The Nature of Long Term Care
Long Term Care, for many the very name conjures up images of heavily medicated elderly staring into the middle distance, taken from productive society as they wait in warehoused fashion for eventual death. Although there is little question this image has more than scant basis in reality, the facts indicate that long term care is much broader than this unpleasant picture we have envisioned.
In this course we will offer a far more complete picture of long term care. We will look at the settings in which it is provided, its costs and who pays them, as well as the likelihood that you, your client, or a loved one will need it. Finally, we will consider long term care insurance, its tax treatment, and some of the important suitability and ethical issues in its sale.
Long term care is not a singular mode of care; rather, it describes a continuum of services, devices and assistance designed to meet an individual’s health or personal needs. Those needs may be mental, emotional or physical ones, and the services offered may or may not be provided over an extended period of time.
While some authorities suggest a minimum period during which care is required for such care to be considered long term care—90 days, for example—we will be somewhat more inclusive in our use of the term in this course. In the text that follows, the term long term care will also be used to refer to care that seldom extends beyond a few weeks, as in the case of hospice care.
According to CMS, the Centers for Medicare and Medicaid Services, “¼long-term care is a variety of services that includes medical and non-medical care to people who have a chronic illness or disability. Long-term care helps meet health or personal needs. Most long-term care is to assist people with support services such as activities of daily living like dressing, bathing, and using the bathroom.”[1]
The help required may involve any of the activities healthy and active people generally take for granted such as walking, taking a shower, alleviating pain, eating, taking prescribed medication, and many other normal activities. In order to bring a more organized approach to determining who is eligible for long term care services, eligibility for these services and the insurance benefits that may pay for them generally requires:
· An inability to perform a certain number of activities that are considered basic to normal living, activities that are called Activities of Daily Living (ADLs); or
· The presence of a cognitive impairment.
Six activities, each of which is generally considered central to leading a normal life, comprise the activities of daily living. These activities are usually shortened to ADLs, and include:
Although the specific definition of these activities may vary slightly from one source or insurer to another, the definitions are commonly those discussed below.
Bathing means washing oneself in a tub or shower, or by sponge bath. It also includes the individual’s ability to get into and out of a shower or tub.
Continence means the individual’s ability to:
Dressing means the individual’s ability to put on and take off:
Eating means the process of putting food into the body:
Toileting means:
Transferring means moving into or out of a:
We noted just above that eligibility for long term care treatment and benefits may be satisfied by the individual’s cognitive impairment. Somewhat similar to the definition of cognitive dysfunction,[2] cognitive impairment is more specific and generally means a deficiency in the individual’s:
· orientation as to person, place, or time. In other words, the individual does not know where he or she is, the people around him or her even though normally familiar, or the time of day or season of the year;
· memory, either short-term or long-term. He or she cannot remember shared experiences, important dates, the places visited just yesterday, etc.;
· deductive or abstract reasoning. For example, the individual may be unable to balance a checkbook, something he or she has done well for years; or
· judgment with respect to his or her awareness of safety issues. For example, a doting grandmother may temporarily forget she was caring for her active toddler grandson and leave the playground without him. Or, the individual may attempt to walk across a busy highway, unmindful of speeding trucks.
Earlier, we described long term care as “¼a continuum of services, devices and assistance designed to meet an individual’s health or personal needs.” Although we can probably all think of one or more situations in which an individual might require such assistance, certain situations and conditions are generally more prevalent among people receiving long term care. They include all of the following:
There is no question about the need for long term care experienced by a large percentage of the United States population. An understanding of the cause for much of the long term care need, however, may be eye-opening.
At the time dawn broke on the twentieth century, the average American then living had a life expectancy of about 47 years. Preliminary data for 2004 from the National Center for Health Statistics indicate the average life expectancy at the beginning of the twenty-first century is 77.9 years.[3] The genius of humanity in eradicating many illnesses that plague us has increased our life expectancy by more than 60 percent in a mere hundred years! That’s the good news, but, in certain ways, it is also the bad news.
In some cases—perhaps a large percentage of them, judging from long term care statistics that we will review later—an early death has been replaced by a prolonged period of disability or chronic illness. One hundred or more years ago, well before the discovery of penicillin and other lifesaving drugs, people with serious illnesses often just died. Witness the influenza pandemic of 1918 during which 675,000 Americans died of the disease, a death toll that exceeds American deaths in all of its wars and a mortality rate that would be unthinkable today.
Today, medical advances have ended many dread diseases; for example, poliomyelitis was the scourge of the 1950s, and it has been eradicated. However, these advances may have simply postponed the graveyard until after an extended period of debilitation during which we require long term care. Medicine and the pharmaceutical industry may have permitted us to extend the quantity of our life at the expense of its quality.
Health care—a term that is broader than, and includes, long term care—is typically categorized with respect to the level of the severity of the health problem it seeks to remedy and may range from intensive care to custodial care. It is convenient and helpful to view health care as being comprised of the following in declining level of criticality:
Although intensive care and acute care may certainly be accessed by patients receiving long term care, those levels of care are not considered long term care. However, regardless of the setting in which long term care is provided, such care falls into one (or more) of the last three general categories, i.e., skilled care, intermediate care, and custodial care. As you review the definitions of these care types, keep in mind that skilled and intermediate care both require the supervision of care by skilled medical personnel; custodial care, however, does not.
Skilled care is a type of nursing care generally required for patients with uncontrolled, unstable or chronic conditions, or for patients recovering from a medical condition that requires hospitalization or from surgery; these patients usually need a relatively high level of monitoring by nursing professionals. It is care provided under a doctor’s order by a licensed healthcare professional, such as a physical therapist or nurse.
Intermediate care is a similar high level of skilled care, except that it is provided on an intermittent basis. Like skilled care it stresses rehabilitation, and its goal is to return function to the patient to enable him or her to return home. It is usually provided to patients in a stable condition who, nonetheless, requires daily medical assistance on a basis that is less frequent than that provided in skilled care.
Intermediate care is care ordered by a physician and normally carried out under the supervision of a registered nurse. An example of intermediate care is a patient’s every-six-hour dressing change. Although intermediate care continues to be provided to patients requiring it, as a term its use is declining. Current requirements for long term care are generally described in terms of skilled care or custodial care, our next category of long term care.
Custodial care is care that primarily involves assisting individuals with the activities of daily living—the ADLs we examined just above. The help with ADLs may be required because of some physical infirmity or condition or because of a cognitive impairment that mandates supervision to ensure the individual does not injure him- or herself or others. Although custodial care is clearly less intensive and does not require the high level of healthcare training required of those administering skilled or intermediate care, the individual providing custodial care must have some training in order to properly assist an individual in performing ADLs.
Unlike skilled care or intermediate care, the objective of custodial care is not to rehabilitate the individual. Instead, it is simply to assist him or her to lead an independent or semi-independent life.
[1] www.cms.hhs.gov.
[2] The term “cognitive dysfunction” applies to a wide range of problems associated with intellectual functioning. Cognitive dysfunction typically refers to difficulties with thinking clearly, problems with recall and decreased concentration.
[3] National Center for Health Statistics, www.cdc.gov/nchs/fastats/lifeexpec.htm