Long-Term Care

September 15, 2011

Long-term care (LTC) typically refers to settings in which individuals reside for ongoing care. Long-term care also refers to heath care needs or supervision that an individual may require for an undetermined time, or even lifelong. Long-term care can be acquired in one’s home or more typically in sheltered care or independence-supporting settings described as continuing care retirement communities. In retirement communities, three levels of care are often described: independent living, assisted living, and nursing home.

On average, women live longer than men, and advanced age is associated with greater likelihood to experience disability, hence the greater need for Long-Term Care in women than in men. In fact, as reported by the American Association of Retired Persons (AARP), 72% of nursing home residents are women. About one in three women 65 years of age or older experiences a disability or a limiting illness, such as heart disease, diabetes, cancer, arthritis, or hypertension. In 1997, women accounted for more than 70% of individuals 75 years of age or older who required help with daily activities, including preparing meals, eating, bathing, or taking medications. Furthermore, women are more likely than men to be economically disadvantaged, raising many important questions as to the affordability of Long-Term Care by women. In 2001, the annual costs of nursing home care were estimated at $55,000 annually. Home health care ranged from an hourly rate of $18 for a home health aide to $37 for a licensed practical nurse. Income is associated with marital status, race, and ethnicity. As such, widows—representing 45% of women 65 years of age or older in 2001—have substantially lower income than married couples. Similarly, African American or Hispanic women are more likely than their white counterparts to have incomes below the Federal Poverty Level.

The decision to place an individual in an Long-Term Care setting is postponed until all efforts to care for that individual in the home environment fail. Maintaining normalcy of the environment and routine in the familiarity of the home is thought to contribute to improved quality of life. What is often overlooked is the burden that an undersupportive physical and emotional environment places on the individual’s functioning, which can result in failure-to-thrive or decompensation of the individual. The decision to place an individual in an Long-Term Care setting is based not only on an individual’s care needs, but also on the caregiver’s abilities and desires.

According to the AARP, the vast majority of individuals with disabilities are cared for in their homes, by informal caregivers—usually wives or adult daughters. In 1997, 20% of such caregivers attended to the disabled individual’s needs at least 40 hours a week, and one out of five caregivers who were employed gave up on their work either on a temporary or a permanent basis; half needed to incorporate flexibility to their working hours (going to work late or working fewer hours) in order to accommodate caregiving.

Caregiver burden, a term used to describe the impact of providing care on the caregiver, can present in two aspects: physical and emotional. This is observed frequently, as nearly one third of caregivers suffer from physical and/or mental problems of their own. Examples of physical burden are activities and responsibilities involved in the day-to-day care of the patient. Emotional burden refers to the feelings the caregiver has toward the patient, or the care receiver, that are the consequence of giving care. Burnout is a term that is used when the caregiver has exhausted the usual supports or when the care receiver’s needs outweigh the ability of one individual to provide care 24 hours a day, 7 days a week. Burnout is suggested when a caregiver’s health suffers or when his/her problem-solving abilities are diminished. The goal of selecting a nursing home is to do this before the caregiver is too exhausted to participate in finding solutions to day-to-day problems or in making decisions about placement of the patient in an Long-Term Care setting. Burnout can manifest itself through the deterioration of the caregiver’s physical health, and a change in the quality of the caregiver-patient relationship. Discussions regarding placement in an Long-Term Care facility can have a psychological impact on both the patient and the caregiver, mainly because of the implied permanence and deterioration of the patient’s independence. When the caregiver realizes that decisions regarding the course and site of care are made based on the individual’s condition and functional abilities, the discussion can become emotionally less charged. Assisting the individual and support persons proceed in planning for Long-Term Care involves an evaluation of the individual’s functional abilities and ability to afford an environment that is ideally most supportive and least restrictive.

Postponing placement to preserve funds is a realistic part of planning for Long-Term Care. Placement decisions involve the site and duration of care. Medicare is an ageand/or disability-based entitlement and typically only covers short-term care that is restorative, or rehabilitative, or “skilled” in nature. Even if an individual has had the foresight to own a liberal Long-Term Care insurance private policy, there may be limitations on the site of care, such as institutional versus home. Medicaid is a payer for individuals with low incomes, and typically covers basic care at the nursing home level that is custodial or “nonskilled” in nature. In the event that an individual’s income exceeds Medicaid income eligibility levels, the individual should spend down the excess amount to the Medicaid income eligibility level in order to become eligible to enroll in Medicaid.

There has been an increase in the number of Long-Term Care insurance policyholders in later years. These policies vary widely in the scope of covered services, as well as in cost. For example, some policies require that the beneficiary suffer severe cognitive impairment, or to need assistance with at least two activities of daily living, or to demonstrate “medical necessity” before providing coverage for Long-Term Care services, and reimburse a fixed amount for daily care ($100 per day in nursing home and $50 per day for home care). The mechanisms of Long-Term Care financing and service delivery have been evolving with the rapidly increasing proportion of the aging population.

Population statistics suggest that as the present “baby boomer” generation ages, health care services must cover the entire spectrum—from wellness programs, to meet the needs of healthier individuals, to skilled nursing and rehabilitative care for individuals with chronic illness and functional limitations. Currently, 5% of the elderly population live in Long-Term Care facilities; however, an increase of this population even by a few percentage points could strain resources both in terms of available facilities and available funding.

SEE ALSO: Activities of daily living, Assisted living, Medicaid, Medicare, Nursing home

Category: L