Dimensions of Long-Term Care Management: An Introduction, Second Edition

by Mary Helen McSweeney-Feld

Overview

Instructor Resources: Test bank, presentation PowerPoint slides, answers to end-of-chapter and case study questions, a sample course syllabus, and a transition guide to the new edition.

The field of long-term care is experiencing significant growth and near-constant change. Older adults and people with disabilities today make up a larger segment of society than ever before, and with this shift in demographics comes an increased demand for long-term services and supports. Technological advancements and evolving consumer preferences are reshaping the services that people want and need, and new models of care reflect a shift in emphasis from institutional to community-based settings. The Affordable Care Act (ACA) and other reform efforts have introduced new regulations, requirements, and pressures for long-term care providers; however, they have also brought new opportunities.

This introductory book examines the various dimensions of long-term care and explores the facets of management essential to success in this rapidly changing environment. The first part of the book provides an overview of key definitions, settings, policy issues, and trends in the delivery of long-term services and supports. The second part relates aspects of management—including leadership, human resources, marketing, facility management, regulatory and legal issues, and financing—to long-term care.

Significantly revised and updated, this edition includes four new chapters, addressing the following topics:

Delivery of long-term services and supports under the ACA Transitions between acute care, residential long-term care, and home and community-based care settings The implications of global trends in long-term care policies and services Quality improvement tools and reform-driven requirements for safety and transparency

Additional updates for this edition focus on specialized care for individuals with chronic and disabling conditions, new technologies that maintain patients’ health information and enhance communication, and the challenges in assembling and retaining an effective direct care workforce.

Product Details

ISBN-13:	9781567938364
Publisher:	Health Administration Press
Publication date:	09/01/2017
Series:	Gateway to Healthcare Management
Edition description:	None
Pages:	496
Product dimensions:	8.00(w) x 10.00(h) x 1.00(d)

About the Author

Mary Helen McSweeney-Feld, PhD, is an associate professor in the healthcare management program at the College of Health Professions at Towson University in Towson, Maryland. She has authored numerous publications in the healthcare and long-term care administration fields, with an emphasis on finance and long-term care issues. Dr. McSweeney-Feld has been involved in a variety of national and state grant and demonstration programs focusing on such topics as Alzheimer’s disease, long-term direct care workers, and emergency preparedness for long-term care administrators. Her professional association activities include work with the American College of Health Care Administrators and the American College of Healthcare Executives, and she was a participant in the 2015 White House Conference on Aging. She has also participated in education and academic program accreditation activities for the Association of University Programs in Health Administration and the National Association of Long-Term Care Administrator Boards. Dr. McSweeney-Feld holds a BA in English and political science from Wellesley College, an MPhil in economics from Columbia University, and a PhD in health economics from the Graduate Center of the City University of New York. She is a licensed nursing home administrator.

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Read an Excerpt

CHAPTER 1

INTRODUCTION TO THE DIMENSIONS OF LONG-TERM CARE

Mary Helen McSweeney-Feld, PhD, and Carol Molinari, PhD

Learning Objectives

After completing this chapter, you should be able to

* explain changing patterns of demographics in the United States in terms of growing demand for long-term care services and supports;

* define long-term care and long-term services and supports and describe models for longterm care service delivery;

* discuss the providers and payers of long-term services and supports, including informal sources of support such as family caregivers;

* apply the theoretical foundations of long-term care service delivery and understand their impact on healthcare policy; and

* understand variations in long-term care service delivery and new directions for long-term services and supports.

Consumers of Long-Term Services and Supports in the United States

Older Americans

The United States is experiencing a remarkable demographic transformation. According to The State of Aging and Health in America, published by the Centers for Disease Control and Prevention (CDC), recent growth in the number of older adults, and in their share of the country's total population, is unprecedented (CDC 2013) (see exhibit 1.1). Compared with previous generations, Americans today are living longer, are more racially and ethnically diverse, and are more prosperous. In 2013, 44.7 million Americans — about 14.1 percent of the US population — were 65 or older, and 6 million were older than 85. By 2050, the number of people aged 65 or older is expected to double to 89 million, and the number of people aged 85 or older is expected to triple to 18 million. In 2013, 75.9 million baby boomers (people born between 1946 and 1964) accounted for almost a quarter of the US population. Rapid growth in this segment is predicted to continue, as is growth in the "oldest old" segment of adults over the age of 85.

Americans older than 65 are better educated than ever before. In 1970, 28 percent of older adults had a high school diploma; by 2014, that number had risen to 84 percent, and 26 percent had earned a bachelor's degree or higher (Administration on Aging 2014). With higher levels of education, older Americans enjoy higher incomes and net worth levels. Furthermore, an increasing share of their income comes from earnings, because more individuals are working past age 65, either from a desire to remain active in the workforce or out of economic necessity. Still, lingering income inequalities remain among older Americans, based on differences in gender, social and economic status, education, and race and ethnic background. Older African Americans and Americans without high school diplomas generally earn less and are less able to support themselves financially than the rest of the US population. For both older Americans and the population as a whole, healthcare expenditures in the United States are significantly higher than those in other developed countries.

Heart disease and cancer affect a large number of older adults in the United States, as do other chronic conditions such as stroke, chronic lower respiratory diseases, Alzheimer's disease, and diabetes (Courtney-Long et al. 2015). The average life expectancy in the United States lags behind that of other developed nations (Administration on Aging 2014). However, recent statistics have shown a decrease in disability and other impairments that restrict the functioning of older adults.

Income disparities and the high costs of healthcare have redefined the notion of retirement in the United States. Today's active elders desire to remain engaged in life — to be self-sufficient and to not burden their families. Recognition of the "third age"— the third stage of life, after retirement but before the onset of any major disabling health problems — is essential for fully comprehending the needs of older Americans.

Adults with Disabilities

Adults with disabilities occupy a significant position within the population of long-term care service consumers, primarily due to their participation in the labor force and their involvement in government programs and policies. According to a report by the CDC, 22 percent of adults in the United States — more than one in every five — have some type of disability (Courtney-Long et al. 2015). The most common type of disabling condition reported was a mobility limitation, such as serious difficulty walking or climbing stairs; this type of disability was reported by one in eight adults. Other common disabilities involved limitations in thinking or memory, independent living, vision, and self-care. Individuals with intellectual disabilities, as well as developmental disabilities, are included in these estimates. Veterans with disabilities also represent a significant portion of this group; according to the US Department of Veterans Affairs (2014), 4 million veterans reported having service-related disabilities in 2014. Exhibit 1.2 shows measures of US disability populations over time.

The CDC report also revealed that non-Hispanic black (29 percent) and Hispanic (25.9 percent) adults were more likely to have a disability than were white non-Hispanic (20.6 percent) adults. Adults who had lower education levels, were unemployed, or had lower incomes were also more likely to report a disability (Courtney-Long et al. 2015). Annual disability-associated healthcare expenditures were estimated at nearly $400 billion in 2006, with more than half those costs related to nonindependent living settings, such as institutional care and personal care services (Anderson et al. 2011). Such high costs underscore the importance of maintaining the health and functional status of individuals with disabilities.

Historically, the needs of older adults and the needs of adults with disabilities were addressed through separate laws and by different government organizations. The Older Americans Act (OAA), passed in 1965, created the Administration on Aging to provide seven types of services specializing in the needs of older adults. The Developmental Disabilities Assistance and Bill of Rights Act of 2000 established the Administration on Intellectual and Developmental Disabilities with six programs that supported and empowered individuals with disabilities living in the community. The government altered its approach to these areas in 2012, when the US Department of Health and Human Services established the Administration for Community Living (ACL) as an umbrella agency that included the Administration on Aging, the Administration on Intellectual and Developmental Disabilities, and the Office on Disability. The goal for ACL was to reduce the fragmentation of government services for older adults and adults with disabilities and to encourage common solutions for community-living services and supports (ACL 2016).

CURRENT ISSUE

Long-Term Care Consumers: Labels Versus Empowering Language

The media have had a challenging relationship with long-term care consumers. People older than the age of 65 are frequently labeled "the elderly" or "senior citizens"— terms that can be considered derogatory and are often associated with ageism, or discrimination based on a person's age. Similarly, individuals with disabilities are frequently described as "wheelchair bound" or "handicapped," suggesting that their disabilities prevent them from living independently or performing meaningful work. Use of these terms can contribute to ableism, or prejudice against people with disabilities.

Much of the language we use in long-term care is in need of replacement. Some of it is unintentionally demeaning to people, contributing to a hierarchical sense of "us and them" instead of promoting a nurturing community with respect for its members (Schoeneman 2016). Advocacy organizations for long-term care consumers recognize these challenges, and they have promoted the use of the terms "older adult" and "elder"— empowering terms that recognize the life experience and wisdom of older members of the community. Similarly, disabilities advocates have recommended the use of the term "people with disabilities" to emphasize that people are not their disability and to focus on the abilities of individuals rather than their weaknesses.

Providers of long-term care services, as well as individuals pursuing careers in the long-term care field, are urged to understand these language changes and to adopt them in their interactions with long-term care consumers.

The reauthorization of the Older Americans Act in 2016 was a significant step forward by Congress to support the needs of older adults. The act keeps core OAA programs intact by authorizing an increase in specific funding levels of 6 percent over a three-year period, allowing for adjustments for states with growing populations aged 60 or older as well as minimizing losses for states losing population. The legislation also adds improvements to better support older Americans living at home and in the community, including assistance for older adults caring for adult children with disabilities (Blancato 2016).

Administration for Community Living (ACL)

An umbrella agency of the US government that provides services and supports for older adults and individuals with disabilities.

ageism

Discrimination based on a person's age.

ableism

Prejudice against people with disabilities.

What Is Long-Term Care?

Long-term care (LTC) consists of a variety of health services, support services, and other assistance provided informally or formally to individuals who have a chronic illness or disability and are unable to function independently. Long-term services and supports (LTSS) may be offered in various settings to people at any age who need help performing activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Examples of ADLs include bathing, dressing, eating, toileting, and transferring (e.g., walking). Examples of IADLs include cooking, cleaning, buying groceries and other essentials, administering medication, handling money or finances, and using the telephone. Individuals with Alzheimer's disease and other dementias, as well as those with intellectual or developmental disabilities, may have additional, specialized needs. Long-term care services can be tailored to clients' physical, mental, emotional, social, spiritual, and financial needs and capacities. Additionally, long-term care services may evolve over time in response to changes in clients' needs and resources. Long-term care is oriented toward living with and managing chronic illnesses or disabilities, not curing them. As such, it aims to ensure continuity of care rather than deliver episodic interventions (Hooyman and Kiyak 2011).

long-term care (LTC)

A wide range of health services, support services, and other assistance provided informally or formally to individuals who have chronic illnesses or disabilities and are unable to function independently on a daily basis.

long-term services and supports (LTSS)

Services and supports provided to individuals at any age and in a wide range of settings that correspond to problems in performing activities of daily living and instrumental activities of daily living.

activities of daily living (ADLs)

Basic and routine daily activities such as eating, bathing, dressing, toileting, and walking. A person's ability to perform ADLs determines the level of long-term care needs.

instrumental activities of daily living (IADLs)

Activities that are not necessary for fundamental functioning but allow people to live independently. Examples include shopping, house cleaning, cooking, and managing finances.

Informal Care and Caregiving

Caregivers supply long-term care services and programs, and they also influence people's decisions on which types of long-term care services to use. Caregiving may be performed formally by paid employees, informally by unpaid family members or friends, or through a combination of formal and informal approaches. Caregivers may live far away from the recipient, in the same community or neighborhood, or in the recipient's residence.

Caregiving is a complex concept that covers a wide range of services. It can extend to all ages: children (younger than 18), adults (aged 18 years or older), older adults (aged 50 to 64), elders (aged 65 to 85), or the oldest old (older than 85). The reason for care may involve impairments at birth, disability after an accident, complications resulting from a chronic condition, or Alzheimer's disease or other dementias.

Measuring the extent of caregiving that occurs is complicated by the fact that some individuals who provide care do not identify themselves as caregivers. Sometimes, care for an older parent or spouse is provided by adult children or spouses who do not label their help as caregiving, but rather as a normal part of family responsibility.

caregivers

Individuals who provide healthcare or supportive long-term care services on a formal, paid basis or on an informal, unpaid basis. Caregivers are an important part of the system of support that enables people who need and use long-term care services to live in the community.

Who Provides Caregiving Services?

Nearly 18 million Americans provide care for a chronically ill, disabled, or aged family member or friend during any given year. Caregivers are more likely to be women (62 percent), and 50 percent are between the ages of 45 and 64. More than half (54 percent) of caregivers spend more than 40 hours per week providing care to their loved ones (Reinhard et al. 2015).

Two-thirds of individuals aged 65 or older rely exclusively on unpaid care for their personal care needs. An additional 30 percent use a mix of paid and unpaid care. The value of unpaid caregiving in 2013 was estimated to be $470 billion, and this figure continues to grow (Reinhard et al. 2015).

The caregiver for an older adult male is most likely to be his spouse. In contrast, older women are more often cared for by another family member — usually an adult child — in part because many women outlive their male spouses. Under the fragmented LTC delivery system in the United States, formal caregivers are more likely to come and go; meanwhile, family caregivers tend to remain and are often the only ones who witness a family member's entire illness (Levine et al. 2010). Caregiving can be highly stressful — especially for individuals caring for loved ones with Alzheimer's and dementia — and it likely impacts the caregiver's health status, finances, and opportunities for professional advancement (Adelman et al. 2014).

There are four challenges with respect to caregiving and caregivers: (1) the difficulty of collecting comprehensive information about family caregivers; (2) continued funding for training and support of caregivers; (3) recognition of the needs of caregivers in programs that transition individuals from institutional to noninstitutional settings; and (4) financing reforms (Levine et al. 2010). Some newer initiatives, such as the US Department of Labor guidelines for minimum wages and overtime pay starting in 2016, may assist formal caregivers and encourage others to provide caregiving services.

The History of Long-Term Care Service Delivery

To understand the structure of today's LTC delivery system, we must first look at the system's rich history and heritage in the United States. Research by Smith and Feng (2010) suggests that the past century has consisted of a series of cycles and concerns in long-term care, with five distinct periods of approximately 20 years each. Each period has focused on a specific concern and a supposed legislative solution, and each has contributed to the inadequate safety net of care that still exists today.

The First and Second Periods

The first period lasted from the early 1900s until the 1930s. During this time, the infirm were placed together in almshouses, sometimes referred to as "poor farms" for elderly "inmates." The Social Security Act, passed in 1935, provided pensions to older people, but with the stipulation that anyone housed in a public facility such as an almshouse could not receive one. Although the intent of the legislation was to bring about the end of almshouses, the law helped establish voluntary and proprietary nursing homes that accepted people with physical and mental infirmities (Mara and Olson 2008). Residence in these private boarding homes allowed those with long-term care needs to be eligible for federal Old Age Assistance, which became the hallmark of the second period — the old-age income security solution.

(Continues…)

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Excerpted from "Dimensions of Long-Term Care Management"
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Copyright © 2017 Foundation of the American College of Healthcare Executives.
Excerpted by permission of Health Administration Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents

Preface,
Acknowledgments,
Abbreviations,
PART I: Overview of Long-Term Care,
Chapter 1 Introduction to the Dimensions of Long-Term Care Mary Helen McSweeney-Feld, PhD, and Carol Molinari, PhD,
Chapter 2 Delivering Long-Term Services and Supports Under the Affordable Care Act Mary W. Carter, PhD, and Patricia M. Alt, PhD,
Chapter 3 Transitions of Care and Post-Acute Care Services Robert R. Kulesher, PhD, FACHE, and Mary Helen McSweeney-Feld, PhD,
Chapter 4 Residential Settings for Long-Term Care Services Mary Helen McSweeney-Feld, PhD,
Chapter 5 Home and Community-Based Care Services and Supports Mary Helen McSweeney-Feld, PhD, and Reid Oetjen, PhD,
Chapter 6 Technology and Delivery in Long-Term Care Services Barbara Edington, DPS, PMP, and Mary Helen McSweeney-Feld, PhD,
Chapter 7 Hospice, Palliative, and End-of-Life Care Judith Jopling Sayre, PhD, and Brian Feld, MSW,
Chapter 8 Chronic and Disabling Conditions and Long-Term Care Mary Helen McSweeney-Feld, PhD,
Chapter 9 Diversity in the Delivery of Long-Term Care Services Carol Molinari, PhD, and Emiko Takagi, PhD,
Chapter 10 Global Trends in Long-Term Care Policies and Services Emiko Takagi, PhD, and Carol Molinari, PhD,
PART II: Management of Long-Term Care, Services, and Supports,
Chapter 11 Management and Leadership in Long-Term Care Settings Jennifer Johs-Artisensi, PhD, Suzanne Discenza, PhD, and Mary Helen McSweeney-Feld, PhD,
Chapter 12 The Design of Long-Term Care Environments Jullet A. Davis, PhD, and Christopher J. Johnson, PhD,
Chapter 13 Strategic Marketing for Long-Term Care Patricia R. Loubeau, DrPH, and Chrissy Mitakakis Martins, PhD,
Chapter 14 Long-Term Care Human Resources Reid Oetjen, PhD, Carol Molinari, PhD, and Mary Helen McSweeney-Feld, PhD,
Chapter 15 Legal and Ethical Issues in Long-Term Care Edward L. King, RN, JD, EdD, and Philip C. DuBois, MS, CNHA, FACHCA,
Chapter 16 The Regulation of Long-Term Care JoAnn Nolin, JD, RN, and Mary Helen McSweeney-Feld, PhD,
Chapter 17 Quality and Safety in Long-Term Care Christian L. Williams, DrPH, Cyrus Y. Engineer, DrPH, and Melanie Eaton, MS, LNHA, CNHA, FACHCA,
Chapter 18 Financing and Reimbursement of Long-Term Care Services Elizabeth Gammon, PhD, CPA, Mary Helen McSweeney-Feld, PhD, and Carol Molinari, PhD,
Epilogue,
Glossary,
Index,
About the Editors,
About the Contributors,

Editorial Reviews

Reviewer: Nicky Martin, MPA, BS, LNHA (University of Missouri)
Description: This book's wide-ranging coverage of topics in long-term care management provides care managers with the tools necessary to understand their role and how they can effectively manage and operate a long-term care facility.
Purpose: This second edition presents current industry trends and regulatory information necessary to plan for the future of long-term care management. The information on healthcare policy is particularly helpful.
Audience: Intended for anyone with an interest in long-term care management, the book would be especially helpful for those working in or studying long-term care administration. It is an excellent resource for students, educators, and long-term care administrators.
Features: The organization of the book enables readers to follow through the complex and sometimes overwhelming reality of long-term care. The two part structure begins with an overview that details the critical elements of long-term care, including care delivery, transitions of care, care settings, and trends in long-term care. The second part nicely complements the first part, building on the basics and evolving into a more comprehensive review of the legal, regulatory, and financial aspects of long-term care. It provides readers with the essential elements of long-term care management ranging from leadership through to the concluding chapter on finance.
Assessment: The use of resources, case studies, references, and perspectives from both care providers and consumers provides information to support long-term care managers in providing quality care in such a demanding industry. The black box topics, such as "Did You Know?" and "Key Points" highlight long-term care issues important in post-acute care settings. From a visual standpoint, the use of color would have been helpful with the different graphs and would make crucial information stand out among the black-and-white pages.

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