Division of Health Interview Statistics, 2016. Affordable Care Act and Access to Care • Insurance coverage and access to health care have increased. • Fewer report problems with medical bills and financial barriers. • Gaps in access to and affordability of care. • Preventive services without cost sharing expanded. Quality of Care • IOM’s quality implications – Quality performance has a range from unacceptable to excellent. – Focuses on services provided by the health care delivery system. – Quality may be evaluated from the perspective of individuals and populations or communities. – Emphasis on desired health outcomes. Dimensions of Quality • Micro view focuses on services at the point of delivery and their subsequent effects. – Clinical aspects – Interpersonal aspects – Quality of life • Macro view looks at quality from the standpoint of populations. Quality Assessment and Assurance (1 of 2) • Quality assurance is based on the principles of total quality management (TQM). – Referred to as CQI • Donabedian model. – See Figure 12-9 The Donabedian Model Figure 12-9 The Donabedian model. Quality Assessment and Assurance (2 of 2) • Processes that improve quality – Clinical practice guidelines – Cost-efficiency – Critical pathways – Risk management Public Reporting of Quality • CMS programs on quality – Initiatives to improve care provided to Medicaid and CHIP enrollees • AHRQ quality indicators – Prevention, inpatient, patient safety, and pediatric • States’ public reporting of hospital quality Affordable Care Act and Quality of Care (1 of 2) • Three objectives 1. Make health care more accessible, safe, and patient centered 2. Address environmental, social, and behavioral influences on health and health care 3. Make care more affordable Affordable Care Act and Quality of Care (2 of 2) • Organizations are incentivized to provide highquality care in two ways. – Penalized for failing to report quality measures – Sharing in the savings generated by quality measures • The number of patient safety and medical errors has decreased since 2010. • Patient-Centered Outcomes Research Institute (PCORI). Summary • Increasing costs, lack of access, and quality concerns pose the greatest challenges. • Lack of universal coverage negatively affects the health status of uninsured groups. • Access to medical care is one of the key determinants of health status. • Health care quality at the micro and macro levels. Assignment 2 (d) - International Healthcare Related SLIDES - Due on May 10 Assignment 2 (a-d) - International Healthcare Related SLIDES - FOUR (4) Assignments: There are Four (4) international healthcare related slide development assignment. Students MUST submit it by uploading it on Blackboard no later than 4:00 pm, on the MONDAY of the week they are due. Any assignment received after the due date mentioned above may not be graded and given a zero unless it is due to acceptable reasons as determined by the instructor. For this assignment: • Students should pick a country of their choice (EXCEPT for the United States). • Then look at some of the issues related to the healthcare industry in that country related to chapters assigned for that week. • Based on what you learned, make at least 15 slides regarding that country's healthcare system. • For this assignment, please use the book and the chapter slides for the associated chapters as a guide. • The slides will be graded for: o Content (remember, use fewer words – less is more concept here, avoid copy & paste of text); o Design (including use of color and types of fonts); o Use of figures/graphs/pictures/etc. (make sure to provide proper citations here if needed); o You can also provide a text/narrative in the notes section in the bottom of each slide; o Provide a list of sources/references used. The Chapters for the Slides assignments for different are listed below: DATE DUE - Lecture week of: Slides related to Chapters: May 10 Chapters 10 – 12 Minimum number of Slides: 15 (EXCLUDING the cover page and references listing page) Maximum number of Slides: 30 Please make sure to have the following information on the cover page: • Your name • Assignment number • Nice title (and maybe even the map/images of the country) • The date of submission