Case Management Society of America


The LTC Continuum, Care Management Primer


U.S. citizens are turning sixty-five years of age at an alarming rate; the U.S. Census Bureau indicates that, beginning in 2015, an average of 10,000 people are turning 65 every day. This phenomenon will continue for nearly 20 years as the “baby boomers” reach retirement age, increasing the demand for community-based and long-term services exponentially. Case managers must be fluent in the long-term care continuum to help guide patients and families in making care decisions. Considerations regarding functional status, financial means and diagnoses are all key factors involved in care coordination for long-term care patients. The information below will assist you in becoming familiar with this aspect of the care continuum.

Rehabilitation Center/Skilled Nursing Facility (SNF): These facilities often service two distinct patient populations: those requiring short-term rehabilitation (PT, OT, ST) or skilled nursing care for continued IV antibiotics or wound care, and those patients who require 24-hour care and supervision and assistance with basic activities of daily living (ADLs). The latter group is considered residential care recipients as the setting becomes their permanent residence.

Case managers should understand the amount of rehab services their patients will receive during their admission, including frequency and duration of treatment as well as the types of treatments available. Other considerations for this setting include frequency of clinician visits, level of nursing staff, social services availability and outcomes of care. Additionally, care managers should be aware of the Area Agency on Aging (AAA), a government-sponsored program that specializes in aging resources including information and referrals, caregiver education and elder rights. A key program offered by the AAA is the long-term care Ombudsman program, which serves as a beacon for residents who reside in licensed LTC facilities to address quality of care concerns. (Nationwide directory of SNFs)

Memory Care Programs: These units are typically part of a SNF or rehab center that specializes in the care of cognitively impaired patients, such as those with Alzheimer’s or dementia. Care managers should be mindful that there is often a waiting list for these programs, which may be challenging when attempting to place combative or aggressive patients; regular LTC facilities may not accept these types of patients. Other considerations may be the additional cost of these units and the geographic locale of the facility for family members. (Alzheimer’s Foundation of America)

Hospice Care: These programs are focused on terminally ill patients and families (defined as one having less than six months to live) and provide a holistic approach to dying by emphasizing quality of life. The hospice care team is composed of clinicians, nurses, social workers, rehabilitation specialists, chaplain services and home health aides. Hospice care also provides inpatient care on a limited basis for patients in crisis (i.e., pain out of control) or respite care for caregivers. However, the majority of hospice care is home-based; therefore, a patient does require a constant caregiver in order to remain at home, as hospice services are intermittent.

Care managers need to understand the contracted hospice providers if case managing a commercially insured patient, as opposed to Medicare beneficiaries who have freedom of choice when electing for hospice care. Other considerations include languages spoken by staff and their inpatient setting (often, hospices contract with SNFs and other inpatient facilities for their inpatient beds).

Palliative Care: Refers to specialized medical care for people with serious illness. This type of care is focused on providing relief from symptoms and stress associated with serious illness, with the goal of improving quality of life.

Care managers need to understand the palliative care resources in their communities; often, palliative care will be provided in acute settings only, or through a hospice agency. The Joint Commission also offers a Community Based Palliative Care Certification for providers. (National Hospice & Palliative Care Organization)

Group Homes: Small, single-family homes that are designed to provide room, board and ADL assistance for children or adults with chronic disabilities. Typically, these homes are limited to six to eight people and have at least one 24-hour trained caregiver. Group homes often specialize in a certain type of resident (i.e., mental retardation or older adults), and often residents may have to share a room or a bath depending on the circumstances.

Care managers should understand that the range of costs for group homes varies widely based on services, accommodations and location. Care managers should encourage patients/families to tour several homes before deciding and keep a list of amenities offered (i.e., transportation to medical visits, group activities, menu and number of caregivers).

Continuity Care Centers (aka Triple C): A senior residential community that offers several levels of care on one campus. CCCs are composed of independent living apartments/homes, assisted living, rehabilitation and skilled nursing, and memory care. CCC residents often find comfort in knowing that if they require a higher level of care or support, they can receive it without changing location. These communities are cost-prohibitive for many of our older adults.