Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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WHAT IS CHRONIC CARE?

Chronic care is an umbrella term that includes acute, subacute, postacute, and

primary facility-based care, in-home care, and community-based services. As the

range of services available for older adults with chronic conditions has increased,

the term chronic care has evolved to describe any combination of medical (acute,

primary, postacute, ambulatory) and social services. Although this type of sup-

port traditionally has been called long-term care, the terminology is changing for

several reasons. Originally, long-term care referred to nursing home care. During

the past several decades, a variety of programs and services were developed to

support older adults in community settings and in their own homes, often called

home-and community-based services (HCBS). Chronic care typically involves

multiple organizations interacting in a loose network rather than in a tight bu-

reaucratic structure. In addition to services, chronic care is often defined by the

population served, including individuals who are functionally impaired and/or

who have medically complex chronic conditions. Terminology to describe those

receiving services varies. For example, those who receive care in facilities are

called residents, those served in day care are called participants, care managers

usually refer to their clients, and those receiving hospice are patients.

Characteristics of chronic care services include the following:

• Are supportive and concerned with maintaining or improving functioning

over an extended period of time, usually 90 days or more

• Encompass social and environmental needs, and are therefore broader than

the acute care medical model

• Are often low-tech, high-touch, hands-on services

• Affect multiple aspects of life over an extended period of time

• Are provided on a formal or informal (family and friends) basis

• Are difficult to define due to variability within services and blurred bound-

aries across services

• Include a wide range of health services, health-related support services, and

housing

• Involve a broad range of help with daily activities that chronically disabled

individuals need for a prolonged period of time (Stone, 2000)

About 60% of those who use chronic care services are older adults. Although

on any given day only about 4% of those age 65 and over are in facility-based care

(i.e., nursing homes), about 14% of older adults require functional assistance of

some type. Consumers of chronic care services also include children and adults

under the age of 65 with developmental disabilities, severe chronic mental disor-

ders, HIV/AIDS, or disabling physical disabilities. Trends such as population

aging, technological advances, the restructuring of health care services toward

less hospital-based care, managed care, and alternative delivery systems are

transforming the field of chronic care service delivery. These trends result in in-

creased demand for services and expanded efforts to identify and apply effective

innovations in multiple settings.

Figure 17.1 illustrates the categories and types of services that may be in-

cluded under the rubric of chronic care. The continuum of chronic care services

for older adults includes a wide range of medically and socially focused services

(Alkema, Shannon, & Wilber, 2003; Dychtwald & Zitter, 1991). These services are

457

Figure 17.1 The Continuum of Chronic Care Service Delivery for Older Adults.

Adapted from “Using Interagency Collaboration to Serve Older Adults with Chronic Care

Needs: The Care Advocate Program,” by G. E. Alkema, G. R. Shannon, and K. H.

Wilber, 2003,

Family and Community Health, 26

(3), 221–229. Adapted with permission.

Geriatric Inpatient - Mental Health

Geriatric Rehabilitation

Sub acute Unit

Skilled Nursing Facility

Intermediate Care Facility

Inpatient Hospital

Geriatric Outpatient Care

Geriatric Evaluation and Management

Home Health Care

Hospice

Group I - Institutional

Adult Day Care / Day Health Care

Respite Care

Health Assessment

Medical / Social Case Management

Health Screening

Board and Care Homes

Assisted Living Facilities

Adult Foster Care

Disease Management

Group II - Personal Care / Evaluation

Information and Assistance

Health Promotion

Senior Centers

Health Education

Caregiver Education

Congregate / Home-Delivered Meals

Resource Counseling

Group III - Health / Wellness

Adult Protective Services

Telephone Reassurance

Friendly Visitor

Emergency Response System

Retirement Communities

Guardianship

Socialization Activities

Group IV - Safety / Support

Senior Housing

Homemaker Services

Chore Services

Employment

Legal Planning

Financial Services / Management

Transportation

Community Recreation

Volunteerism

Group V - Lifestyle

Medical Social

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provided in private homes, community settings, and a variety of 24-hour facili-

ties. Starting at the highest level of intensity, services extend from institutional-

level care, such as hospitals and nursing facilities, down to lifestyle services,

which include legal and financial advice, transportation, and recreation services.

Intensity and dosage of an intervention varies significantly within each specific

service type based on what is appropriate for the consumer’s needs (Weissert,

Chernew, & Hirth, 2003). The arrows represent links between service groups, sig-

nifying that consumers and providers may access any level of care needed as all

groups are connected to each other, and they can access a direct link back to

institutional-level care when appropriate. As policy makers and practitioners

work toward creating a true chronic care model integrating medical and social

care, they must account for myriad service options available and unique configu-

rations of these services together to address the multiple and often unpredictable

needs of older adults with chronic conditions.

CORE VALUES GUIDING SERVICE

DELIVERY TO OLDER ADULTS

One of the major challenges in serving older and dependent adults is to provide

the appropriate level of support while safeguarding basic rights of autonomy and

self-determination. A fundamental approach to keep the important goal of safety

from incorrectly trumping individual freedom is to operationalize these values in

programs available for older adults (Wilber, 2000; Wilber & Alkema, 2006). These

core values include (a) striving to offer the least restrictive appropriate alterna-

tive; (b) facilitating the older person’s ability to live wherever he or she is most

comfortable, often called “aging in place”; (c) centering decisions to the greatest

extent possible around client preferences and expressed needs through programs

that offer consumer choice and direction; (d) drawing from the repertoire of

available interventions to develop an individualized plan of treatment; (e) sup-

porting informal caregivers; and (f) clinically integrating medical, social, and

housing services. Ideally these values are operationalized in the context of self-

determination and person-environment fit, offering providers appropriate tools

to balance respect for the client’s personal freedom with legitimate concerns

about personal safety.

The least restrictive appropriate alternative is a term that originated with a court

case, Lake v. Cameron (1966), in which the District of Columbia Court of Appeals

ruled that less restrictive alternatives must be sought before an individual may be

held in an institution. Since then, this ruling solidified the values that consumers

should be served with as few constraints placed on them as possible, and their

rights and liberties should be recognized and respected. This trend is evident in

state efforts to implement the Olmstead decision, also based on a court ruling. Olm-

stead v. L.C. was decided by the U.S. Supreme Court in 1999. Based on the federal

Americans with Disabilities Act (ADA), the Court found that the ADA prohibits

states from unnecessarily institutionalizing individuals with disabilities due to

the state’s failure to serve them in the most integrated setting appropriate to their

needs and preferences. Although states must respond by making reasonable ac-

commodations for community care options, states are not required to fundamen-

tally alter their existing programs (Rosenbaum, 2000). For a comprehensive update

on state planning to meet the Olmstead decision, see Fox-Grage, Folkemer, and

Lewis (2004).

Community- and Facility-Based Care 459

Aging in place (Callahan, 1993), which we broaden to encompass aging wherever

the older adult wants to live, recognizes that individuals should not be forced to re-

locate to different settings due to needing higher levels of care. Rather, to the ex-

tent possible, services should be designed so that consumers can use them in the

setting of their choice, typically their home, and should be flexible enough to ad-

dress changing needs. Aging in place includes home modifications to make the

living environment manageable and safe (Pynoos, Nishita, & Perelman, 2003),

and incorporating personal care or other compensatory services into the home

environment. Another example of residential-based services that support this

mission is a movement toward cohousing and intentional communities (Thomas,

2004). Day services, such as adult day care (discussed later in this chapter), may

also help with aging in place when there is adequate transportation to facilitate

access and when services support independent living.

Consumer-centered and consumer-directed care suggest that, to the extent feasi-

ble, the recipient of services makes decisions about care rather than the provider

dictating the approach. To support informed decisions, providers need to listen to

recipients’ concerns and questions, inform them of available choices, and discuss

the consequences of using available options (Curry & Wetle, 2001; Kaufman &

Becker, 1996). Recent studies of consumer-directed services in the United States

suggest two general models of implementing consumer-directed support when

providing personal care (Benjamin, 2001). The first model provides full decision-

making power to consumers, who are responsible for hiring, firing, and managing

care providers, and finances the service provision through a fiscal intermediary.

The second model, exemplified in the Cash and Counseling Program, provides a

fixed monthly allowance in a spending account that participants can spend to-

ward disability-related goods and services (B. Phillips & Schneider, 2002). Cash

comes with support from professional case management counseling and fiscal

management to assist consumers with the hiring, firing, and supervising of care

through a local contracted agency. By balancing consumer choice with profes-

sional support, this model can be adapted to consumers of varying functioning

levels. Additionally, literature on the philosophy of consumer direction acknowl-

edges that older adults desire professional support to help with identifying and

assisting with service needs, but maintains that the consumer is responsible for

decisions about when, if, and how he or she wants to use services (Coleman, 2001;

R. A. Kane, 2001; Squillace & Firman, 2002).

Support for family caregiving challenges the long-held myth that families relin-

quish the care of their older adult relatives to nonfamily providers. In reality,

among older adults not residing in 24-hour care facilities, unpaid informal care-

givers provide about 80% of the care (Doty, Stone, Jackson, & Drabek, 2001;

Wiener, Illston, & Hanley, 1994). Given the high demands of caring for a frail

older person, high stress, burnout, and caregiver burden may become problems

(Zarit, Reever, & Bach-Peterson, 1980). Formal services that value, support, and

complement informal care, including counseling, support groups, and respite ser-

vices, offer useful means to ensure continuity and service effectiveness.

Individualized treatment plans are an important component of chronic care ser-

vices given that a one-size-fits-all approach will not meet the varied needs of di-

verse older adults. Given that community- and facility-based services have the

potential to affect every aspect of an individual’s life, treatment planning should

be personalized and targeted to both the needs and preferences of the older

adult. Individualized treatment planning begins with a thorough assessment

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Box 17.1

Chronic care services are also distinct in that they include therapeutic, compensa-

tory, and palliative approaches. Whereas acute health care focuses more on thera-

peutic treatment, the long-term care component of chronic care traditionally

focuses on compensatory and palliative care (R. A. Kane, Kane, & Ladd, 1998). Al-

though therapeutic care has been the focus in health care, the increasing need for

chronic care services requires attention from compensatory and palliative care.

Therapeutic treatment emphasizes:

• Getting better

• Treatment

• Improved functioning

• Reduced decline

Compensatory care focuses on:

• Adapting to disability

• Compensating for areas of impairment

• Consumer focus and control

Palliative care focuses on:

• Increasing daily comfort

• Controlling pain

• Supporting clients and their caregivers at any stage of a serious illness

process, including assessment of the older adult’s needs and preferences and the

informal and professional care systems that provide assistance (Moxley, 1989).

Based on this assessment, treatment plans are developed in context of the older

adult’s service preferences, availability and geographic proximity of those ser-

vices, and eligibility requirements. Treatment plans serve as guiding strategies

to implementing needed services and should be dynamic and responsive to the

individual’s changing needs.

Finally, given that chronic care services tend to be highly fragmented, the array

of specialized services needed by each person must be woven together into a clini-

cally integrated service package for each consumer. Chronic care is a complex en-

deavor, involving a variety of health and social services offered in different

settings by a variety of different professionals and paraprofessionals. Its complex-

ity includes different terminology, administration, financing, and reimbursement.

The fragmentation of health and social care delivery systems, described by the In-

stitute of Medicine (2001, p. 4) as a “nightmare to navigate,” makes it difficult for

those with chronic conditions to gain access to services and coordinate them across

the different types of care needed. Clinical integration of services seeks to over-

come the fragmentation that results from multiple programs and providers engag-

ing in the older person’s care. When it is necessary to weave together services from

numerous providers, the goal of clinical integration is to provide services that con-

sumers perceive to be seamless. Specific means for clinical integration include case

management, multidisciplinary teams, coordination of services offered by differ-

ent organizations, and service integration within a single organization. Regardless

of the approach, it is important that the fragmented delivery system does not nega-

tively affect the older adult’s ability to access and use care (see Box 17.1).

Community- and Facility-Based Care 461

TRENDS AND INCIDENCE

Chronic conditions are highly prevalent in the United States, affecting over 125

million people, or about 40% of the population (Anderson & Horvath, 2002; Wu &

Green, 2000). By 2020, this number is expected to increase to 157 million people

(Wu & Green, 2000). The five most common chronic health conditions are hyper-

tension (26%), mental conditions (22%), respiratory diseases (18%), arthritis

(13%), and heart disease (12%). One of these—heart disease—and four others

(cancers, strokes, chronic obstructive pulmonary disease, and diabetes) are re-

sponsible for two-thirds of all deaths in the United States (Centers for Disease

Control and Prevention, 2002). Nearly half of those diagnosed with a chronic con-

dition (one-fifth of the U.S. population) cope with more than one such condition

(Wu & Green, 2000).

In addition to diagnoses, another way to define who needs chronic care ser-

vices is by identifying people who have functional impairment. Feldman and

Kane (2003) note that defining functioning as “activities of daily living” (ADLs) is

a key concept for long-term care research and provides the backbone of long-term

care practice. Katz, Ford, Moscovitz, Jackson, and Jaffe (1963) defined ADLs as

bathing, dressing, toileting, transferring, continence control, and eating. A few

years later, Lawton and Brody (1969) added a related category which they called

instrumental activities of daily living (IADLs). Whereas ADLs focus on personal

care, IADLs address a person’s ability to manage the environment: managing

money, using the telephone, grocery shopping, personal shopping, using trans-

portation, housekeeping, and managing medications. In 2003, 35% of Americans

age 65 and above reported having at least one ADL or IADL limitation caused by

a chronic condition (National Center for Health Statistics, 2005). Ten percent of

those age 75 and above reported an ADL limitation, and 18% reported an IADL

limitation due to a chronic condition (National Center for Health Statistics, 2005).

Twenty-five percent of those with a chronic condition experience at least one ac-

tivity limitation, and those with multiple chronic conditions are significantly

more likely to have activity limitations. For example, 67% of patients with five or

more chronic conditions have activity limitations (Anderson & Horvath, 2002).

The consequences of having multiple chronic conditions include greater risk for

disability, greater need for caregiver support, greater use of health care services,

and mortality (Anderson & Horvath, 2002).

Although chronic conditions affect people across the demographic spectrum,

women are more likely than men to have a chronic condition (Wu & Green, 2000).

The majority of people with chronic conditions are under 65, but those over 65 are

more likely to have multiple chronic conditions (Anderson & Horvath, 2002; Wu

& Green, 2000). Considering the aging of the population and increasing life ex-

pectancy estimates over the next 40 years (Campbell, 1996; Lee, Miller, & Ed-

wards, 2003; O’Hara-Devereaux, Falcon, Li, & Kristensen, 1999), the projected

impact of chronic conditions on individuals, caregivers, and the U.S. health care

system is substantial. About 70% of health care dollars in the United States are

spent on chronic illnesses (Hoffman, Rice, & Sung, 1996).

In addition to affecting physical and functional health, chronic conditions also

may affect the mental health and coping abilities of older adults (Germain &

Gitterman, 1996), especially if the condition has associated pain. Pain is related

to impaired physical function (Scudds & Robertson, 2000; Williamson & Schulz,

1992), physical disability (Scudds & Robertson, 1998), and increased depression

(Magni, 1991; Parmelee, Thuras, Katz, & Lawton, 1995) among older adults.

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Physical functioning level, number of health conditions, and previous episodes of

depression have been consistently associated with depression across studies

(Copeland, Chen, & Dewey, 1999; Roberts, Kaplan, Shema, & Strawbridge, 1998).

Equally important, depressive symptoms have been linked with increased dis-

ability, impaired functioning, increased morbidity and mortality, and decreased

quality of life (Herrmann, Black, Lawrence, Szekely, & Szalai, 1998; Lesperance,

Frasure-Smith, & Talajic, 1996; Penninx, Leveille, Ferrucci, van Eijk, & Guralnik,

1999; Schoevers et al., 2000; Wells & Sherbourne, 1999). In a large prospective co-

hort study of older adults in the United States, depressed individuals had a

greater decline in physical functioning and performance over a 4-year period

than nondepressed participants (Penninx et al., 1998). As a result of these factors,

people with multiple chronic conditions often experience reduced quality of life.

MPACT OF

HRONIC

ONDITIONS ON

AREGIVERS

One key component of supporting those with chronic conditions is that they re-

quire ongoing care, most often provided by caregivers and health care profession-

als (Anderson & Horvath, 2002). The Kaiser Family Foundation (2002) estimated

that there are approximately 45 million adult caregivers; the vast majority are

middle-aged married women, one-third of whom reported having a serious med-

ical condition of their own. About 20% of caregivers stated that their physical

health has suffered due to care-giving activities (Kaiser Family Foundation, 2002;

Metropolitan Life Insurance Company, 1999). Informal caregivers provide exten-

sive support services: direct personal care (bathing, grooming, etc.), medication

assistance, instrumental activities (shopping, meal preparation, etc.), transporta-

tion, and care coordination with health service professionals (Kaiser Family

Foundation, 2002; Kutner, 2001; Metropolitan Life Insurance Company, 1999). For

those with chronic conditions who received assistance with care coordination,

over 50% reported that their informal caregivers provide that service (Harris In-

teractive Inc., 2000).

The economic value of informal caregiving in 2000, based on what services

would cost in the private sector, was estimated to be $257 billion (Arno, 2002;

Arno, Levine, & Memmott, 1999). Transitions through and out of the labor force

indicate another significant cost of caregiving. Informal caregivers who were

engaged in paid work reported a high incidence of formal adjustments to their

work schedules, including use of paid time off, decreased hours, leaves of ab-

sence, transitions from full- to part-time work, and early retirements (Metro-

politan Life Insurance Company, 1999). Sixteen percent of those who retired at

age 62 did so because of a family member’s poor health, and 33% of Californians

who retired between ages 45 and 70 did so for personal health reasons (Yelin &

Trupin, 1999). The economic costs are realized in the form of out-of-pocket

expenses, decreased paychecks, and decreased allotments to retirement

savings such as Social Security and defined contribution plans (Coleman &

Pandya, 2002; Kaiser Family Foundation, 2002; Metropolitan Life Insurance

Company, 1999).

The need to receive ongoing care often generates concerns for people with

chronic conditions, including the ability to afford care, fear of losing independ-

ence, and worries about becoming a burden to caregivers (Harris Interactive

Inc., 2000). Although informal caregivers may provide care for a close family

Community- and Facility-Based Care 463

member, many seek some form of professional or paraprofessional guidance

about care-giving (Kutner, 2001). Several studies have documented the negative

psychological impact on caregivers as a result of the high stress they experience

when caring for a loved one (O’Connor, Pollitt, Roth, Brook, & Reiss, 1990;

Schulz, O’Brien, Bookwala, & Fleissner, 1995). Among caregivers of people with

Alzheimer’s and other chronic diseases, there is a positive correlation between

the intensity of the caregiver’s psychological morbidity and the length of time

providing care (Gonzalez-Salvador, Arango, Lyketsos, & Calcedo Barba, 1999).

Recent studies have also found that caregivers of loved ones with Alzheimer’s

disease may suffer from depression due not only to the severity of the symptoms

of their infirmed family member, but also due to a lack of available resources

(Gonzalez-Salvador et al., 1999; Vitaliano, Russo, Young, & Maiuro, 1991).

CCESS TO

HRONIC

ARE

ERVICES

It is well known that about 15% of the population lacks basic health insurance

coverage, but most people are not aware that traditional health insurance gener-

ally does not cover chronic care services such as custodial care in a facility, HCBS,

and respite for caregivers. Traditional health care is financed through employer-

based funding mechanisms, yet most working individuals do not need or demand

long-term care insurance coverage. Traditional health care service delivery em-

ploys a medical model that covers two major areas: hospital and physician care,

also called acute and primary care. Based on this model, about 90% of Americans

lack long-term care insurance coverage to pay for chronic care services. Although

most people believe that they are unlikely to need these services, the data suggest

otherwise. For example, in 2001, 12 million people in the United States needed

some form of chronic care services, and more than half were age 65 and above

(Stone, 2000). One study found that 43% of those 65 and above would spend some

time in a nursing facility in their lifetime, and more than half would remain for at

least 1 year (Kemper & Murtaugh, 1991).

ETIOLOGY AND PROGNOSIS OF FACILITY- AND

COMMUNITY-BASED CARE MODELS

In this section we discuss the etiology of several types of facility- and community-

based care models that serve older adults with chronic conditions. We discuss the

future of these types of care models given the scope of population aging that the

United States will experience over the next 50 years.

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Nursing Homes The origins of modern chronic care began with the early institu-

tions for the poor: the county home or “poor home” (Singh, 2005). Because these

“homes” often served to warehouse people who lacked financial or care-giving

resources, they carried the stigma of a service of last resort. Unlike modern-day

facilities, they lacked a medical component of care. This type of care expanded

during the Depression as homeowners supplemented their income by taking in

older adult boarders. The Social Security Act that passed in 1935 included old age

assistance, which provided funding and expanded the number of nursing homes.

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Nursing homes were used when hospital or medical care failed to provide cura-

tive measures for chronic conditions (Abramovice, 1988; Starr, 1984).

In 1960, a shortage of hospital beds increased discharges to less costly nursing

homes. Five years later, financial incentives for nursing facilities were part of the

passage of two of Lyndon Johnson’s Great Society programs: Medicare (for adults

age 65 and above) and Medicaid (for low-income people of all ages). New nursing

homes were designed according to hospital regulations for services and physical

plants. Although Medicaid was not developed to provide custodial care for older

adults, funding available through the Medicaid program led to a boom in the

nursing home industry (Abramovice, 1988).

With the extensive growth, however, came new problems. Nursing home scan-

dals hit the papers in San Diego with tales of neglect and woefully inadequate care.

In addition to newspaper articles, a book was published in 1975 called Tender Loving

Greed: How the Incredibly Lucrative Nursing Home “Industry” Is Exploiting America’s

Old People and Defrauding Us All (Mendelson, 1975). These exposés resulted in out-

rage and created a national backlash against the industry. The 1971 White House

Conference on Aging encouraged the development of home- and community-based

services as alternatives to nursing home care. One of the most dramatic changes

was the industry’s transformation from charity and religious-based organizations

to 75% proprietary ownership. In addition to increasing involvement from the pro-

prietary private sector, small “mom and pop” homes were bought up by corpora-

tions, and several large nursing home chains emerged (Abramovice, 1988).

The nursing home scandals led to a two-pronged effort to improve care for

older and dependent adults: the development of alternatives to nursing homes

and regulatory efforts to improve care in facilities (Miller & Weissert, 2000; Mol-

lica, 2003; Weissert, Cready, & Pawelak, 1988). Alternatives included a number of

HCBS such as adult day care, personal care, and care management (discussed

later). The Nursing Home Reform Act was passed in 1987 to provide fundamen-

tal reform to nursing home operations based on review of standards developed

by the Institute of Medicine (1986). Sometimes referred to as OBRA ’87 because

it was part of the congressional Omnibus Budget Reconciliation Act, it included

improvements in quality assurance measurement based on resident assessments

and care planning. This legislation focused on “residents’ rights” and called for

reduction in and a rationale for use of restraints (physical and chemical). The

Resident Assessment Instrument was developed and implemented to standard-

ize the evaluation and care planning for nursing home residents. This assess-

ment included the Minimum Data Set, which provides a standardized tool for

assessing residents’ functional capacity and care needs and is assessed at admis-

sion and then quarterly.

Despite progress from OBRA ’87 reforms, scandals again made news in the

1990s with a scathing article in Time accusing nursing homes of poor care and

outright neglect (Carlson, 1995). In response the Senate Aging Committee asked

the General Accounting Office (GAO; 1998) to investigate. The GAO report found

that nearly one third of California nursing homes surveyed had serious or poten-

tially life-threatening care problems; licensing enforcement was not catching

many of these problems in the survey process; and when problems were recog-

nized, sufficient state- and federal-level enforcement did not exist. Recommenda-

tions focused on increasing the federal role of nursing home regulations and

enforcement in homes that persisted in providing substandard care.

Community- and Facility-Based Care 465

During this time, a grassroots response to the problems in nursing home set-

tings was evolving under the rubric of “culture change” in all types of facility-

based care. Culture change involves a major shift in thinking about how care

should be provided, focusing on a philosophy that is more consumer-directed, in-

dividualized, supportive, and homelike. The overall goal of culture change is to

direct the focus of facility-based care as places where elders can live and grow

rather than decline and die (Thomas, 1996, 2004). Some of the more prominent

leaders in this effort are the Eden Alternative, the Wellspring Movement, and the

Pioneer Network. Traditionally, a quality-of-life perspective for nursing home

residents has been subjugated by the primacy of quality of care for three reasons:

(1) greater objectivity in measuring quality of care, (2) focus from the disability

community to move people out of nursing homes rather than to improve quality

of life inside, and (3) lack of definitive measurement of quality of life from the

nursing home reform champions (R. A. Kane, 2003).

In addition to increased regulations, federal funding structures began to

change for a variety of facility-based providers starting in the 1980s. Hospital re-

imbursement changed from billing for services after the fact to the prospective

payment for diagnostic related groups. This change contributed to the increased

discharging of patients with greater health care needs to skilled nursing facilities

that received Medicare reimbursement for postacute care. Skilled nursing facili-

ties began expanding their scope of service to include rehabilitation, ventilator

patients, dementia care units, and hospice. Hospitals responded to this change by

opening their own nursing home wings or “distinct parts,” which directly com-

peted with community nursing homes for Medicare-funded rehabilitation pa-

tients. In tandem, Medicare payments to nursing facilities and home health

organizations increased dramatically and at a much higher rate then other

Medicare-funded services. In response, Congress passed legislation in the Bal-

anced Budget Act of 1997 to subsequently fund nursing facilities through a

prospective payment system, as they had done with hospitals and physicians pre-

viously. All of these changes shifted the financing of Medicare services from fee-

for-service arrangements to fixed payments in hopes of controlling costs through

a reimbursement system based on patient acuity and staff time required to ad-

dress the patient’s needs.

Other Facility-Based Settings As nursing homes evolved to meet changing de-

mands, other residential approaches emerged, evolved, and expanded, including

assisted living facilities, board and care homes, supportive housing communities,

and continuing care retirement communities. Assisted living facilities (ALF) are

recognized as a key component of long-term care (Stefanacci & Podrazik, 2005).

Building on Zimmerman et al. (2005), ALF provide room, board, 24-hour staffing,

and assistance with one or more activities of daily living in 24-hour state-licensed

care facilities, excluding licensed health facilities and nursing facilities. Similar

to nursing homes, assisted living facilities include housing; however, they differ

in that their focus is primarily on hospitality services rather then skilled nursing

care or rehabilitation. Some assisted living facilities provide IADL support such

as medication management and personal care support for ADLs. These services

are often part of a cafeteria plan, where residents can select the special support

they need and pay additional monthly premiums accordingly. Although some

states do not use the term “assisted living,” we use it generically here to include