Every day in our country, thousands of senior citizens come to a critical juncture of decisions in regard to their long-term care as they face a sudden change of condition. While in the hospital or coming from home, some with family support and others without, they enter a new part of their life that will strategic planning and significant change. At this time of change, many of these Americans come to understand the importance of long-term care planning and access. The amount of financial contribution and legal planning they’ve completed over the course of their lifetime becomes evident as the costs of care absorb their precious savings. Not everyone is prepared for the financial burden of long-term care though, with many socioeconomic disparities, geographic factors, and cultural norms coming into play. This topic, in particular, is close to my heart as my entire nursing career has been focused on senior citizens and vulnerable populations.
Throughout the decades, family roles have undergone profound changes as both men and women began assuming equal responsibilities at work and home, and an increasing rate of single parent households. With these changing roles, so changed the way we cared for our aging citizens. While historically it was expected that seniors lived at home receiving care from their daughters, sisters, or grandchildren, women’s entrance into the workforce outside of the home shifted this norm. Another factor in long-term care of seniors over the years has been the change of American healthcare from a charity-based model to an industry-based system. Nowadays, skilled nursing facilities, assisted living facilities, and adult family homes are common sights throughout our communities. These businesses are highly regulated by each state’s Department of Social and Health Services and are for-profit enterprises. Now that seniors have less family support to provide in-home care, they are turning to long-term care facilities as one of their few options.
According to Rogers (2003), over 63% of Americans over the age of 65 required long-term care as a result of their chronic conditions and/or functional disabilities. While the Congressional Budget Office (2010) found that 13% of Americans age 85 and older lived in nursing homes in particular. Whether wealthy or poverty-level, all Americans age 65 and up will face the issue of long-term care planning and access. However, those in lower economic classes are feeling the greatest financial strain of coping with their long-term care needs, as most of them have small fixed incomes. The inability of our country to address long-term care planning deficits could result in poor care outcomes, a decrease in life expectancy, and poor quality of life for many senior citizens. Another risk is that the readmission rates for acute care hospitalizations will likely rise as seniors attempt to maintain independence without being connected to vital care resources.
This aging population faces the social injustice of being at the mercy financially of our private sector healthcare organizations and long-term care companies. When a senior patient is discharging from the hospital after a significant change of functional condition, they are assigned a case manager or social worker to coordinate a safe discharge plan to ensure all of their needs will be met. The quality of this “discharge plan” often depends on the subjective effort of the discharge planner assigned and organizational standards set forth by the hospital.
Another dynamic in the discharge process for this patient population is the role of the health insurance payer. Prior to working in the managed care field, I was completely unaware just how much power was held by the payer while a patient is in the hospital or in the process of discharging to an alternative care setting. The payer has the ability to “push” the discharge by threatening to discontinue payment for the stay if the payer feels at any time that services could be provided at a lesser level of care. A good example of this could be an elderly patient without family support who’s recovering from sepsis and does not meet criteria for placement in a skilled nursing facility, though they may still require supervision at a minimum to ensure mobility safe and medication compliance. The patient may be stuck at the hospital for days past the expected length of stay for sepsis while they coordinate with their discharge planner to ascertain their financial resources and what care can be arranged to meet their needs. This “push” can also result in the discharge planner having inadequate time to arrange appropriate resources for the patient at discharge, as the hospital will not want to keep the patient once their stay becomes uncovered by the payer.
Little has been done by federal or state reform to address the deficits in our senior’s long-term care if patients do not meet Medicaid criteria. In fact, long-term care (also known as custodial care) is not a covered benefit for Medicare recipients. This means that those ineligible for custodial care coverage under their state’s Medicaid plan have no recourse other than to pay privately for custodial care (whether in-home or in-facility). The time gap between when the patient experiences their change of condition, realizes they are not eligible for state coverage of custodial care, and are able to liquidate enough assets to actually pay for custodial care can be a considerable amount of time. In the interim, there are patients left in the hospital racking up large bills for uncovered stays or sent home without adequate care resources.
However, in 2006 the Department of Health and Human Services (HHS) did pioneer a national campaign comprising of six states (Georgia, Massachusetts, Michigan, Nebraska, South Dakota, and Texas) aptly titled “Own Your Future”. This campaign, in partnership with the Centers for Medicare & Medicaid Services (CMS), the Administration on Aging (AoA), and the Assistant Secretary for Planning and Evaluation (ASPE), was created to educate aging Americans on the benefits of proactively planning their long-term care and the resources available to do so. HHS cites improved care outcomes, increased quality of life, and more person-centered care as benefits of seniors utilizing this program. Among the features include a free long-term care planning kit, a website solely dedicated to long-term care access information, and community-based activities to generate aware of local resources.
The social exchange theory discussed by Hooyman (2001, p. 309-338) could relate to this issue as senior citizens transitioning from an acute care setting needing a new level of care must adapt to a new environment. As they grow accustomed to their new environment, they may find that they themselves change in unexpected ways. Imagine discharging home from the hospital after a near-fatal bout of pneumonia and having an in-home caregiver present 24 hours per day. Their daily routine and little-known quirks would become glaringly apparent to the stranger now caring for them. It would be difficult for the senior to trust a stranger to not only provide personal care, but also to change their long-standing habits to sync with that of their caregiver.
Among the many helpful policies changed that could be made, it would be useful to require each patient discharging from a hospital stay to receive the “Your Discharge Planning Checklist” (CMS, 2014) with all boxes completed and appropriate resources contacted before they discharge. This requirement could be mandated by CMS and implemented by hospitals—to not only ensure safe discharges to the appropriate care setting, but also reduce the risk of hospital readmissions. Over the last 10 years, the Physician Order for Life Sustaining Treatment (POLST) form has become widely promoted to seniors and those with acute medical conditions as a means for them to clearly state their wishes regarding end of life care. Generally during a senior’s hospital stay and during routine clinic visits with their primary care provider (PCP), a doctor will approach them about the importance of planning ahead for end of life treatment. This would be an ideal time for them to also address the issue of long-term care planning as another means of empowering the patient. The physician could provide the patient with the discharge planning checklist from CMS and stress the importance of not waiting until a change of condition occurs to plan how they will be cared for once their level of independence declines.
Another useful policy change would be to add long-term care insurance into the ever-expanding Medicare Advantage plans. These plans allow Medicare beneficiaries to purchase buy-up plans to cover the gaps in medical coverage presented by the typical fee-for-service Medicare plans. Currently long-term care insurance policies are sold separately from medical plans and have high premiums that increase annually. Living on set incomes, most seniors are not able to afford these policies that would cover custodial care expenses in an event of a change of condition. Combining long-term care insurance into Medicare Advantage coverage would address the issue of poor long-term care access and planning for senior by providing a built-in plan for seniors preventing them from having to do the leg-work of figuring out how they will afford custodial care in the midst of a crisis.
While state-funded Medicaid coverage is a wonderful benefit for those who meet the low-income criteria, what about the masses of citizens who don’t? Could remodeling the Medicaid requirements for custodial care coverage for age 65 and up from a low-income model to a broader need-based model (Stevenson, 2008) bridge the gap? Medicaid eligibility requirements frequently changes, depending on the political climate in each state, with some states seeing expanded income brackets for meeting Medicaid criteria. While others remain unchanged. The Medicaid debate politically often centers on free insurance coverage for all ages, but little is said about long-term care.
In order to change the narrative on long-term care planning and reduce the dread that surrounds it, our society and government will need to adopt a proactive approach. Just as preventative health screenings are gaining momentum as research shows they can decrease long-term medical complications, preventative long-term care planning should also be taught to the masses.