Long-term & Institutional Care
Long-term and institutional care is provided to people with chronic health issues, terminal illnesses and serious mental health conditions such as schizophrenia or dementia. Institutions can vary greatly, and they include nursing homes, hospices, and other institutional environments. Institutions may be run by the private sector, the government, or faith-based services. The primary difference between long-term and institutional care is that long-term care is often a community-based model whereas institutions are typically closed environments.
Keywords Activities of Daily Living; Assisted Living; Continuing Care Retirement Communities; Faith-Based Services; Hospices; Licensed Practical Nurse; Nursing Homes; Palliative Care; Registered Nurse; Retirement Living Communities; Subacute Care
For some, the mention of institutional care options, such as hospice or palliative care, creates worrisome images. However, these services exist to provide important care functions in our communities. Yet, not all people who require care want to go into a nursing home, and many feel they can be taken care of more effectively in their own home. While home care is definitely a viable and important option, one has to take into account the level of care required and how best to provide it. This requires an assessment of the community care services available so that family members do not burn out trying to support their loved ones who require round-the-clock care.
The various options for long-term care require a strict and constant review. It is absolutely vital that the nation's most vulnerable individuals receive professionally appropriate care. However, there have been concerns in the past and in the present as to whether the highest professional standards are being met by care providers.
A wide range of people benefit from care services, from children and young adults who require home care services due to a chronic condition or disability to people who are elderly and require at least some level of care that may be too complicated to provide at home. Many people who need long-term care rely on a combination of family support and formal long-term care, including home care, adult day care, assisted living, and nursing home care.
Individuals require long-term care for many reasons, but it is a misconception to think that only persons who are elderly require these services. Children who are born with disabilities, people with severe mental health issues , young adults who acquire a disabling condition such as multiple sclerosis, and seniors all can require some form of long-term care.
The broad range of assistance that constitutes long-term care results in confusion and disagreement about what long-term care is and how it is distinct from medical care. Other examples of long-term care can range from skilled nursing facility care provided after hospitalization to housing arrangements for healthy seniors and special transportation services (Tumlinson et al., 2007, p. 1).
There is no doubt that most people would rather be in their own environment, but unfortunately it is not always possible. According to a report by the National Commission for Quality Long-Term Care, "many older people with disabilities simply do not have the financial resources to obtain the services they need, either in the community or in long-term care facilities. In some cases, their care options are limited, if available at all" (2007, p. 13).
The choice to provide long-term care at home can be a difficult one. It is often driven by a combination of emotional, financial, and practical considerations. Many families cannot bear to place a loved one into a nursing home or other care facility. In addition, the quality services are very expensive and many families simply do not have the money. Yet, trying to provide the care at home can often be just as costly.
The level of care required is driven by an assessment of Activities of Daily Living (ADL). The assessment must be provided by a home-care professional. The assessment identifies the medical, psychological, functional, and social needs of the client (Phillips, Smith, & Cournoyer, 2004, p. 42).
Home care is not always possible even if a family member prefers to stay in his or her own environment. It is the ADL assessment that determines whether a person can be cared for in the home, who will provide that care, the parameters of care, and the standards that must be adhered to. Although home care sounds like a simpler option (and less expensive), the reality is that home care is often financially and emotionally difficult on family members. An individual may lose income depending on the amount of time they need to be home to care for a relative (or to hire a home care provider) and the emotional toll can sometimes be extremely taxing on a family.
The long-term care workforce includes physicians, nursing home and assisted living coordinators and administrators, registered nurses, licensed practical and vocational nurses, physical therapists, home health aides, and social workers, with nurses providing the majority of professional long-term care. The professionals who work in long-term care facilities are also under a great deal of pressure especially as the US health care system comes under increasing scrutiny. The training required to work in long-term care is highly specialized. In addition, the providers of these services must develop an infrastructure that supports quality-level care. Presently, there is a dire shortage of professionals capable of working in long-term care facilities. The state of many long-term care facilities is thus a cause for concern.
Many providers maintain that inadequate funding makes it difficult for them to upgrade their infrastructures and their care practices. In particular, providers say that they lack the necessary resources to recruit, train and retain quality staff, especially those direct care workers who provide day-to-day care to long-term care consumers. These workers are in short supply, in large part because their demanding jobs don't offer adequate salaries, benefits, training or opportunities for advancement (National Commission Report, 2007, p. 13). According to a 2013 congressional report prepared by the Commission on Long-Term Care, the professional workforce trained to provide long-term care will quickly become inadequate as the population of the United States ages: “There were only 7,356 board-certified geriatricians in the United States in 2012, and there is only 1 geriatric psychiatrist for every 11,000 older adults. If current rates continue, there will only be 1 for every 20,000 older persons by 2030” (Commission on Long-Term Care Report to Congress, 2013, p. 18).
Types of Long Term Care
One option open to persons with the financial means is assisted-living facilities. These are private residences in which an individual who does not need twenty-four-hour or intensive care but may need a small level of assistance or supervision. The consumers who live in assisted-living residences such as these range from young adults with some form of disability who are otherwise independent to older adults (with or without disabilities) who also need some form of assistance with their daily tasks such as cleaning, grocery shopping, transportation, medication management, and other activities of daily living. However, these residences are expensive. The average cost for a private one-bedroom apartment in an assisted-living residence is $3,022 per month, according to the 2009 Overview of Assisted Living (American Association of Homes and Services for the Aging, 2009).
Another option is continuing-care retirement communities. In these residences there are nurses on staff and assisted living is available. Most residents are independent and live in their own apartments within a supportive community.
Unfortunately, the bottom line in long-term care comes back to finances. Someone must pay the bills and that is usually the state and federal governments. There are, of course, private facilities owned and managed by companies and corporations, but the federal government pays a large portion of long-term care in the United States. The federal and state governments pay for approximately 62 percent of paid long-term services and supports, amounting to more than $130 billion a year” (Commission on Long-Term Care Report to Congress, 2013, p. 3). That may sound like a staggering amount, but considering the population of the United States that is quickly aging, that number is likely to increase substantially.
Nursing homes have evolved since the 1950s when standards for care were enforced by the Hill-Burton Act of 1946. The act was a necessity, since nursing homes actually had their beginnings in the old poorhouses of the nineteenth century. The poorhouses were the beginnings of institutionalized care and a place to send people who literally had nowhere else to go (White, 2005). While nursing homes have steadily improved over the last fifty years, it is clear that the term "nursing home" continues to suffer from the social stigma of being a rather gloomy and negative environment despite increased regulations and improved standards of care.
An ongoing problem for nursing homes (as it is for health care in general) is the acute shortage of qualified nurses (Stoil, 2007). Nursing homes are always in competition with home health care services, hospices,...
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