The population of older adults in the United States has grown exponentially over the past few decades. This chapter looks at the unique challenges of meeting the comprehensive healthcare needs of this population. It examines the implications for social policy and gerontological practice and highlights the current models of entitlements and support services for older adults. The chapter also illustrates knowledge and skills required by social workers in this field, and discusses the recommendations for holistic competence. It focuses on four federal social policies that have guided the development of healthcare in the United States. These policies have had a substantial impact on who is eligible for services, the type of services one is entitled to, the quality of services provided, and ultimately the lives of individuals affected by them. The four major social policies are Medicare, Medicaid, the Older Americans Act (OAA), and the Supplemental Nutritional Assistance Program (SNAP).

Long-term care involves the financing and delivery of an array of health and social services to the aged and disabled. In contrast to acute care, which is disease based and curative in orientation, the orientation of long-term care is inherently holistic and function based. The scope of long-term care policies and services thus encompasses the aged, the developmentally disabled, the chronically ill, and persons disabled by trauma. Although both the biological and demographic realities of an aging population and principles of intergenerational justice should propel us toward a feasible approach to the long-term care insurance (whether in the form of social insurance, a normative shift toward the broadscale investments in private long-term care insurance that will reduce the growth of Medicaid long-term care expenditures), the political path to a coherent and effective national long-term care financing strategy remains elusive.

The focus of all good care is to determine need. Long-term care (LTC) is not an extension of acute care—it is distinctive in its very nature. Because LTC continues for prolonged periods, it becomes enmeshed in the very fabric of people’s lives. Screening for LTC is one way in which the federal government and, in particular, a state attempts to eliminate unnecessary or premature placement of older or disabled individuals in nursing homes. There are two types of screening: those for a level of care (LOC) involving just medical need and those that address additional factors of care need, which assess issues such as mental illness, development disabilities, and intellectual disabilities. The determination of LOC addresses whether the individual’s care needs meet criteria for a stay in a nursing facility long term. This chapter provides an overview of long-term care screenings and how the Omnibus Budget Reconciliation Act (OBRA) has and continues to impact this process.

Funeral arrangements are often difficult for people in our culture to discuss. Indeed, for many, the issue of dying and death and the process of making decisions around a person’s death are almost taboo. During the admissions process, social workers can address the topic of funeral arrangements as a general issue. The simple question “Have you, or the resident, a preference for a funeral home?” can open the door to discussions of end-of-life decisions, as well as reveal tensions over illness, loss, and dying. The social worker can assist the family with addressing funeral arrangement issues by discussing the Medicaid application where prepaid funeral arrangements can be an allowable expense. Social workers in nursing facilities are in a prime position to help residents and their families around this key advanced directive issue, and this chapter outlines the key elements of funeral arrangements and other issues related to death in the nursing facility.

There is no paradox that equals that found in the system of health care finance in the United States. The purpose of this chapter is to provide the reader with a general understanding of the dynamics of this paradox, its origins, and the ways in which it is sustained. To accomplish this, the chapter reviews the system of health care finance in the United States, both in terms of its current organization and in the evolvement of its unique structure. The topics include the magnitude and distribution of health care expenditures in the United States, the relative contributions of government and private sector forms of insurance, the fundamentals of risk and insurance, alternative models of health insurance finance and provider structures, and a detailed description of Medicare, Medicaid, and more recent policy initiatives in the public financing of health care.

Room changes may present controversies for social workers for a variety of reasons. Over time, the room and the staff become familiar to the resident and the resident’s family. When rehabilitation is complete and residents remain long term, they are often reluctant to shift to another room even within the same facility because of their familiarity with the physical location and association with the staff. However, most facilities have specific areas for short- and long-term stays. The reasons for this vary, but primarily, rooms that are used for short-term stays may not have the same features as those used for long-term stays. Additional reasons for a room change can include the following: moving a resident because of a medical condition (e.g., infection or precautions) that indicates a need for isolation or more observation; moving a resident at the request of either the resident or the family; moving a resident in order to access a particular section of the facility, such as a specialized Alzheimer’s Unit; moving a resident to support a facility administrative need; and moving a resident because of a change in the status of payment.