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Health Spotlight

Long-Term Care (LTC)

Long-term care (LTC) encompasses an array of services for people who need chronic care for reasons that range from spinal cord injury to chronic illness to frailty. Individuals with unremitting and debilitating conditions require constant care that can be provided in an institutional, home, or community-based setting. Services provided for those who need LTC may include nursing home care, adult day care, hospice, or home health care. In FY 2002, VA provided long-term care services to veterans at a cost of more than $3.3 billion. ¹

Our Aging Population

The degree of disability and dependence on daily living assistance increases progressively with age. The portion of the U.S. population who need long-term care is growing because our population is aging. People aged 65 and older make up about 13% of the population, but by 2030 that number will be as high as 30% and nearly nine million will be 85 years or older.² The numbers of veterans older than 85 will more than double in the next decade, and these are the people who will most need VA’s long-term care services. ¹

The Caregivers

About two-thirds of older Americans (5.6 out of 7 million) are cared for at home, and 72% of those who take responsibility for the daily personal care (e.g., bathing, dressing, feeding) of an older person are women. ³ However, now there are more choices in long-term care, as well as services to assist caregivers. [See Resources below] There are also assisted living and skilled nursing facilities that offer LTC services for those with more complex needs.

VA’s Long-Term Care Services

Veterans who require long-term care prefer not to reside in an institutional setting, if possible, thus VA seeks to provide the best cost-effective long-term care in the least restrictive setting. VA has developed a national strategy to enhance the quality of long-term health care and to improve access to LTC for all eligible veterans. This includes exploring new technologies, such as telemedicine, that allows health care professionals to coordinate care and monitor veterans in their home and community environments.

Further, VA is implementing an integrated care management system that incorporates all of the patient’s clinical needs by developing new patient-centered models for long-term care. This includes an array of home and community-based extended care services, such as:

• Nursing home care: Approximately 2,500 VA approved community nursing homes provide a broad range of care within the veteran’s own community
• Respite care: Relieves a spouse or other caregiver from the burden of caring for a chronically ill or disabled veteran who is living at home. Respite care programs are available in 136 VA medical centers.
• Home-Based Primary Care: Interdisciplinary treatment teams provide long-term medical care in the homes of veterans with chronic illness.
• Adult Day Health Care: Health maintenance and rehabilitative services offered to frail individuals during daytime hours.
• Homemaker/Home Health Aid Services: Health-related services provided in the community by public and private agencies under VA case management.
• Community Residential Care: Provides room, board, limited personal care, and supervision to veterans who do not require hospital or nursing home care, but are not able to live independently and have no family. Medical care is provided primarily on an outpatient basis.⁴

As the largest provider of health care in this country, and as a leader in research, VA strives to improve the quality of health and health care for the elderly, and all of those who depend on long-term care.

HSR&D is very involved in research to improve long-term care. For example, HSR&D recently conducted a State-of-the-ART (SOTA) conference on Long-Term Care that was attended by policy makers, researchers, clinicians, other LTC experts, and VA’s Under Secretary of Health, Robert Roswell, MD. Participants in the LTC SOTA worked to identify what we know about long-term care, as well as what we don’t know. Currently, recommendations and a research agenda are being developed that will assist VA and the larger health care community to provide the highest quality, most cost-effective long-term care for our veterans and the nation.

In addition to the SOTA, HSR&D has developed the Targeted Research Enhancement Program (TREP) that will support and facilitate the development of HSR&D research projects and career development in areas such as long-term care. The TREP program in LTC is located at the Denver VAMC and has a dual mission: 1) improve the quality of care for serious, acute and chronic medical illnesses (i.e., congestive heart failure) that are common among veterans who require long-term care; and 2) enhance quality of life for veterans in LTC by addressing such issues as pain management.

Schizophrenia is a chronic and devastating mental disorder that affects more than 2 million Americans. In FY00FY01, VHA provided care to more than 98,500 102,000 patients with a diagnosis of schizophrenia. ⁵ The number of people with schizophrenia who are older than 55 is increasing rapidly, thus developing efficient and accessible services for them is very important. HSR&D investigators participated in one of the first large-scale studies (102,256 adults) to examine the use of medical services and psychiatric services by older persons with schizophrenia. Investigators studied three age groups (18-44, 45-59, and 60+), examining the relationship between age group, health care utilization, and functioning. Findings show that older adults experienced fewer psychiatric hospitalizations but, when hospitalized had longer stays – averaging 71 days yearly versus 30 days for younger adults. Older patient also had more medical hospitalizations and medical outpatient visits because they have more comorbid conditions, such as hypertension, diabetes, and heart disease. However, the relatively lower use of outpatient psychiatric care by older patients suggests that there may be some barriers to accessing these services. This may be because older patients are more likely to be in nursing homes where they may receive less psychiatric care in general. Understanding how older patients with schizophrenia use health care services will help health care planners and policy makers make decisions about resource allocation and program development. ⁶

Nursing has one of the highest rates of occupational injuries, and transferring patients is a high-risk activity for nurses who work on units with dependent patients in long-term care. HSR&D investigators conducted the first U.S. study to determine the capability of a ceiling-mounted patient lift to reduce the incidence and severity of musculoskeletal injuries in nurses. This study was conducted on one 60-bed VA nursing home care unit. Incident reports were collected monthly and then compared to incident reports one year prior to the installation of the lift, looking specifically at lost time and injury rates. Findings show that over an 11-month period, injuries declined after the installation of the ceiling-mounted patient lift. Also, reported satisfaction with the ceiling lift was high and the staff believed it easy and safe to use. Increasing the job satisfaction of VA nurses and protecting them from costly injuries will help to combat nursing shortages that result in less than optimal patient care for our veterans. ⁷

Pressure ulcers are a common medical problem associated with considerable morbidity, particularly for patients with long-term care needs such as those in nursing homes. Practice guidelines on the prevention of pressure ulcers have been widely disseminated, and these guidelines have been successfully implemented in some VA nursing homes. An HSR&D study sought to assess the overall implementation of clinical practice guidelines for pressure ulcers prevention, as well as the rates of variation among a geographically diverse sample of 35 VA nursing homes. Results show that nursing homes varied significantly in adherence to guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations to prevent pressure ulcers, and from 24% to 75% across 6 key recommendations. These results will assist researchers in finding specific strategies that improve adherence to guideline recommendations. ⁸

The goal of this study is to determine the impact of dementia on veterans’ families in terms of informal caregiving, costs, and quality of life. Further, the direct non-medical costs (i.e., caregiving), indirect morbidity costs (i.e., lost productivity), and quality of life related to caregiving were examined on a national level in relation to the amount and types of services that are being utilized, including institutionalization. Results show that the largest units of caregiving cost come from the amount of time allocated to caregiving and the caregiver’s lost earnings. Moreover, all aspects of costs increase with disease severity and problem behavior, mostly from the increased caregiving time required for physical care. An estimated $4 billion per year could be saved in the U.S. if institutionalization from dementia illnesses, such as Alzheimer’s disease, is delayed by one month. Thus, VA would benefit greatly from an increase in the precision by which community care is monitored and supported. More importantly, veterans with dementia who receive appropriate interventions may be able to remain at home longer in environments that promote maximum independence for both caregivers and patients.⁹

Previous research has shown that sleep disturbance is common among people who are in nursing homes for long periods of time, and that impaired sleep contributes to worse functional status. However, little research has addressed how sleep disturbance may influence successful rehabilitation and other important clinical outcomes for those in nursing homes. The primary objective of this ongoing HSR&D study is to identify factors that affect sleep in rehabilitative nursing home in rehabilitative nursing home residents, and to determine whether sleep impairment is associated with rehabilitation or other clinical outcomes. In this prospective cohort study, elderly people admitted for rehabilitation to one of four nursing home sites (2 VA nursing homes and 2 community nursing homes) will be enrolled for rehabilitation and will be followed for 9 months. Researchers will assess several factors including functional status, physical function, sleep, and comorbidity. Investigators believe that the results of this study will lead to further research that will test interventions to improve quality of care related to the nursing home environment and factors that impact sleep.10

Resources:

For more information about long-term care services, visit the following related links:

• For information on local long-term care resources and programs, visit the Eldercare Locator at http://www.eldercare.gov
• The Health Care Financing Administration publishes the "Guide to Choosing a Nursing Home" and the "Guide to Health Insurance for People with Medicare," at http://cms.hhs.gov/
• American Association of Homes and Services for the Aging at http://www.alfa.org National Institute on Aging at http://www.nia.nih.gov

1. U.S. General Accounting Office (GAO). Service gaps and facility restrictions limit veterans’ access to non-institutional care. 03-487. 2003; Washington, D.C.
2. "Federal Panel Offers Recommendations for Research on Aging." NIH New Release. National Institutes of Health, National Institute on Aging. http://www.nia.nih.gov/news/pr/1995/08-31.htm
3. Research for a New Age: Long-Term Care. National Institutes of Health, National Institute on Aging. http://ww.nia/nih.gov/health/pubs/research/pages8.htm
4. VA Long-Term Care, VHA Public Affairs Fact Sheet. May 2003.
5. Mental Health QUERI Fact Sheet. VA's Health Services Research and Development Quality Enhancement Research Initiative (QUERI). February 2003. http://www.hsrd.research.va.gov/publications/internal/querifactsheetMHB.pdf
6. Barry KL, Blow FC, Dornfeld M, Valenstein M. Aging and schizophrenia: Current health services research and recommendations. Journal of Geriatric Psychology and Neurology 2002; Fall;15(3):121-7.
7. Tiesman HM, Nelson A, Charney B, Siddharthan K. The impact of new lifting technology in a long-term care unit. 2002 HSR&D Annual Meeting Abstract, Session number 1074.
8. Salbina D, Rubenstein L, Simon B, Hickey E, Ferrell B, Czarnowski E, Berlowitz D. Adherence to pressure ulcer prevention guidelines: implications for nursing home quality. The Journal of the American Geriatrics Society. 2003 Jan;51(1):56-62.
9. Moore MJ, Zhu CW, Clipp EC. Informal costs of dementia care: Estimates form the National Longitudinal Caregiver Study. Journal of Gerontology 2001;56B:S219-S228.
10. Littner M, Alessi C. Obstructive sleep apnea: Asleep in our consciousness no more. Chest 2002;121:1729-1730.