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Design a LTC System
• Who gets coverage?
• What will you cover?
• How will you pay for it?
Health Services for Older Persons Long Term and Acute Care
Bruce Leff, MD
Associate Professor of Medicine
3 October, 2006
Let’s Think About…
• Community-based long term care
• Who the users are and the services they use
• Medicare home health care
• Various models CBLTC:
• Acute care issues and models
Where Should / Could These People Live?
What Will Determine Where They Live?
• 85 yo F: CHF, OA, vision, 4 ADLs, alone
• 78 yo F: DM, CVA, hemiparesis, bedbound,
total ADL dependent, has family
CBLTC
• ADL or IADL assistance > 3 mos / yr
• National Long Term Care Survey
– ~20% elderly receive LTC in comm or instit
– ~50% rely entirely on informal care
– 80% CBLTC provided by informal family
caregivers - women
NH v Community v CBLTC
Age > 85
Women
ADL Dep
Community
Incontinent
Demented
0
10
20
30
40
50
60
NH v Community v CBLTC
Age > 85
Women
ADL Dep
NH
Community
Incontinent
Demented
0
20
40
60
80
NH v Community v CBLTC
Age > 85
Women
NH
Community
CBLTC
ADL Dep
Incontinent
Demented
0
20
40
60
80
Another Question
•
Which type of community-based long
term care services are more commonly
provided?
A. Formal services
B. Informal services
CBLTC: Formal v Informal
%
Distribution of All Elderly LTC Population
Between Formal and Informal Providers by
Availability of Immediate Family
80
70
60
50
40
30
20
10
0
Informal care only
Formal care,
community
Formal care,
institution
All recipients Unmarried, Married with
no children
children
CBLTC: Formal v Informal
Distribution of All ELderly LTC Population
Between Formal and Informal Providers by
Disability Level
80
Informal care only
%
60
Formal care,
community
Formal care,
institution
40
20
0
5 ADLs
IADLs Only
Question– Medicare Home Health Benefit
• Your 88 yo spouse has severe
Alzheimer’s disease, is uncooperative
when it comes to bathing and you are
too frail to force him/her to do so.
• True or false - your Medicare home
health benefit will pay for a home health
aide to come to your home to give your
spouse a bath?
Medicare HH Benefit
• Eligible
– Homebound
– Under MD care
– Skilled RN or PT or speech need
• Skilled need
– Assessment, teaching, or evaluation
• Physical therapy or skilled nursing opens the door to the
Medicare HH benefit
• Coverage
– Skilled RN, PT, OT, aide, speech, SW / equip
Medicare Fee-for-Service Home Health
Expenditures
After rising rapidly for most of the decade, total home health spending
fell 37 percent in 1998.
18
$16.7
Billions of Dollars (Nominal)
16
14
12
10
IPS
took
effect
Operation
Restore Trust
launched
8
$7.9
6
$3.7
4
2
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
Calendar Year
Note: Medicare program payments represent fee-for-service only. IPS is the interim payment system created by Congress in the
Balanced Budget Act of 1997. Operation Restore Trust was a comprehensive anti-fraud initiative sponsored by HHS.
1999
Data Source: Welch HG, et al. The use of Medicare Home Health Services. NEJM 1996;335:324-329
Medicare Fee-for-Service Home
Health Expenditures
18
$16.7
Billions of Dollars (Nominal)
16
14
IPS
took
effect
12
Operation
Restore Trust
launched
10
$7.9
8
$3.7
6
4
2
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
Calendar Year
Note: IPS is the interim payment system created by Congress in the Balanced Budget Act of 1997. Operation
Restore Trust was a comprehensive anti-fraud initiative sponsored by HHS.
1999
Persons Served and Average Number of
Visits by Home Health Agencies
76
73
112
71
107
108
Average
Number of
Visits
102
97
95
66
61
92
51
87
Persons
Served
82
36
77
57
72
67
62
57
56
•Largest reduction of any MC
service
•Responsible for decline in total
MC $ in ’99
•HHA avoiding sick patients –
money losers
51
46
41
36
52
31
19 9 0
19 9 1
19 9 2
19 9 3
19 9 4
Calendar Year
19 9 5
19 9 6
19 9 7
19 9 8
Average Number of Visits per Home Health ser
Persons Served per 1,000 Enrollees
117
What’s the Big Deal?
Effects of Home Care on:
“Health or personal care services
delivered in a person’s home”
Function?
Satisfaction?
Hospital use?
NH use?
O/P care use?
Total costs?
Mortality?
Effects of Home Care
•
•
•
•
•
•
•
Functional ability
Satisfaction
Hospital use
NH use
O/P care use
Total costs
Mortality
None
Small transient ⇑
Slight ⇑
Slight ⇓
Slight ⇑
15 % ⇑
Slight ⇓
No effects significant @ p < 0.05
Hedrick& Inui. HSR 20:851, 1986
Problems Evaluating CBLTC
• Study design difficulties
– Allocating resources randomly
– Severity of illness difficult to control for
– Treatment and study groups differ
– Attrition
– Changes in health care system
– Varied outcomes measured
Home Visits to Prevent NHP & Fx Decline
•
•
•
•
•
•
Preventive in-home visits, > 70 yo
Screened 1349 abstracts
18 trials included
Assessed trial quality
18 trials – 13,447 pts
Heterogenous interventions,
intervention personnel (most w/o MD), #
f/u visits (0-12), CGA v non CGA
Stuck, JAMA 2002;287:1022
Stuck et al. JAMA 2002;287:1002-8
• Conclusion: Preventive home visitation
programs appear to be effective, provided
the interventions are based on
multidimensional geriatric assessment and
include multiple follow-up home visits and
target persons at lower risk for death.
Benefits on survival were seen in youngold rather than old-old populations.
Program for All-Inclusive Care
for Elderly - PACE
• Multidisciplinary day hospital model - On Lok
• Serves dually eligible - MC + MA who are
nursing home eligible
• What is special about the dually eligible?
Self-Reported Health Status of Dually
Eligible and Non-Dually Eligible Beneficiaries, 2000
Over half of the dually eligible population is in poor or fair health.
100%
8%
20%
90%
18%
80%
Percent of Beneficiaries
55%
70%
60%
35%
32%
50%
40%
30%
28%
27%
20%
10%
12%
15%
5%
0%
Non-Dually Eligible
Excellent
Dually Eligible
Very Good
Good
Fair
Poor
Total Health Expenditures by Payer for Dually Eligible and
Non-Dually Eligible Beneficiaries, 1999
Health expenditures for the dually eligible population were more than double that
of the non-dually eligible.
$18,000
$16,278
$16,000
Per Capita Dollars Spent
$14,000
$12,000
$7,396
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Non-Dually Eligible
Medicare
Risk HMO
Out-of-Pocket
Dually Eligible
Private
Medicaid
Other Public
Note: Out-of-Pocket does not include premium payments. Payers will not sum to total due to some small categories being omitted.
“Other Public” includes VA, DOD, and state-based pharmaceutical assistance programs.
Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS) 1999
Integrated Financing – The Key
MEDICARE
MEDICAID
2.39 x AAPCC
and/or PRIVATE
PAY
1/3 PACE $
85 - 95% of
cost of FFS care of
comparable
population
2/3 PACE $
MONTHLY
CAPITATION
PACE Expenditures
Center-Based Services: 32%
8%
32%
17%
In-Home Care: 22%
Admin&Plant: 21%
Inpatient Services: 17%
21%
Other Medical Services: 8%
22%
PACE
• Outcomes
– Ave pt: 80 yo, 7.8 med conditions, 2.7 ADL
40% live alone
42% demented
– 2500 hospital days / 1000 / yr (480 - 5000)
– 1 MD visit/mo, 6 nurse visit/mo, low subspec use
– 5% PACE days are NH days (~ 4-5% / yr)
Assisted Living Community
• Not independent, don’t need 24 hr skilled
nursing
• Usually offer some help with ADL, IADL
• No set definition of services - wide variation
• Monthly: $1500-3500
Continuing Care Retirement
Communities (CCRC)
• Long term contract: guarantees lifelong
shelter and access to specified health
services
• Lump sum payment and monthly fee
• If you get sick, needs will be met
• Usually independent on entry
Consumer Directed CBLTC
• Services usually provided by HH agencies
• New programs allow recipients to independently
arrange and supervise personal assistance services
at home
• Rationale: advocacy, autonomy, demedicalization,
costs, shortage of HHA workers
• Can hire family or friends
Cash and Counseling for MA
Personal Care Services
• Advocates
– Individuals, not
agencies are best
suited to make
decisions about care
and people they hire
– Reduce NH placement
• Critics
– Misuse funds intended
for care
– Receive inadequate
care
– Use cash benefit to
pay family member to
provide care once
provided for free
– Raise total MA costs
Dale, et al. Health Affairs Web exclusive W3-567, November 19, 2003
Cash and Counseling
• Treatment group receive fewer hours of
unpaid care than controls
• But, majority of hours still provided by unpaid
caregivers – c/w easing burden on family
• Long term effect on spending still unknown
Acute Care for Elderly
Injuries in Older Patients in Acute Hospital –
Harvard Medical Practice Study
65-74
75-84
>85
Diagnostic mishap
3.7
6.3
7.4
RR
>65/<65*
1.7
Therapeutic
mishap
Drug complication
4.9
5.6
16.6
4.1
12.8
12.0
9.2
2.4
Falls
1.2
4.2
7.4
10
Operative
complications
27.7
30.3
48.1
2.3
NEJM, 1991;324:370
What is an ACE Unit?
• Create physical environment to foster
independent function
– Carpets, clocks, calendars, toilets, lighting, common
area
• Multidisciplinary assessment and care
– Led by primary nurse. Guidelines focus on geriatric
syndromes
– Daily rounds by team – focus on fx, early d/c planning
• Medical review
• Comprehensive discharge planning including
home assessment
ACE Results
• RCT
– Hypothesis: pts admitted to ACE unit would be
more independent in ADLs at discharge
– N = 661, age > 70
ADL improve
ADL same
ADL worse
(p < 0.01)
ACE
34%
50%
16%
Usual Care
24%
54%
24%
Fewer ACE pts to nursing homes (p = 0.02)
Post Acute Hospital Care Disease Focus
Prob Not Being Readmitted
100
Treatment
90
Control
80
67 %
70
60
54 %
50
40
0
15
30
45
60
Days After Hosp D/C
Rich et al. NEJM 333:1190, 1995
75
90
- Readmissions
for all reasons
decreased
- Quality of life
improved
- Costs: $216
per patient
treated
Comprehensive D/C Planning
and Home Follow-up
100
*
*
Control
60
*
40
80
76
37
Intervention
49
20
*
11
* P < 0.05
7
0
20
27
% Pts
Readmit 6
Mos
Total #
Readmits
Hosp Days 6 LOS for
Mos x 10
Readmitsdays
Naylor et al.
JAMA 281:613,
1999. Comment
by Boling.
JAMA 281:656,
1999
Hospital at Home
• Australia, United Kingdom and Israel
– All nursing led interventions, under national
medical insurance
• United States
– National Demonstration Project of physician
led model
– Favorable clinical, quality, satisfaction, cost
outcomes
Summary