Long Term Care

1. Long Term Care The Continuum of Care

2. What is Long Term Care? • Health, mental health, social and residential services provided to temporarily or chronically disabled person over extended period of time

3. Characteristics of LT Care • Physical or mental, temporary or permanent • Need based on functional disabilities • Promotes or maintains health and independence in functional abilities and quality of life • To enable us to die peacefully and with dignity • Multiple services and multiple professions spanning broad spectrum • Multifaceted • Designed around unique needs of the individual • Service can change over time

4. Who needs LT Care • Chronic – permanent or indefinite period of time • Impaired – a decrease in or loss of ability to perform • Disabled – short or long term; varies by age group • Functional ability – person’s ability to perform the basic activities of daily living

5. Understanding demand for LT Care • Patient represent “mosaic of sub-segments” of the population. Often co-morbid conditions • Services can be organized across dimensions of users • Some users of LT care have significant differences from other users

6. Organization of LT Care • Informal organization – most LT care is provided by family and friends • Each community may be different regarding availability of services • Ideal system – client oriented continuum of care.

7. What is Continuum of Care? • Matches resources to patient’s condition • Monitors the client’s condition and changes services as needs change • Coordinates care across disciplines • Integrates care in a range of settings • Enhances efficiency, reduces duplication, streamlines patient flow • Maintains comprehensive record keeping

8. Categories of Continuum of Care • Extended care • Acute inpatient care • Ambulatory care • Home care • Outreach • Wellness • Housing NOTE: Not all LT care clients get this full range of care. This is ideal that may offset or delay chronic illness.

9. Providers of LT Care • Hospitals • Nursing homes (average costs $4,500 per month) • Home health agencies • Hospices • Adult day service programs • Housing organizations

10. Types of LT Care Services(Source: http://www.medicare.gov/LongTermCare/Static/CommunityServices.asp

11. Paying for LT Care • Nursing home care represents approximately 8% of personal health care expenditures • Home health care about 2% of expenditures though this is trending higher • Since LT care is provided mostly by family and friends, these figures don’t represent full cost • Medicare, Medicaid cover much of the cost • Out of pocket costs for LT care are significant • Little private insurance currently pays for LT care though incentives have been implemented to cover that area

12. How we pay for LT Care • Long Term care insurance – only about 10% of LT care recipients have this coverage • Using personal funds – method typically used first until funds run out • Medicare – only provides short term percentage of LT care (does not include custodial care) • Medicare covers 100% cost for first 100 days • Provides 80% costs for next 80 days • Provides no reimbursement for subsequent • Medicaid – once income eligibility is met, pays for most of the cost of LT care

13. Medicaid Spend Down – Exempt Assets • Medicaid eligibility based on income • Pays for skilled care and custodial care • Some exemptions apply • Up to $2,000 in cash assets • Home, no matter the value • Personal belongings • One car or truck • Burial spaces • Up to $1,500 designated as burial fund for applicant and spouse • Value of life insurance if less than $1,500 (otherwise, must surrender value in excess of amount up to cost of care)

14. Medicaid Spend Down Non-exempt Assets • All cash assets above $2,000 • Certificates of deposit • Stocks, bonds, mutual funds • Land contracts or mortgages for real estate sold • U.S. Savings bonds • Most IRAs • Nursing home accounts • Prepaid funeral contracts issued in Nevada • Most trusts • Real estate other than primary residence • More than 1 car or truck • Boats or recreational vehicles

15. Getting around the Spend Down process • IRS allows $11,000 gift tax per child, but this does not apply to Medicaid and gifts over $4,500 3 years prior to care will result in loss of eligibility until full gift costs are met. • Division of assets • At home spouse is able to keep ½ of all assets up to $92,000 • The other half must be spent down for care • Spousal support: At home spouse is allowed to make up to $1,561 per month in income. If income does not meet that much, allowed to use other LTC spouse income up to that amount. (Court orders can increase this amount)

16. Mental Health Care The Forgotten Population

17. Incidence and Prevalence of MH Disorders in U.S. • 30-40% experience some psychiatric disorder in their lifetime • 21% of children ages 9 – 17 receive MH services in a year • Ranks 2nd in terms of burden of disease in established economies • In general, 19% of population have mental disorder alone, 3% have dual diagnosis, and 6% have addictive disorder

18. MH Descriptives • Most people with Psych disorders experience onset prior to age 38 • Men • More common among men (mostly alcohol abuse and antisocial personality disorder or “Cochran’s Syndrome”) • Phobia and alcohol abuse most common • Cognitive impairment most common among those 65 and older • Women • Somatization disorders (somatization of symptoms masking underlying psych disorder), obsessive compulsive, and depressive disorder • Rates for MH disorders drop after age 45 (except for cognitive disorders)

19. Early Views on Mental Illness • Based primarily on values. Aberrant behavior could be viewed as demonic or evil spirits. • Lunatic hospitals began in Elizabethan England (primarily to protect society from misfits) • Mental illness began as diagnosis during scientific revolution in Germany • Freud changed the way we viewed mental illness and related it to unconscious development difficulties

20. Mental Illness Attitudes in U.S. • During 20th century, there has been increasing acceptance of pluralistic determinants of mental illness • Greater reliance on the disease concept • Better understanding of the role of personality development from social or cultural influences • Still an underlying current of the “Eurocentric” perspective – abnormal or deviant behavior as a reflection of values, norms and belief systems of the mainstream

21. Recent U.S. Mental Health Policy • Development of psychopharmacology in the 1950s • Mental Retardation Facilities and Community Mental Health Centers Constructions Act of 1964 built more mental health centers • Mental Health System Act proposed by Pres. Carter would have provided better funding but was not implemented by Reagan or Bush the First. • Expansion of health insurance to cover treatment (generally significantly less coverage than other health insurance)

22. MH Delivery System • 1955-80, most services provided in state or county mental hospitals • Public and private sector health care • Public sector primarily paid by Medicare or Medicaid • Major decline in state mental health hospitals • Outpatient services account for nearly 75% of MH services

23. Mental Health and the Future • Greater reliance on psychopharmacology • Debate of MH vs. Values will continue • Is Mental Illness an excuse? • Are all of our personality problems attributable to mental illness? • Relationship of mental illness and homelessness (approximately 20-25% of homeless have mental illness) • Up to 50% have co-occurring mental illnesses and substance use disorders. • Their symptoms are often active and untreated, thus difficult to obtain basic needs for food, shelter and safety and causing distress to those who observe them. • They are impoverished, and many are not receiving benefits for which they may be eligible.

24. Mental Illness and Las Vegas Don’t feed the homeless! It’s the law! • Overcrowding of emergency rooms by mentally ill • Shortage of mental health facilities and professionals • Implementation of Legal 2000 to transport and hold mentally ill • Nevada ranks 2nd nationally in suicide