Academic Geriatric Resource Center
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AT A GLANCE

Glossary

0. Introduction
1. Demography And Epidemiology
1.1 The Changing Face of Aging: Objectives
1.2 Local and Regional Variations Among Older Adults in the United States
1.3 Implications of an Aging Society for Health Care Needs and Resources
1.4 Common Chronic Conditions Associated with Advanced Age
1.5 Post Test
2. Biology and Physiology of Aging
2.1 Introduction and Background
2.2 Theories of Aging
2.3 Physiological Changes with Aging
2.3.1 Loss of Homeostatic Reserve--Hyperthermia
2.3.2 Loss of Homeostatic Reserve--Hypothermia
2.3.3 Vulnerability of Older Adults to Hypothermia
2.3.4 Clinical Importance of Vulnerability to Hypothermia
2.3.5 Loss of Homeostatic Reserve--Other Examples and Clinical Implications
2.3.6 Clinically Important Age-Related Changes in Organ Systems
2.3.7 Clinically Important Age-Related Changes in the Renal System
2.3.8 Clinical Significance of Age-Related Changes in Renal System
2.3.9 Clinically Important Age-Related Changes in the Cardiovascular System
2.3.10 Clinical Significance of Age-Related Changes in the Cardiovascular System
2.3.11 Clinically Important Age-Related Changes in the Pulmonary System
2.3.12 Clinical Significance of Age-Related Changes in the Pulmonary System
2.3.13 Age-Related Changes in the Neurologic System
2.3.14 Clinical Significance of Age-Related Changes in the Neurologic System (I)
2.3.15 Clinical Significance of Age-Related Changes in the Neurologic System (II)
2.3.16 Clinically Important Age-Related Changes in the Gastrointestinal System
2.3.17 Clinical Significance of Age-Related Changes in the Gastrointestinal System (I)
2.3.18 Clinical Significance of Age-Related Changes in the Gastrointestinal System (II)
2.3.19 Clinically Important Age-Related Changes in the Immune System
2.3.20 Clinical Significance of Age-Related Changes in the Immune System
2.3.21 Clinically Important Age-Related Changes in the Endocrine System (I)
2.3.22 Clinically Important Age-Related Changes in the Endocrine System (II)
2.3.23 Clinical Significance of Age-Related Changes in the Endocrine System
2.3.24 Clinically Important Age-Related Changes in the Musculoskeletal System
2.3.25 Clinical Significance of Age-Related Changes in the Musculoskeletal System (I)
2.3.26 Clinical Significance of Age-Related Changes in the Musculoskeletal System (II)
2.3.27 Clinically Important Age-Related Changes in the Genitourinary System (I)
2.3.28 Clinically Important Age-Related Changes in the Genitourinary System (II)
2.3.29 Clinical Significance of Age-Related Changes in the Genitourinary System
2.3.30 Clinically Important Age-Related Changes in the Sensory Systems
2.3.31 Clinical Significance of Age-Related Changes in the Sensory Systems (I)
2.3.32 Clinical Significance of Age-Related Changes in the Sensory Systems (II)
2.3.33 Clinically Important Age-Related Changes in the Integument
2.3.34 Clinical Significance of Age-Related Changes in the Integument
2.4 Pharmacologic Considerations
2.5 Post Test
3. Socio-cultural And Psychologicial…
3.1 Module Objectives
3.2 Social Theories of Aging
3.3 Psychological Development In Late Life
3.4 Ethno-Cultural Issues And Age-Stratified Societies
3.5 Late-Life Transitions
3.6 Dependent Elders: Special Concerns
3.7 Cultural Views of Death
3.8 References
3.9 Post Test
4. Assessment Of The Geriatric…
4.1 Module Objectives
4.2 Domains of Assessment: Functional Assessment
4.2.1 How to Use Information from a Functional Assessment
4.2.2 Vision Impairment
4.2.3 Hearing Impairment (I)
4.2.4 Hearing Impairment (II)
4.2.5 Oral and Dental Health
4.2.6 Introduction to Oral Health Assessment
4.2.7 Oral Health Assessment
4.2.8 Common Oral Conditions in Older Adults: Tooth Loss (I)
4.2.9 Common Oral Conditions in Older Adults: Tooth Loss (II)
4.2.10 Common Oral Conditions in Older Adults: Care of Dentures
4.2.11 Common Oral Conditions in Older Adults: Dental Decay
4.2.12 Common Oral Conditions in Older Adults: Periodontal Disease
4.2.13 Common Oral Conditions in Older Adults: Candidiasis Infection
4.2.14 Common Oral Conditions in Older Adults: Leukoplakia and the Risk for Oral Cancer
4.2.15 Guidelines for a Dental Referral
4.2.16 Falls and Gait Assessment
4.2.17 Assessing for Falls
4.2.18 Techniques for Gait Assessment
4.2.19 Gait Assessments and Falls Interventions
4.2.20 Risk Factors for Falls and Targeted Interventions
4.2.21 Modification of Risk Factors: Ability to Get Up After a Fall
4.2.22 Modification of Risk Factors: Fracture Risk
4.2.23 Modification of Risk Factors: Anticoagulation
4.2.24 Incontinence
4.2.25 Skin Breakdown: Pressure Ulcers
4.2.26 Cognition/Dementia
4.2.27 Benefits of Early Detection of Dementia
4.2.28 Screening Techniques for Dementia
4.2.29 Decision-Making about Dementia Screening
4.2.30 Nutrition
4.2.31 Alcohol Use and Alcoholism
4.2.32 Medication and Complementary Therapies
4.2.33 Case Example: Mr. Singh
4.2.34 Mr. Singh--Use of Herbal Medicines
4.2.35 Mr. Singh--Possible Interventions
4.2.36 Mr. Singh--Concerns about Marathon Running at 92?
4.2.37 Mr. Singh--Considerations for Patient/Family Well-Being
4.2.38 Assessing for Polypharmacy (I)
4.2.39 Assessing for Polypharmacy (II)
4.3 Domains Of Assessment: Psychosocial Health And Functioning
4.4 Special Considerations In Assessment
4.5 Post Test
5. Health Care Policies
5.1 Module Objectives
5.2 The Policy-Making Process
5.3 Financing Health & Long Term Care
5.4 Quality Of Care Issues In Long Term Care
5.5 Need And Access Across The Spectrum Of Care
5.6 References
5.7 Post Test
6. Exploring Age-Related Body…
6.1 Cardiovascular System
6.2 Endocrine System
6.3 Immune System
6.4 Musculo-Skeletal System
6.5 Neurological System
6.6 Renal System
6.7 Post Test

Module 5: Health Care Policies

5.1: Module Objectives


Upon completion of this module, participants will be able to:

  1. Define categories and types of health policies relevant to older persons and persons with disabilities.
  2. Describe the policy-making process.
  3. Identify critical financing and cost policies that are important to older adults and those with disabilities.
  4. Describe quality problems in long term care and identify policies to address the quality issues.
  5. Discuss access problems to appropriate long term care services encountered across the spectrum of care.
  6. Delineate long term care labor market problems and the factors that impact on the labor market.
  7. Discuss steps that can be taken to address long term care policy issues.

 

5.2: The Policy-Making Process


Major Policy-Making Processes: Legislative Actions

There are four major avenues through which public policies are made: (1) legislative, (2) administrative, (3) budgetary, and (4) judicial. Legislative actions are taken by elected representatives of the public (state legislators or Congress). At the national level, districts are established for the public to elect members of the House of Representatives and the Senate. Bills passes by the legislative branch must be signed by the head of the executive branch (the governor at the state levels or the President at the national level).

Chart indicating how a bill becomes a law

5.3: Financing Health & Long Term Care


Sources for Financing Long Term Care I

Medicare and Medicaid (called MediCal in California) are the primary public programs that pay for long term care.

Chart suporting below stats

Total expenditures for long term care were $150.8 billion in 2003. Almost three-quarters ($111 billion) was spent on nursing homes, with the remainder providing funds for home health.

The Centers for Medicare & Medicaid Services (CMS) (note: this link will open in a new browser window; close it to return here) provides national statistics on health care expenditures, data on Medicare and Medicaid, all CMS manuals, regulations, transmittal letters to states, descriptions of the programs, internet guide to nursing home comparisons, etc.

5.4: Quality Of Care Issues In Long Term Care


Nursing Facilities and Quality of Care

About 18,000 nursing facilities in the U.S. provide care to 1.63 million adults with disabilities that require nursing care (NCHS, 2002). Approximately 90% of these individuals are aged 65 years or and older, with younger persons with severe disabilities comprising the remaining 10% (NCHS, 2002). Most need assistance with bathing, dressing, and toileting and have many chronic and/or acute illnesses that require 24-hour nursing care services. Nursing homes must comply with state licensing laws in order to provide services and comply with federal regulatory standards if they want to provide care to individuals qualified for Medicare and Medicaid services. The federal rules require periodic surveys of nursing facilities for compliance with these requirements. Since the early 1970s, there have been studies by the US Senate about poor quality of nursing home care (US Senate Special Committee on Aging, 1963-1974). In 1983, when President Reagan planned to deregulate nursing facilities, Congress asked the Institute of Medicine (IOM) to conduct a study about nursing home regulation. The Institute published its report entitled Improving the Quality of Care in Nursing Homes in 1986 (IOM, 1986).

5.5: Need And Access Across The Spectrum Of Care


Demand for Long Term Care Facilities

The supply of long term care beds in the U.S. has changed over the last decade. Between 1990 and 2000, there was a 9% increase in the number of nursing home beds in the U.S. However, between 2000 and 2002, there was a reduction of approximately 41,000 beds. For residential care facilities, the number of beds nearly doubled between 1990 and 2002. The number of ICF/MR beds steadily declined between 1990 and 2002, resulting in a decrease of nearly 38,000 beds.
 
Chart supporting above stats  Chart supporting above stats

Even though the elderly population has increased substantially in the last few years, nursing home occupancy rates are declining. Between 1997 and 2003, there was a steady decrease in the nursing home occupancy rate. Nationally, over 1 million beds are available in licensed supportive housing including residential care and assisted living, foster family homes, group homes, and social rehabilitation facilities (Harrington et al., in press). An equal number probably live in unlicensed boarding homes (Newcomer & Maynard, 2001). Little is known about supply and demand for residential care. Although there was a rapid increase in the number of assisted living facilities in the 1990s, some of the growth replaced existing facilities or consolidated facilities under large corporate ownership or management.

5.6: References


Arno, P.S., Levine, C., & Memmott, M.M. (1999). The economic value of informal caregiving. Health Affairs, 18(2), 182-188.

Block, L.E. (2004). Health policy: what it is and how it works. In C. Harrington & C.L. Estes (Eds.), Health Policy (pp. 4-14). Sudbury, MA: Jones & Bartlett.

Board of Trustees, Federal Old-Age and Survivors Insurance and Disability Insurance Trust Funds. (2004). The 2004 Annual Report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Disability Insurance Trust Funds. Downloaded from the website: http://www.ssa.gov/OACT/TR/TR04/ on April 13, 2005.

Bureau of Labor Statistics (BLS). (2005). National industry-occupation employment matrix. Downloaded from the website: http://data.bls.gov/oep/nioem/empiohm.jsp on April 13, 2005.

Burwell, B., Sredl, K. & Eiken, S. (2004). Medicaid LTC Expenditures in FY 2003. Medstat: Cambridge, MA.

Centers for Medicare and Medicaid Services (CMS). (2001). Prepared by ABT Associates Inc. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress: Phase II Final. Volumes I-III. Baltimore, MD: CMS.

Centers for Medicare & Medicaid Services (CMS). (2004a). Frequently asked questions: What are the Medicaid premiums and coinsurance rates for 2005? Downloaded from the website:http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_adp.php?p_faqid=1560&p_created=1095443945&p_sid=di17zyBh&p_lva=&p_sp=cF9zcmNoPSZwX3NvcnRfYnk9JnBfZ3JpZHNvcnQ9JnBfcm93X2NudD0zNDcmcF9wYWdlPTE*&p_li= on April 13, 2005. Last updated on September 20, 2004.

Centers for Medicare & Medicaid Services (CMS). (2004b). Health and Health Care of Medicare Population (2000). Chapter 2, Trends in the MCBS: 1992-2000. Downloaded from the website: http://www.cms.hhs.gov/mcbs/MCBSsrc/2000/00cb2.pdf on April 13, 2005. Last updated on September 23, 2004.

Centers for Medicare & Medicaid Services (CMS). (2005). Medicaid Statistical Information Systems (MSIS), Fiscal Year 2002. Downloaded from the website: http://www.cms.hhs.gov/medicaid/msis/tables2002.asp on April 13, 2005. Last updated on February 14, 2005.

Chapman, S., Kaye, S., and Newcomer, R. (2005). Center for Personal Assistance Services, tabulations of public use microdata from the 2003 American Community Survey. Downloaded from website:
http://www.pascenter.org/state_based_stats/acs_workforce_all.php?title=Number+of+Home+and+Personal+Care+Workers+by+State Last updated on February 18, 2005.

Families USA. (2005). The New Medicare Drug Benefit: How Much Will You Pay? Downloaded from the website: http://www.familiesusa.org/site/DocServer/Benefits_table_.pdf?docID=2761 on April 13, 2005.

Federal Interagency Forum on Aging Related Statistics. Older Americans 2004: Indicators of Well-Being. Federal Interagency Forum on Aging Related Statistics. Washington, D.C. U.S. Government Printing Office. November 2004.

General Accounting Office (GAO). (1998). California nursing homes: Care problems persist despite federal and state oversight. Report to the Special Committee on Aging, U.S. Senate. GAO/HEHS-98-202. Washington, DC: Author.

General Accounting Office. (1999a). Assisted living quality of care and consumer protection issues in four states. GAO/HEHS-99-27. Washington, DC: Author.

General Accounting Office. (1999b). Nursing homes: Additional steps needed to strengthen enforcement of federal quality standards. Report to the Special Committee on Aging, U.S.Senate. GAO/HEHS-99-46. Washington, DC: Author.

General Accounting Office. (2001a). Health workforce: Ensuring adequate supply and distribution remains challenging. GAO-01-1042T. Washington, DC: Author.

General Accounting Office. (2001b). Long-term care: Implications of Supreme Court’s Olmstead decision are still unfolding. GAO-01-1167T. Washington, DC: Author.

Grassley, Charles, Senator, Senator John Breaux, & Senator Jack Reed. (2000, October 6). Nursing Home Improvement Act of 2000 (S 3177). News Release, US Senate Special Committee on Aging.

Harrington, C., Chapman, S., Miller, E., Miller, N., and Newcomer, R.(in press). Trends in the Supply of Long-Term Care Facilities and Beds in the United States. The Journal of Applied Gerontology.

Harrington, C. (2005). Nurse Staffing in Nursing Homes in the United States Part II. Journal of Gerontological Nursing 31(3), p. 9-15.

Harrington, C., Carrillo, H., & Crawford, C. (2004). Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1997 Through 2003. Department of Social and Behavioral Sciences: San Francisco, CA.

Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Burger, S., Mohler, M., Burke, R., & Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the United States. The Gerontologist, 40, 5-16.

Hawes, C., Wildfire, J.B., & Lux, L.J. (1993). The regulation of board and care homes: Results of a 50-state survey. Washington, DC: American Association of Retired Persons.

Hawes, C., Rose, M., & Phillips, C.D. (1999). A national study of assisted living for the frail elderly: Results of a national survey of facilities. Beachwood, OH: Myers Research Institute.

Hawes, C., Phillips, C.D., Rose, M., Holan, S., and Sherman, M. (2003). A National Survey of Assisted Living Facilities. The Gerontologist 43(6): 875-882.

Health Care Financing Administration. (2000). Report to Congress: Appropriateness of minimum nurse staffing ratios in nursing homes, Volumes I-III. Baltimore, MD: Author.

Health Resources and Services Administration (HRSA).(2001). The Registered Nurse Population: Findings from The National Sample Survey of Registered Nurses. U.S. Department of Health and Human Services: Washington, D.C.

Health Resources and Services Administration (HRSA). (2003) Changing Demographics: Implications for Physicians, Nurses, and Other Health Workers. U.S. Department of Health and Human Services: Washington, D.C.

Heffler, S., Levit, K., Smith. S., Smith, C., Cowan, C., Lazenby, H. and Freeland, M. (2001). Health spending growth up in 1999; Faster growth expected in the future. Health Affairs, 20(2), 193-203.

Heffler, S., Smith, S., Won, G., Clemens, M.K., Keehan, S., and Zezza, M. (2002). Health Spending Projections for 2001-2011: The Latest Outlook. Health Affairs 21(2): 207-218.

Institute of Medicine (IOM), Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes. (1986). Nursing staff in hospitals and nursing homes: Is it adequate? Washington, DC: National Academy Press.

Institute of Medicine (IOM). Wunderlich, G.S., & Kohler, P. (Eds.). (2001). Improving the quality of long-term care. Washington, DC: National Academy of Sciences, Author.

Kaiser Family Foundation (KFF). (2005). Medicare Fact Sheet: The Medicare Prescription Drug Benefit. Publication #7044-02.
Downloaded from the website: www.kff.org on April 13, 2005.

Kaiser Family Foundation (KFF). (2003). Medicare Fact Sheet: Medicare and Prescription Drugs. Downloaded from the website: http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14186 on April 13, 2005.

Kane, R.A., & Kane, R.L. (1987). Long-term care: Principles, programs, and policies. New York: Springer Publishing Company.

Kitchener, M., Ng, T., Miller, N., & Harrington, C. (2005). Medicaid Home and Community-Based Services: National Program Trends. Health Affairs, 24(1): 206-212.

Kitchener, M., Ng, T., & Harrington, C. (2004). Medicaid 1915(c) Home and Community-Based Services Waivers: A National Survey of Eligibility Criteria, Caps, and Waiting Lists. Home Health Care Services Quarterly 23(2): 55-69.

Klemm, J.D. (2000). Medicaid Spending: A Brief History. Health Care Financing Review, 22(1), 105-112.

Konetzka, R.T., Stearns, S.C., Konrad, T.R., Magaziner, J., and Zimmerman, S. (2005). Personal Care Aide Turnover in Residential Care Settings: An Assessment of Ownership, Economic, and Environmental Factors. The Journal of Applied Gerontology 24(2): 87-107.

LaPlante, M., Harrington, C., & Kang, T. (2002). Estimating paid and unpaid hours of personal assistance services in activities of daily living provided to adults living at home. Health Services Research, 37(2), 397-415.

LaPlante, M., Kaye, H.S., Kang, T., and Harrington, C. (2004). Unmet need for personal assistance services: Estimating the shortfall in hours of help and adverse consequences. J. Gerontol. B. Psychol. Sci. Soc. Sci. 59: S98-S108.

Levit, K.R., Cowan. C., Lazenby, H.C., Sensenig, A. McDonnell, P, Stiller, J., Martin, A. and the Health Accounts Team. (2000). Health spending in 1998: Signals of change. Health Affairs, 19(1), 124-132.

Levit, K., Smith, C., Cowan, C., Lazenby, H. & Martin, A. (2002). Inflation spurs health spending in 2000. Health Affairs, 21(1), 172-181.

Max, W. (2004). Economic analysis in health care. In C. Harrington & C.L. Estes (Eds.), Health policy (pp. 260-270). Sudbury, MA: Jones & Bartlett.

Medicare Payment Advisory Commision (MedPAC). (2004a). Report to the Congress: Medicare Payment Policy. MedPAC: Washington, DC.

Medicare Payment Advisory Commision (MedPAC). (2004b). A Data Book: Healthcare Spending and the Medicare Program. MedPAC: Washington, DC.

Medicare Payment Advisory Commission (MedPac). (2002). Report to Congress: Medicare payment policy. Washington, DC: Author.

National Center for Health Statistics. (2002). The National Nursing Home Survey: 1999 Survey. Downloaded from the website: http://www.cdc.gov/nchs/data/nnhsd/nnhs99currentres_selectedchar.pdf

National Center for Health Statistics. (2004a). Table 1. Number of home health and hospice care agencies, current patients, and discharges: United States, 1992, 1994, 1996, 1998, and 2000. Downloaded from the website: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/NHHCS/Trends/TABLE1HHC2000.pdf on April 13, 2005. Last updated on December 16, 2004.

National Center for Health Statistics. (2004b). Table 1. Number, percent distribution, and rate per 10,000 population of home health care discharge by age, according to sex, race, and region: United States, 2000. Downloaded from the website: http://www.cdc.gov/nchs/data/nhhcsd/homecaredischarges00.pdf on April 13, 2005. Last updated February, 2004.

National Center for Health Statistics. (2004c). Table 1. Number, percent distribution, and rate per 10,000 population of hospice care discharge by age, according to sex, race, and region: United States, 2000. Downloaded from the website: http://www.cdc.gov/nchs/data/nhhcsd/hospicecaredischarges00.pdf on April 13, 2005. Last updated February, 2004.

National Center for Health Statistics. (2004d). Table 1. Number, percent distribution, and rate per 10,000 population of current home health care patients by age, according to sex, race, and region: United States, 2000. Downloaded from the website: http://www.cdc.gov/nchs/data/nhhcsd/curhomecare00.pdf on April 13, 2005. Last updated February, 2004.

Newcomer, R., & Maynard, R. (2001). Residential care for the elderly: Supply, demand and quality assurance. (Report for the California Healthcare Foundation, pp. 1-75). San Francisco, CA: University of California.

Office of Management and Budget (OMB). (2004). Budget of The United States Government, Fiscal Year 2005. Downloaded from the website: http://www.whitehouse.gov/omb/budget/fy2005/tables.html on April 13, 2005.

Olmstead v. L.C., 527 U.S. 581. (1999).

Omnibus Budget Reconciliation Act of 1987 (OBRA). (1987). Public Law 100-203. Subtitle C: Nursing Home Reform. Washington, DC: U.S. Government Printing Office.

Phillips, C.D. & Hawes, C. (2005). Care Provisions in Housing With Supportive Services: The Importance of Care Type, Individual Characteristics, and Care Site. The Journal of Applied Gerontology 24(1): 55-67.

Provost, C. (2000). Medicaid: 35 years of services. Health Care Financing Review, 22(1), 141-153.

Senate Special Committee on Aging. (1963-1974). Special Hearings on Nursing Homes. Washington, DC: U.S. Senate.

Smith, C., Cowan, C. Sensenig, A., Catlin, A., and the Health Accounts Team. (2005). Health Spending Growth Slows in 2003. Health Affairs, 24(1): 185-194.

Social Security Administration, Office of Policy (2004). Fast Facts & Figures About Social Security, 2004. Washington, D.C.: Social Security Administration. http://www.ssa.gov/policy/docs/chartbooks/fast_facts/2004/ff2004.pdf

Stone, R.I., with Wiener, J.M. (2001). Who Will Care for US? Addressing the Long-Term Care Workforce Crisis. Washington, DC: Urban Institute and American Association of Homes and Services for the Aging.


Module 5: Health Care Policies
4.5 Post Test
5.1 Module Objectives