Understanding the looming crisis in elderly care

A.T. Still, MD, DO, was ahead of his time in promoting preventive medicine and focusing on treating the whole patient rather than just symptoms. In this spirit, it is critical that we apply this overall philosophy to caring for our aging population (which is soon to rapidly expand).

As a family medicine physician, I practice traditional health care in a rural setting. I see patients in the clinic, hospital and long-term care settings. Seeing the need for high-quality care for the elderly, I obtained the certified medical director designation from the Post-Acute and Long-Term Care Association. I now serve as the medical director of three long-term care facilities, and I recently founded Doctor’s Inn Care Homes, a physician-owned and led personal care home business.

DOs’ philosophy of practicing medicine aligns well with providing high-quality care for elderly patients. I encourage DOs to consider becoming medical directors of long-term care facilities or seeing patients in home settings.

Below, I will discuss the demographics of the elderly population in the U.S. as well as facility care options and their offerings. I’ll also explain how to understand the costs and challenges associated with care of the aging.

Demographics

Around half of all assisted living residents are at least 85 years old. Individuals in this age group are members of the Silent Generation, a generation that, at one time, included roughly 50 million individuals in the U.S. In 2028, 82-year-olds will be from the Baby Boomer generation, which includes 73 million Americans. Current estimates show that the Baby Boomer generation makes up 16% more of the population than the current Silent Generation. By 2030, all Baby Boomers will be at least 65.

We already struggle to provide age-friendly services, health care and facilities. There are currently over 800,000 people living in assisted living facilities; this does not include those in long-term care, and many more will need options in the future. There is about to be a huge mismatch between what the health care industry currently offers versus what is needed.

Care settings

In general, people can choose to live at home or move into an independent living, assisted living or long-term care facility.

Home care: In the home, people can—pending finances and caregivers—receive basic, non-24-hour activities of daily living (ADL) assistance, along with assistance with household chores, meal preparation, home health and hospice. Of note, many homes could require substantial modifications for safety. Also, Medicaid and Medicare do not pay for sitters or caregivers.

Homecare pros

• Senior gets one-on-one care tailored to their needs and preferences
• Senior can stay in their home or a relative’s home as they age
• Costs can be lower, depending on hours of care needed and caregiver skill level
• Family gets to choose the caregiver
• Senior gets to know one caregiver, rather than being cared for by many different people
• Flexibility in care arrangements; could combine family members/friends

Homecare cons

• High costs if 24/7/365 care is needed
• Ongoing family involvement is needed for hiring and managing caregivers as well as planning backup care options
• Potential for social isolation, which can contribute to depression, cognitive decline or health problems
• Home may need modifications for safety or wheelchair accessibility
• Housekeeping and home maintenance need to be done, and groceries and personal care and household supplies need to be bought
• Family is required to focus more on caregiving than at-home family time

Assisted living: Typically, assisted living facilities (ALFs) help with at least one ADL need. These are nonmedical facilities but they can provide home health or physical therapy services to their residents. Staff have basic caregiving training, but there may be no official CNAs or LPNs. These facilities are required to have an on-call RN, mostly for specific medications, but these requirements vary by state. The facilities provide assistance with ADLs, caregiving, food and activities. Typically, residents must be able to ambulate and physically take their medicine. Assisted living facilities are not funded by Medicaid or Medicare and are overseen by state health agencies.

ALF pros

• More affordable way to get 24/7 supervision and care
• Family can focus more on the relationship rather than on care needs
• Senior has plenty of opportunities for social interaction with other residents
• Family doesn’t need to worry about hiring, scheduling or managing caregivers
• Level of care can be ramped up as needed because staff is already in place

ALF cons

• One-on-one care won’t be as personal or consistent as it is at home; frequent changes in staff are common
• Quality of care can vary depending on the staff
• If significant one-on-one care is needed, hiring (and paying out-of-pocket for) a private aide may become necessary
• Seniors could get kicked out of the community for a variety of reasons with little notice (typically at least 30 days)
• Senior may not enjoy being in a group living environment

Long-term care (LTC) facilities: For those who need significant assistance with ADLs or who have high medical needs such as rehabilitation after a hospital stay, surgical procedures, illness or injury, long-term care facilities may be the best care option. These facilities offer end-of-life medical services, acute/chronic severe pain management, and care for those with permanent disabilities and those who need round-the-clock supervision, as well as patients with severe medical conditions or cognitive impairments. These facilities are largely paid for by Medicaid and Medicare, which means CMS provides oversight of them.

LTC pros

• 24-hour nursing staff with medical oversight
• Medication management
• Physicians often round on sight
• Fairly high level of medical services and support
• Planned activities and meals

LTC cons

• Most expensive option
• High staff turnover and variability
• Less home-like environment than ALF

Costs

According to genworth.com, the national average cost for an assisted living facility is $5,350 monthly, and the average for private room long-term care is $9,733 monthly. These numbers for assisted living and long-term care are for average facilities; luxury facilities can cost significantly more. These can also vary greatly from state. Home care costs have a great variability from $1,000-$2,000 per month for occasional assistance, up to $18,000 per month for 24/7/365 trained staff at home.

For the most part, home care and assisted living facilities are private pay, but there are some insurance and waiver programs that provide financial assistance.

Long-term care facilities can be covered by Medicaid, but only for shared rooms. Medicare can sometimes pay for an acute stay of up to 100 days (copay after the first 20 days required), but Medicare does not provide any payment for long-term stays.

Moving forward

As evident by these facts and figures, a huge mismatch between available care and care needed is inevitable. Even with proper planning, a great number of people may not be able to afford any of these care options. Just as Dr. Still saw that surgical care, medications and overall medical therapy were not adequate during his time, we too must foresee these obstacles regarding the care of our elderly. It will take physicians, social workers, administrators, legislators and many others to help address these coming needs.

DOs are uniquely positioned to tackle these obstacles, as we have always known the patient is more than just the sum of their parts. We also serve in high numbers throughout rural or underserved areas where these needs are most critical. As DOs, we can use our philosophy, connections and respect from our communities to bring awareness to these issues.

Related reading:

Preventing illness and injury: Is it ever too late to adopt a healthy lifestyle?

The 4th wave of osteopathic medicine: Re-establishing osteopathic distinctiveness