NSU Long Term Care & Affordable Care Act Scrutiny of US Health System Analysis

write a critical analysis paper demonstrating understanding and application of key concepts learned on chapters 1-13. Your paper will include a critical analysis of the concepts below. A critical analysis entails a comprehensive examination of key concepts and/or theories. The grading rubric is attached. Please critically analyze the following:Components that have contributed to the development and need for long-term careProvisions of the Affordable Care Act (ACA) that directly impacts long-term care providersAddress components of accessibility to long-term care servicesTrends likely to affect assisted living in the futureBenefits of integration for long-term care consumersMeaning of long-term care being reimbursement driven Chapter 1
Long-Term Care Today:
Turbulent Times
Learning Objectives
1. Define the current long-term care
system, including how it developed, and
key strengths and weaknesses of the
system.
2. Define the term continuum of care.
3. Identify and define the consumers and
providers of long-term care.
Learning Objectives (continued)
4. Define institutional and non-institutional
care and the strengths and shortcomings
of each approach.
5. Identify the changes taking place in longterm care today.
Defining the Long-Term Care System
Long-Term Care:
Care of “those persons requiring
healthcare, personal care, social, and
supportive services over a sustained
period of time” (Continuing Care Council, 1992, p.1)
Factors Contributing to Development
of the Long-Term Care System
1. Financing: Growing role of government
2. The impact of regulations
3. The results of past successes
4. Cost-reduction efforts
Components of the
Long-Term Care System
Consumers:
✓ Elderly users of long-term care
• The elderly as a political force
✓ Nonelderly long-term care users
• Physically handicapped
• Mentally ill & intellectually disabled
✓ Baby boomers: new long-term care consumers
Components of the
Long-Term Care System
Providers:
✓ Nursing facilities
✓ Subacute care
✓ Assisted living / residential care
✓ Elderly housing
✓ Community-based services
Institutional vs. Noninstitutional Care
Institutional:
• Nursing facilities
• Assisted living
• Subacute care
Noninstitutional:
• Adult day care
• Home care
• Hospice care
Long-Term Care as
Part of a Continuum
The Continuum of care is:
✓ Client oriented
✓ Comprehensive
✓ Integrated
Strengths and Weakness in the
Long-Term Care System
Strengths:
✓ Response to changing needs
✓ Uniquely American nature
✓ Dedication of caregivers
✓ Focus on customer service
✓ Innovative types of care
✓ Integration efforts
Strengths and Weakness in the
Long-Term Care System
Weaknesses:
✓ Reimbursement-driven system
✓ Inequitably distributed services
✓ Fragmented and uncoordinated
✓ Mix of health and social services
✓ Multiple entry points
Strengths and Weakness in the
Long-Term Care System
Weaknesses (continued):
✓ Overshadowed by the acute system
✓ Poor public image
✓ Inadequate support for informal
caregivers
✓ Confusing and “user-unfriendly” system
Summary
The long-term care system has taken years to
develop and is still evolving. It is a critical part of
the overall continuum of care and has both
strengths and weaknesses.
Chapter 2
The Affordable Care Act
Learning Objectives
1. Discuss how the Affordable Care Act
came to be and the factors leading to
its passage.
2. Discuss the content of the Affordable
Care Act of 2010.
Learning Objectives (continued)
3. Identify and discuss the impact of the
Affordable Care Act on long-term care
providers and consumers.
4. Identify and discuss the issues still
remaining in the Affordable Care Act.
Introduction
The stated aim of the ACA was to:
1. “Increase the quality, affordability, and
rate of health insurance coverage for
Americans.”
2. “Reduce the costs of health care for
individuals and the government.”
Key Components of the ACA
✓ Requires individuals to have insurance coverage
and businesses to provide coverage or pay fines.
✓ Creates health insurance exchanges to provide a
marketplace where individuals and small
businesses can buy insurance.
✓ Requires insurance companies to cover all
applicants within new minimum standards
regardless of pre-existing conditions.
History/Passage of the Law
✓ Passed without a single Republican vote, and
34 Democrats also voted against it.
✓ Attempts to filibuster the bill were defeated by
Senate President Harry Reid (D-NV) who used
a budgetary process called “reconciliation” to
pass the bill with only 51 votes.
✓ Various public polls at the time (and since)
showed that more than 60% of Americans did
not approve of the law.
Constitutionality of the Law
✓ The constitutionality of the act was
challenged, specifically targeting one
provision of the act known as the
“individual mandate.”
✓ On June 28, 2012, the United States
Supreme Court upheld the constitutionality
of the Affordable Care Act.
Implementation
✓ Designed to be implemented over several
years.
✓ Began with some of the more popular
portions.
✓ More controversial regulations (increased
taxes, expansion of Medicaid, etc.) were
designed to be spread out over later years.
Regulations
✓ The ACA has spawned from 10,000 to
30,000 pages of new regulations.
✓ Only a portion apply to long-term care.
Funding of the ACA
✓ Funded by a combination of taxes and
cost offsets (reductions).
✓ Major Medicare taxes include:
•
•
•
A much-broadened tax on mid-level and highlevel incomes.
An annual fee on insurance providers.
A 40% excise tax on “Cadillac” insurance
policies.
Funding of the ACA (continued)
✓ Cuts in Medicare to finance part of the
new spending include reductions in:
• Funding for Medicare Advantage policies.
• Medicare home healthcare payments.
• Certain Medicare hospital payments.
Impact on Long-Term Care
✓ Majority of provisions in the act,
including many of the more controversial,
are tangential to long-term care.
✓ Originally, it was thought that long-term
care would be a potential cost saver
because this type of coverage would not
be needed immediately.
Impact on Long-Term Care
(continued)
✓ Health insurance exchanges
✓ Shifting focus away from institutional care
✓ CLASS Act
✓ Community First Choice Option
✓ Balancing Incentives Payment Program
✓ Money Follows the Person program
Impact on Long-Term Care
(continued)
✓ Spousal impoverishment protections
✓ No Wrong Door system
✓ Aging and disability resource centers
✓ Health homes
✓ Dual-Eligible Initiative
Other Provisions Impacting
Long-Term Care
✓ Improving nursing home quality
✓ Pay-for-performance
✓ Bundling
✓ Accountable care organizations (ACOs)
✓ Medicaid expansion
Other Provisions Impacting
Long-Term Care (continued)
✓ Asset recovery
✓ Readmissions reduction
✓ Medicare Advantage Plans
✓ Medical device tax
✓ Employer mandate
✓ Projected staff shortages
In Summary
The Affordable Care Act (ACA) of 2010 is
the most significant health-related piece of
legislation since passage of the Medicare
and Medicaid amendments of 1965. While
many of its provisions do not impact longterm care, others do.
Chapter 3
Toward an Ideal System
Learning Objectives
1. Identify the characteristics of an ideal
long-term care system
2. Describe what it means for the long-term
care system to be consumer-driven
3. Identify the roles of formal and informal
caregivers
Learning Objectives (continued)
4. Define the components of a full and
uniform assessment of a consumer’s
service needs
5. Discuss the need for incentives for
providers and consumers
The Criteria for Designing or
Evaluating a Long-Term Care System
✓What are they?
✓How were they developed?
✓How are they used?
Criterion I. The long-term care system should
be based on recognition of the needs, rights,
and responsibilities of individuals.
It should:
A. Be consumer driven
B. Meet all of the needs of the consumers
C. Focus on the individual, recognizing that
individuals have unique needs
D. Respect different cultures and cultural values
Criterion I (continued)
It should:
E. Promote quality, dignity, and selfimprovement for consumers
F. Balance consumer rights and
responsibilities
G. Offer consumers a choice of service
providers and service delivery modalities
Criterion II. The long-term care system should
be easily accessible.
It should:
A. Be universally accessible
B. Be user friendly
C. Provide care in the least restrictive
environment
D. Encourage single-site care availability
Criterion III. The long-term care system should
coordinate professional, consumer, family, and
other informal caregiver resources.
It should:
A. Integrate professional, community, family,
and other informal caregiver efforts
B. Evolve from the current medical model to
a holistic model of service delivery
C. Involve families in case management and
care delivery
Criterion IV. The long-term care system should
be an integral part of the health and social
system to promote integration, efficiency,
and cost-effectiveness.
It should:
A. Include a full continuum of services
B. Include a full and uniform assessment
(initial and ongoing) of the consumer’s
needs.
Criterion IV. (continued)
It should:
C. Provide emphasis on, and reimbursement
for, illness prevention efforts as an
integral part of the overall system
D. Be planned and coordinated to reduce
fragmentation and inefficiencies
E. Be based on outcome-oriented
accountability
Criterion V. The long-term care system should be
adequately and fairly financed.
It should:
A. Utilize public and consumer resources
to ensure universal access to services
B. Provide incentives for consumers to
use services in an appropriate and
cost-effective manner
C. Provide incentives for consumers to
self-finance their care
Criterion V. (continued)
It should:
D. Avoid causing impoverishment of
consumers and families
E. Provide incentives for providers to develop
cost-effective measures
F. Develop payment mechanisms that allow
efficient providers to adequately compensate
staff and to allow for appropriate operating
surplus and/or return on investment
Criterion V. (continued)
It should:
G. Operate within the limits of a wellconceived budget
H. Provide significant flexibility to enable
consumers to meet long-term care needs
as each consumer defines those needs
I. Be based on uniform financial eligibility
criteria
Criterion VI. The long-term care system should
include an education component to create
informed consumers, providers, reimbursers,
and regulators.
It should:
A. Include community education
B. Include education for providers
C. Educate young, healthy persons to better
prepare them to cope with chronic illness
Summary
The Criteria provide a basis for evaluating
the current long-term care system and for
developing an ideal long-term care system.
Chapter 4
Nursing Care Facilities
Learning Objectives
1. Define and describe nursing facilities
2. Identify sources of financing for nursing
facilities
3. Identify and describe regulations affecting
nursing facilities
Learning Objectives (continued)
4. Identify and discuss ethical issues
affecting nursing facilities
5. Identify trends affecting nursing
facilities in the near future and describe
the possible impact of those trends
What is a Nursing Facility?
Includes:
✓ Facilities licensed by the states offering
room, board, nursing care and some
therapies
✓ Those certified by Medicare as skilled
nursing facilities (SNF) and what used to
be called intermediate care facilities (ICF)
How Nursing Facilities Developed
✓ Early charity-based forms of care
✓ Poor public image
✓ Increased regulation
✓ Significant improvement
✓ Still under scrutiny
Philosophy of Care
✓ Medical vs. social model
• “care not cure”
✓ Multidisciplinary approach
✓ Family involvement
Ownership of Nursing Facilities
✓ Largely for profit (68%)
✓ Nonprofit (25%)
✓ Government owned (6%)
✓ Growth in multifacility chains (55%)
Services Provided
✓ Nursing
✓ Physical therapy
✓ Occupational therapy
✓ Speech therapy
✓ Medical and dental services
✓ Medications
✓ Laboratory and X-ray services
✓ Room and board
Special Care Units
✓By diagnosis or disability:
• Alzheimer’s disease
• Mental health and intellectual disabilities
• Brain injury
• AIDS
✓By age:
• Pediatric
• Young adult
Those Served
✓ Elderly – over 90%
✓ Female – two-thirds, male – one-third
✓ Both physical and mental disabilities
• Two-fifths have dementia
• Many have depression
Activities of Daily Living (ADLs)
✓ Bathing
✓ Dressing
✓ Eating
✓ Toileting
✓ Transferring
* Average resident needs help with 4 ADLs
Market Forces
✓ Need-driven admissions
✓ Family- and physician-initiated admissions
✓ Hospital Readmissions
✓ Location relative to resident’s family
✓ Alternative types of care (or lack of)
© 2010 Jones an Brtlett Publishers, LLC
Regulations
Purpose of regulations:
✓ Care is safe and of high quality
✓ Care is not unnecessarily expensive
✓ Services are uniformly accessible
✓ Rights of workers are protected
Types of Regulations
✓ Affecting residents
✓ Affecting employees
✓ Affecting building construction
and safety
Financing Nursing Facilities
Reimbursement sources:
✓Medicaid – 66%
✓Medicare – 13%
✓Private pay and other sources –
the remainder
Medicare Coverage
Restrictions:
✓Covers only skilled nursing care
✓Must follow 3-day hospital stay
✓Limited to 100 days per “benefit period”
✓Requires co-payment for days 21–100
Staffing and Human Resource Issues
✓ Nursing
✓ Certified nurse aides (CNAs)
✓ Medical coverage
✓ Other specialists
• Often on contract basis
Legal and Ethical Issues
Responsibility to:
✓Protect residents’ rights
✓Act ethically
Types of Legal and Ethical Issues
✓ Day-to-day quality-of-life issues:
• Autonomy (choice)
• Privacy
✓ End-of-life issues:
• Advance directives
• living will or power of attorney
• Patient Self-Determination Act of 1990
• Cognitive ability?
Management Qualifications
✓ Licensed by the states
✓ Differing state regulations cover:
• Education requirements
• Hands-on experience
• Continuing education
• NAB
Management Challenges
and Opportunities
✓ Balancing cost and quality
✓ Integration of differing levels of service
✓ Coordination with other facilities and
organizations
Significant Trends
✓ Rising acuity levels
✓ Managed care
✓ Prospective payment
✓ Private long-term care insurance
✓ Payment bundling
✓ Rising liability insurance costs
✓ Consumer choice
Summary
Nursing facilities have a long history but
are evolving, as is the overall system.
They have gone from being the dominant
form of long-term care to one of many
provider types.
Chapter 5
Subacute and
Postacute Care
Learning Objectives
1. Define and describe subacute
and postacute care
2. Identify where subacute care fits
in the continuum of care
3. Identify sources of financing for
subacute care
Learning Objectives (continued)
4. Identify and describe regulations
affecting subacute care
5. Identify and discuss ethical issues
affecting subacute care
6. Identify trends affecting subacute
care for the near future and the
impact of those trends
What is Postacute Care?
Postacute care:
✓Improves transition from hospital to
the community
✓Provides services to patients needing
additional support following
discharge from the hospital
Postacute Care Providers
Include:
✓ Inpatient rehabilitation facilities
✓ Long-term care hospitals
✓ Skilled nursing facilities
✓ Home health agencies
What is Subacute Care?
✓ Comprehensive inpatient care
✓ Comes after, or instead of, acute care
✓ Between acute and long-term care
✓ Usually for a defined period of time
✓ Developed largely for cost savings
Philosophy of Care
Four types:
✓Transitional
✓General
✓Chronic
✓Long-term transitional
Ownership of Subacute Facilities
✓Mostly freestanding SNFs (two-thirds)
• Rehabilitation focus
✓Hospital-based
• Medical focus
✓Many owned by corporate chains
Services Provided
• Rehabilitation
• Physical therapy
• Occupational therapy
• Respiratory therapy
• Cardiac rehabilitation
• Speech therapy
• Postsurgical care
• Other specialty care
• Chemotherapy
• Parenteral nutrition
• Dialysis
• Pain management
• Complex medical care
• Wound management
• Ventilation care
Care Planning
✓ Focus on quality of care and outcomes
✓ Initial assessment
✓ Interdisciplinary team
✓ Weekly team conferences
✓ Ongoing evaluation
Case Management
✓Focus on efficiency, cost-effectiveness
✓Manage resources to optimize outcomes
at lowest cost
✓Case managers may be:
• “External” – hired by payer
• “Internal” – hired by provider
Consumers of Subacute Care
✓
✓
✓
✓
✓
✓
✓
✓
✓
Post hip-replacement surgery
Spinal cord or brain injuries
Strokes
Cancer
AIDS
Wounds
Cardiac recovery
Respiratory ventilation
I.V. therapy or feedings
Market Forces
✓ Cost-saving efforts
✓ Managed care
✓ Choice
Regulations
Purpose of regulations:
✓Care is safe and of high quality
✓Care is not unnecessarily expensive
✓Services are uniformly accessible
✓Rights of workers are protected
Types of Regulations
✓ Medicare
✓ OBRA
✓ Other – similar to other providers
Accreditation
✓ Joint Commission
✓ CARF International
✓ NCQA
Financing Subacute Care
Reimbursement Sources:
✓Medicare – two-thirds
• Pays as SNF
✓Other third:
• Managed care
• Medicaid
• Private insurance, self-pay, and other
Staffing
Interdisciplinary team:
✓ Program administrator
✓ Physicians
✓ Nursing
✓ Other professional staff
✓ Nonlicensed staff
Legal and Ethical Issues
✓ Meeting regulations
✓ Liability issues
Management Qualifications
✓ Licensed by the states as nursing
facility administrators
✓ Hospital-based units must find a
licensed administrator or get one of the
hospital administrators licensed
Management Challenges
and Opportunities
✓ Changing the culture of the
organization
✓ Balancing cost and quality
✓ Coordination, competition
✓ Physical facility considerations
Significant Trends
✓ Managed care
✓ Changes in acuity levels
✓ Emphasis on outcomes
Summary
Subacute care is the newest form of long-term
care, falling between acute and long-term care.