AHCA BACKGROUND
HOME CARE & NURSING FACILITY CARE: SERVING SEPARATE POPULATIONS
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Contact: Dave Kyllo 1-202-898-6312 |
Seventy-five million babies were born in the United States from 1946 to 1964. This is the Baby Boom generation, an independent-minded generation that has grown up demanding that society provide a growing array of life-style options from which they can pick and choose. For their parents and for themselves in the next century, this generation will seek and demand choice in long term care. To meet that demand, the spectrum of long term care services being offered is expanding to provide choice and to meet individual care needs.
Home and community-based (HCB) programs have become increasingly popular with lawmakers, the media and the public. The rapid growth in private and public HCB expenditures is one way that interest can be measured.
According to the Health Care Financing Administration (HCFA), public and private HCB expenditures grew from $1.9 billion in 1980 to $24.2 billion in 1994. Projections are that substantial growth will continue.(1)
Supporters justify the need for HCB care by asserting that it is a cost-efficient alternative to nursing facilities. While public sentiment for HCB care is high, three myths about nursing facilities and the people who live in them perpetuate the false perception that HCB care is a cost-effective substitute for nursing facility care.
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Myth #1: Home And Community-Based Care Will Reduce The Total Cost Of Long Term Care. |
In a 1994 report to Congress, the General Accounting Office concluded that states receiving waivers to provide care in HCB settings as a substitute for nursing facility care often found those seeking HCB care did not come from nursing facilities, but from "out of the woodwork." This resulted in an increasing number of people receiving long term care at government expense.(2)
In recent years, additional studies have shown that HCB does not reduce the cost of nursing facility care:
 | Public Policy Institute (1995): "Experimental evidence
on the cost-effectiveness of formal services [including HCB care] as
a substitute for institutional services [including nursing
facilities] is, at best, inconclusive and, at worst,
discouraging."(3)
| University of Wisconsin-Madison (1995): "Many policy
makers, researchers and service providers were convinced that CBLTC
[community-based long term care] programs would provide an
alternative to nursing homes. ... In essence, CBLTC was assumed to
be more cost effective than nursing home care, i.e., it could
provide similar or better care at a lower cost. ... The CBLTC
projects failed to achieve cost savings. In fact, the majority of
projects led to an increase in public expenditures."(4)
| General Accounting Office (1995): "In the United
States and some other countries, concerns about costs are a key
factor driving changes in long-term care financing and service
delivery. The attempted substitution of home and community-based
services for institutional care is the most visible response to cost
concerns. ... Whether increased reliance on home and community-based
services and limitations on institutional care will reduce the rate
of spending growth, however, is not yet clear."(5)
| Institute for Health Policy (1993): "Increased
financing for HCB services may be desirable but will not
significantly influence nursing home expenditures. The underlying
assumption is that the delivery system is correct, but funding is
inadequate. ...We must seek to justify HCB on grounds other than
cost effectiveness or clinical efficacy: the debate should focus on
how much community care we are willing to purchase as a society,
rather than how much money we can save by purchasing these
services."(6)
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Myth #2: Nursing Facility Residents Generally Can Care For Themselves With Minimal Assistance. |
Many people today assume that nursing facilities simply provide custodial care for older, generally ambulatory people. While that may have been true decades ago, it is not true today. The typical nursing facility resident today is older, sicker and needier than ever before.
On average, today’s nursing facility residents need help with 3.9 activities of daily living (ADLs), which include eating, bathing, toileting, dressing and transferring.(7) By comparison, HCB patients need assistance with 2.5 ADLs.(8) The following comparison of nursing facility and HCB patients in each ADL category further illustrates a distinct level of need.
Because of medical advancements, Americans today live longer than ever before. According to the U.S. Census Bureau, people age 85 and older are the heaviest users of long term care. In 1990 nearly one in four (24.5 percent) lived in a nursing facility.(9) Octogenarians suffer more chronic and serious medical problems than the "young" elderly. But no matter how old, a typical nursing facility resident simply is unable to live independently – even with daily visits from a health care professional.
Because of the increasingly complex medical needs of nursing facility residents today, facilities have made adjustments to provide the required medical services. Nursing facility staff members are no longer simple custodians of care, but are highly trained providers of around-the-clock nursing care. More and more nursing facilities – now equipped to handle serious medical needs that cannot be accommodated in a home setting – are beginning to specialize. They are offering, for example, special AIDS, Alzheimer’s and rehabilitation units.
Nursing facilities are also moving rapidly into the "subacute" market, providing services for people who need higher levels of skilled care, but do not require the expensive, acute-care services of a hospital. Examples of subacute services include intravenous therapy, post-operative care, complex wound management, rehabilitation for stroke, and other critically ill patients.
Bruce Vladeck, HCFA Administrator, recognizes the importance of nursing facility care for the elderly American.
Vladeck has written: "...there is little question that in most communities, most nursing home residents are pretty ill and pretty disabled. Almost all have multiple, serious medical problems; perhaps as many as half have significant cognitive impairments."
"Continuing growth in the number of impaired elderly persons necessitates a continued reliance on nursing homes to care for at least those who are most impaired or most lacking in other supports ..."(10)
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Myth #3: Home And Community-Based Care Will Reduce Nursing Facility Utilization. |
The services offered in nursing facilities and the services provided by HCB care are quite different and simply cannot be compared.
Study after study – spanning more than a decade – have shown that substituting HCB care for nursing facility care is unrealistic because separate populations utilize each service. Consider the following:
| The New England Journal of Medicine (1996): "...we did
not find any evidence that home visits were substituted for care
provided by skilled-nursing facilities ..."(11)
| University of Wisconsin-Madison (1995):
"Unfortunately, after nearly two decades of experimentation,
various approaches to CBLTC [community-based long term care] have
produced disappointing results. With few exceptions, CBLTC
demonstrations failed to reduce nursing home or other health service
use; they added to public LTC expenditures rather than reducing
them; and they had only minimal effects on the health, functional
status, or well-being of older persons participating in the
programs."(12)
| Journal of the American Geriatrics Society (1994):
"Policy makers should decide to offer CBLTC because some
patients desire it. Expecting most patients to use it as a
substitute for nursing home care in unrealistic. Most who use it
will not be at high risk of nursing home use. As a group, home care
patients are about five years younger than nursing home patients,
and they suffer few risk factors for nursing home use. More home
care patients are married, fewer have multiple dependencies in
activities of daily living, fewer suffer mental disorders."(13) | |
More than a decade of government and university studies, pilot projects, and demonstration programs have exposed the fallacy of assumptions that:
| HCB care will reduce the total cost of long term care;
| Nursing facility residents generally can care for themselves with
minimal assistance; and
| HCB care will reduce nursing facility utilization. | |
It is a time-tested fact that HCB care does not reduce the cost of long term care; it actually increases the amount spent on those services. It is a time-tested fact that nursing facility residents generally cannot live on their own. It is a time-tested fact that HCB care and nursing homes serve different populations.
The myths about the intersection of HCB care and nursing facilities persist because the public has expressed a strong and understandable desire to receive care in the most comfortable and familiar setting possible. But that sentiment cannot mask the reality that HCB care and nursing facilities have distinctly different roles in our health care system.
The American Health Care Association (AHCA) believes that HCB programs are a vital part of the long term care continuum. Appropriate care in the appropriate setting is in the common interest of all providers – providers of HCB care and providers of nursing facility care – as well as of those needing long term care. Both HCB care and nursing facility care are needed to meet the diverse, long term care needs of the nation’s rapidly aging population.
February 1997
(1) Health Care Financing Administration. Health Care Financing Review. Summer 1995; 16(4):256.
(2) U.S. General Accounting Office. Report to Congressional Requesters. Medicaid: Long-Term Care, Successful State Efforts to Expand Home Services While Limiting Costs. August 1994:5.
(3) Newman, Sandra J. and Kirsten Envall. A Public Policy Institute Report for the American Association of Retired Persons: The Effects of Supports on Sustaining Older Disabled Persons in the Community. September 1995:6.
(4) Sanger, Mark A. and Greg Arling. A Review of Community Based Long Term Care with Emphasis on Wisconsin’s Community Options Program. April 1995:4.
(5) U.S. General Accounting Office. Report to Congressional Requesters. Long-Term Care, Current Issues and Future Directions. April 1995:15.
(6) Hallfors, Diane Dion. Center for Vulnerable Populations, Institute for Health Policy, Brandeis University. State Policy Issues in Long-Term Care for Frail Elders. March 30, 1993:8.
(7) American Health Care Association. 1996 Facts and Trends: The Nursing Facility Sourcebook. 1996:9.
(8) U.S. Department of Health and Human Services. Advance Data, March 28, 1994.
(9) Hobbs, Frank B. and Bonnie L. Damon. 65+ in the United States. U.S. Bureau of the Census. Current Population Reports, Special Studies. April 1996:23-190.
(10) Vladeck, Bruce C. "Long-Term Care for the Elderly: The Future of Nursing Homes."
Western Journal of Medicine February 1989; 150:215-220.
(11) Welch, H. Gilbert, David Wennberg, and W. Pete Welch. "The Use of Medicare Home Health Care Services." New England Journal of Medicine August 1, 1996:328.
(12) Sanger, Mark A. and Greg Arling. pp. 4.
(13) Weissert, William G. and Susan C. Hedrick. "Lessons Learned from Research on Effects of Community-Based Long-Term Care." Journal of the American Geriatrics Society March 1994:352.
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