The Continuum of Care
The continuum of care describes the different types of long-term care available. While it’s relatively easy to understand each service or facility individually, it’s a little more difficult to comprehend how one progresses along the continuum. You might ask, what necessitates moving to the next level of care, and what makes it more beneficial than the one before?
An individual’s journey along the continuum of care might begin when his independence starts to decline. Mr. Smith, for example, is an elderly man who has lived alone for the past 10 years. In the last several months, he has needed more and more help doing things for himself. He has had trouble making meals, and he finds that he is becoming increasingly afraid to move about his house because he fears he might fall. In Mr. Smith’s situation, some home- and community-based services (HCBS) options, such as home-delivered meals and the installation of minor home modifications that help with mobility, will allow him to maintain a great deal of independence and stay at home.
After some period of time, however, Mr. Smith begins needing help with activities of daily living, which are often referred to as ADLs. These activities are physical functions, such as bathing, dressing and eating. He also needs someone to do general household chores. While he could get help with these through HCBS, Mr. Smith is getting lonely. At this point, a residential home for the aged (RHA) becomes a better alternative than living at home alone. There, he will receive help with bathing, hair and nail grooming, dressing and laundry. He will also benefit from being around others.
As more time passes, Mr. Smith forgets to take his medications and sometimes doesn’t remember how to get around the facility. Now may be the right time to move to an assisted care living facility (ACLF). Here, someone will remind him to take his medications and make sure he takes the right dosage. Meals will continue to be prepared for him, but the environment will be just a little more controlled and more personal assistance and monitoring will be provided.
But, Mr. Smith’s mental and physical condition continues to decline, especially after suffering a stroke. He now needs a secure environment and 24-hours of care, where someone will make sure his medical needs, as well as his emotional, spiritual, social and psychological needs, are met. Mr. Smith now needs a nursing home. While this progression through the continuum of care is a logical one, it’s not always the way things happen.
Every individual’s needs for long-term care are the result of unique circumstances. Some have a short-term need. That need might start with a broken hip caused by a fall that necessitates a short hospitalization and then a brief need for rehabilitation. After a one- or two-month nursing home stay, the individual may be able to return home and continue receiving some services, such as physical therapy, from a home health care agency, if necessary.
Others have more extended or permanent needs. The need might be due to Alzheimer’s disease or dementia, where one becomes unable to communicate or unable to remember how to perform such a simple task as swallowing. Furthermore, they may become combative and, without realizing it, actually cause harm to family caregivers trying to take care of them in their home. In this case, long-term placement in a nursing home is needed.
Understanding the different types of long-term care and knowing what each offers is key to finding The Right Care at the Right Time. Here is a closer look at the options available to people in need of assistance.
Nursing homes, or nursing facilities, represent the fundamental link in the continuum of long-term care. Their job is to provide 24-hour nursing care to those who are chronically ill or injured, have health care needs as well as personal needs and are unable to function independently. But, a nursing home is about more than medical care. It’s a place where patients can go on with their lives – and even engage in many activities they may have never taken part in before – while under the secure and capable watch of a team of trained caregivers.
Nursing home issues often center on the types and levels of medical care provided, and, although medical care obviously is essential, it alone does not address all the facets of individual well-being. Especially in the long-term care setting, caregivers understand that patients not only have physical needs but also mental, social, emotional and spiritual needs – the basic premise of holistic or “whole person” care.
Through the holistic approach, nursing home care encompasses all aspects that define a healthy life. Nursing home staff, both medical and non-medical, collaborate to assess patients’ needs and create individualized care plans, all targeting a single objective – restoring each patient to his highest possible level of functioning.
Home- and community-based services
In Tennessee and across the nation, the long-term care delivery system is expanding into services that allow certain elderly and disabled individuals to live in the community and remain as independent as possible. These services are referred to as home- and community-based services or HCBS for short. Tennessee’s statewide HCBS program operates under a waiver approved by the federal Centers for Medicare and Medicaid Services (CMS) to serve a limited number of individuals across the state. The Tennessee Commission on Aging and Disability, along with the Area Agencies on Aging and Disability, administer the waiver program.
Individuals wishing to enroll in the HCBS waiver must be financially eligible for Medicaid.* They must also obtain approved pre-admission evaluations (PAE) for Level 1 nursing facility care. Level 1 care refers to the basic level of care provided in nursing homes. It is provided to those patients who need less intensive regimens of care than certain other nursing home patients, which are classified as Level 2.
Additionally, prospective HCBS enrollees must be residents of Tennessee, be over the age of 21 and have caregivers available to assure their health, safety and welfare.
Currently, the following services are offered through the state’s HCBS waiver program:
- Adult day care. These programs provide social activities, meals, assistance with personal needs, health education and supervision in a safe environment on a temporary basis. Most adult day care centers are open Monday through Friday during normal business hours and allow full-time caregivers an opportunity to continue their daily work routine while providing supervision and care for the elderly or disabled person.
- Assisted living. Assisted living coverage includes personal care services, homemaker services and medication oversight offered in an assisted care living facility, but does not include room and board.
- Assistive technology. Assistive technology includes assistive devices, adaptive aids, controls or appliances which enable a patient to increase his ability to perform activities of daily living.
- Home-delivered meals. Home-delivered meals are nutritionally well-balanced meals delivered to individuals in their homes. The meals provide at least one-third but no more than two-thirds of the current daily recommended dietary allowance. Special diets are provided as needed.
- Homemaker services. Homemaker services are general household activities and chores, such as sweeping, mopping, dusting, making the bed, washing dishes, personal laundry, ironing, mending and meal preparation and/or education about the preparation of nutritious, appetizing meals. It also includes assistance with the maintenance of a safe environment and errands – grocery shopping, having prescriptions filled, etc.
- In-home respite care. In-home respite care offers relief for home caregivers by providing services to individuals unable to care for themselves. In-home respite services are provided on a short-term basis to individuals in their home. The intent of respite is to provide short-term relief for a caregiver while he is on vacation or during emergency situations that may involve the temporary loss of a caregiver.
- Institutional respite care. Similar to in-home respite care, except the service is furnished on a short-term basis in a nursing facility or assisted care living facility.
- Minor home modifications. This service entails the provision and installation of certain home mobility aids such as ramps, rails, non-skid surfacing, grab bars and other devices that facilitate mobility. It also provides for other modifications to the home that enhance safety. This service does not include improvements to the home that are of general utility, such as carpeting, roof repair, central air conditioning, etc. Nor does it provide direct medical or remedial benefit to the individual.
- Personal care attendant services. Personal care attendant services includes the intermittent provision of direct assistance with activities such as toileting, bathing, dressing, personal hygiene, eating, meal preparation, budget management, attending appointments and interpersonal and social skill building to enable the patient to live in a community setting.
- Personal care services. Personal care services assist individuals with the activities of daily living and related essential household tasks, such as making the bed or washing soiled linens or bedclothes that require immediate attention. This also includes cleaning and maintaining a safe home environment.
- Personal Emergency Response Systems. Personal Emergency Response Systems (PERS) allow for individuals to secure help in an emergency through electronic devices and a response center. The system is connected to a person’s phone and programmed to signal a response center once a “help” button is activated. The individual may wear a portable “help” button to allow for mobility. Trained professionals staff the response center.
- Pest control. Pest control covers the use of sprays, poisons and traps in the enrollee’s residence.
Residential homes for the aged
These facilities provide their residents room and board as well as some assistance with personal needs, such as eating and grooming. Someone who lives in a home for the aged must be physically and mentally capable of finding his way to safety in the event of an emergency without assistance from someone else.
Homes for the aged are neither staffed nor licensed to provide nursing care. In fact, state law prohibits homes for the aged from accepting residents who need medical care. They’re designed to provide a place where people who are able to care for themselves with little or no help may receive room, board and personal services. State regulations clearly define the scope of personal services in homes for the aged as help with:
- Bathing, hair and nail grooming;
- Laundry; and
- Self-administration of medications.
The regulations permit the administration of medicine by a licensed nurse. Homes for the aged must be licensed and are generally family-type dwellings. Neither Medicare* nor Medicaid pays for the cost of living in a home for the aged.
Assisted care living facilities
Assisted living is a long-term care option for seniors who need more assistance than is available in a retirement community but who do not require the intense medical and nursing care provided in a nursing home. Many seniors relocate to an assisted care living facility, after a period of rehabilitation in a nursing home or hospital, while others come directly from their homes. These facilities provide the same services as a home for the aged as well as assistance with medications. Some facilities are staffed to provide care for people who have some memory loss or are in the early stages of Alzheimer’s. Some assisted care living facilities offer assistance with incontinence care and other special services.
Assisted living bridges the gap between homes for the aged and nursing homes. This licensing category was created in response to the needs of a large number of the elderly who may require assistance with certain medical services that typically can be self-administered. For example, a diabetic woman who normally gives herself daily insulin injections is no longer able to do so because of advancing arthritis. She needs help with the injection but has no other health problems. She is an ideal candidate for assisted living.
Home Health Care
Home health agencies provide skilled nursing and rehabilitative care, such as physical, occupational and speech therapy. Personal services, such as assistance with bathing and grooming, are also available. And, if a physician determines that someone is in need of home health care, services to complement the health care services, such as assistance with housecleaning or grocery shopping, are also available. Some of these services are reimbursable through Medicare and the Medicaid HCBS waiver program.
Traditionally provided at home for the terminally ill, hospice care focuses on palliative rather than restorative care. Hospice addresses not only physical needs but also psychological, spiritual and emotional needs for patients, family members and friends. Some nursing homes participate in partnerships with local hospice organizations. While the services provided are dependent on the arrangement between the nursing home and hospice organization, the following services may be offered: supplemental services such as inpatient respite care to allow home caregivers a break from their duties, or “room and board” services in which patients already residing in a nursing home elect to receive hospice care.
Group living for security and social purposes is offered by retirement communities. Typically complexes of apartments or condominiums, retirement communities are facilities in which seniors live independently. Recreational opportunities commonly are available as well as certain support services such as meals and transportation. Retirement communities sometimes adjoin nursing homes as part of what is called a “continuing care” campus providing a number of different services within the continuum of long-term care.
Nursing homes may be able to fulfill the needs of some patients through outpatient services. Patients may be brought to the facility for physical, occupational, speech or respiratory therapy; testing, fitting or training in the use of prosthetic devices; social and psychological services; nursing care; or medications and biologicals that cannot be self-administered.
* Medicaid is a program sponsored by the federal government and administered by states. It is intended to provide health care and health-related services to low-income individuals. In Tennessee, that program is known as TennCare. Medicare is a federal health insurance program for people age 65 or older, people under age 65 with certain disabilities and people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).