WHAT IS LONG-TERM CARE?
Long-term care includes a wide variety of settings and services which are available to meet people's special needs.
For example, someone recovering from surgery who no longer needs to see a doctor everyday may be discharged to a nursing home to complete the recovery process. A stroke or accident victim can receive nursing care and speech, physical and occupational therapy at a skilled nursing facility before returning home or to a lower level of care. A person who requires assistance with activities of daily living such as dressing and bathing, but doesn't need 24-hour nursing, may choose a residential care facility or a large assisted living community.
Other options include respite care and adult day health care to ease the burden on family caregivers, special Alzheimer's programs, services for persons with developmental disabilities, mental health care, and home and community based care.
WHO NEEDS LONG-TERM CARE SERVICES?
Two out of every five Americans will need long-term care at some point in their lives.
Seniors are the fastest growing segment of population and the heaviest users of long-term health care services. California has 3.5 million people over the age of 65. This number is expected to increase to more than 6 million by 2020.
More than any other socioeconomic group, women are disproportionately affected by long-term care. The reason behind this lies in the fact that women live longer than men and are more likely to develop the functional ailments that require long-term care services. Two-thirds of residents in long-term care facilities are women.
Several other factors contribute to the need for long-term care. Families are geographically scattered. Time, travel expenses and other responsibilities make it nearly impossible to provide the care older family members need. In addition, the primary caregivers in most families are women, and today more women work outside the home.
Although most long-term care services are used by the elderly; young adults, children, and even infants use long-term care services due to chronic illness, disability or accident.
WHAT TYPES OF LONG-TERM CARE SERVICES ARE AVAILABLE?
Assisted Living/Residential-Care Facilities for the Elderly (RCFEs) - Assisted living facilities provide personal care and safe housing for people who may need supervision for medication and assistance with daily living but who do not require 24-hour nursing care.
Regulation – Licensed by Dept. of Social Services (DSS), Community Care Licensing Division.
Payment – Funded primarily though private payments. Nearly 30% of RCFE residents rely on SSI/SSP non-medical out-of-home grants.
Continuing Care Retirement Communities (CCRCs) - Includes three levels of care: independent, assisted living and skilled nursing care. CCRCs require an entrance fee paid by the applicant upon admission and includes services for more than one year and up to the lifetime of the resident.
Regulation – Licensed by Dept. of Social Services, Continuing Care Contracts Branch. Skilled nursing level licensed by the California Department of Public Health (CDPH)
Payment – Private Payment
Intermediate-Care Facilities (ICFs)- These facilities provide room and board along with regular medical, nursing, social and rehabilitative services for people not capable of full independent living.
Regulation – Licensed and Medi-Cal and/or Medicare certified by CDPH.
Payment – Funded primarily by Medi-Cal. Some funding through Medicare and private payment.
Intermediate-Care Facilities for the Developmentally Disabled (ICFs/DD) - Known at the federal level as ICFs/MR (mental retardation), these facilities provide services for people of all ages with mental retardation and/or developmental disabilities. ICF/DDs have 16 or more beds; ICF/DD-H (habilitative) and -Ns (nursing) have 15 or fewer beds and average six beds in a home setting. ICF/DD-CN (Continuous Nursing) is a 10 facility waiver pilot program providing licensed vocational or registered nursing on a 24-hour basis for 4-15 clients in a home-like community based setting.
Regulation – Licensed and Medi-Cal certified by CDPH. The Department of Developmental Services and Regional Centers are responsible for placement and quality assurance.
Payment – Nearly 100% Medi-Cal.
Institutes for Mental Health (SNFs/STP) - Designated in California as "special treatment programs," these facilities provide extended treatment periods for people of all ages with chronic mental-health problems; many of the clients are younger than 65. Specialized staff serve clients in a secured environment.
Regulation – Licensed and Medi-Cal certified by CDPH. Local mental health departments are responsible for placement and program content.
Payment – A combination of state and county funding.
Skilled Nursing Facilities (SNFs) - Also called nursing homes, convalescent hospitals, and skilled nursing and rehab centers, these facilities provide comprehensive nursing care for chronically ill or short-term residents of all ages, along with rehabilitation and specialized medical programs.
Regulation – Licensed and Medi-Cal and/or Medicare certified by the California Department of Public Health (CDPH).
Payment – Funded primarily by Medi-Cal. Some funding provided through Medicare, managed care and private payment.
Subacute-care Facilities - Specialized units often in a distinct part of a nursing facility, subacute-care facilities focus on intensive rehabilitation, complex wound care and post-surgical recovery for residents of all ages who no longer need the level of care found in a hospital.
Regulation – Licensed and Medi-Cal and/or Medicare certified by CDPH.
Payment – Funded primarily by Medi-Cal. Some funding through Medicare, managed care and private payment.
Home and Community-Based Care
Adult Day Health Care - Adult day health care that provides some medical care, plus physical, occupational and speech therapy.
Regulation – Licensed and Medi-Cal certified by CDPH. These programs also receive oversight from the Department of Aging.
Payment – Primarily Medi-Cal.
Community Care Facilities - Community care facilities also includes Residential Care Facilities for the elderly (RCFE) and Adult Residential facilities (ARFs). ARFs may serve persons with developmental disabilities who are clients of regional centers via the Home and Community Based Services Waiver.
Regulation - Licensed by Dept of Social Services, Community Care Licensing Division.
Payment - Funding through home and community-based Medi-Cal waiver program. Regional Center funding for the developmentally disabled, or private pay.
Congregate Housing - Housing with a common living area and non-medical support services to meet basic needs of older people.
Regulation – Dept of Social Services, Community Care Licensing Division.
Payment – Grants provided through the Federal Government (Housing & Urban Development). Some funding through SSI/SSP for those eligible.
Home Health Care - Home health care provides medically-oriented care for acute or chronic illness in the patient's home, usually as a follow-up to acute or other facility discharge.
Regulation – Licensed and Medicare and Medi-Cal certified by California Department of Public Health.
Payment – Funded primarily through Medicare, with limited coverage through Medi-Cal, private insurance and private payments.
Hospice - Hospice provides care and support for terminally ill people and their families. Can be provided in a facility setting or at home.
Regulation – Hospice license required for in-home care. Dual license required in a facility setting. Medicare certification required for Medicare or Medi-Cal payments.
Payment – Funded through Medicare, Medi-Cal, private insurance and private payments.
Personal Care Services - Personal care services are provided for people who need assistance with daily living but do not require nursing.
Regulation – No separate license required.
Payment – Primarily funded through In-Home Supportive Services for those eligible. Some Medi-Cal, for those eligible and private payments.
Respite Care - Respite care provides short term inpatient or home care delivered to an elderly person as a substitute for their regular caregiver.
Regulation – No separate license required of existing licensed providers.
Payment – Funding through home and community based waivers and the Department of Aging.
WHO PAYS FOR LONG-TERM CARE?
As America ages, the need to address how we pay for long-term care becomes increasingly urgent. A recent study indicates that one in five Americans age 50 or over may need long-term care sometime within the next 12 months. Most are ill-equipped to deal with the enormous cost – just one in four Americans can afford the cost of long-term care for a year.
Although Medicare covers skilled nursing care up to 100 days for a spell of illness, in fact the average covered days under Medicare is 10 - 20 days. Coverage depends on the degree of skilled care needed. After a stay of at least three days in the hospital, once a resident is stabilized in a skilled nursing facility, Medicare typically does not pay.
Medicaid (known as Medi-Cal in California)
Nearly two-thirds of all nursing facility residents rely on Medi-Cal. The proportion is even higher at facilities caring for people with developmental disabilities, where nearly 100 percent of clients are Medi-Cal beneficiaries. Unfortunately, seniors must deplete their life savings and impoverish themselves in order to become eligible for Medicaid.
The objective of the Medicaid program is to provide essential medical care and services to preserve health, alleviate sickness and mitigate handicapping conditions for individuals or families receiving public assistance, or whose income is not sufficient to meet their individual needs. The covered services are generally recognized as standard medical services required in the treatment or prevention of diseases, disability, infirmity or impairment.
States design their own programs within broad federal guidelines. Thus, Medicaid programs vary from state to state.
Medicare, administered by the U.S. Department of Health and Human Services (HHS), is a federal insurance program for (1) people age 65 and over: (2) people disabled for at least two years; or (3) people suffering from chronic kidney disease. Nursing facility coverage under Medicare is very limited — the average length of stay paid for by Medicare is 26 days.
Medicare pays for approximately 12 percent of nursing facility patient days in California.
Long Term Care Insurance
Long term care insurance can protect an individual's assets and provide peace of mind. A good long- term care insurance policy will cover all levels of care, especially personal care, and all settings, including facility care, community adult day care, assisted living facilities, and nursing facilities.
The cost of a long term care insurance policy primarily depends on the age of the policy holder when purchased. The annual premium for a low-option policy for a person at age 55 is about $709. This same policy for a 65-year-old person is about $1,342 per year; for older persons, the policy would cost much more.
Recognizing the growing need for better insurance coverage, the State of California formed the Partnership for Long-Term Care, an innovative program offered by the Department of Health Care Services in cooperation with a select number of private insurance companies. The insurance companies which participate in the program have agreed to offer high quality policies that meet stringent requirements set by the Partnership and the State of California. For more information, visit the California Partnership for Long Term Care.
Supplemental Security Income/State Supplementary Programs (SSI/SSP)
The SSI Program is a federally funded program which provides income support to those aged 65 or older, blind or disabled. SSI benefits are also available to qualified blind or disabled children. The SSP Program is the state program which augments SSI. Both SSI and SSP benefits are administered by the Social Security Administration (SSA) Eligibility for both programs is determined by SSA using Federal criteria. A person who qualifies for SSI also qualifies for SSP. Benefits are in the form of cash assistance.
Third Party Payors
This category of financing includes individual insurance plans other than Medicare or Medi-Cal; Veteran's Benefits; Municipal Assistance benefits; and long term care insurance policies. These sources account for about nine percent of long term care payment.
WHAT STANDARDS APPLY TO LONG-TERM CARE FACILITIES?
California's oversight of long-term care facilities is the most rigorous in the nation and the most comprehensive for any category of provider in the state. The California Department of Public Health, the Department of Social Services, the Department of Mental Health and the Department of Developmental Services each plays a role in licensing and regulating care providers.
Providers must meet state licensure standards, and in the skilled setting, are also governed by a stringent set of federal requirements. In addition, several other federal, state and local agencies – including the federal Centers for Medicare and Medicaid, state departments of Aging, Justice and Consumer Affairs and the Office of the State Fire Marshal – also review facility services in California.
Facilities must demonstrate compliance with hundreds of very detailed regulations. To ensure compliance with these standards, CDPH surveyors annually conduct thorough inspections of each facility.
WHAT ROLE DO STATE AGENCIES PLAY?
State agencies play a significant role in the oversight of long-term care. The California Health & Human Services Agency has primary responsibility over long-term care providers. The various Departments under Health & Human Services have specific responsibilities:
The California Department of Public Health is responsible for licensing health facilities, home health agencies and hospices, and for general oversight of the services they provide. The Department of Health Care Services is responsible for California public health programs and administers the Medi-Cal program.
The Department of Social Services manages California's integrated social service and income maintenance programs. The Department's Community Care Licensing Division licenses residential care facilities, and its Adult and Family Services Division is responsible for monitoring elder abuse.
The Department of Developmental Services is responsible for services to Californians with developmental disabilities such as mental retardation, cerebral palsy, epilepsy and autism.
The Department of Mental Health sets overall policy for the delivery of mental health services; establishes priorities, standards and procedures within which mental health services operate; assists in planning programs; monitors, reviews and evaluates the actual operation of services; and oversees any changes brought about by the evaluation and review process.
The Department of Aging serves as the focus for community-based services to California's seniors. Its mission is to provide leadership in addressing issues related to aging Californians, and in developing community-based systems of long-term care services throughout the state.
The Ombudsman Program within the Department of Aging, advocates for the rights of all residents of 24-hour long-term care facilities and adult day health care centers in the state.
In addition to the Health & Human Services agencies, other state and local agencies, such as state and county Fire Marshals, Department of Industrial Affairs (Cal-OSHA), the Office of Statewide Health Planning and Development and the Department of Consumer Affairs also have roles in the oversight of long-term care in California.
Nursing facilities are subject to an extensive set of standards prescribed in state licensing law and federal Medicare/Medicaid certification requirements. State inspectors spend hundreds of hours each year enforcing these regulations in their annual compliance visits to each of California's long-term care facilities.
WHAT RIGHTS DO RESIDENTS HAVE?
Observance of and adherence to the bill of residents' rights are the guiding forces in the daily operations of today's long term care facilities. The statement of patient's rights is a lengthy document designed to promote and protect the rights of individuals in a facility. These are just a few of the many areas addressed by the statement of rights:
Residents have the right to:
Participate to the fullest extent possible in their own care plans;
Manage their own finances or to have the responsibility given to a designated guardian (i.e. family or friend);
Privacy, both in their rooms and during visits from family/friends;
Safe, clean living conditions;
Participate in activities both in and out of the facility;
Retain and exercise all constitutional, civil and legal rights to which the patient is entitled by law;
Maintain religious practices; and
Prepare advance directives for health care.
Complete list of nursing facility resident rights
Upon admission, long-term care providers are required to give residents and/or their guardians a copy of the statement of patient rights. In addition, facilities must give a copy to the resident's next of kin, all facility staff and must post these rights prominently in a public place within the facility.
FACTS ABOUT LONG-TERM CARE
There are approximately 1,112 licensed nursing facilities in California. These facilities care for more than 350,000 Californians each year.
There are approximately 8,100 assisted living/residential care facilities in California.
There are approximately 760 ICF/DD-H homes and approximately 400 ICF/DD-N homes and 10 ICF/DD-CN homes in California.
There are 16 intermediate care facilities in California.
In 2015, the average reported cost per patient day for a skilled nursing facility was approximately $289 or ($105,485 annually).
Two-thirds of California's nursing home residents rely on Medi-Cal to pay for their care in a nursing facility. The average Medi-Cal reimbursement rate is $205.87 per day.
Almost 100 percent of clients who reside in homes for the developmentally disabled rely on Medi-Cal to pay for their care.
Medi-Cal does not pay for assisted living. About 90 percent of assisted living services are paid for with private funds.
The length of stay in today's nursing facility is less than three months for 80 percent of the resident population; with fewer than seven percent of all residents remaining in the facility for one year or more.
Sixty percent long-term care residents are women.
Approximately 80 percent of long-term care residents in California are age 65 or older.
On average, nursing facility residents require some level of assistance with three or more of the activities of daily living, which include bathing, dressing, transferring, toileting and eating. Assisted living residents need help with on average 1.6 activities of daily living.
California has four million people over the age of 65. This number is expected to increase to more than 6 million by 2020.
GLOSSARY OF TERMS
Activities of Daily Living (ADLs) – The physical functions necessary for independent living. These usually include bathing, dressing, using the toilet, eating and moving about (transferring).
Acute Hospital - A hospital which provides care for persons who have a crisis, intense or severe illness or condition which requires urgent restorative care.
Area Agencies on Aging (AAA) – Local government agencies which grant or contract with public and private organizations to provide services for older persons within their area.
Assisted Living/Residential Care Facilities for the Elderly (RCFE) – Personal care and safe housing for people who require supervision for medication and assistance with daily living, but who do not require 24-hour nursing care. RCFEs amy also provide a secure environment for persons with Alzheimers Disease.
Chronic – A lasting, lingering or prolonged illness.
Copayments – Copayments are those payments made by an individual at the time that he or she uses health care services. Copayments are generally a set amount depending upon the specific service received.
Custodial Care – Care is considered custodial when it is primarily for the purpose of meeting personal needs and could be provided by persons without professional skills or training.
Developmental Disability (DD) – Disability which originates before age 18; can be expected to continue indefinitely; constitutes a substantial handicap to the ability to function normally; and is attributable to mental retardation, cerebral palsy, epilepsy, autism, or any other condition closely related to mental retardation which results in similar impairment of general intellectual functioning or adaptive behavior.
Durable Power of Attorney for Health Care – This legal document authorizes the person given the power to make decisions regarding the person's medical treatment only when the person giving the power becomes incompetent.
Home Health Agency (HHA) – A home health agency is a public or private agency that specializes in giving skilled nursing services, home health aides, and other therapeutic services, such as physical therapy, in the home.
Hospice – A hospice is a public agency or private organization that primarily provides pain relief, symptom management, and supportive services to terminally ill people and their families in the home or SNF.
Intermediate Care Facility (ICF) – An ICF provides health related care and services to individuals who do not require the degree of care or treatment given in a hospital or skilled nursing facility, but who (because of their mental or physical condition) require care and services which is greater than custodial care and can only be provided in an institutional setting.
Institutes for Mental Disease (IMDs) – Provide supplemental special programs for mentally disordered individuals in a locked and/or secured skilled nursing facility setting. They operate directly with County Mental Health Department.
Long-Term Care Insurance – A policy designed to help alleviate some of the costs associated with long term care needs. Often, benefits are paid in the form of a fixed dollar amount (per day or per visit) for covered LTC expenses.
Ombudsman – Individual designated by a state or a sub state unit responsible for investigating and resolving complaints made by or for older people in long term care facilities. An ombudsman is also responsible for monitoring federal and state policies that relate to long term care facilities, for providing information to the public about the problems of older people in facilities, and for training volunteers to help in the ombudsmen program. The ombudsman program is authorized by Title III of the Older Americans Act.
Managed Care – Medical care delivery system, such as HMO or PPO, where someone "manages" health care services a beneficiary receives; each plan has its own group of hospitals, doctors and other health care providers called a "network"; usually promote preventive health care; may have to pay a fixed monthly premium and a co-payment each time a service is used.
Medicaid (Medi-Cal in California) – The state medical assistance program which provides essential medical care and services for individuals and families receiving public assistance, or whose income is not sufficient to meet their individual needs. Sixty-five percent of residents in skilled nursing facilities rely on Medicaid.
Medicare – The nation's largest health insurance program, Medicare covers 37 million Americans. Medicare provides insurance to people who are 65 years old; people who are disabled; and people with permanent kidney failure. Medicare provides only limited benefits for skilled care, and under specific guidelines, for nursing home and home health care. Only 12 percent of individuals in skilled nursing facilities rely on Medicare.
Medicare Part A – Hospital and Skilled Nursing Facilities program. Medicare Part B - Voluntary program to cover physician care and certain outpatient services and items. Medicare Part C - This encompasses various Medicare managed care plans which may be chosen at the time of enrollment in the program or during open enrollment once per year. Medicare Part D - This insurance pays for necessary drugs through enrollment with one of many approved drug plans. Many Medicare managed care plans also include drug coverage.
Medicare Supplementary Insurance – This insurance pays the 20 percent of the Medicare approved amount of which Medicare pays 80 percent.
Medigap Insurance – Medigap insurance are private insurance products that provide insurance protection for the costs of hospital services that are rendered to a Medicare beneficiary that exceed the amount Medicare will pay for the hospital services.
Occupational Therapy – Activities designed to improve the useful functioning of physically and/or mentally disabled persons.
Personal Care – Involves services rendered by a nurse's aide, dietician or other health professional. These services include assistance in walking, getting out of bed, bathing, toileting, dressing, eating and preparing special diets.
Physical Therapy – Services provided by specially trained and licensed physical therapists in order to relieve pain, restore maximum function, and prevent disability, injury or loss of a body part.
Respite – The in-home care of a chronically ill beneficiary intended to give the care-giver a rest. Can also be provided in a hospice or nursing home (as with hospice respite care).
Skilled Nursing Care – Care which can only be provided by or under the supervision or licensed nursing personnel. Skilled rehabilitation care must be provided or supervised by licensed therapy personnel. All care is under the general direction of a physician and necessary on a daily basis. Therapy that is needed only occasionally, such as twice a week, or where the skilled services that are needed do not require inpatient care, do not qualify as skilled level of care.
Skilled Nursing Facility (SNF) – Provide 24-hour nursing care for chronically-ill or short-term rehabilitative residents of all ages.
Social Security – A national insurance program that provides income to workers when they retire or are disabled and to dependent survivors when a worker dies. Retirement payments are based on worker's earnings during employment.
Speech Therapy – The study, examination, and treatment of defects and diseases of the voice, speech, spoken and written language.
Sub-Acute Care Facilities – Specialized units often in a distinct part of a nursing facility. Provide intensive rehabilitation, complex wound care, and post-surgical recovery for persons of all ages who no longer need the level of care found in a hospital.
Supplemental Security Income (SSI) – A federal program that pays monthly checks to people in need who are 65 years or older and to people in need at any age who are blind and disabled. Eligibility is based on income and assets.