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The scope of enduring care, the benefits of long-term acute care hospitals, and what the shift in demographics means to the viability of the industry

The need for durative care is not going anywhere. As the makeup of the American population continues to shift toward a top-heavy, senior-laden demographic, long-term care is set to become a defining focal point of this and of future generations. The writing is on the wall: In 2007, 9 million men and women over the age of 65 required one form or another of long-term care. By 2020, 12 million will require such services.

While we wait for the vast waves of Americans to spill into older age groups, the focus today rests on the existing options and transitions that are able to provide the smoothest roads for our patients. In the diverse landscape of long-term care, which is both a common and expensive latelife option, which services will best serve you or your patients?At its most fundamental, long-term care is a set of services that addresses medical or non-medical needs of people with chronic disease or disability. In most cases, the goal of long-term care is to grant individuals an optimal level of functioning. Long-term care options like skilled nursing facilities and assisted living facilities focus on the quality of daily living rather than striving for a cure.

One long-term care institution, however, does the exact opposite. Known as long-term acute care hospitals, or LTACs in the jargon of the industry, these facilities provide extended treatment for some of most severe and complex conditions seen in the folds of the health care canvas. The goal of LTACs is to help patients recover and return them home to their former way of life.

Whether an LTAC is a good fit for a patient can be determined largely by medical complexity, says Robin Lester, a senior director of case management at Kindred Healthcare, which operates more than 80 LTAC hospitals around the country. “Most of our patients have one primary diagnosis and 16 or more complications or comorbidities,” Lester says. “They are pretty complex medical patients, which is why they necessitate, on average, a 25-day length of stay.”

Length of stay is one requirement of admission. Other hallmarks of the LTAC hospital include a requisite amount of skilled nursing hours per day and the availability of specialized equipment.

“Long-term acute care hospitals have a vital role in the overall health care continuum,” says Adriane Lutes, senior vice president of operations for Select Specialty Hospital, which operates close to 90 LTAC hospitals in 25 states. “Select Specialty Hospital is designed for medically complex and critically ill patients who require a longer acute-care stay than a traditional hospital usually can offer.”

Before negotiating the specific elements of LTACs and how they differ from other forms of long-term care, it is important to understand the environment in which these facilities and services can engage and prosper.

Sharp Changes Coming

On March 5, 2008, the Caring for an Aging America Act, a bill that carries significant implications for the status of long-term care, was introduced in the Senate. California Senator Barbara Boxer spearheaded its introduction, which was cosponsored by seven members of Congress and supported by dozens of leading organizations, including the American Geriatrics Society, AARP, the American College of Physicians, the National Association of Professional Geriatric Care Managers, and the National Association of Social Workers.

The impetus of the bill is the potentially harrowing consequences that could arise should the institutions involved in long-term care fail to implement policies and programs that can adapt to the shifting demographics of the country.

In addition to the support and advancement of those working within the long-term care paradigm, and the call for an expansion of the industry, the bill seeks to establish a “Health and Long-term Care Workforce Advisory Panel for an Aging America” that would, among other tasks, inform Congress on issues related to the care of the aging population.

Those in support of the bill cite the following facts and statistics for the pressing need of legislative activity:

GROWING OLDER

The age group that most requires long-term care — those aged 85 and older — is projected to double by 2030, and to double again by 2050, when it will consist of nearly 21 million individuals. The Family Caregiver Alliance estimates that 27 million Americans will utilize long-term care services by 2050.

WORKFLOW SHORTAGE

There are roughly 7,000 physicians who are certified geriatricians today, according to the American Geriatrics Society. That number will have to increase fivefold, to 36,000, to keep up with the population shift.

CHRONIC ILLNESS

More than 80 percent of older adults have one chronic condition and nearly two-thirds have multiple chronic conditions. Chronic illness complicates long-term care.

The Caring for an Aging America Act is currently in the hands of the Health, Education, Labor and Pensions Committee for review, and its status is uncertain despite the endorsements of the many leading organizations behind it.

In the immediate future, the election of a democratic president may spell changes to long-term care.

The American Association of Homes and Services for the Aging (AAHSA), which supports the Caring for an Aging America Act, is an association of 5,700 not-for-profit providers of aging services including adult day care, home health, nursing homes, senior housing, assisted living residences, and continuing care retirement communities. It predicts that elements of Medicare that affect long-term care now have a greater chance of being addressed. Among them are issues related to Medicare Part D, including the 2010 payment update for skilled nursing facilities, home health care providers and hospice.

Among other initiatives, AAHSA advocates the creation of an insurance trust that would cover all disabled adults. Visit www.thelongtermcaresolution.org to learn more about the issue.

Looking Ahead

When searching for the right long-term care option, education and foresight play an essential role. Many consumers do not consider their options until thrust into the center of a crisis. Planning ahead will help grant the desired services should the need arise. What follows is an analysis of long-term care options, including the curative-based entity of the long-term acute care facility.

LTAC Hospitals

These hospitals, with their focus on curative care, must maintain specific characteristics to meet the definition of the category. These include:

• An average length of stay of 25 days.
• The provision of skilled nursing care greater than or equal to six and a half hours per day.
• The availability of specialized equipment.
• A multidisciplinary team led by a physician that is required to convene on a weekly basis to develop a plan of care.
• Daily intervention by an MD/PA/NP.

Case managers and discharge planners may not always be aware of the availability of LTACs. It depends on the region of the country in which they work, says Robin Lester, the overseer of case management at Kindred. In some cases, LTACs may be a new phenomenon. “It’s specific to different parts of the country where they’ve had more exposure over longer periods of time,” Lester says. Kindred, for instance, operates LTACs in three counties in New Jersey but none in New York.

While location is key for awareness, what matters more may be the type of patient who would be a prime candidate for the multidisciplinary services of an LTAC. The keyword here is complexity. Lester offers an example. She relates the story of a patient, an older man, who one day suffered an aortic aneurysm. “He went to shortterm acute care, and everything that could have went wrong did,” she says. “He ended up on a ventilator and, because of his cardiovascular compromised state, ended up with multiple decubitis ulcers. They gave him a very unfavorable prognosis.”

The patient was soon transferred to an LTAC in Indianapolis. He lost his leg to amputation. But over the course of a seven-month stay, his treating team was able to stabilize him. “He required special intervention for nutrition. They had a wound care team working with him. They had a plastic surgeon. They had a cardiovascular surgeon, a general surgeon, a cardiologist, a pulmonologist,” Lester recounts. “This was eight years ago and they didn’t think he was going to make it another month in short-term acute care.”

Despite his difficulties, the man thrived. Through the hospital, he was able to rehabilitate. He received an artificial limb. He continued rehabilitation on an outpatient basis and he now lives on his own and works part-time.

Many patients who visit LTACs are respiratorycomplex. Also common is the prevalence of infectious disease, wound and skin issues, and cardiovascular disease. “It is truly a very sick patient who has multiple complexities and comorbidities,” Lester says.

Skilled Nursing Facility

Also known as a nursing home, a skilled nursing facility, or an SNF, is appropriate for individuals who require frequent medical or custodial care. Medical care can include:

Wound care after a major surgery.

• Administering I.V. antibiotics.
• Physical therapy to correct strength and balance.
• Speech therapy.
• Occupational therapy.

Custodial care, which addresses activities of daily living, may assist individuals with the necessities of bathing, dressing, eating and getting up from bed, for example. Custodial care is frequently long term for elderly individuals. Long-term care at an SNF is common for those who suffer from Alzheimer’s, those with extreme frailty, or those who have suffered a stroke.

Whether insurance will cover a stay at an SNF is dependent on several factors. According to Helpguide, a noncommercial information provider, private insurance and Medicare pay for a limited time, allowing for the following:

• Minimum, three-day prior hospitalization.
• Admittance to SNF within 30 days of hospitalization.
• Coverage of first 20 days, followed by a daily deductible.
• A 100-day maximum stay.
• The documentation of rehabilitative progress.

For more information, visit the applicable pages about Medicare Part A at www.medicare. org.

Assisted Living Facilities

With these facilities, there is a focus on minimal intervention. While providing 24-hour supervision, they concentrate on custodial care rather than medical services. An example of a suitable patient is one who suffers from a memory disorder or someone who needs help with mobility or incontinence but does not require medical care.

Assisted living facilities are generally less expensive than SNFs. It is estimated that 1 million Americans live in assisted living facilities today.