"Long Term Care is that care rendered to people of all ages, on a sustained basis, to restore, conserve and enhance maximum settings." (HCSCH Long Term Care Task Force). The above definition of long term care, developed by the HCSCH Task Force, indicates the emphasis that its members have placed on the need for services to prevent "functional dependency" and unnecessary institutionalization. As described by the Institute of Medicine, National Academy of Sciences: "Functional dependency among the elderly is emerging as a critical challenge to our society. The functionally dependent elderly are those individuals over 65 whose illnesses, impairments or social problems have become disabling, reducing their ability to carry out independently the customary activities of daily life." (Institute of Medicine, 1977). Functional dependency does not respect the boundaries of chronological age; thus, the HCSCH Long Term Care Task Force emphasizes that long term care is designed to enhance maximum functional capacity to the degree possible for people of all ages. Functional dependency is, however, most prevalent in those persons ages 75 and over: "The 75 and over group is the fastest growing segment of the U. S. population. Since 1900, the proportion of persons 75 and over, within the entire elderly population over 65, has increased from 29 percent to 38 percent and is expected to reach 45 percent of the elderly population by 2000. Even more dramatic has been the increase in the 85 and over population from 4 percent in 1900 to 9 percent today, to a projected 11 percent in 2000." (Institute of Medicine, 1977). Hawaii residents enjoy the longest life expectancy rate in the world, after Sweden, and the number of people over the age of 64 increases yearly. Population projections from the 1978 Report of the Hawaii Department of Planning and Economic Development (DPED) (Series II-F) estimate the population of elderly in Hawaii to increase as follows: Over 65 Total Population, Hawaii % of Total Pop. over 65 *Subset of over 65 17,100 25,300 34,200 43,900 53,100 61,200 868,400 942,300,020,900 1,091,500 1,163,800 1,225,900 10.94% 11.38% 6.78% 7.82% 9.17% 10.23% (DPED, 1978) Hawaii's elderly population will more than double within the next twenty years. Correspondingly, the population at risk for long term care services, both medical and social, will increase as well. Other characteristics of functionally dependent elderly persons include: Substantial limitations in physical performance, i.e., 42% of individuals 75 and over are limited in walking, climbing and bending (only 19.8% of those 65-74 are so encumbered). • Heavy utilization of health services; i.e., elderly people use two to three times as many health services as those under 65. Limitations of income and assets, i.e., the medium income for families whose head of household is 65 and over is one-half of that for families where the head of household is under 65. • More likely to be socially isolated. (Note: Hawaii Gerontology Center reports in 1969 that 16.5% of Hawaii's elderly population over 65 live alone). More likely to have children approaching old age themselves. (Institute of Medicine, 1977) As the frail elderly lose their various forms of support, services must be obtained from public and private sources. The financial resources to purchase the necessary health and social services are often severely constrained for this segment of the population. Reimbursement is more likely to occur after the assets of the individual are drained and institutionalization becomes the only alternative. More specifically, older adults are on fixed incomes, primarily Social Security, during a time when the annual inflation rate is above 10%. Although they are eligible for the in-kind services of Medicare, many older adults can barely survive on Social Security. Paying for the services of a companion or a homemaker may be outside the budget range of such a person. As aging brings on more handicaps, the receipt of social and medical services in a nursing home may look attractive, since the nursing home is often the only provider of even the most basic support services for an aging adult. By dissolving his/her assets and becoming medically indigent, an older adult becomes eligible for SSI (Supplemental Security Income) and Medicaid reimbursements for institutional care. Once inside the nursing home, many adults lose the remaining functions and contacts that they had when they were on their own and become totally dependent on the nursing home. This unfortunate pattern is common throughout the country and contributes to the spiraling cost of medical care as well as to the further segregation of the elderly and the handicapped. (Mendelson, Mary Adelaide. Tender Loving Greed, New York: Alfred A. Knopf, 1974). It is therefore in the interest of society to prevent the development of unnecessary dependency for any citizen and to minimize its impact once functional capacity has declined. B. BARRIERS TO THE DEVELOPMENT OF NONINSTITUTIONAL LONG TERM CARE SERVICES The State Commission on Aging contracted a study on reducing the risk of functional dependency and on the increase in medical costs. This study, the Hawaii Comprehensive Master Plan for the Elderly, was published in 1974 and argues that 69% of elderly persons in skilled nursing beds could be gradually shifted to community-based care settings utilizing a system of accessible home health, homemaker, and chore services. This would result in considerable savings in state operational costs and improvements in the basic health care of the elderly. (Gordon Associates, 1974). A plan to operationalize this recommendation was never developed by the State. However, the HCSCH Long Term Care Task Force notes that some progress has been made in expanding the range of supportive services to prevent functional dependency since the time the Hawaii Comprehensive Master Plan for the Elderly was written. One example is that there are now three home health agencies serving the population of Oahu where there was formerly only one. Other indicators, however, point out that factors identified by the Hawaii Comprehensive Master Plan for the Elderly, which have prevented the development of supportive care arrangements, are still with us. These problems include a lack of coordination, lack of financing, and lack of importance attached to support services by decision makers. It is the contention of the Task Force that we need to change our thinking so that these support services are not viewed as "alternatives," but as necessary supports to the natural assistance mechanisms of the family, church, neighborhood, and community. These barriers to the development of support services must be examined and removed. Another major problem is the inappropriate use of acute care and institutional long term care beds. Our investigations have shown that there is a backlog of patients who could be moved from acute, skilled and intermediate care facilities into less costly alternatives if adequate support services were available. This inappropriate utilization of beds is due to several factors: (1) the current system of reimbursement under Medicare and Medicaid emphasizes inpatient services; (2) there is a lack of lower level care and supportive services that would maintain independent living longer and prevent early institutionalization of patients; and (3) there is a lack of sheltered housing for older adults. Examples of inappropriate utilization of institutional beds in Hawaii follow: • The 1978 Annual Report of the Utilization Review Committee of the Honolulu County Medical Society points out that 2,141 (or 39%) of 5,488 SNF patients reviewed by the Committee in 1978 were actually nonskilled and could be transferred to lower levels of care.* Based on 1973 and 1974 Department of Social Services & Housing (DSSH) surveys of recipients of medical assistance in SNFs, it was estimated that 69% of persons in SNFs could be placed at lower levels of care as indicated below: SNF to Home Health and other social long term care services . 17% However, a substantial number of SNF residents do need skilled care. A recent profile of three large SNFs on Oahu (caring for 40% of Oahu's SNF patients) indicates that the average age of the SNF patient is 75 years, that 65% have three or more diagnosed handicaps, that only 22% have spouses living, and only 51% have children nearby. Twenty-five percent of the patients in these SNFs die within the first year of residency. (See Appendix II). * The County Medical Society reviews eleven SNFS in the State. Most hospitals conduct their own review of their SNF components. At present, the institutionalized population is only about 5% of the total number of the State's elderly residents. However, about 37% of the State's Medicaid budget goes to pay for long term care institutions (HMSA, 1978). Honolulu does have a fairly diverse array of services for persons and families in need of long term care support outside of the institution, but many of these services have eligibility limitations based on income and/or are being utilized to capacity. In general, however, institutional care is reimbursable, noninstitutional care is not. The Long Term Care Task Force shares the view of Congressman Claude Pepper, Chairman of the House Committee on Aging, in his comments on a recently released study by the General Accounting Office (GAO) documenting the advantages of expanding home health benefits for the elderly: "The GAO study underscores my long held contention that the government has adopted a costly counterproductive institutional bias toward the elderly who need health care. It is tragic that home health care is considered the alternative to institutionalization. The GAO report concluded, 'until older people become greatly or extremely impaired, the cost of nursing home care exceeds the cost of home care, including the value of general support services provided by family and friends.'" (Abdellah, 1978). The Long Term Care Task Force believes that it is necessary to reverse the trend toward institutionalization of the elderly and to consider institutional care only after all other support services have been explored. The goal should be care out of the insititution for as long as it is possible and feasible to provide the needed services of primary prevention, maintenance, and rehabilitation. Institutional care then becomes the alternative to noninstitutional care. The care of the long term care patient should center on prevention of disability and prevention of dependency. |