Discussion Topic- Hospice or Adult Day Services
In this forum, explain what you would tell a friend who is thinking about hospice or adult day facilities, in regards to financing? Can you help him/her make a decision?
At least 275 words.
Course Materials: Pratt. J. Long-Term Care- Managing Across the Continuum. 4th edition. Jones and Bartlett ISBN: 978-1-284-05459-0.
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Also described as “non-institutional”, they include home health care, hospice care and adult day
care.
What is Home Health Care? – health care delivered to consumers in their homes.
What is Hospice Care? – services provided to meet the needs of patients who are
diagnosed with a terminal illness and have a limited life span.
What is Adult Day Care? – a form of long-term care that provides interim (less than 24-
hour) supervision for individuals who cannot be without supervision or assistance.
Home Health Care
Began in the latter part of the 1800s as a service of city health departments called
visiting nurse
services.
As third party reimbursement became more available, home health care agencies
became even more independent.
As reimbursement sources, particularly Medicare and Medicaid, looked for ways to
reduce their ever-increasing costs, there was a concerted move to divert long-term
care residents from institutional care to home-based care.
Hospice Care
Began in England in 1960s.
© 2015 Jones and Bartlett Publishers, LLC 1
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Came to U.S. in 1974
Adult Day Care
Developed from the concept of respite
Provides a short reprieve from the responsibilities of caregiving for those who have a
family member living with them who needs constant care and supervision
Home Health Care – to take health services to the consumer rather than requiring the
consumer to go to where the services are delivered. Medicare requires:
Physician-Ordered Care – separates it from non-health home care
Intermittent Care – given fewer than 7 days per week or less than 8 hours per day
Homebound Consumers – recipients must be unable to leave home without a major
effort.
Hospice Care – based on a concept of providing comfort and support to patients and their
families when a life-limiting illness no longer responds to cure-oriented treatments.
Goal is to improve the quality of a patient’s last days by offering comfort and dignity.
A central concept of hospice is provision of palliative care, also called comfort care,
which concentrates on providing pain and symptom relief.
Adult Day Care – based on providing needed services for both the person receiving the
care and those responsible for that care.
Family members very important
Ownership
© 2015 Jones and Bartlett Publishers, LLC 2
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Mix of for-profit and not-for-profit.
Many affiliated with hospitals or health care systems
Some nursing facilities create community-based services if not otherwise available.
Home Health Care
Deliver a wide variety of health care and supportive services, ranging from
professional nursing and HCA care to physical, occupational, respiratory, and speech
therapies.
May also provide social work and nutritional care and laboratory, dental, optical,
pharmacy, podiatry, x-ray, and medical equipment and supply services.
Hospice Care – services aimed at easing pain and assisting patients and families,
including:
Supportive services
Pain and symptom management
Family and caregiver support
Communication among the individuals, families, and program staff
Assistance with advance care planning.
Adult Day Care – adult day care centers are generally grouped into two categories: social
day care and health day care. There is a third group, dementia day care, but it is usually
included in one of the others.
Generally elderly, more women than men
© 2015 Jones and Bartlett Publishers, LLC 3
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Home health care consumers may need temporary care
Hospice care consumers receive care until they die
Adult day care consumers often use services for long period of time.
The family members of the consumers of community-based long-term care services must also be
included as beneficiaries of community-based long-term care services. Often, the caregivers are
spouses, children, friends, and volunteers. To distinguish them from those who give care as part
of their jobs, they are referred to as informal caregivers.
Consumer Choice – often favors community-based services over institutional services.
Cost-Effectiveness – seen by payers as less costly making them more attractive.
Social and Demographic Changes – families of the elderly are often not available to help.
Competition among Other Providers – adding community-based services can help them
improve their market position.
Regulations – regulations affecting community-based services fall into three general categories:
(1) Medicare certification, (2) licensing of provider organizations and (3) licensing of
professional staff.
1. Medicare Certification
Home health and hospice care are covered by Medicare
Adult day care is not.
2. Licensure of Provider Organizations – is handled at the state level:
© 2015 Jones and Bartlett Publishers, LLC 4
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Most, but not all, states do license home health care agencies.
Nearly all states now license hospice providers.
Regulation of adult day care centers is highly inconsistent, varying from state to state.
3. Licensure of Staff
Professional staff, such as physicians, nurses, and social workers, must be licensed by
their state licensing boards regardless of what type of health care organization they
work for.
Accreditation – applies to the organizations, not the staff members as such.
Home health care and hospice agencies may be accredited by any of three separate
organizations: the Joint Commission, the Community Health Accreditation Program
(CHAP), or the Accreditation Commission for Health Care (ACHC).
Adult day care is not accredited.
Certification of Professionals –applies to individuals acquiring voluntary verification of
their qualifications.
Medicare
Is the largest single payer of home health care and hospice care.
A pilot program allows a portion of Medicare home health-care benefits to go toward
adult day care.
Medicaid
© 2015 Jones and Bartlett Publishers, LLC 5
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Medicaid coverage of community-based services is growing
Most states offer a hospice benefit as part of their Medicaid coverage.
Some state Medicaid programs pay for adult day care through federal waivers that
allow them to waive some Medicaid rules in order to use less costly services.
Private Health Insurance and Managed Care
Coverage is increasing.
Private Out-of-Pocket
Community-based care services are personnel-intensive, that is, payroll for staff is the
largest portion of the budget.
They rely on a mix of professional and nonprofessional staff working as a care team. The
team includes nurses (both RNs and LPNs), aides, therapists (physical, occupational,
speech), social workers, and numerous other specialties.
All use some volunteers, but hospice uses more of them and more integrally in the
provision of care.
Patient Noncompliance – many of these patients want a high level of autonomy, which
may be at variance with professional opinions.
Patient Safety – is more difficult when patients are not under the supervision of
professionals at all times.
© 2015 Jones and Bartlett Publishers, LLC 6
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Patients’ Rights – again, involves balancing patient autonomy and professional
responsibilities.
The Decision to Accept Hospice Care – Some patients do not want to accept that their
conditions are terminal, or their families do not.
Inequitable Access – community-based services are not uniformly accessible, depending
on geography and/or the urban/rural nature of the community.
Management – administrators of community-based service providers are not regularly licensed
as are nursing facility administrators and, in some states, administrators of assisted living
facilities.
Supervision of Staff: Home Health and Hospice Care – it is difficult to supervise staff
who are working in the patient’s homes.
Hospice: Coordinating Professional and Volunteer Staff – such coordination can be
difficult due to different points of view.
Hospice: The Emotional Element – impending death creates emotions for both
patients and those who care for them, and must be recognized.
Cultural, Religious, and Ethnic Differences – some ethnic groups involve family
members more than others, and different religious groups have different views on
death.
Community and Philanthropic Groups – these services rely on such groups and
working with them is essential, but sometimes difficult.
© 2015 Jones and Bartlett Publishers, LLC 7
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Consumer Choice/Quality of Life – favors community-based services over institutional
services.
Olmstead Decision – requires treatment in the least restrictive setting.
Technology – is changing these services for the better.
Managed Care – is rapidly becoming an important player in community-based services.
Wellness Programs – some community-based services are beginning to create wellness
programs for elderly individuals who are not yet in need of more traditional services.
© 2015 Jones and Bartlett Publishers, LLC 8
- CHAPTER EIGHT: COMMUNITY-BASED SERVICES
- Regulations – regulations affecting community-based services fall into three general categories: (1) Medicare certification, (2) licensing of provider organizations and (3) licensing of professional staff.
- Management – administrators of community-based service providers are not regularly licensed as are nursing facility administrators and, in some states, administrators of assisted living facilities.
CHAPTER HIGHLIGHTS
What are Community-Based services?
What is Home Health Care? – health care delivered to consumers in their homes.
What is Hospice Care? – services provided to meet the needs of patients who are diagnosed with a terminal illness and have a limited life span.
What is Adult Day Care? – a form of long-term care that provides interim (less than 24-hour) supervision for individuals who cannot be without supervision or assistance.
Origins and Development
Home Health Care
Hospice Care
Adult Day Care
Philosophy of Care
Home Health Care – to take health services to the consumer rather than requiring the consumer to go to where the services are delivered. Medicare requires:
Physician-Ordered Care – separates it from non-health home care
Intermittent Care – given fewer than 7 days per week or less than 8 hours per day
Homebound Consumers – recipients must be unable to leave home without a major effort.
Hospice Care – based on a concept of providing comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments.
Adult Day Care – based on providing needed services for both the person receiving the care and those responsible for that care.
Services Provided
Home Health Care
Hospice Care – services aimed at easing pain and assisting patients and families, including:
Adult Day Care – adult day care centers are generally grouped into two categories: social day care and health day care. There is a third group, dementia day care, but it is usually included in one of the others.
Consumers Served
Informal Caregivers
Market Forces Affecting Community-Based Services
Consumer Choice – often favors community-based services over institutional services.
Cost-Effectiveness – seen by payers as less costly making them more attractive.
Social and Demographic Changes – families of the elderly are often not available to help.
Competition among Other Providers – adding community-based services can help them improve their market position.
1. Medicare Certification
Home health and hospice care are covered by Medicare
Adult day care is not.
2. Licensure of Provider Organizations – is handled at the state level:
3. Licensure of Staff
Accreditation and Certification
Accreditation – applies to the organizations, not the staff members as such.
Certification of Professionals –applies to individuals acquiring voluntary verification of their qualifications.
Financing of Community-Based Services
Medicare
Is the largest single payer of home health care and hospice care.
Medicaid
Private Health Insurance and Managed Care
Private Out-of-Pocket
Staffing and Human Resource Issues
Legal and Ethical Issues
Patient Noncompliance – many of these patients want a high level of autonomy, which may be at variance with professional opinions.
Patient Safety – is more difficult when patients are not under the supervision of professionals at all times.
Patients’ Rights – again, involves balancing patient autonomy and professional responsibilities.
The Decision to Accept Hospice Care – Some patients do not want to accept that their conditions are terminal, or their families do not.
Inequitable Access – community-based services are not uniformly accessible, depending on geography and/or the urban/rural nature of the community.
Management Challenges and Opportunities
Supervision of Staff: Home Health and Hospice Care – it is difficult to supervise staff who are working in the patient’s homes.
Hospice: Coordinating Professional and Volunteer Staff – such coordination can be difficult due to different points of view.
Hospice: The Emotional Element – impending death creates emotions for both patients and those who care for them, and must be recognized.
Cultural, Religious, and Ethnic Differences – some ethnic groups involve family members more than others, and different religious groups have different views on death.
Community and Philanthropic Groups – these services rely on such groups and working with them is essential, but sometimes difficult.
Significant Trends and Their Impact
Consumer Choice/Quality of Life – favors community-based services over institutional services.
Olmstead Decision – requires treatment in the least restrictive setting.
Technology – is changing these services for the better.
Managed Care – is rapidly becoming an important player in community-based services.
Wellness Programs – some community-based services are beginning to create wellness programs for elderly individuals who are not yet in need of more traditional services.
Chapter 8
Community-Based
Services
1. Define and describe community-based
long-term care services
2. Identify and define the components of
community-based long-term care services
3. Identify and describe regulations affecting
community-based service providers
4. Understand the financial, ethical, and
managerial issues facing community-
based long-term care service providers
5. Identify trends in community-based
long-term care services and management
Community-based: Any service provided outside of a
facility, including home health care, hospice care and
adult day care
Home health care: Skilled nursing and other health-
related services provided in the consumer’s home
Hospice care: End-of-life care
Adult day care: Interim supervision and socialization
City public health department’s
visiting nurse services
Freestanding visiting nurse associations
Growth based on better reimbursement
England in 1960s
U.S. in 1974
Compassionate care for the
dying
To provide respite for family
caregivers who needed to work
Began with friends and family –
eventually became more organized
To take services to consumers’ homes
Eligibility requirements (based on
Medicare regulations):
• Physician-ordered
• Intermittent
• Homebound
Not a place, but a philosophy
Patient must be at or near the end of life
Designed to make last days comfortable
May be provided in a home or in an
institution
Serves both patient and family
Less than 24-hour services
Provides both supervision and
socialization
Holistic approach, designed to
maintain quality of life
Allows family caregivers to work
Ownership of Community-Based
Service Providers
Mix of nonprofit, for profit, government owned
Growing number are affiliated with other
health care organizations:
• Hospitals
• SNFs
• Rehabilitation facilities
• Nursing • Therapy
• Dental care • Lab tests
• Nutrition • Care
management
• Personal care • Homemaking
• Transportation • Education
• Physician services
• Nursing services
• Social services
• Counseling
• Medical appliances
• Pain management
• Homemaker services
• Therapies
Social day care
Health day care
Dementia day care
• usually included in the
other types
Consumers Served:
Home Health Care
Largely elderly
Some need ongoing care
Others need only temporary care
following a hospital stay
Consumers Served:
Hospice Care
Often very elderly
No hope of a cure
Very vulnerable, often emotionally
exhausted
Consumers Served:
Adult Day Care
Need some supervision, but not
institutional care
Most live at home or with family
members
Family members and friends who
provide much community-based care
Make great sacrifices
Little assistance from the system –
financial or other
Consumer choice
Cost-effectiveness
Social and demographic changes
Competition among other providers
Medicare certification
• Home health and hospice care
State licensure of provider organizations
Licensure of staff
Joint Commission:
• Home health and hospice
CHAP:
• Home health, hospice and some other services
ACHC:
• Home health, hospice and some other services
Medicare
• PPS
Medicaid
Other government programs
Managed care
Private health insurance
Self-pay and other sources
Medicare
• Some, but not all services
Medicaid
• Increasing number of states
covering hospice
Self-pay and other sources
Medicaid
• Some states use federal waivers
Managed care
• Some, but not much
Private insurance
• Some, but not much
Self-pay and other sources
Combination of professional and
non-professional staff
Nurses
Home health aides
Therapists
Social Workers
Other specialists
Volunteers – especially in hospice care
Patient noncompliance
Patient safety
Patient rights
Decision to accept hospice care
Inequitable access
Not regularly licensed
Medicare “conditions of participation”
(where applicable)
Certifications
Management Challenges
and Opportunities
Home health and hospice – supervision
of staff
Hospice – coordinating professional and
volunteer staff
Hospice – the emotional element
Cultural, religious, and ethnic differences
Community and philanthropic groups
Consumer choice, quality of life
Olmstead decision
Technology
Managed care
Wellness programs
Community-based services, particularly
home health care, hospice care, and adult
day care, have become increasingly
attractive in recent years and should
continue to grow.
- Slide 1
- Ownership of Community-Based Service Providers
- Consumers Served: Home Health Care
- Consumers Served: Hospice Care
- Consumers Served: Adult Day Care
- Management Challenges and Opportunities
Learning Objectives
Learning Objectives (continued)
Definitions
How Home Health Care Developed
How Hospice Care Developed
How Adult Day Care Developed
Philosophy of Home Health Care
Philosophy of Hospice Care
Philosophy of Adult Day Care
Services Provided: Home Health Care
Services Provided: Hospice Care
Services Provided: Adult Day Care
Informal Caregivers
Market Forces
Regulations
Accreditation and Certification
Financing Home Health Care
Financing Hospice Care
Financing Adult Day Care
Staffing
Legal and Ethical Issues
Management Qualifications
Significant Trends
Summary