I have experienced case management from a personal experience. My mother-in-law was hospitalized with a catastrophic stroke on the very day my oldest son was graduating from grade school. We were heart broken. Marianne was a very important part of our lives. She helped babysit for our boys when we were both at work and we were her only family in Milwaukee. I am a nurse and was working on the very unit that she was admitted to. Everyone in the family felt I was very qualified to decide what would be needed for Marianne when she would go either to home, rehab, or the nursing home. Even though I understand the health care system, I was devastated that my mother-in-law had a stroke. She was confused and anxious. She was so different than her "real" self. I kept hoping for a complete recovery all while knowing it wasn't going to happen. During this time health care was very overwhelming to my husband and myself. As her condition stabilized it was obvious she wouldn't be able to return home. The question now was could she go to a rehab unit or would she need to be in a nursing home. This was when our case manager was incredibly helpful. She arranged a rehab consult. We didn't know how to even begin with that. She was there when we were told Marianne was denied access because they felt her stroke was to severe and she wouldn't improve. Knowing that case manager knew us and our hopes, we believed she had done all that was possible and that Marianne wasn't an appropriate candidate for rehab. When the sad decision of nursing home placement was the last option we received help from our case manager. She helped narrow our search. She took into consideration our feelings, Marianne's strong faith, and our proximity to the facility. She arranged visits at three nursing homes after discussing the positive and negatives of each. We chose the nursing home and our case manager arranged the transfer of Marianne to The Lutheran Home. The transfer went smoothly and we truly felt supported. Our case manager gave us direction during one of the saddest times in our life. At that point in time I was a hurt and confused daughter-in-law, not a nurse.

Guest Patient Long-Tem Care Comments

Health care, where does one begin to solve the problems that are emerging as we speak. As stated in this blog, the number of patients needing long term care increases daily and will be on the rise for a very long time. As a nation devoted to taking care of the ageing, I believe we are taking steps backwards. The reforms proposed all make a lot of sense to me however they do require some additional spending and it seems to be very hard to get people to realize that change and betterment does not come free. I strongly agree that we need to require better training on the parts of the care givers. I find it hard to believe that you can spend one week and learn everything you need to know to care for an individual who needs medical care. As a health care patient myself, I would be very upset if my care giver was just someone who spent a few hours learning very little about caring for patients and administering medication. It seems to me that we are just trying to get by the cheapest way possible by replacing licensed nurses who have received years of training with someone who can be paid less, requires only hours of training, and will get the job done even if it might not be done in the best interest of the patient. As either patients now or future patients, I believe we need to take a stand and push for reforms like those stated in this blog. By doing this we must also look to our future. As stated in reform #2, we must ourselves take action on long term care insurance. We can not rely on the government to take care of us down the road. Long term care insurance needs to become a staple in our lives just like health, home and car insurance. Many will say that they just can't afford it but the truth is they can't afford not to have it. If the importance of this can be taught to all people early in life and more people start purchasing it, it should become more affordable and also something that people won't be without. As a cancer survivor, I received wonderful care from skilled doctors and nurses who I know were very well trained in what they were doing. I can't imagine what my experience would have been like had they have been people with very little training. As I get older I would like my future experience with health care to be the same as my past experience. Just because people get old or are near death should not mean that they are not as important and don't need wonderful experienced caregivers. We need to care for all ages or illnesses the same. No one life is more important than another. Quality care must become a requirement and reforms like those stated in this blog are just the start.

Guest Student Comment

Healthcare has been a very touchy subject in the last few years and is something that needs reform, especially when dealing with long term care for the elderly. This is a topic that severely needs to be addressed especially since the baby boomer generation is entering or only a few years away from needing long term care. I believe and agree with most of the arguments made in this blog and long term health care should be affordable, available for everyone who is in need, and an overall better quality of care is needed.

I think the most important issue right now is the issue talked about in the Reform Proposal #4, unskilled men and women providing “care” for the elderly. This is a huge problem and one place I think the government needs to step in and reform. Like it was said in the reform proposal, thousands of elderly adults are receiving inadequate care from untrained providers. I believe there is a line that has been crossed by many health care facilities because they are trying to save money. Hiring unskilled and uneducated (in the field of healthcare) men and women to give medications, look for signs and symptoms of the medication they administer, and provide other healthcare needs is just not acceptable. If I was in a long term healthcare facility I would want a trained RN to be watching my symptoms and not someone who was trained for 34 or even 85 hours (6 to 11 days on the job). I would want someone who went to school for years to learn about these medications and the symptoms that could result to be my healthcare provider. This type of treatment does lead to extra hospital visits, increased stress and pain, and a higher cost of long term care for the patients. Also the long term care provider can make a few extra dollars. This is just unacceptable in healthcare. The patients should always feel as they have the best healthcare provided to them as possible, which is not happening at the moment. The government needs to step in and make tougher requirements for these types of long term healthcare positions. Training needs to be increased for all workers and medication handout and all other healthcare provisions should be provided by a trained RN who knows what to look for and how to provide the best care possible.

I also believe that long term care should be offered by medical insurance plans and not only offered but become the norm. When a patient is planning for retirement, it should be in their retirement plan that long term care may be needed, this means purchasing long term care insurance. If this became a “normal” thing to do, long term care would be a better service because most of the money for the care would not be coming from government funded programs like Medicaid. I am a firm believer that government run healthcare is NOT a benefit for overall healthcare. Also, like stated in proposal 2, if purchasing long term healthcare insurance became something that all Americans did, the cost of that type of insurance, which is high now would decrease tremendously as well as provide more money to long term healthcare providers. This would be an overall win for everyone involved. The patients, although spending more, would receive much better care from the facilities, because the facilities would be making more because they would not be getting most of the money from Medicaid. Also, the government would be spending billions less, therefore reducing the national deficit.

I also agree with the fact that many TRAINED nurses do not have the working conditions and benefits needed to stay in this field. There are thousands of shortages because the working conditions and benefits are not what they are in other healthcare facilities. In order to keep trained nurses in this field, wages need to be increased; retirement and healthcare benefits need to be improved, and a better working environment must be provided. Also, these trained RN’s should not be let go so a “trained” CNA can be hired. Like stated in proposal 1, this could easily be done by the healthcare providers. If they increased the number of RN’s in their facilities they would decrease the long wearisome hours the current trained nurses have to work. Also, if they increased wages and benefits, more of these trained professionals would want to stay creating a happier environment for residents and the nursing staff. This extra spending could save the healthcare provider in the long run by decreasing recruitment and training expenses which costs billions of dollars a year.

One proposal that I did not completely agree with is that a hospital should be required to provide a case manager for each patient. Although this idea sounds good in practice I do not think it would work. I believe this because many of the patients in long term care already have doctors, nurses, and other care providers to deal with. Many of these patients want to live their life as best they can without assistance. Adding another person grilling them and talking about the care they need would not be beneficial. If a case manager is needed, it should be provided by the long term provider and go from hospital to hospital with the patient tracking the case. This case provider should also be extremely educated not only about the patient but also the care being provided which leads to the issues talked about earlier. Also, there is the problem with funding for a case manager. Hospitals do not have the time or resources to find and assign a case manager to every patient in long term care. Putting that responsibility on a hospital that sees the patient only a few times a year is not the answer. I also do not think the long term healthcare provider should provide a case manager but should do their best to provide the best healthcare possible and adding an extra thing like case management would decrease healthcare provision. I think the best way to fund a case manager is for the family of the patient or the patient to pay for their assistance. This way it removes all the issues of the patient not wanting a case manager and who should be providing this case manager.

Overall, I think this blog provided a lot of insight into the field of long term care. Providing this care for the elderly who fought for our country, inspired the youth, and provided for us while we were young is extremely important and should be top notch. Right now there are many issues in the field that need to be dealt with before the number of patients receiving this care increases dramatically. I think this blog is very educational as well as provides fixes for the many issues plaguing long term healthcare.

-Josh Kolz

I am studying Biomedical Engineering/Pre-med at UW-Madison. I plan to go into the field of cardiology or orthopedics. Both of these fields deal with heavily with patients who need or will need long term care in the near future.

Reform Proposal #4

Hospice care is a specialized form of care given to terminally ill patients at the end stage of their life (National Cancer Institute, 2011). This care is designed to focus on comfort rather than cure. The goal of the care is to adequately attend to the patient’s physical pain and mental suffering. In order to better relieve their suffering, pain medication is often used. However, ethical issues behind the use of pain medications in both hospice and palliative care have been globally debated. According to Douglas, Kerridge, and Ankeny (2008) a major issue that persists is, “the fear that the use of analgesic or sedative medications will hasten death” (p. 166). This may include the overdose of patients, especially in the mentally or terminally ill patients, who cannot express the severity of their pain.

The exact administration of analgesics and sedatives that are given to relieve the suffering of terminally ill patients are often times hard to determine because these drugs have a “double effect” (LaDuke, 2006). This is when the medications that are meant to ease and relieve terminal pain cause deterioration of the vitals, speeding up the end of life. According to LaDuke (2006), “studies have found that many physicians have trouble on a moral level distinguishing between administering medications that might hasten death to giving drugs that hasten death” (P. 165). If unskilled, unlicensed, and uneducated providers are hired in long-term care facilities to distribute pain medications to hospice patients, not knowing the side effects or even the effects of the medication itself, they could end up hastening a patients death.

Over the years, long-term care and end-of-life care has become very expensive. In order to accommodate to the increase in price, facilities have found ways around state restrictions and regulations. In doing so, many facilities have hired unskilled men and women. These care providers don’t know the first thing about the medications they administer or the side effects and symptoms of the drugs. They also don’t know how to accurately assess pain. By hiring unprofessional and unskilled workers to care for our elder generation, in order to decrease expenses, has overall decreased the quality of long-term health care.

In order to improve the quality of long-term health care, I propose that the federal government passes a bill that increases the hours of training for all workers, especially those who provide care to terminally ill patients, before the administration of drugs and the assessment of pain. I believe that before any nurse, doctor, or other health care professional administers medication they should be properly educated about pain management and hospice care. They should also be properly educated on the different kinds of medication that are administered, and there side effects and symptoms. The increase in education and training will increase the quality of care. In addition, it will lower the cost spent on sending patients out of the facility and to hospitals because of medication overdoses or horrible side effects that unskilled workers are not catching (P. Beilfuss, personal communication, March 20, 2011). It will also increase the access for any terminally ill patient to receive picture-perfect care.

Anyone who needs long-term care or end-of-life care should feel confident that those who provide it have the required knowledge, training, and skills. I also propose that all states regulate all long-term care facilities in order to have appropriate oversight and leadership. These elderly men and women deserve to be able to easily access good quality end-of-life care. The Wisconsin Board on Aging and Long Term Care believe that long term care consumers have the right to be treated with respect and dignity (Board on Aging and Long Term Care). In addition according to Horazdovsky (2009), “these individuals have lived productive lives, defended our country, and raised today’s leaders. Yet they are, at worst, threatened to be left behind or forgotten.”

-Written By Amber Wesela

Resources

Board on Aging and Long Term Care. Advocating for Residents Rights. Retrieved from http://longtermcare.wi.gov/subcategory.asp?linksubcatid=3001&linkcatid=1953&linkid=1014&locid=123

DOUGLAS, C., KERRIDGE, I., & ANKENY, R. (2008). MANAGING INTENTIONS: THE END-OF-LIFE ADMINISTRATION OF ANALGESICS AND SEDATIVES, AND THE POSSIBILITY OF SLOW EUTHANASIA. Bioethics, 22(7), 388-396. doi:10.1111/j.1467-8519.2008.00661.x

Horazdovsky, D. J. (2009, June 23). Long-Term Care is Vital Aspect of Health Care Reform. Retrieved from http://www.rollcall.com/news/-36168-1.html.

LaDuke, S., 2006. Attending Death with Dignity. In F. Mullan & E. Ficklen (Eds.), Narrative Matters (pp. 161-167). Baltimore, Md: The Johns Hopkins University Press.

National Cancer Institute. (2011). Hospice Care. Retrieved from http://www.nlm.nih.gov/medlineplus/hospicecare.html.

Reform Proposal 3

According to the Wisconsin Board on Aging and Long Term Care, long term care consumers have the right to be…

…fully informed of their rights, services available and all charges prior to admission to a facility or enrollment into a program.

…given advance notice of transfer, discharge, disenrollment, termination, or charges in services (1).

Case management can be defined as “the process of matching client needs with available services that are likely to best address those needs” (4). I believe the rights outlined above affirm the importance of “case management.” The purpose of case management is to assess the special needs of older adults, to prepare a care plan to address those needs, to specify services that are most appropriate, to determine eligibility for services, to make referrals and coordinate delivery of care, to arrange for financing, to ensure that clients are receiving services, and reevaluate needs as circumstances change over time (4).

I propose that hospitals be more active in their patient’s care beyond the hospital setting into the long term care location. They should make a commitment to their patient in seeing them through all their care even after discharge to a long term care facility. Under this approach, hospital-based case managers would identify clients, assess their needs, develop care plans, coordinate service delivery, and monitor results (2). This kind of care would be an extension of the hospitals services since the care is given after the patient has been discharged.

Policy makers have been urging hospitals to be more active in their patients care beyond the hospital walls. This is because the hospitals have been failing to meet the post discharge needs of their elderly patients with chronic health problems (2).

The federal government should act on this and make an attempt to have case management a regular part of the care of the hospital to ensure continuity of service. A case manager should be assigned to the patient and assess the care from acute care to the long term care facility (5). A case manager could be a nurse or social worker hired to see through their case from start to finish. For this to work, the hospital should run the case manager program in whatever way they see fit as long as they follow the guidelines from the government. The social worker or nurse would be assigned to each patient based on need. They will be able to monitor and coordinate the services more closely than an independent case manager (4).

The ultimate goal of case management is to bridge the gap between the acute care received at the hospital and the long term care (2). Case management assists in decreasing nursing home care through increased supportive services (3). If case management is available to the patient, it is found to be extremely beneficial in preventing unnecessary costs on the patient and their family. With this new policy, readmission of Medicare patients to the hospitals could be reduced and that would improve hospital profit margins. Since the quality of care would increase with case management, more patients might be attracted to this specific hospital and profits would increase. The care provided would be more appealing than competing hospitals without that service.

Case management protects the patient by allowing them to receive the care they need through a needs assessment by the case manager. The quality of care for others in the facility increases since these specialists are more readily available for patients who actually need them.

Since long-term care services, eligibility requirements, and financing can be overwhelming for the patient and the family it is important for case management to be there to support these issues. Many patients or older individuals live far from their children, so these services are comforting to the family as a whole (4). The patient will have increased access to the care they need because they will be receiving a direct assessment of their needs from their case manager.

A potential problem to this case management is that the patients might not find it necessary to spend the time with their case manager. The problem might arise with cooperation from the patient. The multiple consultations and time commitment with case managers could be a burden.

The funding for the case managers could be an issue. Depending on the type of patients referred to the case manager, the cost could come from within the hospital or vary based on insurance coverage.

1. Board on aging and long term care (n.d.). History. Retrieved February 16, 2011, from http://longtermcare.wi.gov/subcategory.asp?linksubcatid=3001&linkcatid=1953&linkid=1014&locid=123

2. Christianson, J., Warrick, L, Netting, F., Williams, F., Read, W. et al. Hospital case management: bridging acute and long-term care Health Affairs, 10, no.2 (1991):173-184

3. Cress, Cathy. (2007). Handbook of geriatric care management. Jones & Bartlett Publishers: Sudbury, MA.

4. Shi, L., & Singh, D. A. (2008). Delivering health care in America: A systems approach (4thed.). Boston: Jones and Bartlett.

5. Wilson, Margaret. (2011). Case management in long-term care: challenges, changes, and opportunities. The CBS Interactive Business Network. Retrieved March 2011, from http://findarticles.com/p/articles/mi_m0FSS/is_n1_v6/ai_n18607261/?tag=content;col1.

Reform Proposal 2

Long-term care is a variety of services including medical and non-medical care to people who have a chronic illness or disability (2). Long-term care assists patients to meet health or personal needs, primarily providing assistance with Activities of Daily Living (ADL’s) such as dressing, bathing, using the bathroom, and eating. Although long-term care may be needed at any age, it is especially prevalent among older adults. By 2020, 12 million older Americans will need long-term care (1).

Many people believe they can rely on Medicare to cover the costs of long-term care services that may be needed in the future. What people don’t know is that Medicare and private health insurance programs do not pay for the majority of long-term care services that most people need. In general, Medicare pays for about 20 percent of long-term care and will provide coverage only under specific circumstances. The majority of long-term care is covered by Medicaid. Eligibility for Medicaid and the services that are covered vary from state to state. Eligibility for long-term care coverage by Medicaid is primarily based upon the individual’s income level and personal resources. People with financial means do not qualify for Medicaid until they deplete those resources (1).

Purchasing long-term care insurance is another option for individuals. Long-term care insurance covers the costs of long-term care services including home assistance with Activities of Daily Living and care in a variety of facility and community settings (1). Long-term care insurance policies are very flexible, allowing the individual to choose from a range of care options and benefits. The cost of this insurance depends upon the type and amount of services chosen for coverage, age of the individual when they purchased insurance and any additional benefits they included in their plan.

Only 5 percent of Americans currently have private long-term care insurance (3). Most people are either unaware of this option or chose not to purchase long-term care insurance because they rather wait until Medicaid will cover their costs. In order for Medicaid to cover long-term care costs the patient first must deplete their own financial resources. If the patient has sufficient resources, Medicaid may never cover the costs, leaving the patient with extremely high expenses.

I propose that the federal government enact a bill in which long-term care insurance is offered by medical insurance plans. When individuals sit down to select a medical insurance plan, they should be provided with information regarding long-term care insurance. Long-term care insurance should be introduced as an option for all individuals. “A study by the U.S. Department of Health and Human Services says that people who reach age 65 will likely have a 40 percent chance of entering a nursing home” (2). Introducing long-term care insurance allows individuals to analyze their options and decide what would best suit them. It also provides them the opportunity to pay for long-term care over a period of time.

Purchasing long-term care insurance would initially raise individual costs by raising individual premiums. The individual would be required to pay pre-determined premiums. Payment of these premiums would allow the patient to access long-term care when they need it. Purchasing long-term care insurance at an early age insures the individual will receive care when needed later on in life, instead of being burdened with an extremely high cost after a catastrophe occurs. The cost of long-term care premiums can be reduced, if long-term care insurance is purchased early in life.

Although long-term care insurance would increase individual costs, it would reduce Medicare and Medicaid costs because government insurance companies would not be required to cover all long-term care costs. Legislation proposed by the late Ted Kennedy predicted that shifting long-term care costs from Medicaid to the individual would generate over 70 billion dollars in savings over a ten year period (3). As the number of individuals purchasing long-term care increases, the risk would be spread out among more individuals. This would lower the cost of individual premiums, thus making purchasing the insurance more affordable. As individuals become aware of the increasing likelihood of needing long- term care and the threat of only receiving services at the cost of their life’s savings, the value of long-term care insurance will be realized.

References

1. "Costs of Care." National Clearinghouse for Long Term Care. U.S. Department of Health and Human Services, 5 Dec. 2010. Web. 09 Mar. 2011. .

2. "Long-Term Care." Medicare.gov. 25 Mar. 2009. Web. 9 Mar. 2011.
.

3. Pickert, Kate. "Should Long-Term-Care Insurance Be Part of Health Reform?" TIME. Time
Inc., 8 Dec. 2009. Web. 13 Mar. 2011.
.

4. Shi, L., & Singh, D. A. (2008). Delivering health care in America: A systems approach
(4thed.). Boston: Jones and Bartlett.

5. Smith, MD, Michael W. "Medicare and Long-Term Care." WebMD. WebMD, LLC, 16 Aug.
2009. Web. 09 Mar. 2011. .

Reform Proposal 1

The U.S Census Bureau reports that by 2030 the number of U.S adults aged 65 and older will double from 36 million to 71.5 million. By 2050 that number is expected to grow to 86.7 million.5 This is a huge problem because as the population gets older there is an increasing demand for long term care workers, despite the current shortage of nurses we have today. The U.S Bureau of Labor Statistics estimates the workers in long term care needed will increase by 45%, while more than 1 million new and replacement nurses will be needed across the entire medical field by 2012.4

The growing nursing shortage is degrading the standards of long term care. Nursing home staff and management cannot produce a decent environment for residents until there are major improvements in staffing ratios, staff management and training, decent pay, benefits and incentives, and safety protection. Long term care facilities are also facing challenges of turning down elderly from their care facilities that have special needs. Such elderly that have feeding tubes or ventilators. Patients who need extra care and attention like these can’t get that needed care with a shortage of staff. There are nearly 96,000 nursing positions vacant in long term care.3 We propose there needs to be more courses of training in geriatrics and an improved working environment for nurses. This will increase quality of care, keep nurses in the field, and possibly attract nurses to this occupation.

More legislation is needed to solve the nursing shortage and level of quality care in the long term care facilities. Several bills have been attempted at both the federal and state levels to address the issue of understaffing and working conditions in long term care, but few have been passed. I propose a new bill that increases the hours of training needed of workers in long term care facilities. This will increase quality in our long term care sectors. Currently long term care workers need only 34 hours of training, that’s less than half the training required of workers who provide the same type of care in nursing homes.1 I propose long term care workers need the same level of training as workers in nursing homes which concludes 85 hours of training and certification of standard.1 If there’s going to be a shortage of workers, they need to be masters in their field so they can perform their duties quickly and efficiently to get from one patient to the next.

Another reason for lack of quality due to shortage of nurses is partially in part by the high turnover rate. The rate far exceeds 50%.2 Reasons for such a high turnover rate can be due to long hours and duties that far exceed what they’ve been trained. I propose there needs to be more incentives and benefits that will attract workers and keep them in one place for a long time. Initiatives include wage increases, helping workers obtain health insurance, bonuses, childcare assistance, and transportation assistance. Yes, incentives cost more money but incentives will greatly decrease the turnover rate which in turn saves money. Currently long term care facilities spend $4 billion a year in recruitment and training expenses.1 With less turnover rate this money can be spent on workers and a better environment for them to keep them happy in one place for a long time.

References:

1. Dapper, N., & Ryan, L., (2008, April 22). More training for long term care workers. Retrieved February 26, 2011, from http://www.seattlepi.com/opinion/360135_longtermcare23.html
2. Department of Health and Human Services Office of the Assisstant Secretary for Planning and Evaluation (2003, May 14). The Future Supply of Long-Term Care Workers in relation to The Aging Baby Boom Generation. Retrieved February 26, 2011, from http://aspe.hhs.gov/daltcp/reports/ltcwork-A.htm
3. United Press International (2005, July 11). Nursing shortage affects long-term care. Retrieved February 26, 2011, from http://www.medicineonline.com/news/12/1004/Nursing-shortage-affects-long-term-care.html
4. U.S Bureau of Labor Statistics. Retrieved February 26, 2011 from http://www.bls.gov/
5. U.S Census Bureau (2011, Jan 6). Retrieved February 26, 2011 from http://www.census.gov/