What are the varying levels of care?


What is acute (hospital) care?

Acute care is a care setting where a patient is treated for a brief but severe episode of illness. The term is generally associated with care rendered in an emergency department, ambulatory care clinic, or other short-term stay facility. The most common acute care setting is a traditional hospital, which typically offers both inpatient and outpatient care in specialty areas including but not limited to emergency care, intensive care, coronary care, cardiology, surgical services, psychiatric care and childbirth and pediatric care. The function and goal of acute medical care is to diagnose and treat the presenting condition or illness and return the person to his/her state of health prior to the episode.

Acute care settings often have full-time physicians and hospital staff who are available 24 hours a day. They may offer higher nurse-to-patient ratios, including licensed nursing staff especially trained in acute care. Acute care hospitals often also have social workers, dieticians, physician specialists, pharmacists and rehabilitation staff on-site.

Who pays for hospital care?

The cost of hospital care varies widely depending on the length of stay and type of care received. Sources of payment for hospital care include private insurance, Medicare, private funds (self-pay), or some combination of those. It is important to know ahead of time what your insurance plan covers, and what costs you may be responsible for.

Long-term acute care facilities

What is a long-term acute care hospital (LTAC)?

A long-term acute care hospital is an acute care hospital that specializes in the treatment and rehabilitation of medically complex patients who require an extended stay in a hospital setting. LTACs are focused on patients with serious medical problems that require intense, special treatment for a long time (usually about 20-30 days). These patients often transfer from intensive care units in traditional hospitals. It would not be unusual for a LTAC patient to need ventilator or other life support medical assistance. The typical LTAC patient is older with three to six concurrent active diagnoses, or someone who has suffered an acute episode on top of several chronic illnesses.

How is care in an LTAC paid for?

Similar to acute care hospitals, the cost of care in an LTAC can vary widely, and sources of payment include private insurance, Medicare, private funds (self-pay), or some combination of those.

Long-term care

What is long-term care?

Long-term care is a concept that encompasses a full continuum of care provided in a wide variety of settings. It includes everything from long term acute care to nursing home care to assisted living and even hospice care. Such care can be provided in almost every conceivable setting, from an individual’s home to a retirement community or even a long-term acute care hospital. Long-term care settings provide a variety of services and supports to meet health or personal care needs over an extended period of time. Most long-term care is non-skilled personal care assistance, such as help performing everyday activities of daily living (ADLs), which are:

  • bathing
  • dressing
  • using the toilet
  • transferring (to or from bed or chair)
  • caring for incontinence
  • eating

The goal of long-term care services is to help you maximize your independence and functioning at a time when you are unable to be fully independent.

Who needs long-term care?

Long-term care is needed when you have a chronic illness or disability that causes you to need assistance with activities of daily living. Your illness or disability could include a problem with memory loss, confusion, or disorientation. (This is called cognitive impairment and can result from conditions such as Alzheimer’s disease.) Many people who need long-term care develop the need for care gradually. They may begin needing care only a few times a week or one or two times a day, for example, help with bathing or dressing. Care needs often progress as you age or as your chronic illness or disability become more debilitating, causing you to need care on a more continual basis, for example help using the toilet or ongoing supervision because of a progressive condition such as Alzheimer’s disease. Some people need long-term care in a facility for a relatively short period of time while they are recovering from a sudden illness or injury, and then may be able to be cared for at home. Others may need long-term care services on an on-going basis, for example someone who is disabled from a severe stroke. Some people may need to move to a nursing home or other type of facility-based setting for more extensive care or supervision if their needs can no longer be met at home.

The importance of planning for long-term care needs

It is important to gain a basic understanding of what is and perhaps more importantly is not, provided in different levels of care in different settings, ideally before you are faced with having to pursue such care. It is also critical to understand how much care costs, and what options are available to pay for it.

It is estimated that at least 70 percent of people over age 65 will require some long-term care services at some point in their lives. And, contrary to what many people believe, Medicare and private health insurance programs do not pay for the majority of long-term care services that most people need – help with personal care such as dressing or using the bathroom independently. Planning is essential for you to be able to get the care you might need.

To make the best decisions about how to pay for long-term care you need to understand what services cost, what public programs you are eligible for and what they cover, what private financing options are available, and which ones work best for you. It is important to understand the differences among the public programs and private financing options for long-term care services. Each public program and each private financing source has its own rules for what services it covers, eligibility requirements, co-pays, and premiums.

Long-term care is expensive. One year of care in a nursing home, based on the 2008 national average, costs over $68,000 for a semi-private room. One year of care at home, assuming you need periodic personal care help from a home health aide (the average is about three times a week), would cost almost $18,000 a year.

Costs for long-term care services vary greatly depending on the type and amount of care you need, the provider you use, and where you live. For example, many care facilities charge extra for services provided beyond the basic room-and-board charge, although some may have “all inclusive” fees. Home health and home care services are usually provided in two-to-four-hour blocks of time referred to as “visits.” An evening, weekend, or holiday visit may cost more than a weekday visit. Some community programs, such as adult day service programs, are provided at a per-day rate, and rates may differ based on the type and variety of programs and services offered.

Consumer surveys have revealed some common misunderstandings people have about which public programs pay for long-term care services. Many people believe they can rely on Medicare to pay for any long-term care services they will need. However, Medicare only pays for long-term care if you require skilled services or recuperative care for a short period of time. Medicare does not pay for what comprises the majority of long-term care services – non-skilled assistance with activities of daily living.

Medicaid is the joint Federal and state program that pays for the largest share of long-term care services, but only if you meet financial and functional criteria. Other federal programs such as the Older Americans Act and Veterans Affairs pay for some long-term care services, but only for specific populations and in specific circumstances.

Most forms of employer-sponsored or private health insurance, including Health Maintenance Organizations (HMO) or managed care, follow the same general rules as Medicare. If they do cover long-term care, it is typically only for skilled, short-term, medically necessary care. Therefore most people who need long-term care end up paying for some or all of their care on their own out of their income or assets.

There are, however, an increasing number of private payment options that help to cover the costs of long-term care services. These include long-term care insurance, reverse mortgages, and other options.

Where is long-term care provided?

Long-term care, often associated with institutional care, is provided in many different settings. But, most long-term care is actually provided at home – either in the home of the person receiving care or at a family member's home. It’s estimated that individuals currently turning 65 may need three years of long-term care in their lifetime, with almost two years of that care provided at home. The majority of care that is provided at home, about 80%, is provided by unpaid caregivers. There is also an increasing amount of long-term care available in the community through programs such as adult day service centers, transportation services, and home care agencies that often supplement care at home or provide respite for family caregivers.

For people who cannot stay at home, but who do not need the level of care provided in a nursing home, there are a variety of residential care settings, such as assisted living, board and care homes, and continuing care retirement communities (CCRCs). Nursing homes provide long-term care to people who need more extensive care, particularly those whose needs include nursing care or 24-hour supervision in addition to their personal care needs.

Home and community based services (HCBS)

Home and community-based services (HCBS) describe a range of personal, support, and health services provided to individuals in their homes or communities to help them stay at home and live as independently as possible. Most people who receive long-term care at home generally require additional help either from family or friends to supplement services from paid providers. This is because so much of the care needed is personal care: help with activities such as bathing and dressing, help managing medications, or supervision for someone with a condition such as Alzheimer's disease.

Some of the most common home and community services are:

  • Adult day service (ADS) programs, designed to meet the needs of adults with cognitive or functional impairments, as well as adults needing social interaction and a place to go when their family caregivers are at work. They provide a variety of health, social, and other support services in a protective setting during part of the day. Adult day centers typically operate programs during normal business hours five days a week; some have evening and weekend hours. These programs do not provide 24-hour care.
  • Case managers/geriatric care managers, health care professionals (typically nurses or social workers) who specialize in assisting you and your family with your long-term care needs. This includes, but is not limited to assisting, coordinating, and managing long-term care services; developing a plan of care; and monitoring your long-term care needs over extended periods of time.
  • Emergency response systems, which provide an automatic response to a medical or other emergency via electronic monitors. If you live alone, you wear a signaling device that you activate when you need assistance.
  • Friendly visitor/companion services, which are typically staffed by volunteers who regularly pay short visits (under two hours) to someone who is frail or living alone.
  • Home health care/home care are two different services, which may be provided by a single agency or separate agencies. Home health care typically includes skilled, short-term services such as nursing, physical or other therapies ordered by a physician for a specific condition. Home care services are most often limited to personal care services such as bathing and dressing, and often also include homemaker services such as help with meal preparation or household chores.
  • Homemaker/chore services, can help you with general household activities such as meal preparation, routine household care, and heavy household chores such as washing floors, windows, or shoveling snow.
  • Meals programs, which include both home-delivered meals (so called “Meals-on-Wheels”) or congregate meals, which are provided in a variety of community settings.
  • Respite care, which gives families temporary relief from the responsibility of caring for family members who are unable to care for themselves. Respite care is provided in a variety of settings including in the home, at an adult day center, or in a nursing home.
  • Senior centers, which provide a variety of services including nutrition, recreation, social, and educational services, and comprehensive information and referral to help people find the care and services they might need.
  • Transportation services that can help you get to and from medical appointments, shopping centers and access a variety of community services and resources.

Facility-based long-term care services

There are numerous types of facility-based programs that provide a range of long-term care services. Some facilities provide only housing and related housekeeping, but many also include help managing medications, assistance with personal care, supervision and special programs for individuals with Alzheimer's disease, or 24-hour nursing care. The services available in each facility are often regulated by the state in which the facility operates (for example, some states do not allow some types of facilities to include residents who are wheelchair bound or who cannot exit the facility on their own in an emergency). Facility-based care is known by a wide variety of names, including board and care, assisted living, adult foster care, continuing care retirement communities (CCRCs), and nursing homes.

Assisted Living

Assisted living is designed for people who want to live in a community setting and who need or expect to need help functioning, but who do not need as much care as they would receive at a nursing home. Some assisted living facilities are quite small – with as few as 25 residents, while some can accommodate 120 or more units. Residents often live in their own apartments or rooms, but enjoy the support services that a community setting makes possible, such as:

  • Up to three meals a day
  • Assistance with personal care
  • Help with medications, housekeeping, and laundry
  • 24-hour security and onsite staff for emergencies
  • Social programs

The cost of assisted living varies widely, depending in part upon the services needed by the resident and the amenities provided by the facility. Assisted living is regulated in all states, however, the requirements vary.

Continuing care retirement communities (CCRCs)

Continuing care retirement communities (CCRCs) are also called life care communities. They offer several levels of care in one location. For example, many offer independent housing for people who need little or no care, but also have assisted living housing and a nursing facility, all on one campus, for those who need greater levels of care or supervision. In a continuing care retirement community, if you become unable to live independently, you can move to the assisted living area, or sometimes you can receive home care in your independent living unit. If necessary, you can enter the on-site or affiliated nursing home. The fee arrangements for CCRCs vary by the type of community. In addition to a monthly fee, many CCRCs also charge a one-time “entrance fee” that may be partially or completely refundable (often on the sale of the unit).

Nursing homes

Nursing homes, also called skilled nursing facilities (SNF) or convalescent care facilities, provide a wide range of services, including nursing care, 24-hour supervision, assistance with activities of daily living, and rehabilitation services such as physical, occupational, and speech therapy. Some people need nursing home services for a short period of time for recovery or rehabilitation after a serious illness or operation, while others need longer stays because of chronic physical, health, or cognitive conditions that require constant care or supervision. Families typically seek nursing home care when it is no longer possible to care for a person at home safely or when the cost of round-the-clock care at home becomes too great. Nursing homes are highly regulated and must be licensed by state governments.

What is Hospice Care?

Hospice is the name for a special program of care for terminally ill (dying) patients and their families. Rather than trying to cure an illness, hospice efforts are directed toward making the patient comfortable, easing pain and other troublesome symptoms, and supporting the family through a sad time.

A hospice care program tries to provide the best quality of life for dying persons by providing a holistic approach--that means giving spiritual, mental, emotional and physical comfort to the patients, their families and their other caregivers.

Hospice services can be provided in a variety of settings, including the patient’s home, an assisted living facility, a nursing home, or even an inpatient facility dedicated to the care of hospice patients. Hospice care is typically provided by a group of dedicated professionals, support staff and volunteers who understand the special goals of hospice care. The team includes doctors, nurses, social workers, chaplains, aides and volunteers. The hospice team members focus their efforts on easing the symptoms of the terminally ill patient and providing support to the patient's family.

How much does hospice care cost and who pays for it?

Hospice care is typically paid for by Medicare and private insurance. Many hospice programs also receive support through community donations, and are then able to provide services to people who are uninsured or underinsured.


Palliative Care

What is Palliative Care?

Palliative care is often confused with hospice care, but the focus of the two is different. While hospice care is for the terminally ill who are no longer seeking a cure for their illness, palliative care can be provided at any stage of a serious illness, and can be provided in conjunction with care meant to prolong the patient’s life. Palliative care provides specialized medical care for people with serious illness and is focused on providing patients with relief from the symptoms, pain, and stress of the disease, whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate for patients at any age.

Palliative care is offered in many settings, including the patient’s home, a hospital, long-term care facility or inpatient hospice facility.

Who pays for Palliative Care?

Most insurance plans cover all or part of the palliative care treatment you receive in the hospital, as with other hospital and medical services. This is also true of Medicare and Medicaid. Drugs and medical supplies and equipment may also be covered.

Inpatient Acute Rehabilitation Care

What is Inpatient Acute Rehabilitation Care?

Acute inpatient rehabilitation is a special type of rehab care often required when an individual’s medical status requires more intense services that can’t reasonably be provided in an alternative setting. Such care settings might be in a hospital or skilled nursing facility or a free-standing facility and are licensed and certified and primarily promote special rehabilitative health care services rather than general medical and surgical services. Examples of conditions requiring acute inpatient rehabilitation include, but are not limited to, individuals with significant functional disabilities associated with stroke, spinal cord injuries, acquired brain injuries, major trauma and burns.

The goal of acute inpatient rehabilitation care is the restoration of a disabled person to self-sufficiency or maximal possible functional independence. An inpatient rehabilitation program utilizes an inter-disciplinary coordinated team approach that typically involves a minimum of three (3) hours of rehabilitation services daily. These services may include physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, or a combination thereof.

Who pays for Inpatient Acute Rehabilitation Care?

Care at this level is typically paid for by private insurance and/or Medicare. However, patients must often meet strict requirements related to their medical needs and rehabilitative progress and frequent updates to insurance companies are required to ensure continued payment for this level of care is appropriate.

Psychiatric Care

What is Psychiatric Care?

Psychiatry is the medical specialty devoted to the treatment of mental disorders. These disorders include various behavioral and cognitive conditions including depression, anxiety, schizophrenia and personality disorders, to name just a few. Treatment for psychiatric conditions includes the use of a variety of modalities, including psychotherapy (sometimes referred to as “talk therapy”), the use of medications and a wide range of other techniques. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of the functional impairment or on other aspects of the disorder in question.

Who pays for psychiatric care?

Sources of payment for such care vary widely and are often dependent on the level of treatment required, the care setting, etc. Most private insurance plans, Medicare and Medicaid include at least some benefit for psychiatric care, however given the level of variability patients should inquire as to payment levels and benefits on a case-by-case basis with their insurance provider.