CHAPTER 12

Long-Term Care

Lecture guidelines

The material in this chapter on institutionalization and financing of mental health and medical services provides important up-to-date information on one of the major issues facing the world today. The topic of institutional adaptation is one of the oldest areas within gerontology and ties together many relevant issues that fit within a biopsychosocial perspective. Furthermore, as many students taking the course will be (or maybe are) working within these settings, there is a great deal of value in exploring these topics in depth. Technical issues involved in the financing of health care are important to cover, as students who complete this course should be familiar with the structure of Medicare and Medicaid. Although not "psychological" in the narrow sense, these health care financing systems contribute in important ways to the well-being of older adults.

Videos and films

There is an extensive amount of material that can be used to illustrate institutionalization and financing of long-term care. In addition to news reports on Medicare funding, which has been given a great deal of attention with the healthcare reform debate in the U.S., there are many movies that depict institutionalization, for better or worse. Some movies from the 1970s portray the "bad old days" prior to the Nursing Home Reform Act and are interesting to show as contrast to what we think of now as improved nursing home care. These old movies include "Where's Poppa?," "I Never Sang for my Father," and "Do You Remember Love?" More recent movies, which still emphasize negative aspects of institutionalization include "Happy Gilmore." The Simpson’s episode, “The Old Man and the C Student” shows a humorous depiction of children visiting a nursing home (and trying to change it).

There is an excellent documentary entitled “Sunset Story” that provides a poignant and extremely well-crafted portrayal of a group of aging “radicals” (http://www.sunsetstory.com/).

Discussion questions

Institutional facilities for long-term care

How is a nursing home different from a hospital?

Would you consider placing a chronically ill relative in a nursing home? Why or why not? What would you look for in a nursing home?

What are some of the advantages of residential care facilities compared to nursing homes?

How do assisted living facilities fall short of their goal of "aging in place"?

Community-based services and facilities

What are some of the advantages of home health services compared to a nursing home or residential care facility?

Why don't nursing homes take advantage of behavioral methods of reducing incontinence in residents? If you were a consultant to a nursing home, how would you recommend that such training be instituted?

The financing of long-term care

Why is there so much concern in the U.S. about Medicare funding?

What do you think about the need for nursing home residents to "spend down" so that they qualify for Medicaid?

What steps could states take to cut down on Medicaid costs, or should no limits be set on Medicaid?

Legislative landmarks in long-term care of older adults

Why was the Nursing Home Reform Act needed? Do you think it went far enough or should there be more regulation of nursing homes?

If you were a nursing home administrator, how would you enforce the rights of residents as mandated by the Nursing Home Reform Act?

Visit a local nursing home and see if you can spot any of the deficiencies found in the 2007 GAO report.

The Quality of Long-Term Care

Why is lack of infection control so important to long-term care of older adults?

What might contribute to the low quality of care in the District of Columbia in the U.S.?

Psychological issues in long-term care

How would the competence-press model apply to the dormitory that you live in?

Why is it difficult for institutions to meet the needs of the average resident?

Can changes in nursing homes to personalize the living areas significantly improve the extent to which residents adjust to life in an institution?

Multiple choice questions

AgeFeed

Compassionate care

According to AgeFeed, compassionate and considerate care in long-term care facilities includes:

1. encouraging residents to cook their meals alone in their rooms.
2. maintaining a uniform environment from room to room.
3. having sing-alongs with local daycares and schools.
4. keeping birthday and holiday celebrations to a minimum.

Encouraging physical activity

According to AgeFeed, residents do best in long-term care facilities that engage in which practice?

1. Keeping residents out of kitchen areas so that they do not injure themselves.
2. Restricting group activities such as game nights that could interfere with recovery.
3. Making sure that all residents take their meals alone in their rooms.
4. Encouraging physical activity through dance or fitness classes.

Institutional facilities for long-term care

Assisted living facility payment

A retired couple is moved from their home to an assisted living facility, but realize this might be difficult because assisted living facilities typically involve payments coming from:

1. a combination of Medicare and Medicaid
2. personal savings and pensions
3. salaries paid in return for room and board
4. shared costs among groups of residents.

Medicare pay-as-you-go

Medicare, like Social Security, is a “pay-as-you-go” system, meaning that people paying into it now:

1. are supporting current beneficiaries.
2. pay lower tax rates than those who don’t contribute.
3. contribute 100% of their payments to the Trust Fund.
4. receive a guarantee of support when they retire.

Medicaid

The medical funding program known as Medicaid provides coverage for:

1. government workers.
2. retired individuals only.
3. privately insured employees.
4. medically needy individuals.

Medicare Part A

An 83-year-old retiree was surprised and disappointed to find out that Medicare Part A would not cover the cost of her:

1. laboratory tests.
2. rehabilitation.
3. dental care.
4. intensive care.

Donut hole

Those 65 and older in the U.S. enrolled for what type of medical coverage are likely to find themselves in the “donut hole”?

1. Blue Cross
2. Part B of Social Security
3. Part D of Medicare
4. Medicaid

Ombudspersons

Patient advocates known as _____________ in long-term care institutions were guaranteed as part of nursing home reforms.

1. ombudspersons
2. geropsychologists
3. geriatricians
4. assisted care aides

Acute rehabilitation

An older adult with a broken hip is sent to the hospital for surgery to repair the fracture. Complete recovery will require two weeks of intense care, which would most appropriately be provided in:

1. an intermediate care facility.
2. acute rehabilitation.
3. assisted living facility.
4. partial day hospital.

Acute rehabilitation

Acute rehabilitation would be the most appropriate setting for recovery of an older adult patient with which medical condition?

1. terminal cancer
2. pneumonia
3. stroke
4. substance abuse

Diagnosis among nursing home residents

The most common diagnosis among residents of nursing homes is:

1. neurocognitive disorder.
2. depression.
3. pneumonia.
4. hypertension.

For profit

For profit facilities make up _____% of all nursing homes in the United States.

1. 69.8
2. 49.4
3. 18.7
4. 31.2

Cost per day (semi-private)

The average cost per day (in dollars) of a semi-private room in a nursing home, according to the U.S. National Nursing Home Survey:

1. 116
2. 225
3. 375
4. 253

Cost per month (private)

The average cost per month (in dollars) of a private room in a nursing home, according to the U.S. National Nursing Home Survey:

1. 3628
2. 5662
3. 7698
4. 6844

National chains

In the U.S., what percentage of nursing homes are affiliated with a national chain?

1. 69.8
2. 48.1
3. 39.2
4. 57.6

Aides

The majority of care provided to patients in residential care facilities is provided by:

1. aides.
2. licensed nurses.
3. physician’s assistants.
4. registered nurses.

Payment for assisted living facilities

The majority of residents in assisted living facilities pay for their costs out of what types of funds?

1. Combination of Medicare and Medicaid
2. Personal savings and pensions
3. Salaries paid in return for room and board/Contributions from charitable foundations
4. Shared costs among groups of residents

Home Health Agencies

The majority of home health agencies operate on what financial basis?

1. private, non-profit
2. public, for profit
3. public, non-profit
4. private, for profit

Registered nurses

Which sector of long-term care employs a majority of registered nurses?

1. assisted living
2. respite care
3. board and care home
4. home health care

Community-based services and facilities

Age in place

Suggestions for enabling older adults to be able to “age in place” include what modifications to the home?

1. adding more walls between rooms
2. replacing bathtubs with showers
3. keeping lighting levels low
4. lowering water heater temperature

Age in place

An older adult couple decide that they would rather invest their retirement income in making changes in their house rather than moving to an assisted living facility. Which renovations would be least likely to help them achieve this goal?

1. changing to assistive technology around the home
2. adding more grab bars around showers and baths
3. installing higher shelves in closets to allow more storage
4. adding more lights in hallways and staircases

Adult day services

As of 2019, there were a reported _____________ individuals, mostly 65 and older, receiving adult day services in the community.

1. 2.9 million
2. 120 thousand
3. 286 thousand
4. 1.3 million

Accessory dwelling unit

In an accessory dwelling unit, older adults live in which community-based situation?

1. second living space in a home usually with family
2. nursing home attached to an assisted living facility
3. low-rent apartment supported by federal funds
4. group living quarters with other older adults

Geriatric partial day hospital

Older adult patients needing _________are served in a geriatric partial day hospital,

1. psychiatric care
2. physical therapy
3. hospital follow-up services
4. adult respite care

The financing of long-term care

Medicare federally-funded

Medicare falls into which overall category of funding for health care in the U.S.?

1. federally-funded medical and long-term care
2. state-funded costs of outpatient care
3. privately-funded personal health insurance
4. pensions used to pay for long-term care

CMS

Difficulty:

The Center for Medicare and Medicaid Services (CMS) is responsible for overseeing:

1. legislative efforts to improve long-term care.
2. privately funded health insurance.
3. federal and state funded health programs.
4. payments made for private in-home care.

Part A

Difficulty:

Part ___ of Medicare covers hospital stays and follow-up nursing home treatment.

1. A
2. E
3. B
4. Z

Part B

Medicare Part B covers which type of health care needs for older adults?

1. outpatient care
2. mental health care
3. hospital expenses
4. home health services

Part C

People seeking to purchase insurance through Part C of Medicare would be looking for plans called:

1. Hospital Insurance
2. Medicare Advantage
3. Respite Care
4. Long-Term Disability

Part D

Which U.S. legislation established Part D of Medicare?

1. Affordability Care Act
2. Medicare Modernization Act
3. Health Care Services Act
4. Medicare Advantage Act

Medicaid funding

Funding for Medicaid comes from which sources?

1. Federal and state government
2. City and township property taxes
3. Private insurance companies
4. Retail sales taxes

Medicare vs. Social Security

One primary difference between the funding of Medicare and Social Security is that Medicare involves:

1. state-based appropriations.
2. personal background security checks.
3. personal payments by recipients.
4. reimbursements for cost-of-living expenses.

Medicare payments 2018

Benefits paid out by Medicare in 2018 amounted to ___________ billion dollars (rounded off).

1. 495
2. 190
3. 741
4. 320

Donut hole

The point at which people leave the “donut hole” in Medicare Part D is referred to as the beginning of:

1. affordable care.
2. catastrophic coverage.
3. pay-as-you-go.
4. assisted living.

Medicaid expenditures

Medicaid provided a majority of its expenditures on which segment of the health care market in 2016?

1. prescription drugs
2. physicians
3. intermediate care facilities
4. hospitals

Title XX

Title XX of the Social Security Act included the provision that states must:

1. provide funding for prescription drugs.
2. conduct surveys to assess nursing home quality.
3. expand partial hospitalization in community centers.
4. prevent or reduce inappropriate care.

Legislative landmarks in long-term care of older adults

NNHQI

Consumer resources to help families and patients choose nursing homes were first mandated by federal law by the:

1. National Nursing Home Quality Initiative.
2. Nursing Home Reform Act.
3. Title XX of the Social Security Act.
4. Affordable Care Act.

NHRA

Stipulations of the 1987 Nursing Home Reform Act included ensuring that facilities:

1. cover all costs after residents spend down.
2. provide care at the lowest possible cost.
3. employ one nurse for every two residents.
4. maintain resident confidentiality and privacy.

Administration for Community Living

In 2000, the Administration for Community Living was formed by the U.S. federal government to support:

1. halfway houses for older adults.
2. geriatric partial day hospitals.
3. family caregivers at home.
4. group board and care homes.

The Quality of Long-Term Care

OSCAR scorecard (L)

In the OSCAR scorecard, a facility receives a deficiency labeled “L” for which type of violation?

1. a pattern of actual harm that is not immediate jeopardy
2. widespread conditions that put residents in immediate jeopardy
3. isolated instances with moderate potential for harm
4. no actual harm, or isolated cases of minimal harm

Number one deficiency

The number one deficiency in U.S. nursing homes in 2018, involving 45% of all institutions, was:

1. lack of infection control.
2. high-accident environment.
3. lack of pharmacy consultation.
4. unsanitary food handling.

OSCAR scorecard (G)

Ratings of a G or higher on the OSCAR scale signify which feature of a nursing home’s quality?

1. services to residents considered appropriate for their level of needs
2. better care than the average of other local facilities
3. reportable deficiency in a specific aspect of care
4. costs that exceed federal levels of funding

OSCAR online

A woman is trying to locate the best nursing home for her husband, as he requires treatment for chronic pulmonary disease. She discovers an online site gives him access to OSCAR Reports, allowing him to learn about:

1. the individual ratings of specific staff in area nursing homes.
2. which social media would be the best to use for seeking help.
3. names of the physicians who work there.
4. the extent to which facilities adhere to standards of care.

Dignity

A nursing home that receives a deficiency rating on the dignity dimension fails in which aspect of care?

1. recognition of individuality
2. receiving necessary services
3. measurable objectives and timetables
4. staff who can carry out a written care plan

Nursing Home Compare

Nursing Home Compare uses which type of system to provide information to consumers on long-term care facilities?

1. consumer reviews
2. A-L deficiency scores
3. paid advertising
4. 5-star quality ratings

Psychological issues in long-term care

Competence-press model

In the competence-press model of institutional adaptation, the “competence” function includes:

1. whether the individual has resources to pay for care.
2. the extent to which family are involved.
3. whether the home is in a rural or urban location.
4. the individual’s physical and psychological abilities.

Competence-press model

Within the competence-press model of adaptation to the institutional environment, which dimension captures the resident’s cognitive and physical abilities?

1. press
2. comfort
3. competence
4. stress

Culture change

Which of the following is a criterion for culture change in nursing homes?

1. offering only communal dining
2. allowing residents to have privacy
3. requiring residents to attend group meetings
4. discouraging too many family visits

Culture change

Organized efforts by advocates to improve the quality of nursing home care to make them less “institutional” is called the ______________ movement.

1. culture change
2. radical reinvention
3. good gerontology
4. aging in place

Green House Model

The layout for an institution based on the Green House model would include which architectural feature?

1. resident rooms arranged in long hallways
2. garage located close to the entrance
3. a hearth and seating area
4. laundry facilities in an adjacent building

Short answer questions

Institutional Facilities for Long-Term Care

1. What are the four types of residential care facilities for older adults?
2. Summarize the steps that can lead from home care to residence in a nursing home.
3. What are the three most common diagnoses in nursing homes?

Community-based Services and Facilities

1. What are the three main types of adult day services?
2. List five of the types of services provided by home health services.

The Financing of Long-term Care

1. Summarize the main features of the four parts of Medicare.
2. What is the definition of pay-as-you-go in the provision of Medicare?
3. What are the four periods of coverage provided by Part D of Medicare?

Legislative landmarks in long-term care of older adults

1. Summarize three major legislative initiatives intended to reform nursing home care.
2. Define Title VIII, Title XVIX, and Title XX of the Social Security Act.

Characteristics and Needs of Nursing Home Residents

1. Describe the major shortcomings of nursing homes in terms of the categories of the National Nursing Home Study.
2. List the top five deficiencies noted in the most recent survey of U.S. nursing home quality. Why do you think these problems exist?

Essay questions

1. What is the basis for current controversies over Medicare funding? Do you feel that Medicare should be expanded or do you think it is too extensive already? Provide data to support your argument.
2. Discuss the implications of the competence-press model for the design of nursing home environments. How would you put this model into practice if you were a psychologist consulting in a nursing home?
3. What are four examples of criteria for culture change in nursing home care?
4. What are the potential advantages and disadvantages of the Green House Model?