American Journal of Nursing 2000 February Volume 100, Issue 2

How Long-Term Care Is Changing

For the past several years, the long-term care (LTC) system has been transformed by the many alternatives to nursing homes. Today, long-term care is provided in assisted living and continuing-care retirement communities, community-based centers, or in the home. Less than 5% of elderly individuals—approximately 1.4 million—live in nursing homes.

Part of the transformation is driven by consumer demand, a trend that will grow as the population ages and more national attention is focused on health care in general. “The future of long-term care has yet to be fully realized,” says Arizona Nurses Association member Marge Drugay, ND, RN,C, of Arizona’s Drugay & Associates—Consultants on Healthy Aging. “We have an imperative to create new solutions to old problems. Long-term care—institutional, community-based, or in the home—will become more responsive to consumer needs and must seek new ways to address workforce issues. Reimbursement issues must also be addressed now, with options designed to address future needs. We cannot afford to wait one more day.”

While the skilled nursing care facility certainly has its place, the ANA believes most LTC services can and should be provided within a community-based health care delivery system, using a care management approach. In addition, while LTC primarily meets the needs of the elderly, other population groups, such as people with disabilities or people with AIDS, also benefit from it. In fact, the ANA reframed its definition of LTC in the mid-1990s to reflect a broader scope, encompassing all population groups and allowing for more varied care settings.

Current LTC Nursing Practice

This change in attitude has led to increased client numbers and a change in the definition of the “typical” nursing home resident. With a growing elderly population comes a need for more LTC nurses and more advanced LTC education.

“Historically, there has been a lack of professional nurses educated to provide care to geriatric and other clients with long-term care needs. In recent years, however, this has been addressed by establishing an increasing number of gerontologic and rehabilitative nursing programs at the master’s level,” notes Arkansas Nurses Association member Cornelia Beck, PhD, RN, FAAN, who represents the ANA on the Joint Commission on the Accreditation of Healthcare Organizations’ Professional and Technical Advisory Committee on Long Term Care. She is a professor in the department of geriatrics, College of Medicine, at the University of Arkansas for Medical Sciences in Little Rock, Arkansas.

Beck also said general gerontologic and rehabilitative content is being integrated into baccalaureate nursing curricula or taught in courses on geriatric nursing. She cited the programs promoting geriatric nursing education and research at the John A. Hartford Institute for Geriatric Nursing at the division of nursing at New York University.

Nursing practice is currently expanding from the extended-care facility into the community. In fact, nurses have taken the lead in providing community-based care, most notably by developing community nursing organizations (CNOs). Supported by the federal government, CNOs are nurse-operated managed care programs that offer Medicare benefits to the elderly in noninstitutional settings. Since their inception in 1994, CNOs have been praised for delivering high-quality, cost-effective care. One of the CNOs, the Living at Home/Bloc Nurse Program in St. Paul, Minnesota, was lauded in U.S. News and World Report two years ago as an innovative solution to helping the elderly. The other CNOs are Carondelet Health Care in Tucson, Arizona, Carle Clinic in Urbana, Illinois, and the Visiting Nurse Service of New York in Long Island, New York.

“This program really recognizes nurses as primary care providers,” says Minnesota Nurses Association member Linda Robertson, MPH, RN. “The CNOs have been able to keep people independent and out of nursing homes.” Another program, the Program for All-inclusive Care for the Elderly (PACE), has grown out of the highly regarded On Lok program, an early demonstration of integrated acute care and long-term care for nursing-home-level, low-income clients in San Francisco’s Chinatown.

LTC's Future

As the large baby-boom generation ages, LTC will continue to be a hot issue. While LTC nursing education has advanced in recent years, more is needed, specifically continuing education programs for those in or interested in LTC practice. Programs should include physical assessment of the geriatric patient, utilizing the minimum data set (MDS), a tool that is critical to the future of facility-based long-term care. The MDS can be used in the community when integrated with the Outcome and ASsessment Information Set (OASIS) to ensure the comprehensive assessment required by the Health Care Financing Administration.

Nursing practice in LTC will also need to continue to evolve, for it will eventually move from the community to the home. Home care accentuates the differences between cure and care, illness and wellness, dependence and independence, and most important, between medicine and nursing.

Despite its obvious benefits, home health care took a financial setback in the 1997 Balanced Budget Act, which put several home health care agencies and nursing homes under severe financial strain. (See The American Nurse, Nov–Dec. 1999, “The BBA: A Case of Saving Money, Sacrificing Care.”) Several groups lobbied, including the ANA and individual nurses, and this fall Congress passed legislation rectifying the cuts. It remains to be seen if the changes will aid struggling home health care agencies.

What the ANA is Doing

Besides lobbying for legislation to address funding needs and reimbursement issues in long-term care, the ANA is collaborating with other groups to reach consensus on standards of gerontologic nursing practice and to advance nursing’s LTC agenda. To help meet the continuing education needs of LTC nurses, the ANA developed Prospective Payment for Long-Term Care, a video and workbook designed to update registered nurses’ knowledge of the MDS.

“With increasing age, there are more chronic illnesses, and as the professional nurse’s focus is on the effect of illness on the ability of individuals to do what they need or want to do, it is evident that registered nurses can provide or direct much of the formal health care in both institutional and community long-term care settings,” states Linda C. Mondoux, MS, RN, CDONA, NHA, of Strat LTC, a Michigan consulting firm, and former president of the Michigan Nurses Association. “Certainly, advanced practice nurses can have a major role in diagnosing and intervening in both chronic and acute conditions of the elderly, and in making referrals, as appropriate, to other members of the interdisciplinary team.”