Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

CHAPTER NINETEEN: INTO THE FUTURE: TRENDS TO WATCH

CHAPTER HIGHLIGHTS

Introduction – the field of long-term care has gone through, and is still experiencing, a time of

great change.

 Some challenges have been met, at least in part.

 The desire of consumers to receive care in the most appropriate setting and the desire

for a high quality of life have led to development of more and better alternative

services.

 Institutional care providers have done much to make their facilities more homelike

and conducive to a high quality of life.

 Integrated health services and networks have affected how care is delivered, the cost

of delivering it, and the way it is used by consumers.

 There has been progress in allowing consumers to have more say in their care.

 We have also seen a move toward “culture change – supporting the creation of

environments where residents and their caregivers are able to express choice and

practice self-determination in meaningful ways at every level of daily life.

 Some of the solutions created new challenges.

 As government and private corporations began to experience health care expenses

beyond their ability to cover, they found relief in the form of managed care.

 The rise of managed care presented the long-term care system with other problems:

 Providers have had to pay much more attention to cost-effectiveness while trying

to maintain high quality.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 They have had to face complaints that managed care organizations (MCOs) put

cost savings ahead of choice or quality.

 Integration of services has been a positive step overall, but it has been fatal for some

providers.

 Creation of new services has created additional demand.

 Other challenges of the recent past still show little, if any, resolution.

 The long-term care system is still essentially reimbursement driven.

 The services received depend somewhat on the reimbursement available.

 There is still more demand for service than there is money to pay for it.

 Access to and availability of long-term care services continue to be areas of

shortcoming.

 Services are not distributed equitably for a variety of reasons.

Future Directions – where the system is likely going and why.

 Changing Consumer Demographics – the demographics of long-term care consumers

have been changing faster than the system has been able to adjust.

 The Aging of Society

 The growth in the number of elderly will be a driving influence on the system for

years to come.

 The number of elderly (65+) is projected to mushroom to 70 million by the

year 2030 – nearly twice what it is today.

 The group who are 85 and older will increase by at least four fold.

 They are living longer for a number of reasons and will continue to do so.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 The longer life is due, in large part, to the improved quality of the medical care

they have received.

 Many of the diseases that killed people as children or as young adults have

been effectively eradicated.

 Two of the greatest killers in recent years – heart disease and cancer – have

declined.

 Longer life can also be attributed to changes in people’s lifestyles.

 A third reason for the growth in numbers of elderly is the aging of the baby

boomers

 Their impact over the next couple of decades will be more significant than any

other population cohort seen to date.

 They are more likely to be open to better education about the system and

learning how to use it wisely.

 The impact of the aging of society on long-term care, will be twofold.

 It will extend the time over which the elderly will require long-term care

services.

 The elderly will continue to use acute care services, but not significantly more

than at present.

 The need for acute services will simply come at a later age.

 Long-term care may be needed for many years.

 Increase in Chronic Conditions

 There will be an increase in chronic conditions as society ages.

 By 2030 half the population will have one or more chronic conditions.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 The number of people with chronic conditions increases dramatically with age.

 There will be an increase in “new” diseases – actually, existing diseases with new

prominence: Alzheimer’s disease, macular degeneration, osteoarthritis,

osteoporosis, dementia, cardiovascular disease, and diabetes.

 Greater Cultural/Ethnic Diversity – long-term care consumers are also changing in

terms of their cultural, racial and ethnic backgrounds.

 They bring with them different languages, cultural practices, and some unfamiliar

diseases.

 Cultural diversity is also bringing a need for providers to be more sensitive to

different cultural practices.

 Diseases that have been largely eradicated in the U.S., such as polio and tuberculosis,

have begun to appear as people emigrated from other parts of the world.

 A Consumer-Driven System – the most important descriptor of the future health care

system is that it will be a system that is consumer-driven.

 Consumers of tomorrow will demand more choice in both the care they receive and in

how their dollars are spent.

 Consumers of tomorrow will be better educated and informed than those of the recent

past.

 They will be better able to make choices.

 They will have more disposable income. Because they will be more conscious that

they are paying for their care, either directly or indirectly, consumers will want the

ability to shop around.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 People who have adapted their lifestyles over the course of many years will want to

continue those lifestyles as much as possible in their later years.

 They will look for care that is flexible and adaptable to their particular lifestyles, even

extending to alternative medicine and self-care.

 Providers and payers will need to accommodate their desires.

Focus on Quality and Outcomes – consumers of long-term care are learning how to judge

quality as it pertains to them and will continue to as they become better informed. They will

judge the system and its providers by how they are affected.

 Quality – Quality concerns fall into three distinct but related categories:

 Quality of Care – consumers are concerned about the quality of care they receive.

 Studies have shown that quality of care is not equitable across the U.S.

 The ongoing media hype focusing on examples of poor care raises concerns.

 The frequent number of lawsuits in the news, and concerns about the effects of

cost-cutting cause consumers to have their doubts about quality of care.

 Patient Safety – patient safety will assume new prominence, both in acute care and in

long-term care.

 As consumers learn to demand more of a role in their care, they will become less

and less forgiving of clinical errors or lapses in care.

 Payers will continue to insist on fewer errors.

 Providers have more tools to work with, such as technology which can help them

collect and manage relevant information to avoid errors.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 The government has taken several steps to ensure safety, including requiring that

all skilled nursing facilities have sprinklers as part of their fire prevention and

control systems.

 A new concern for long-term care – at least newly realized – has come about

because of the damage caused in recent years by hurricanes such as Katrina and

Rita.

 Quality of Life – Quality of life will assume a high priority with tomorrow’s long-

term care consumers.

 They want care that is either provided in their homes or in surroundings and in a

manner that is as close to home as possible.

 Institutional providers have responded with amenities such as ala carte menus,

home-like living settings, and flexible treatment regimens.

 Other adaptations include more flexible outpatient care, and remote monitoring

and safety call systems that allow more of them to actually stay in their homes.

 Consumers want more control of their lives and are willing to look around until

they find it.

Outcomes – Payers and regulators are beginning to understand outcomes measurement and

will rely on it more in the future.

 They have previously focused primarily on process and structure, not outcomes. Both

government regulators and private accreditation agencies are moving toward outcomes-

based quality measurement systems

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 They will gradually move from judging how care is delivered to assessing it based on

what it accomplishes.

Changes in the Workforce – The long-term care workforce will change dramatically in the

future. The trends to watch in relation to the workforce are:

 Growth in Demand – Health care (including long-term care) is already one of the largest

and fastest-growing occupations.

 Aging of the Workforce – The workforce is getting older, paralleling the aging of society

in general.

 Many of them are baby boomers since that is the largest age cohort we have.

 The post-baby boomers are a smaller group, providing fewer people for the

workforce.

 Staff Shortages – we are facing a serious shortage of staff to care for the growing number

of elderly needing care.

 Blending of Professional Roles – If the kind of changes in organization and delivery that

are foreseen here are going to be accomplished there will have to be some breaking down

of the artificial barriers created by health care professionals.

 This means moving from the traditional medical model toward more of a holistic

model of care.

Changes in the Organization & Delivery of Long-Term Care – There will be many changes in

the way long-term care is organized and delivered in the future. No single delivery system is

likely to emerge as the one best system

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Toward a Seamless System of Care – There is already significant movement toward a

more seamless system of care.

 Increased demand and strain on resources that are already stretched to the

breaking point will continue to emphasize efficiency.

 The demands of consumers for more choices in the types of care available to them

will lead to a continuum that is more user-friendly, reducing much of the

fragmentation and confusion that exists today.

 One of the most important elements of a seamless system of care is the melding of

what are now essentially separate systems of health care and social support

services.

 The degree to which the system of care becomes seamless will depend on

advances in technology

 Consumer-Directed Care – consumers of the various forms of long-term care will

expect to direct their own care as much as possible.

 A 2008 Medicaid rule permits Medicaid recipients to self–direct their own health

care and supportive services.

 New Living/Housing Options – , long-term care providers have made significant

strides toward meeting the needs of consumers for convenient, homelike living

situations.

 Cohousing

 Small house design

 Sustainable Design Practices

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Improved and Enhanced Amenities

Technological Advances – perhaps the most significant and unpredictable factor in determining

the shape of health care in the future will be the continued explosion in technology.

 Providers may find it difficult to keep up with the rapid changes in technology,

 Technology will also dominate how the health care system is organized and managed.

 Consumers will need to be provided with information accessible through technology.

 Future consumers are familiar with the use of technology.

More & Better Clinical Applications – over the next decade or two, there will be new clinical

procedures that we cannot even begin to imagine today.

Innovative Delivery Methods – coming decades will see a continuation and escalation of the

changes that have occurred lately in how care is delivered.

 . New forms of care, changes in assessment methods and care planning, and efforts to

become more consumer oriented have all improved the lot of the consumer of long-term

care.

 Special Care Units – there will be an increase in special care units designed to treat

people needing highly specialized care.

 Informal Caregivers – the long-term care system will (finally) find ways to make

better use of informal caregivers.

New Organizational Relationships – in trying to secure their share of a particular market, long-

term care providers will find many new and innovative ways to deliver care.

 Among Providers – integrated care systems will dominate because they will have the

ability to provide more of the seamless system of care

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 There will be a move toward “niche” marketing.

 Providers of different types and levels of long-term care services will get together

to meet consumer needs.

 There will be more internal organization along the lines of strategic business

units.

 Between Providers and Payers – providers will find new ways to work more closely in

partnerships with payers.

 Both care management and case management will continue to grow.

 Institutional to Non-Institutional Care – the shift that has been taking place from

institutional to community-based or noninstitutional care will continue.

 Efficiency – we will see delivery methods that are more efficient—that are more

responsive to the needs of consumers—without significant loss of quality.

 Providers will utilize technology to increase efficiency.

 These changes will not take place easily if not properly supported by regulators

and payers, especially the federal government.

Changes in Financing & Reimbursement – the critical role financing plays in the delivery of

long-term care will not only continue, but will intensify.

 Overall Spending on Health Care Increasing – both public and private reimbursement

sources will find it difficult to keep up.

 Decrease in Employer-Sponsored Insurance – employers are also trying to reduce

costs, particularly in the recent economic situation.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Public Payers Continue to Struggle – government payment sources are also finding it

difficult to survive.

 Medicare is threatened with insolvency.

 Medicaid is one of the largest costs for state governments.

 They will continue to use managed care.

 Providers Continue to Struggle – due in part to the difficulties their most significant

payer sources are having.

 Innovative Financing – the future will also bring innovations in health care financing.

 The current trend toward capitation and other prepaid group contracts will continue

and grow.

 Prospective payment will become the dominant form of payment for long-term care

providers.

 We can expect a significant expansion of pay-for-performance initiatives

 Public/Private Partnerships – the key to future financing of the health care system may

well be public-private partnerships.

Ethical Dilemmas – both the number and scope of ethical issues that will arise and need to be

resolved will increase.

 Life and Death Issues – clinical advances have created additional issues concerning life

and death.

 We can extend life much longer than before

 The issues involve:

 Balancing extended life with quality of life

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Balancing needs of consumers and providers (not making providers provide care

not in keeping with their own beliefs)

 As providers join integrated health systems, there may be a clash in values.

 Allocation of Resources

 Shortage of resources increases the difficulty of allocating them fairly

 That may involve having to provide services that are not financially viable in order to

meet the needs of consumers.

 The Affordable Care Act calls for greatly extending coverage.

Regulation – will definitely increase.

 Regulation of Quality

 Regulation of cost

Health System Reform – the fragmented system needs reform, primarily financing reform.

 Government Involvement

 How much or how little?

 Most Americans want government to pay more, but do not want them to run health

care

 The Obama administration achieved passage of the Affordable Care Act (ACA).

Only time will tell how it work out.

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