CHAPTER 9 - LONG-TERM CARE
|NOTE: Charts and graphs for this chapter are listed in the right column of the page.|
Content Last Updated: 6/17/2010 8:25:29 PM
Graphics Last Updated: 6/15/2009 9:06:22 AM
Originally written by Deanna Okrent, Alliance for Health Reform. Updated April 2010 by Deanna Okrent. This chapter was made possible by the Robert Wood Johnson Foundation.
- Two-thirds of people age 65 today will need some long-term care in their lifetimes.1
- Of the 10 million Americans who need assistance with daily activities, 1.7 million live in the nation’s 16,000 nursing homes and approximately 520,000 live in assisted living facilities.2
- Fourteen percent of Americans age 85 or older live in nursing homes.3
- A total of $207 billion was spent on long-term care in the U.S. in 2005.4
- Of total long-term care spending, Medicaid spending accounts for 49 percent, Medicare accounts for 20 percent, out-of-pocket spending equals 18 percent and private health and long-term care insurance makes up 7 percent.5
- There are 52 million unpaid caregivers who contribute an estimated $375 billion in value to the U.S. economy. 6
- The Community Living Assistance Services and Supports (CLASS) Act, enacted in the health reform law of 2010, establishes a new voluntary long-term care insurance program that will be federally administered.7
”Long-term care” (LTC) generally brings to mind images of nursing homes and older people living in them who can no longer care for themselves. In truth, long-term care comes in many different forms and is provided in many different settings.
It is institutional care. It is assisted living. It is also home- and community-based services, including home health care, adult day care, home delivered meals and other services authorized under Title III of the Older Americans Act.8 (See chart, “Numbers of People Receiving Home and Community-Based Services, 2006.”)
These services are financed by Medicaid, Medicare, private long-term care insurance, private out-of-pocket spending and appropriations under the Older Americans Act. (Despite what many Americans believe, Medicare is not a major payer for LTC, as discussed later.)
Yet the majority of long-term care services aren’t paid for at all. They are provided by 52 million unpaid caregivers -- primarily family members and friends of those needing LTC. Their services, if paid for, would have cost an estimated $375 billion in 2007 – almost double what the federal government spent that year on Medicaid.9 10
LTC serves both people who are over the age of 65 and people under that age (for example, see chart, “Nursing Home Residents by Age & Gender”).
Cost and Financing of Long-term Care
In 2008, the average annual cost of a private room in a nursing home was more than $76,000.11 The average cost for an assisted living facility in 2007 was $35,628.12 (See Glossary for the differences between the two.) These costs vary widely from region to region and are highest in the Northeast. 13 Costs also vary by certification status, size and type of ownership of the facility.
Medicaid is a public health insurance program funded by federal and state governments. (See Chapter 8, “Medicaid,” for more.) Medicaid is a major payer for long-term care because federal law requires that Medicaid programs in every state must provide nursing home care and home health care for the qualified poor.
Medicaid accounts for almost half of national long-term care spending.14 (See chart, “Financing of Long-Term Care, 2005.”) Of that amount, most is for institutional care, though spending for non-institutional care is growing and reached 37 percent of Medicaid’s share of LTC spending in 2005.15 Though over half of those who use Medicaid long-term care services are over 65, a third (34 percent) are disabled children and adults under 65. 16
Beyond the basic federal requirements, Medicaid LTC benefits vary from state to state. Home and community-based services (HCBS) are provided under Medicaid waivers in all states but the programs serve limited populations, and vary greatly in scope from state to state. (See Glossary for details about Medicaid waivers.)
Since 2007, under a provision of the Deficit Reduction Act (DRA) of 2005, waivers are no longer required for some home and community-based services, such as case management, homemaker/home health aide services, personal care services, adult day health, and habilitation services.
The health reform law of 2010 (The Patient Protection and Affordable Care Act , orPPACA) contains provisions that may shift more care to home and community-based services in the future. It establishes additional optional HCBS benefits that states may offer under Medicaid and provides financial incentives to states to expand existing HCBS programs.17
Though many people think that Medicare covers long-term care, in reality it provides only limited coverage of nursing home stays and home health care. Eligibility is based on, and follows, a hospital stay of at least three days. Medicare covers short-term stays in skilled nursing facilities – full coverage for 20 days, partial coverage for up to 80 additional days. This spending, plus spending for home health benefits for eligible Medicare beneficiaries, accounts for 20 percent of long-term care expenditures.18
Private Long-Term Care Insurance
A relatively small number of people purchase long-term care insurance – approximately 7 million policies were in force in 2005. 19 Although it seems entirely logical to minimize the risk of impoverishment from the high cost of long-term care, long-term care insurance has not had broad market appeal.
Younger people don’t yet recognize the need for long-term care insurance, although the cost of it for them is low. When people are closer to the age when they might need long-term care, many cannot afford the then-high priced insurance premiums.
The Robert Wood Johnson Foundation, in 1987, initiated an experimental program called the Program to Promote Long-Term Care Insurance. Also referred to as the Partnership Program, it involves a public-private partnership between Medicaid and private insurance. Those buying long-term care insurance can protect a portion of their assets that otherwise would count against them were they to apply to Medicaid to cover their long-term care expenses. (See the Alliance for Health Reform issue brief on this topic at www.allhealth.org under “Resources.”)
The Partnership Program began as a demonstration project in four states and is now available for replication in all states. Twenty-nine states had implemented Partnership Programs as of June 2009 and many others are in the process of implementing these programs. 20 All told, long-term care insurance pays for approximately 7 percent of national long-term care spending.21
The Community Living Assistance Services and Supports (CLASS) Act, enacted in the health reform law, establishes a new voluntary long-term care insurance program that will be federally administered. Individuals will be automatically enrolled if their employers agree to participate and premiums will be paid through payroll deductions unless an individual opts out. 22 Though this feature makes participation easy, the program is not projected to make an immediate, sizable difference in the insurance rolls. Many details of the new program have yet to be determined by the Secretary of Health and Human Services.
For people without insurance, including those who do not qualify for Medicare or Medicaid benefits, long-term care costs are paid out-of-pocket. This includes payment for nursing home care, assisted living and home health care. The average annual cost of home care by one industry estimate is close to $44,000.23 Out-of-pocket spending accounts for 18 percent of national spending for long-term care.24
The CLASS Act would provide qualified enrollees a cash benefit to help with these expenses.
LIKELY POLICY DEBATES
As noted, Medicaid serves as the nation’s safety net for individuals with long-term care needs. Many individuals who initially pay for nursing home care out of pocket become impoverished by the high cost of care and later qualify for Medicaid. Can Medicaid continue to fund the largest share of long-term care? Will state budgets hold up under the strain? Will the provisions in PPACA alter the ratio of institutional care to home and community based services and if so, what effect might this have on nursing homes?
Policymakers also wonder how to support family caregiving and other informal caregivers. When family members stay home from work or leave their jobs to care for loved ones, this takes an economic toll on them and on society. How could governments reduce the strain?
Perhaps long-term care insurance can play a greater role. How can we increase its appeal and thereby its market share? Are consumer protections needed to allay fears that the insurance policies of today will cover the needs of tomorrow? Will new products be marketed to supplement the voluntary long-term care insurance program in the CLASS Act?Many states are experimenting with programs that reduce the need for nursing home placements. 25 Such programs require that people needing long-term care be able to live in the most integrated setting appropriate. One innovative effort, Vermont’s “global budgeting,”26 allows Medicaid funds to be spent on whichever service is most appropriate for persons found to be eligible for long-term care. Global budgets do not separate funding for nursing homes or home and community-based services into different “silos.” Will the financial incentives in PPACA encourage the expansion of these and other innovative programs?
Throughout the health care arena there is a workforce shortage27 and this is dramatically so for direct care workers in long-term care.28 29 Studies have shown that quality of care is directly related to nurse staffing ratios, 30 yet in very few states does the average staffing ratio meet the minimum standard recommended by each state. Questions abound on how to increase recruitment, retention and job satisfaction of direct care workers. The biggest question is: Will the workforce supply be ready to meet the baby boomer demand?
Certified nursing assistants (CNAs), who make up the majority of direct care providers in most facilities (see chart, “Distribution of Direct Care Workers”), currently get minimal training, benefits and opportunity for advancement. PPACA establishes a three-year initiative to strengthen the direct care workforce. It will fund state demonstration projects that train personal or home care aides in 10 core competencies. These projects will be evaluated on job skills mastery, job satisfaction, and beneficiary and family satisfaction with services. 31
Quality of Care and Resident-directed Care and Services
In 2007, nearly 17 percent of nursing homes inspected by state regulators were cited for serious deficiencies.32 Some say the inspection system is broken. 33 Others say quality of care is the issue, and that nursing home ownership is a contributing factor34 (with most of the criticism lodged against certain for-profit chains). PPACA provisions require disclosure of ownership and governance.35
Medicaid reimbursement and other historical factors have long fostered a bias toward institutional long-term care. In addition to the PPACA provisions mentioned above, some new models of care are being demonstrated across the country.
Among these is the Green House® model, which provides person-centered long-term care in small home-like settings as an alternative to larger, institution-like nursing homes. (For more, see the Alliance issue brief “ Changing the Nursing Home Culture.”)
Studies have shown improved resident and caregiver satisfaction at these types of facilities.36 But the question remains: Are current long-term care providers sufficiently motivated to make the necessary structural changes in older facilities that would be required to create a more individualized, home-like environment? Can they afford to do so?
In a 2008 survey of long-term care opinion leaders,37 84 percent felt that long-term care should be rebalanced away from traditional nursing homes and toward home- and community-based services. Some 61 percent were in favor of expanding consumer-directed programs such as “Cash and Counseling,” a way for those needing long-term care to direct expenditures made on their behalf. (Read more about Cash and Counseling at www.cashandcounseling.org/about.) PPACA provisions referenced earlier will provide financial incentives to states to expand HCBS options.
A 2007 study showed a relationship between racial segregation and quality disparities in U.S. nursing homes. 38 The study found that blacks were more likely to live in poor quality nursing homes than whites. Blacks were almost three times as likely to live in a nursing home housing predominantly Medicaid residents. The study offered policy recommendations including Medicaid payment reform that would close the gap between Medicaid per diem rates and those paid by private payers.
TIPS FOR REPORTERS
- It is a common misperception that Medicare covers long-term care. It is not well understood that the Medicare “long-term care” benefit is limited to 100 days of skilled care and that it must follow a hospital stay of three days or more. The Center for Medicare Advocacy has information about skilled nursing facility (SNF) care, therapy care, rehab care, and other Medicare issues on its web site,www.medicareadvocacy.org. You can also learn about Medicare benefits at www.cms.gov.
- There is often confusion between Medicare and Medicaid. It is not well understood that Medicaid covers long-term care for qualified individuals and that it is a means-tested benefit. Most publicly funded long-term care is financed by Medicaid.
- Gifts to family members or others within the five-year period prior to applying for Medicaid count as assets of the potential beneficiary for purposes of determining Medicaid eligibility. The period in which such gifts are counted as assets is known as the “look-back period.” The “look-back period” for Medicaid changed from three years to five years in February 2006. It is commonly asserted that individuals divest themselves of assets in order to qualify for Medicaid and be eligible for long-term care coverage. However, studies have found little evidence of this phenomenon.39
- The movement to resident-centered care or person-centered care is often linked with the Green House® movement. (NCB Capital Impact, with support from the Robert Wood Johnson Foundation, is pursuing the development of Green Houses across the country. Click here for more information about this replication initiative.) However, resident-centered care can and should occur in all long-term care facilities, not only ones of a particular architectural design. This movement has many shapes and forms depending on developments on the local and state level and subject to state and federal regulations. A good resource for information about this movement is www.pioneernetwork.net. The movement is also known as “culture change.”
- Many long-term care facilities require residents to sign admissions agreements with mandatory arbitration clauses. There have been successful cases challenging the legality of such clauses. However, it is still a common occurrence. It is also common to request that a family member accept financial responsibility for their loved one in the facility. Family members are not required to accept such responsibility but often don’t realize what they have signed until much later down the road.
- Long-term care workforce – Is your state conducting a training demonstration for certified nurse assistants(CNAs)? Are there tangible results in lower turnover rates and higher job satisfaction?
- Long-term care workforce and immigration — What would be the effects of proposed federal immigration reforms? Will tighter restrictions increase the workforce shortage?
- Long-term care costs and the economic downturn — How are state Medicaid budgets faring in the face of an economic downturn? What will happen to the long-term care safety net for the poor? Will families be able to continue their out-of-pocket spending for long-term care? Will Medicaid enrollment swell?
- Facility residents’ costs of care are paid for by a variety of sources such as out-of-pocket, private long-term care insurance and Medicaid. The mix of residents by payer source often varies by location of the facility. Is the economic downturn having an effect on the payer source mix of facilities in your community? Will private-pay facilities have to take in more Medicaid residents to fill their beds? Might we see more facility closures due to the economic recession?
- Are innovative models of care gaining market share? How is the Green House® project progressing? Has the economic downturn slowed progress toward changing institutional models of care into more home-like settings?
- Are current HCBSs sufficient to meet the increased demand? Will new models develop? Will they be public-private partnerships or depend solely on Medicaid funding? Will some traditional nursing facilities face diminishing occupancy rates and be forced to close their doors?
- Are baby boomers changing the face of long-term care? Are they requesting/demanding different services, benefits for themselves than their parents demanded? Are more institutions offering email and Internet access to their residents? Will baby boomers find innovative solutions to aging at home? Will this speed the movement away from the current institutional bias? Are baby boomers more aware of “residents’ rights?” For information about residents’ rights contact the National Long-term Care Ombudsman Resource Center. They have an information-packed website at www.ltcombudsman.org.
- Health reform –Can cost containment efforts be effective without encompassing the share spent by Medicaid and Medicare on long-term care? What effect will the CLASS Act have on the long-term care insurance market?
EXPERTS AND WEBSITES
Lisa Alecxih , Vice President, The Lewin Group, 703/269-5542
Melanie Bella , Senior Vice President, Center for Health Care Strategies, 609/528-8400, firstname.lastname@example.org
Randall Brown , Vice President and Director of Health Research, Mathematica Policy Research, 609/799-3535
Stuart Butler , Vice President, The Heritage Foundation, 202/546-4400
Eric Carlson , Attorney, National Senior Citizens Law Center, 213/639-0930 ext.313
Bruce Chernof , Chief Executive Officer, The SCAN Foundation, 562/308-2858, email@example.com
Steven Dawson , President, PHI, 718/402-7471, SDawson@PHInational.org
Jennifer Douglas , Assistant Research Scientist, LTC Research, LIMRA International, 860/688- 3358
David Durenberger , Chairman, The National Institute of Health Policy, 651/962-4630
Charles Fahey , Program Officer, Milbank Memorial Fund, 718/817-5356
Judy Feder , Professor, Public Policy Institute, Georgetown University, 202/687-8397
Lynn Friss Feinberg , Deputy Director, National Center on Caregiving, Family Caregiver Alliance, 415/434-3388, firstname.lastname@example.org
James Firman , President and CEO, National Council on Aging, 202/479-1200, email@example.com
Len Fishman , President and CEO, Hebrew SeniorLife, 617/363-8211, firstname.lastname@example.org
Marty Ford , Chairman, Consortium for Citizens with Disabilities, 202/783-2229
Lex Frieden , Senior Vice President, The Institute for Rehabilitation and Research, 713/520-0232, email@example.com
Robert Friedland , Associate Professor, School of Nursing and Health Studies, Georgetown University, 202/687-1287
Robert Greenwood , Vice President of Public Affairs, National PACE Association, 703/535- 1522
Stuart Guterman , Senior Program Director , Program on Medicare's Future, The Commonwealth Fund, 202/292-6735, SXG@cmwf.com
Val Halamandaris , President, National Association for Homecare and Hospice, 202/547-7424
Catherine Hawes , Director, Program on Aging and Long-Term Care Policy, School of Rural Public Health, Texas A&M University System Health Science Center, 979/458-0081, Hawes@srph.tamhsc.edu
Antoinette Hays , Dean, Regis College School of Nursing and Health Professions, 781/768-7122, firstname.lastname@example.org
Alice Hedt , former Director, NCCNHR, AliceHedt@aol.com
John Holahan , Director of Health Policy Research, Urban Institute, 202/261-5666
Joy Johnson Wils on, Federal Affairs Counsel, National Conference of State Legislatures, 202/624-5400, email@example.com
Mary Jane Koren , Assistant Vice President, Quality of Care for Frail Elders, The Commonwealth Fund, 212/606-3849, firstname.lastname@example.org
Risa Lavizzo-Mourey , President & CEO, Robert Wood Johnson Foundation, 888/631-9989, email@example.com
Barbara Lyons , Deputy Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202/347-5270, firstname.lastname@example.org
Stephen McConnell , Ageing Programme Executive, Atlantic Philanthropies, 212/916-7300, email@example.com
Mark Meiners , Professor, Department of Health Administration and Policy, George Mason University, 703/993- 1909
Charles Milligan , Executive Director, Hilltop Institute, UMBC, 410/455-6274, firstname.lastname@example.org
Larry Minnix , President and CEO, American Association of Homes and Services for the Aging, 202/783-2242
Marilyn Moon , Vice President and Director of the Health Program, American Institutes for Research, 301/592-2101, MMoon@AIR.org
Vincent Mor , Chair, Department of Community Health, Brown University, 401/863-3172, email@example.com
Paul Nathanson , Executive Director, National Senior Citizens Law Center, 213/639-0930
Carol O'Shaughnessy , Principal Policy Analyst, National Health Policy Forum, 202/872-0239, firstname.lastname@example.org
Richard Price , Director of Grassroots and Communications, Hart Health Strategies, 202/783- 2229
Donald Redfoot , Senior Policy Advisor, Public Policy Institute, AARP, 202/434-3840, email@example.com
Charles Reed , Consultant, C.E. Reed and Associates, 360/943-8188, firstname.lastname@example.org
Susan Reinhard , Director, AARP Public Policy Institute, 202/434-3841, SReinhard@aarp.org
Martha Roherty , Executive Director, National Association of State Units on Aging, 202/898- 2578 x138, email@example.com
John Rother , Executive Vice President for Policy and Strategy, AARP, 202/434-3701, firstname.lastname@example.org
Diane Rowland , Executive Vice President, Kaiser Family Foundation, 202/347-5270, email@example.com
William Scanlon , Senior Policy Advisor, Health Policy R & D, 202/624-3975
Ray Scheppach , Executive Director, National Governors Association, 202/624-5320
Judith Stein , Executive Director, Center for Medicare Advocacy, 860/456-7790, firstname.lastname@example.org
Paul VandeWater , Senior Fellow, Center on Budget and Policy Priorities, 202/408-1080, vandewater@ cbpp.org
Bruce Vladeck , Principal, Ernst & Young, 212/773-3000, email@example.com
Alan Weil , Executive Director, National Academy for State Health Policy, 202/903-0101
Janet Wells , Director of Public Policy, The National Consumer Voice for Quality Long- Term Care (formerly NCCNHR), 202/332-2276 ext.205
Tim Westmoreland , Visiting Professor of Law, Law Center, Georgetown University, 202/662- 9876
Josh Wiener , Senior Fellow & Program Director, Aging, Disability, and Long-Term Care, RTI International, 202/728-2094
John Dicken , Director, Health Care, Government Accountability Office, 202/512-7043, firstname.lastname@example.org
Judith Frye , Director, Office of Family Care Expansion, Wisconsin Department of Health, 608/266-8560, Judith.Frye@dhs.wisconsin.gov
Stuart Hagen , Principal Analyst, Health and Human Resources Division, Congressional Budget Office, 202/225-2644
Ruth E. Katz , Deputy to the Deputy Assistant Secretary, Office of Disability, Aging and Long-term Care Policy, ASPE, email@example.com
Laura Lawrence , Chief of the FSA, Life, and Long Term Care Insurances Group, Office of Personnel Management, 202/606-1413, firstname.lastname@example.org
Frank Titus , Assistant Director for Insurance Services, Office of Personnel Management, 202/606-0745
Edwin Walker , Deputy Assistant Secretary for Program Operaations, Administration on Aging, Department of Health and Human Services, 202/401-4634, email@example.com
Mark Cohen , Vice President, LifePlans, Inc, 781/893-7600
Jennifer Cook , Health Policy and Legislative Analyst, National Association of Insurance Commissioners, 202/471-3990, firstname.lastname@example.org
Irene Fleshner , Vice President for Strategic Nursing Initiatives, Genesis Health Care, 610/925- 4169, Anne.Marie.Lysle@genesishcc.com
Lee Goldberg , Policy Director, Long Term Care Division, Service Employees International Union, 202/730-7850, email@example.com
Mary Kennedy , Director of Medicare, Association for Community Affiliated Plans, 202/701-4749, firstname.lastname@example.org
Robyn Stone , Senior Vice President of Research, American Association of Homes and Services for the Aging, 202/508-1208, Rstone@aahsa.org
AARP Public Policy Institute www.aarp.org/research/ppi
Administration on Aging, HHS www.aoa.gov
Alzheimer's Association www.alz.org
American Association for Homes and Services for the Aging www.aahsa.org
American Association of People with Disabilities www.aapd-dc.org
American Institutes for Research www.air.org
American Network of Community Options and Resources www.ancor.org
America's Health Insurance Plans www.ahip.org
Bazelon Center for Mental Health Law www.bazelon.org
CBO, Health and Human Resources Division
Center for Health Care Strategies www.chcs.org
Center on an Aging Society, Georgetown University http://ihcrp.georgetown.edu/agingsociety
The Commonwealth Fund www.commonwealthfund.org
Consortium for Citizens with Disabilities www.c-c-d.org
Disability Policy Collaboration (The Arc of the United States/United Cerebral Palsy) www.thearc.org
Families USA www.familiesusa.org
Federal Long Term Care Insurance Program www.ltcfeds.com/index.html
Genesis Health Care www.genesishcc.com
Georgetown Public Policy Institute http://gppi.georgetown.edu
Georgetown University Health Policy Institute http://ihcrp.georgetown.edu
Government Accountability Office www.gao.gov
Health Reform GPS http://www.healthreformgps.org/
Hebrew Rehabilitation Center for Aged www.hebrewrehab.org
Heritage Foundation www.heritage.org
HHS Office of Disability, Aging and Long-Term Care Policy http://aspe.hhs.gov/daltcp/home.shtml
The Hilltop Institute, UMBC www.chpdm.org
Institute for Rehabilitation and Research www.tirr.org
John Hancock Long Term Care Insurance www.johnhancocklongtermcare.com
Kaiser Family Foundation www.kff.org
Lewin Group www.lewin.com
LifePlans, Inc www.lifeplansinc.com
Mathematica Policy Research www.mathematica-mpr.com
Metropolitan Life Insurance www.metlife.com
Milbank Memorial Fund www.milbank.org
National Academy for State Health Policy www.nashp.org
National Academy of Social Insurance www.nasi.org
National Association for Homecare and Hospice www.nahc.org
National Association of Insurance Commissioners www.naic.org
National Association of State Units on Aging www.nasua.org
National Center for Assisted Living www.ncal.org
National Center on Caregiving, Family Caregivers Alliance www.caregiver.org
National Conference of State Legislatures www.ncsl.org
National Council on Aging www.ncoa.org
National Governors Association www.nga.org
National Institute of Health Policy www.nihp.org
National PACE Association www.npaonline.org
National Senior Citizens Law Center www.nsclc.org
NCCNHR: The National Consumer Voice for Quality Long-Term Care www.nccnhr.org
Open CRS www.opencrs.com
Robert Wood Johnson Foundation www.rwjf.org
RTI International www.rti.org
Rutgers Center for State Health Policy www.cshp.rutgers.edu
The SCAN Foundation www.thescanfoundation.org
Service Employees International Union www.seiu.org
Urban Institute www.urban.org
1 AARP Public Policy Institute (2007). “Long-Term Care Trends.” ( http://www.aarp.org/research/longtermcare/trends/fs27r_ltc.html).
2 CDC/NCHS. “National Nursing Home Survey.” Table 1. Number of nursing homes, beds, current residents, and discharges. ( http://www.cdc.gov/nchs/nnhs.htm).
3 AARP Public Policy Institute (2007). “Fact Sheet: Nursing Homes.” (http://www.aarp.org/ppi).
4 Long-Term Care Financing Project. Georgetown University (2007). “Fact Sheet: National Spending for Long-Term Care.” February. ( http://ltc.georgetown.edu/pdfs/whopays2006.pdf).
5 Long-Term Care Financing Project. Georgetown University (2007). “Fact Sheet: National Spending for Long-Term Care.” February. ( http://ltc.georgetown.edu/pdfs/whopays2006.pdf).
6 AARP Public Policy Institute (2008). “Valuing the Invaluable: The Economic Value of Family Caregiving, 2008 Update.” November, p. 1. ( http://assets.aarp.org/rgcenter/il/i13_caregiving.pdf).
7 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. ( http://www.nashp.org/sites/default/files/LongTermServ%20Final.pdf).
8 National Health Policy Forum (2008). “The Basics: Older Americans Act of 1965.” April 21. ( www.adrc-tae.org/tiki-download_file.php?fileId=27289). For information on the 2006 amendments to the Older Americans Act, go to www.aoa.gov/oaa2006/Main_Site/oaa/oaa.aspx.
9 AARP Public Policy Institute (2008). “Valuing the Invaluable: The Economic Value of Family Caregiving, 2008 Update.” November, p. 1. ( http://assets.aarp.org/rgcenter/il/i13_caregiving.pdf)
10 U.S. Office of Management and Budget (2008). “Analytical Perspectives, Budget of the United States, Fiscal Year 2009.” Table 20-4, p. 334. ( www.whitehouse.gov/omb/budget/fy2009/pdf/apers/dimensions.pdf).
11 Genworth Financial (2008). “Long Term Care Survey: Future Trends in Long Term Care from Genworth Financial.” ( www.genworth.com).
12 AARP. “State-by-State Long-term Health Care Costs.” ( www.aarp.org/family/caregiving/articles/state-by-state_long-term.html ).
13 AARP. “State-by-State Long-term Health Care Costs.” ( www.aarp.org/family/caregiving/articles/state-by-state_long-term.html ).
14 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University. ( http://ltc.georgetown.edu/pdfs/whopays2006.pdf).
15 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University. ( http://ltc.georgetown.edu/pdfs/whopays2006.pdf).
16 Kaiser Commission on Medicaid and the Uninsured (2007). “Long-term Services and Supports: The Future Role and Challenges for Medicaid.” September. (www.kff.org/medicaid/7671.cfm).
17 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. ( http://www.nashp.org/sites/default/files/LongTermServ%20Final.pdf).
18 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University ( http://ltc.georgetown.edu/pdfs/whopays2006.pdf).
19 AARP Public Policy Institute (2007). “Fact Sheet: Long-Term Care Insurance.” ( http://www.aarp.org/research/health/privinsurance/fs7r_ltc.html).
20 National Clearinghouse for Long-Term Care Information. “Paying for Long-Term Care.” (www.longtermcare.gov ).
21 AARP Public Policy Institute (2007). “Fact Sheet: Long-Term Care Insurance.” ( http://www.aarp.org/research/health/privinsurance/fs7r_ltc.html)
22 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. ( http://www.nashp.org/sites/default/files/LongTermServ%20Final.pdf).
23 Genworth Financial (2008). “Long Term Care Survey: Future Trends in Long Term Care from Genworth Financial.”
24 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University ( http://ltc.georgetown.edu/pdfs/whopays2006.pdf).
25 Kitchener, Martin; Willmott, Micky; Wong, Alice; Harrington, Charlene (2006). “Home and Community-Based Services: Medicaid Research and Demonstration Waivers.” UCSF National Center for Personal Assistance Services. ( http://www.pascenter.org/demo_waivers/demoWaiverReport_2006.php).
26 Kaiser Commission on Medicaid and the Uninsured (2006). “Medicaid Facts: The Vermont Choices for Care Long-Term Care Plan.”( http://www.kff.org/medicaid/upload/7540.pdf).
27 The National Academies News Release (2008). “Health Care Work Force Too Small, Unprepared For Aging Baby Boomers; Higher Pay, More Training, And Changes In Care Delivery Needed To Avert Crisis.” ( http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12089 ).
28 National Center for Health Workforce Analysis, HRSA (2004). “Nursing Aides, Home Health Aides, and Related Health Care Occupations – National and Local Workforce Shortages and Associated Data Needs.” ( http://newsroom.hrsa.gov/NewsBriefs/2004/healthcareaides.htm).
29 National Clearinghouse on the Direct-Care Workforce (2005). “Results of the 2005 National Survey of State Initiatives on the Long-Term Care Direct-Care Workforce.” September 2005. ( http://www.directcareclearinghouse.org/l_art_det.jsp?res_id=184110).
30 Zhang, Ning Jackie et al. (2006). “Minimum Nurse Staffing Ratios for Nursing Homes.” Nursing Economics. May 2006.
31 Justice, Diane (2010). “Long Term Services and Supports and Chronic Care Coordination: Policy Advances Enacted by the Patient Protection and Affordable Care Act.” National Academy for State Health Policy. ( http://www.nashp.org/sites/default/files/LongTermServ%20Final.pdf).
32 OIG Memorandum report (2008). “Trends in Nursing Home Deficiencies and Complaints.” OEI-02-08-00140. ( http://www.oig.hhs.gov/oei/reports/oei-02-08-00140.pdf).
33 U.S. News and World Report (2008). “GAO Faults State Nursing Home Inspections.” May 2008. ( http://www.usnews.com/articles/news/national/2008/05/15/gao-faults-state-nursing-home-inspections.html ).
34 OIG Memorandum report (2008). “Trends in Nursing Home Deficiencies and Complaints.” OEI-02-08-00140. ( http://www.oig.hhs.gov/oei/reports/oei-02-08-00140.pdf).
35 Healthcare Finance News (2008). “Legislation would increase transparency, penalties for nursing homes.” February 2008.
36 Kane, R.A; Lum, T.Y.; Cutler, L.J. et al. (2007). “Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program.” Journal of the American Geriatrics Society, 55(6):832-39. ( www.tlc4ltc.org/news_greenhouse_study.html).
37 Miller, Edward Alan; et al. (2005). “The Commonwealth Fund Long-Term Care Opinion Leader Survey: Top-Level Findings.”
38 Health Affairs News Release (2007). “New Study: In many U.S. Cities, Blacks More Likely Than Whites to Live in Poor Quality Nursing Homes.”
39 GAO (2007). “Medicaid Long-Term Care: Few Transferred Assets before Applying for Nursing Home Coverage.” ( http://www.gao.gov/new.items/d07280.pdf).
24 Long-Term Care Financing Project (2007). “Fact Sheet: National Spending for Long-Term Care.” February. Georgetown University ( http://ltc.georgetown.edu/pdfs/whopays2006.pdf).