This chapter examines the history of long-term services and supports (LTSS) programs to document their racially and ethnically disparate impact, and explain the current research on the access and quality of LTSS used by older adults in communities of color. LTSS are a set of health and social services delivered over a sustained period to people who have lost or never acquired some capacity for personal care. The high costs of LTSS have led a smaller number of low-income older adults to consume a large share of Medicaid expenditures. Cultural beliefs about family responsibility to care for older adults as well as attitudes toward the use of formal and/or public health and long-term care services can shape older adults’ use of LTSS. The coming sociodemographic shift of older minority adults calls attention to other structural and cultural issues that facilitate or inhibit the appropriate use of LTSS.

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).

The care given in the nursing facility takes place as part of the continuum of long-term care and the broader healthcare system. This section provides background on the nursing facility industry and information on several of the laws of which the administrator must be aware while operating a facility. The nursing facility is part of a continuum of caregiving. The section provides information about other providers in the healthcare field. The everyday life of the facility takes place within the rules set by Medicare and Medicaid, labor laws, occupational safety laws, the Life Safety Code, and the Americans with Disabilities Act Accessibility Guidelines for facilities. The nursing facility resident population is heavily dependent on the nursing facility staff, especially the nursing assistants. The section details some of the outside groups and organizations that may directly or indirectly impact the lives of nursing facility administrators.

Public policy bearing the labels of elder rights and elder justice is scant and only recently appeared on the scene. The terms “elder rights” and “elder justice” have been largely appropriated by the field of elder abuse, which has applied them narrowly to policies and programs that address elder and dependent adult abuse and mistreatment. But “aging policy” in the United States is grounded in social justice principles and goals. This explains how Social Security, Medicare, Medicaid, Supplemental Security, the Older Americans Act, and the Elder Justice Act have advanced individual rights and social justice. It also explores how discrimination against older people has been addressed, explicitly, through measures like the Age Discrimination in Employment Act, and by policies that protect older people as members of other groups. This includes laws and regulations that protect people with disabilities, residents of institutions, consumers, crime victims, prison inmates, and others.

The older adults most at risk for poverty are those who have experienced cumulative disadvantage as a result of low education attainment, entering the workforce for the first time during an economic recession, health problems that limit their ability to work over long periods of time, and involve extraordinary expenses for either themselves or family members and other vagaries of life. This chapter reviews the social insurance programs that support older Americans, poverty rates, modern retirement compared to “old-fashioned retirement”, gender differences, income equality, and the broad reach of Social Security. It also covers the mechanics of Medicare and Medicaid. There are three Voices in the chapter. One addresses the “comfortable retirement” and its differential meaning and possibility, another focuses on women 50 and over, and the final Perspective piece covers the broad reach of Social Security and its importance to families of all ages.

Reimbursements from Medicare and Medicaid account for well over half of the typical nursing facility cash flow. This section discusses the Social Security Act (Medicare and Medicaid), and the Medicaid concepts such as spend down and buy-in agreements. Medicaid and Medicare were both passed as amendments to the Social Security Act. Medicare has been essentially an insurance program for recipients of Social Security benefits. Medicaid has not been insurance; as designed, it has been medical aid for persons receiving assistance (formerly referred to as “welfare”) and for comparable groups of persons defined as medically indigent. Licensed nursing facilities may apply to be certified for participation in the Medicare and/or Medicaid program voluntarily. Facilities may participate in (a) the Medicaid only program, (b) the Medicare only program, or (c) in the Medicare/Medicaid dually certified program.

The Patient Protection and Affordable Care Act (PPACA) that was commonly called the Affordable Care Act (ACA), or “Obamacare”, was a U.S. federal statute signed into law by President Barack Obama on March 23, 2010. The ACA was enacted to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce healthcare costs for individuals and the government. The law also required insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of preexisting conditions or sex. The ACA continued a trend of shifting Medicaid and Medicare spending toward greater home- and community-based services care and away from skilled nursing care reimbursement. The offerings are similar in all states, but the benefits are state-specific as it is a Medicaid outreach program.

Health promotion, exercise, and the need to focus on these to enhance a healthy long life are discussed. Identification of significant areas of health promotion and barriers to achieving good health are presented. Next, disease prevention along with primary, secondary, tertiary, and quaternary preventive measures are listed. Healthy People 2030, the fifth national health initiative, and its objectives are outlined along with the Patient Protection and Affordable Care Act. Exercise, its meaning, and value in modifying age-related changes are briefed. Types of exercise programs; isometric, isotonic, and aerobic and their recommended use by older adults are listed.

A nursing facility’s ability to survive economically is affected by an increasing variety of pressures, such as federal and state reimbursement policies, the types of services offered by the facility, and resident payment sources. Over the past decades, government regulators who pay for the care of Medicare and Medicaid residents in nursing facilities have sought ways to narrow the margin of facility profit to achieve mandated government cost savings. The nursing facility is in the business of marketing services. Marketing employs the management techniques, using a vocabulary explicitly developed for the field of marketing. Without marketing, a facility will most likely close its doors. The federal government and surveyors are among your most important customers. This section helps the reader to understand the forces leading to the intense competition among facilities. It also explains how healthcare marketing is evolving.

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 surveyors determine the level of compliance with each of the federal requirements through the survey process. Deficiencies are issued for standards of care not met. Deficiencies are divided into resident-centered and facility-centered. A dietary food handling violation would be a facility-related deficiency. Resident-centered requirements must be met for every resident regardless of whether that resident is receiving Medicare or Medicaid reimbursement for care or any payor source. The deficiencies are reportable outcome measures applied by the surveyors to care given in the facility. The surveyors use the Scope and Severity grid in judging the seriousness of each deficiency issued to a facility. For each deficiency, the surveyor determines the level of harm to the resident or resident(s) involved and the scope of the problem within the nursing facility. The Scope and Severity matrix is an integral part of how nursing facility scores are calculated in the scoring system.

Medicare and Medicaid are often confused with each other, likely due to their similar names. Older adults can benefit from both Medicare and Medicaid, if they meet the respective eligibility requirements of each program, in which case they are deemed dual-eligible beneficiaries. Although both programs relate to healthcare services, they are distinct programs. Medications play an essential role in the health of older adults. “Geriatric health care professionals and their patients rely heavily on pharmacotherapy to cure or manage diseases, palliate symptoms, improve functional status and quality of life, and potentially prolong survival.” This chapter outlines the various components of the Medicare and Medicaid programs. It describes some of the medication-related problems older adults experience and offers insights into how to avoid them. Managing multiple medications is particularly challenging for older adults; it is, therefore, the focus of the Practical Application presented at the end of the chapter.

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.

The field of health promotion has come a long way since it was initially defined as exercise, nutrition, and smoking cessation. Moreover, older adults were typically excluded from early writings on health promotion and disease prevention. They were old after all, perhaps resistant to change and without much of a future. Health promotion and aging now covers dozens of topics. Health professionals need to be careful about defining good health among older adults. Health promotion is a more proactive approach than primary prevention, which tends to imply a reaction to the prospect of disease. Directing a client’s anger or frustration into political advocacy work is a proactive, health-promoting enterprise that benefits both the individual and society. Medicare, Medicaid, and Social Security have had a tremendous impact on health. It is important, therefore, to review these legislative acts, as many people do not even understand the difference between Medicare and Medicaid.

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.

The rights to health and health care in the event of illness, disability, or old age are detailed in Article 25 of the Universal Declaration of Human Rights (UNDHR). These rights are fundamental to the well-being of older adults as their needs for medical care increase with age. As episodes of acute illness decline, chronic conditions increase with age, impacting both individuals and society. Chronic conditions such as arthritis and heart disease permeate many areas of a person’s life, often increasing demands for an array of support. Medicare was developed in the 1960s to address the needs of the aging population with regard to health care. Medicaid, Title XIX, under the Social Security Act was passed in 1965 to provide health care for those below the poverty line. Consumer-directed care programs have the older person responsible for hiring the care provider and determining the services he or she wants.