#041 Long Term Care Geriatrics Services
Fast Facts and Concepts #041 PDF
Authors: Jessica Kuester MD, Jennifer Carnahan MD, Judi Rehm, Steve Denson MD, Edmund Duthie MD
Objectives: List and describe available outpatient geriatrics care services
Context: Geriatrics Outpatient Medical Care
Action: Identify which geriatrics long term care options(s) would be most beneficial for individual patients.
Incidence/Prevalence: The US Census Bureau reports that in 2012, 13.7% of the approximate 313,914,040 people in the United States are age 65 and older. This equals approximately 43 million people. While a significant amount of focus in medical education is placed on inpatient care, the majority of geriatric patients will spend most of their time navigating available outpatient care systems. For example, approximately 735, 000 people were estimated to live in assisted living facilities in 2012. The Centers for Disease Control estimates that there are 1.7 million current nursing home residents.
Adult Day Care: Non-residential day program that allows for clinical monitoring of chronic medical conditions, medication management, assistance with ADLs, meals, and group interaction. Participants are commonly patients with dementia who require supervision while their primary caregivers are at work/need respite. This model is often used as an alternative to either in-home care or skilled nursing home care, at a fraction of the cost. These programs require a family member or caregiver to assist the individual at home.
Adult Foster Care: Program that provides room, board, and supervision/ basic assistance in ADLS by a paid care provider who typically also lives in the home. Participants are typically frail elderly adults that are unable to live independently, require a minimal level of supervision and ADL assistance, desire a more home-like environment and do not require skilled nursing services. (Regulations for adult foster care vary state to state. Typically patients with dementia are excluded. Please refer to individual states for details. )
Assisted Living: Home-like living environment that provides care services to its residents. Services available vary greatly regionally and nationally. Services can include assistance in ADLs/IADLs, social activities, meals, and transportation. Participants are commonly people who are no longer safe to live fully independently, but do not yet require the degree of nursing care that would make them eligible for a nursing home. Residents need to be able to provide some level of their own care independently to be deemed safe for assisted living.
PEARL: Assisted living facilities are not covered by Medicare.
Continuing-Care Retirement Communities: Also called “life-care communities”; “step-up” model of care in which participants typically pay an entry fee in addition to monthly fees to join the care community. Care levels available range from independent living through assisted living to nursing home level of care. As the individual requires more assistance, they transition into the next level of care. Initial participants are generally healthy and financially independent.
Geriatric Resources for Assessment and Care of Elders (GRACE): Home-based primary care model that that provides comprehensive geriatric assessment. The core team consists of the patient, a nurse practitioner, and a social worker who partner with the patient’s primary care provider (PCP) and an interdisciplinary team to develop an individualized care plan with special focus on managing common geriatric conditions. Participants are typically low income frail elderly adults.
Greenhouse Project Homes: Living environment that provides nursing home level care (RN on site) to typically 10-12 individuals. Goal is to form a community in which all residents have an active role. Participants typically qualify for nursing home level of care. http://thegreenhouseproject.org/
Group Homes: Apartment or home in which two or more unrelated people live together. Participants typically share common living spaces but have their own bedroom. Level of care provided varies but participants typically have to be independent in ADLs. RNs are not on site. Residents are more functional than assisted living participants.
Home Care: Please see Geriatric Fast Fact #025
Home Hospital: Intensive level of home care provided by visiting RNs and MDs for a time limited management of an acute illness (ex. CHF exacerbation, cellulitis). Participants typically meet requirements for an inpatient hospitalization but are instead managed in their home living environment.
Nursing Home: Living environment that provides room and board, assistance with ADLs, medication management, and recreational activities. RN available on site 24/7. More than half the residents require supervision/assistance in all five ADLs. PEARL: Medicare reimbursement is limited to short term acute rehab stays in nursing homes. Long stay care is not Medicare reimbursable.
Outpatient Consultation: Outpatient consultative clinical care model in which typically a geriatrician-led team provides a comprehensive geriatric assessment and develops a care plan. Care recommendations are then provided to the patient and their primary care provider. Participants tend to be community dwelling adults referred by their primary care providers or caregivers.
Program of All-Inclusive Care for the Elderly (PACE): Community based interdisciplinary team provides all outpatient, inpatient, and long-term medical care including medications and home nursing. Participants are typically frail community dwelling adults older than 55 who meet state requirements for nursing home level of care and are dual eligible for Medicaid and Medicare. PACE utilizes many of the programs listed (e.g., adult day care, assisted living, group homes, home care, nursing home).
Senior Health Clinic: Primary care clinic that specializes in older adults that utilizes a multidisciplinary team to provide comprehensive geriatric assessment and management. Care team members help coordinate care throughout the outpatient and inpatient settings. Participants are community dwelling older adults.
Underlying Science: The economics of the provision of long term care services is important. The average costs of long term care are in excess of $205/d or $6235/month for a nursing home semi-private room. Assisted living costs $3293/month for a one-bedroom unit. In contrast, adult day services cost $67/day, home health aides $21/hour, and homemaker services $19/hour [2010 data, LongTermCare.gov/costs-how-to-pay/costs-of-care/]. With a significant increase in aged persons as the boomer population ages, safe and cost-effective means of caring for frail, vulnerable older adults is a critical economic and policy issue.
ACGME Competencies: Systems Based Practice, Patient Care
Counsell SR. Outpatient care systems. Geriatric Review Syllabus. 2013;1-7.
Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the geriatric resources for assessment and care of elders care management intervention. J Am Geriatr Soc. 2009; 57(8): 1420-1426.
United States Census Bureau 2012. http://quickfacts.census.gov
Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. National Center for Health Statistics. Vital Health Stat 13(167). 2009.
Caffrey C, Sengupta M, Park-Lee E, Moss A, Rosenoff E, Harris-Kojetin L. Residents living in residential care facilities: United States, 2010. NCHS Data Brief. 2012 (91):1-8.
Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: GFF#041 Long Term Care Geriatrics Services, Jessica Kuester MD, Jennifer Carnahan MD, Judi Rehm, Steve Denson MD, Edmund Duthie MD; December 2013.
Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Disclaimer: Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.