What is Changing about Long Term Care?
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Long-term care isn't what it used to be — and that's a good thing. There are many more options for living at home or in the community, where the vast majority of people want to be.
Technology is making it possible to have your healthcare monitored at home and to keep you in touch with family and friends. There is a greater awareness of the importance of a stimulating environment for mental and physical health.
Nursing homes are changing too, as they move toward a more person-centered focus and introduce elements of stimulating activity and participation for their long-stay residents. There are several reasons for the changes in long-term care.
Money is a factor in long term care
One reason is economic: Medicaid — the federal-state program for low-income people — is the major payer of long-term care.
According to a February 2013 report from the National Health Policy Forum, in fiscal year 2011 Medicaid paid 62.3 percent of long-term care expenditures, with 21.9 percent paid for out-of-pocket, 11.6 percent by other private sources, including long-term care insurance, and a small percentage (4.6 percent) by other public sources, such as the U.S. Department of Veteran Affairs (VA).
To keep this spending in check, Medicaid has tried to move away from what has been called an institutional bias, which means that the bulk of funding goes toward nursing homes, putting it instead toward more community-based care.
While this should be a win-win situation, it has proven difficult to implement fully, partly because of the need for more housing options and direct-care workers to provide community care. Another reason is that federal rules require Medicaid programs to provide institutional care but home- and community-based services are optional.
Legal reasons for new long term care options
The federal Americans with Disabilities Act (ADA) is another reason for the change. In 1999, the U.S. Supreme Court held in Olmstead v. L.C. that unjustified segregation of persons with disabilities in nursing homes constitutes discrimination in violation of Title II of the ADA.
The Court held that public programs such as Medicaid must offer community-based services to persons with disabilities when such services are appropriate, the affected person doesn't oppose community-based treatment, and community-based services can be reasonably accommodated, taking into account the resources available and the needs of others who are receiving disability services from the entity.
In its ruling, the Supreme Court explained that institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable of or unworthy of participating in community life.
Furthermore, confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.
Although the case that reached the Supreme Court was about two young people with mental disabilities, the Olmstead decision applies to people of all ages and all different kinds of disabilities. (Many states, including Georgia, the state where the plaintiffs in the Olmstead case lived, have yet to implement fully a plan for moving eligible people from institutions to the community.)
People want change in long term care
In addition to economic incentives and legal rulings, consumer demand has also played a part in moving away from old forms of long-term care to more home-like and person-centered settings. As people live longer — often into their 90s and beyond — the length of time a person needs various forms of care has increased and has required accommodation to various levels of need.
Although the trends of longer lives and person-centered settings are positive, implementation across the country is inconsistent and variable. At best, the system is a patchwork quilt of settings and services, some strong and some weak, with different eligibility requirements and payment sources. But compared to a few decades ago, the quilt itself is bigger because people have demanded better options.