Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt

CHAPTER EIGHT: COMMUNITY-BASED SERVICES

CHAPTER HIGHLIGHTS

What are Community-Based services?

Also described as “non-institutional”, they include home health care, hospice care and adult day

care.

 What is Home Health Care? – health care delivered to consumers in their homes.

 What is Hospice Care? – services provided to meet the needs of patients who are

diagnosed with a terminal illness and have a limited life span.

 What is Adult Day Care? – a form of long-term care that provides interim (less than 24-

hour) supervision for individuals who cannot be without supervision or assistance.

Origins and Development

 Home Health Care

 Began in the latter part of the 1800s as a service of city health departments called

visiting nurse services.

 As third party reimbursement became more available, home health care agencies

became even more independent.

 As reimbursement sources, particularly Medicare and Medicaid, looked for ways to

reduce their ever-increasing costs, there was a concerted move to divert long-term

care residents from institutional care to home-based care.

 Hospice Care

 Began in England in 1960s.

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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt

 Came to U.S. in 1974

 Adult Day Care

 Developed from the concept of respite

 Provides a short reprieve from the responsibilities of caregiving for those who have a

family member living with them who needs constant care and supervision

Philosophy of Care

 Home Health Care – to take health services to the consumer rather than requiring the

consumer to go to where the services are delivered. Medicare requires:

 Physician-Ordered Care – separates it from non-health home care

 Intermittent Care – given fewer than 7 days per week or less than 8 hours per day

 Homebound Consumers – recipients must be unable to leave home without a major

effort.

 Hospice Care – based on a concept of providing comfort and support to patients and their

families when a life-limiting illness no longer responds to cure-oriented treatments.

 Goal is to improve the quality of a patient’s last days by offering comfort and dignity.

 A central concept of hospice is provision of palliative care, also called comfort care,

which concentrates on providing pain and symptom relief.

 Adult Day Care – based on providing needed services for both the person receiving the

care and those responsible for that care.

 Family members very important

Ownership

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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt

 Mix of for-profit and not-for-profit.

 Many affiliated with hospitals or health care systems

 Some nursing facilities create community-based services if not otherwise available.

Services Provided

 Home Health Care

 Deliver a wide variety of health care and supportive services, ranging from

professional nursing and HCA care to physical, occupational, respiratory, and speech

therapies.

 May also provide social work and nutritional care and laboratory, dental, optical,

pharmacy, podiatry, x-ray, and medical equipment and supply services.

 Hospice Care – services aimed at easing pain and assisting patients and families,

including:

 Supportive services

 Pain and symptom management

 Family and caregiver support

 Communication among the individuals, families, and program staff

 Assistance with advance care planning.

 Adult Day Care – adult day care centers are generally grouped into two categories: social

day care and health day care. There is a third group, dementia day care, but it is usually

included in one of the others.

Consumers Served

 Generally elderly, more women than men

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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt

 Home health care consumers may need temporary care

 Hospice care consumers receive care until they die

 Adult day care consumers often use services for long period of time.

Informal Caregivers

The family members of the consumers of community-based long-term care services must also be

included as beneficiaries of community-based long-term care services. Often, the caregivers are

spouses, children, friends, and volunteers. To distinguish them from those who give care as part

of their jobs, they are referred to as informal caregivers.

Market Forces Affecting Community-Based Services

 Consumer Choice – often favors community-based services over institutional services.

 Cost-Effectiveness – seen by payers as less costly making them more attractive.

 Social and Demographic Changes – families of the elderly are often not available to help.

 Competition among Other Providers – adding community-based services can help them

improve their market position.

Regulations – regulations affecting community-based services fall into three general categories:

(1) Medicare certification, (2) licensing of provider organizations and (3) licensing of

professional staff.

1. Medicare Certification

 Home health and hospice care are covered by Medicare

 Adult day care is not.

2. Licensure of Provider Organizations – is handled at the state level:

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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt

 Most, but not all, states do license home health care agencies.

 Nearly all states now license hospice providers.

 Regulation of adult day care centers is highly inconsistent, varying from state to state.

3. Licensure of Staff

 Professional staff, such as physicians, nurses, and social workers, must be licensed by

their state licensing boards regardless of what type of health care organization they

work for.

Accreditation and Certification

 Accreditation – applies to the organizations, not the staff members as such.

 Home health care and hospice agencies may be accredited by any of three separate

organizations: the Joint Commission, the Community Health Accreditation Program

(CHAP), or the Accreditation Commission for Health Care (ACHC).

 Adult day care is not accredited.

 Certification of Professionals –applies to individuals acquiring voluntary verification of

their qualifications.

Financing of Community-Based Services

 Medicare

 Is the largest single payer of home health care and hospice care.

 A pilot program allows a portion of Medicare home health-care benefits to go toward

adult day care.

 Medicaid

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Long-Term Care: Managing Across the Continuum, Fourth Edition
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 Medicaid coverage of community-based services is growing

 Most states offer a hospice benefit as part of their Medicaid coverage.

 Some state Medicaid programs pay for adult day care through federal waivers that

allow them to waive some Medicaid rules in order to use less costly services.

 Private Health Insurance and Managed Care

 Coverage is increasing.

 Private Out-of-Pocket

Staffing and Human Resource Issues

 Community-based care services are personnel-intensive, that is, payroll for staff is the

largest portion of the budget.

 They rely on a mix of professional and nonprofessional staff working as a care team. The

team includes nurses (both RNs and LPNs), aides, therapists (physical, occupational,

speech), social workers, and numerous other specialties.

 All use some volunteers, but hospice uses more of them and more integrally in the

provision of care.

Legal and Ethical Issues

 Patient Noncompliance – many of these patients want a high level of autonomy, which

may be at variance with professional opinions.

 Patient Safety – is more difficult when patients are not under the supervision of

professionals at all times.

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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt

 Patients’ Rights – again, involves balancing patient autonomy and professional

responsibilities.

 The Decision to Accept Hospice Care – Some patients do not want to accept that their

conditions are terminal, or their families do not.

 Inequitable Access – community-based services are not uniformly accessible, depending

on geography and/or the urban/rural nature of the community.

Management – administrators of community-based service providers are not regularly licensed

as are nursing facility administrators and, in some states, administrators of assisted living

facilities.

 Management Challenges and Opportunities

 Supervision of Staff: Home Health and Hospice Care – it is difficult to supervise staff

who are working in the patient’s homes.

 Hospice: Coordinating Professional and Volunteer Staff – such coordination can be

difficult due to different points of view.

 Hospice: The Emotional Element – impending death creates emotions for both

patients and those who care for them, and must be recognized.

 Cultural, Religious, and Ethnic Differences – some ethnic groups involve family

members more than others, and different religious groups have different views on

death.

 Community and Philanthropic Groups – these services rely on such groups and

working with them is essential, but sometimes difficult.

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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt

Significant Trends and Their Impact

 Consumer Choice/Quality of Life – favors community-based services over institutional

services.

 Olmstead Decision – requires treatment in the least restrictive setting.

 Technology – is changing these services for the better.

 Managed Care – is rapidly becoming an important player in community-based services.

 Wellness Programs – some community-based services are beginning to create wellness

programs for elderly individuals who are not yet in need of more traditional services.

© 2015 Jones and Bartlett Publishers, LLC 8

Chapter 8
Community-Based
Services

Learning Objectives

1. Define and describe community-based
long-term care services

2. Identify and define the components of
community-based long-term care services

3. Identify and describe regulations affecting
community-based service providers

Learning Objectives (continued)

4. Understand the financial, ethical, and
managerial issues facing community-
based long-term care service providers

5. Identify trends in community-based
long-term care services and management

Definitions

Community-based: Any service provided outside of a
facility, including home health care, hospice care and
adult day care

Home health care: Skilled nursing and other health-
related services provided in the consumer’s home

Hospice care: End-of-life care

Adult day care: Interim supervision and socialization

How Home Health Care Developed

 City public health department’s
visiting nurse services

 Freestanding visiting nurse associations
 Growth based on better reimbursement

How Hospice Care Developed

 England in 1960s
 U.S. in 1974
 Compassionate care for the

dying

How Adult Day Care Developed

 To provide respite for family
caregivers who needed to work

 Began with friends and family –
eventually became more organized

Philosophy of Home Health Care

 To take services to consumers’ homes
 Eligibility requirements (based on

Medicare regulations):
• Physician-ordered
• Intermittent
• Homebound

Philosophy of Hospice Care

 Not a place, but a philosophy
 Patient must be at or near the end of life
 Designed to make last days comfortable
 May be provided in a home or in an

institution
 Serves both patient and family

Philosophy of Adult Day Care

 Less than 24-hour services
 Provides both supervision and

socialization
 Holistic approach, designed to

maintain quality of life
 Allows family caregivers to work

Ownership of Community-Based
Service Providers

 Mix of nonprofit, for profit, government owned
 Growing number are affiliated with other

health care organizations:
• Hospitals
• SNFs
• Rehabilitation facilities

Services Provided: Home Health Care

• Nursing • Therapy
• Dental care • Lab tests
• Nutrition • Care

management
• Personal care • Homemaking
• Transportation • Education

Services Provided: Hospice Care
• Physician services
• Nursing services

• Social services
• Counseling
• Medical appliances
• Pain management
• Homemaker services
• Therapies

Services Provided: Adult Day Care

Social day care
Health day care
Dementia day care

• usually included in the
other types

Consumers Served:
Home Health Care

 Largely elderly
 Some need ongoing care
 Others need only temporary care

following a hospital stay

Consumers Served:
Hospice Care

 Often very elderly
 No hope of a cure
 Very vulnerable, often emotionally

exhausted

Consumers Served:
Adult Day Care

 Need some supervision, but not
institutional care

 Most live at home or with family
members

Informal Caregivers

 Family members and friends who
provide much community-based care

 Make great sacrifices
 Little assistance from the system –

financial or other

Market Forces

 Consumer choice
 Cost-effectiveness
 Social and demographic changes
 Competition among other providers

Regulations

 Medicare certification
• Home health and hospice care

 State licensure of provider organizations
 Licensure of staff

Accreditation and Certification

 Joint Commission:
• Home health and hospice

 CHAP:
• Home health, hospice and some other services

 ACHC:
• Home health, hospice and some other services

Financing Home Health Care

 Medicare
• PPS

 Medicaid
 Other government programs
 Managed care
 Private health insurance
 Self-pay and other sources

Financing Hospice Care

 Medicare
• Some, but not all services

 Medicaid
• Increasing number of states

covering hospice

 Self-pay and other sources

Financing Adult Day Care

 Medicaid
• Some states use federal waivers

 Managed care
• Some, but not much

 Private insurance
• Some, but not much

 Self-pay and other sources

Staffing

Combination of professional and
non-professional staff

 Nurses
 Home health aides
 Therapists
 Social Workers
 Other specialists
 Volunteers – especially in hospice care

Legal and Ethical Issues

 Patient noncompliance
 Patient safety
 Patient rights
 Decision to accept hospice care
 Inequitable access

Management Qualifications

 Not regularly licensed
 Medicare “conditions of participation”

(where applicable)
 Certifications

Management Challenges
and Opportunities

 Home health and hospice – supervision
of staff

 Hospice – coordinating professional and
volunteer staff

 Hospice – the emotional element
 Cultural, religious, and ethnic differences
 Community and philanthropic groups

Significant Trends

 Consumer choice, quality of life
 Olmstead decision
 Technology
 Managed care
 Wellness programs

Summary

Community-based services, particularly
home health care, hospice care, and adult
day care, have become increasingly
attractive in recent years and should
continue to grow.