Skilled Nursing Facilities and Other Long Term Care Facilities: Addressing Issues of Cost and Quality By Emma Nochomovitz Defining Long Term Care Long term care as it exists today is broad in its definition and generally refers to a range of services that support the daily needs of individuals with limited functioning or disability (Houser 2007). Limited functioning or disability is typically determined according to an individual’s ability to complete activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Such activities include eating, bathing and dressing, as well as management of food, medication or household chores(Binstock, Cluff et al. 1996). The long term care population generally refers to the nearly 70% of the Americans age 65 or older who will require some type of long term care within their lifetime (Aging 2008). According to the U.S. Department of Health and Human Services, older Americans represented 12.4% of the population in 2004. Among this proportion, 18.1% of individuals age 65 and over were racial minorities (Services 2005). Furthermore, within this population there were 139 women for every 100 men. Projections show that the older population will grow significantly in the years to come. As life expectancy continues to increase and the baby boomers grow older, the proportion of the population represented by older Americans is estimated to increase by 30% by the year 2030(Services 2005). Moreover, older Americans will represent 20% of the entire population. It remains to be seen whether the long term care industry is wellenough equipped to fulfill the long term care needs of increasing numbers of elderly individuals. Types of Long Term Care Facilities A nursing home is commonly defined as a skilled nursing facility (SNF), which provides 24-hour skilled medical care for both acute and chronic conditions, as well as additional help for daily activities of living (Services). Discussions of long term care most commonly refer to these institutions. In 2004, there were 16,100 SNFs in the United States, approximately 17,000 of which were for-profit institutions (Statistics; Grabowski and Hirth 2003). These homes held a total of 1,730,000 beds with an average of 107.6 beds her home. Approximately 1.5 million people, or 4.5% of older Americans, lived in United States’ nursing homes in 2004 (Houser 2007; Services 2005). The average age of an individual when she or she is admitted into a nursing home is 79 years old (Aging 2008). Women living in nursing homes outnumber men 3 to 1 (Aging 2008). Assisted living facilities (ALF), while sometimes similar to SNFs in the care they provide, generally provide basic care for chronic illnesses and some assistance with activities of daily living, while offering greater independence and autonomy for its residents than a SNF. ALFs emerged in the United States in the mid 1980s and have experienced great increases in numbers. Data on nursing homes suggesting declines in its use over time has been explained by some as the result of increased use of assisted living facilities (Wright 2004). It is difficult to provide a standard definition or obtain reliable data for ALFs because licensure for these types of care facilities varies by individual state and may be defined differently across studies (Statistics). Despite the difficulty ofdefining ALFs, a national survey estimated that there were 11,459 ALFs nationwide in 2003 (Hawes, Phillips et al. 2003). These facilities included 611,300 beds. According to the American Association of Homes and Services for the Aging, over 900,000 elderly individuals reside in assisted living facilities (2008). Continuing care retirement communities (CCRC) are yet another source of long-term care for the elderly. This care setting often includes a skilled nursing facility, but the level of care received by each resident is dependent on his/her individual needs (Center for Medicare and Medicaid Services). According to the American Association of Homes and Services for the Aging, there are currently 1900 CCRC in the United States, in which approximately 745,000 older adults reside. Home health care is another option that elderly individuals, especially those with extensive support networks, may choose to meet their long term care needs. Home health care may be provided by close friends or family. In addition, there were 9,284 Medicare certified home health agencies in 2007 (Hospice 2008). In 2000, 7.2 million, or 2.5% of Americans received formal home care services (Hospice 2008). Over half recipients of home care in 2006, were indicated to have suffered from diseases related to the circulatory system or the heart (Hospice 2008). History of Long Term Care and the Nursing Home Industry Historically, there has always been a need for the provision of healthcare specific to elderly individuals and other vulnerable populations. In medieval times, principally in the 13th century, a movement of women based in feminism ideology and spirituality lay the groundwork for care of the sick and needy (McDonnell 1954). Originating inNorthern Europe, these sisterhoods were called Beguines. Within America, the beginning of care of the elderly and feeble rested in the hands of family, and in particular, the responsibility fell to the women of the family (Holstein and Cole 1996). By the 1900s, the colonial almshouse became the first institution in America to resemble institutionalized management of care for poor, elderly and disabled (Starr 1982; Foundation 1996-2008). Given that hospitals at this time were primarily concerned with curative and acute care, almshouses became the default care location for chronically ill elderly individuals (Holstein and Cole 1996). The 1930s and the reign of President Roosevelt encouraged greater acknowledgement of the needs of elderly citizens; resulting in the establishment of Social Security and Old Age Assistance in 1935 (Foundation 1996-2008). This administrative reform aimed to provide elderly individuals with a steady source of income, which would allow them to better care for themselves (Holstein and Cole 1996). While Social Security served to eliminate the need for almshouses and the stigma associated with poverty that accompanied these institutions, it did not remove the need for a venue for chronic care for elderly individuals. Thus, the development of home care planning and nursing homes emerged throughout