CHAPTER TWO
Clients of the Continuum
Subsets of LTC Clients
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Functional Status
Need vs. Demand
Static vs. Dynamic
Short-Term LTC vs. Long-Term LTC
Institutional vs. Community-Based Care
Functional Status
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The primary consideration that makes
an individual appropriate for LTC
Multiple Dimensions
– physical
– cognitive
– emotional
– social
Functional Status
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Activities of Daily Living (ADL)
– most commonly used measure of physical
functioning; basic activities necessary for
personal care
– bathing, dressing, toileting, transferring,
continence control, and eating
– scale
•
•
•
•
1 = totally independent
2 = requiring mechanical assistance
3 = requiring assistance from another person
4 = unable to do the activity at all
Functional Status
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Instrumental Activities of Daily Living
– activities necessary to live independently in
the community
– preparing meals, grocery shopping,
personal shopping, managing money,
telephoning, housekeeping, and doing
chores
Functional Status
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Both ADLs and IADLs decline with
advancing age
– 65-70 y.o.
• 10% men; 11% women
– 75-84 y.o.
• 18% men; 28% women
– 85+ y.o.
• 46% men; 62% women
Need vs. Demand

Need
– considered to be the result of a professional
judgment that a specific service or treatment
should be provided to an individual in order to
improve his condition

Demand
– an individual’s overt request for a service or
treatment, presumably the result of a perceived
deficit and a belief in the benefits of the requested
service or treatment
Need vs. Demand

Not perfectly correlated
– professional’s judgment vs. client’s needs

Distinction important in LTC because
needs are multidimensional
– difficult for providers to recognize need
– clients may not want to admit a loss of
independence, demand may be weak
Dynamic vs. Static

Static perspective
– no immediate needs; functionally independent,
have a well-established support network, and
stable health conditions
– modest needs; relatively complicated problems
that require more assistance than their informal
networks can provide
– severe needs; more complicated ongoing
problems or acute flare-ups of otherwise
manageable problems
Dynamic vs. Static
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Dynamic perspective
– needs can range over time from no need, to
moderate need, to acute need--and back again
Short-Term vs. Long-Term LTC
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Short-term LTC
– clients whose complex problems are rapidly
changing and who require care for a short period
of time but with greater coordination than the
patient or family can expect to handle without
formal or professional assistance
– in need of an integrated continuum of care due to
functional disabilities
– use of formal services is finite
Short-Term vs. Long-Term LTC
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Short-term LTC
– clients are characterized by their rapidly changing
patterns of needs, by an expectation of recovery
or rehabilitation, and by their shorter reliance on
an integrated continuum
– etiologies of their present conditions are specific
and of short duration (recent stroke, surgery,
accident, or change of family situation that causes
temporary dysfunctioning
Short-Term vs. Long-Term LTC
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Long-term LTC
– clients whose complex problems likely will require
multifaceted care over an extended or indefinite
interval
– clients tend to have chronic, persistent, multiple
problems with etiologies that are permanent
– clients functional abilities may vary of time, but
tend to decline rather than improve
– the majority of clients that are able to stay in their
own homes with specific types of assistance have
worked out informal relationships with friends and
families to provide the assistance they need
Short-Term vs. Long-Term LTC

Long-term LTC
– some clients depend on the formal system and
pay out-of-pocket for help on a regular or
intermittent basis
– a relatively small number of clients --about 5%-have health conditions and/or functional
disabilities too great or support systems so
minimal that they cannot remain in their homes
and reside in institutions (e.g., nursing homes,
adult group homes)
Short-Term vs. Long-Term LTC
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Providers may serve both short-term
LTC and long-term LTC clients, as well
as acute patients
Reasons for making distinctions include
– staffing assignments
– reimbursement policies
– efforts to educate patient and family about selfcare
Institutional vs. CommunityBased Setting
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Factors that determine setting include
– family support and social structure
– marital status
– home owner status
– financial situation
– state and federal regulations
Institutional vs. CommunityBased Setting
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Long-term care services can be
provided to people regardless of their
location of residence
30% of people admitted to nursing
homes leave within 90 days; 50% leave
within one year
Subsegments of LTC Clients
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Older Adults
People with Disabilities
Mentally Impaired, Mentally Retarded,
Developmentally Disabled
AIDS/ARC
Acute Episode Patients
Older Adults
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Characterized by advanced age, particularly
age 75 and above
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Largest group of potential users
– numerous undiagnosed and diagnosed
pathologies that impair independent functioning
– chronic illnesses
– frailty of advanced age
– acute episodes with long recovery periods
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In 1997, 1.5 m persons 65+ were in nursing
homes, representing 4% of the older
population
Number of Persons 65+
70
60
50
40
30
20
10
0
1900 1920 1940 1960 1980 1990 2000 2010 2020 2030
Older Adults
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Older population will continue to grow
significantly in the future
By 2030, there will be about 70 million older
persons, more than twice the number in 1998
People 65+ are projected to represent 13% of
the population in the year 2000 but will be 20%
by 2030
In the US, 21.5% of civilian, noninstitutionalized
persons are 60+; 13% are 65+; 1.2% are 85
years and older
Older Adults
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Elderly population is growing at a faster rate
than the population as a whole
The population 85+ is growing faster than the
elderly population as a whole
– between 1960 and 1994, their numbers rose
274%
– the elderly population in general rose 100%; the
entire US population grew only 45%
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1/2 of the current elderly residents of nursing
homes were 85+
Older Adults
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During the 1990s, the number of
centenarians nearly doubled
– from about 37,000 counted at the start of the
decade, to more than an estimated 70,000 today
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This per-decade doubling trend may
continue
– the centenarian population in the US could
possibly reach 834,000 by 2050
Older Adults
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Limitations on activities because chronic
conditions increase with age
In 1996, over 1/3 (36.3%) of older adults
reported that they were limited by chronic
conditions
– Among all elderly, 10.5% were unable to carry on
a major activity
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In contrast, only 10.3% of the population
under 65 were limited in their activities
– only 3.5% were unable to carry on a major activity
Top 10 Chronic Conditions
Among Older Adults (1996)
Chronic Condition
Arthritis
Hypertension
Hearing Impairment
Heart Conditions
Cataracts
Orthopedic Impairment
Sinusitis
Diabetes
Tintinitus
Visual Impairment
45-64
240
214
132
116
23
178
174
58
60
48
65+
483
364
303
269
172
158
117
100
88
84
Top 10 Chronic Conditions
Among Older Adults (1996)
Chronic Condition
Arthritis
Hypertension
Hearing Impairment
Heart Conditions
Cataracts
Orthopedic Impairment
Sinusitis
Diabetes
Tintinitus
Visual Impairment
1987
480
394
296
277
141 (7)
173 (5)
169 (6)
98 (8)
85 (10)
95 (9)
1996
483
364
303
269
172
158
117
100
88
84
Older Adults
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Accounted for 36% of all hospital stays
and 49% of all days of care in hospitals
in 1997
ALOS was 6.8 days for older people,
compared to only 5.5 days for people
under 65
Averaged more contacts with doctors in
1997 than did persons under 65 (11.7
contacts vs. 4.9 contacts)
Functional Disability
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In the US, 17.3% of persons 60+ and 49.8%
of those 85+ have a self-care or mobility
limitation or both
1.2 million fewer older adults were disabled in
1994 than would have been expected based
on disability rates observed in 1982
– the number of older adults with functional
problems in 1994 stood at 7.1 million, not the 8.3
million who would have been impaired if health
had not improved over the last few years
Functional Disability
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Many factors may be involved in the decline
in disability
–
–
–
–
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public health measures and nutrition
higher levels of education
improved economic status
medical advances
In order to maintain and accelerate the
decline, we need to pinpoint how each of
these factors is contributing to the improved
health of older adults
Functional Disability (1987)
Age
Needs Help with1 or
more ADLs
Needs Help with 1
or more IADLs
65-69
14.7
19.9
70-74
21.1
24.7
75-79
24.1
29.2
80-85
34.4
40.0
85+
49.8
55.2
Functional Disability (1995)
Age
% with Any
Disability
% with Severe
Disability
65+
52.5
33.4
15-64
18.7
8.7
0-14
9.1
1.1
Functional Disability
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In 1996, 27% of older adults assessed their
health status as fair or poor
Over 4.4 million (14%) had difficulty in
carrying out ADLs and 6.5 million (21%)
reported difficulties with IADLs
Percentages with disabilities increase sharply
with age; race and gender are also factors
– women more likely than men to be disabled
– blacks more likely than whites to be disabled
People with Disabilities
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Children or adults with permanent
disabilities
–
–
–
–
–
–
–
neurological diseases
degenerative conditions
accidents resulting in paralysis
children with congenital dysfunctions
paralyzing strokes
end-stage cancers
blindness
Mentally Impaired & Retarded,
Developmentally Disabled
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Biomedical and technological advances in
treatments and management now allow large
numbers to live long lives
Difficult to estimate precisely the number of
people in this group who might be clients for
a long-term continuum of care
Although the majority are treated on an
outpatient basis, an integrated continuum
oriented toward mental health services would
be appropriate
AIDS/ARC
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Unless substantial inroads are made in the
search for a cure or a vaccine, the numbers
of infected people are expected to grow
dramatically
– the CDC estimates that between 650,000 and
900,000 people are living with HIV
– at least 40,000 new infections occur each year
– through December 1998, a total of 688,200 cases
of AIDS had been reported to the CDC
AIDS/ARC
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The majority of HIV+/AIDS/ARC people
will be clients for an effective continuum
at some stage of their illness
– new treatments have extended the healthy
lifespan of many people with AIDS
Acute Episode Patients
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Total number difficult to estimate
because it is a composite of all of the
people who have certain acute illnesses
that may involve long-term care
Alzheimer’s Disease
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Affects an estimated 4 million Americans
– Approximately 19 million Americans say they have
a family member with Alzheimer’s and 37 million
know someone with it
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Manifested initially by mild forgetfulness, this
devastating disease eventually erodes all
cognitive and functional abilities, leading to
total dependence on caregivers and,
ultimately, to death
Alzheimer’s Disease
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Prevalence increases dramatically with age
– age 65-74 have 1 in 10 chance of having it
– age 85+ have 1 in 2 chance of having it
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14 million Americans will have Alzheimer’s by
the middle of this century unless a cure or
prevention is found
US society spends at least $100 billion a year
on Alzheimer’s Disease
– neither Medicare nor private health insurance
covers the type of LTC most patients need
Alzheimer’s Disease
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A person with Alzheimer’s lives an average of
8 years and as many as 20 years or more
from the onset of symptoms
More than 7 out of 10 people with Alzheimer’s
live at home
– almost 75% of home care is provided by family
and friends; remainder is “paid” care costing an
average of $12,500 per year, most of which is
covered by families
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Half of all nursing home patients suffer from
Alzheimer’s or a related disorder