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Long Term Care
& Behavioral Health

The long term care and behavioral health sectors have undergone various initiatives in the last couple of decades, most often dealing with securing funding and improving access to care. The following section will highlight some significant initiatives from each sector.

Long Term Care

Patient and Nurse

Concepts such as aging in place, continuing care communities, naturally occurring retirement communities, and high-technology home care are some of the recent initiatives that offer enriched alternatives to long-term care recipients (Sultz & Young, 2018).
 

  • Aging in Place

    • There has been an increased effort to attempt to keep older adults in their own homes as long as possible, since moving to long term care facilities can be stressful and unwanted change. An aging in place program allows older adults to maintain their health while living as independently as possible in their own homes (Sultz & Young, 2018). These programs utilize services such as home care aides, transportation to medical appointments, homemaker services, and more.

  • Continuing Care Retirement Communities

    • CCRCs provide residences on a retirement campus (such as an apartment complex) designed for functional older adults​ who do not choose to remain in their own homes. CCRCs offer a comprehensive program of social services, meals, and access to contractual medical services in addition to housing (Sultz & Young, 2018). CCRCs provide the most comprehensive services for older adults in the US, but are also the most expensive option.

  • Naturally Occurring Retirement Communities

    • NORCS describe apartment complexes, neighborhoods, or sections of communities where residents have remained in their homes as they age​ (Sultz & Young, 2018). The Administration on Aging provides grants for NORC programs, which utilize services such as nursing, nutrition, health education, social activities, and more, to test and evaluate methods to assist older adults with aging at home.

  • High-technology Home care

    • Improvements and innovations have taken place in the portability, mobility, reliability, and cost of medical devices such as intravenous therapy pumps, long-term venous access devices, continuous ambulatory peritoneal dialysis equipment, and ventilators (Sultz & Young, 2018). ​This has allowed patients who have been discharged to their homes, who still require intensive and high-technology care, to receive therapeutic treatments in a home setting.

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The aforementioned initiatives have been critical to meet the diverse medical and personal needs of older adults in the US. However, one limitation that common to each of these initiatives is a lack of adequate funding which often affects those not eligible for Medicaid or able to afford home services out-of-pocket. In particular, CCRCS offer the most comprehensive benefits but fewer than 1 percent of older adults have taken advantage of this option because of the expense and  requirement of an extended contractual commitment (Sultz & Young, 2018).


Recommendations for improvement include:
 

  • expanding insurance coverage for long term care

    • includes private insurance and Medicare​

  • more state choice in redesigning Medicaid programs to meet the unique needs of citizens

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Behavioral Health

Holding Hands

There have been some notable trends within the behavioral health sector over the last decade, including two paradigm shifts directed toward a more integrated and effective system of behavioral health care (Sultz & Young, 2018).

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  • Recovery Oriented Systems of Care

    • The ROSC focuses on providing patients with choice, empowerment, and hope through a holistic and integrated approach. For instance, evaluations, formerly focused on establishing a diagnosis and a list of problems, are now, through the ROSC​, person-centered and strength-based (Sultz & Young, 2018). It often involves connecting patients with resources in their communities and problems related to their behavioral health issue are seen as obstacles that can be overcome to achieve greater life goals.

  • Integration of Primary Care and Behavioral Health Services

    • Behavioral health integration encompasses the management and provision of health services so that individuals receive a continuum of preventative and restorative behavioral health and substance abuse services according to their needs over time, and across different levels of the health system (SAMHSA-HRSA, n.d.). The integrated care model has various strengths, in part because it aims to defragment the provision of care. Because patients with a serious mental illness on average die sooner than those without, and psychotropic medications can have negative physical side effects, it is important for behavioral health specialists and primary care physicians to work together for optimum patient health outcomes. Furthermore, primary care physicians are often the first personnel to recognize mental illnesses or substance abuse disorders in the beginning stages.

​These two shifts in the behavioral health sector have been important in providing patients with care that is more hopeufl, integrated, and connected. However, the integrated care model is not without limitations. Two major challenges that hinder the full implementation this model include underfunding for behavioral health services and a shortage of trained and available behavioral health professionals. Sustainable financing mechanisms have not been developed and current behavioral health specialists will require retraining to acquire skills and techniques for working with the integrated care model (Sultz & Young, 2018).

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Recommendations for improvement include:
 

  • adequate reimbursement for behavioral health professionals to cover costs within a primary care setting

  • additional grant opportunities for fostering the integration of behavioral and primary healthcare from federal agencies

  • additional grant opportunities for behavioral workforce development from federal agencies

Legislation

In addition to the paradigm shifts, there have also been legislative initiatives affecting behavioral health, including:

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  • MHPA and MHPAEA

    • The Mental Health Parity Act of 1996 equated aggregated lifetime limits and annual limits for behavioral health services with aggregate lifetime and annual limits for medical care (Sultz & Young, 2018). In essence, the MHPA promised that insurers would provide equal coverage for behavioral health. The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 added onto the original MHPA to also include equal coverage for substance abuse disorders. Moreover, important strengths of the MHPAEA include a broad definition of mental health and substance abuse benefits, equal coverage for annual and lifetime dollar limits with medical coverage, behavioral health and substance abuse benefit coverage must be provided at equivalence with other medical/health benefits coverage, among others.​

  • Affordable Care Act

    • The ACA has also been instrumental in the increase of behavioral health coverage through the expansion of Medicaid and has improved access to treatment. This is significant because in the past, a large number of US citizens lacked insurance coverage for the treatment of behavioral or substance abuse disorders. The ACA mandates behavioral health coverage for most health insurers and Medicaid expansion under the ACA would have affected millions of low-income adults and some children covered through the CHIP (Sultz & Young, 2018).

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These legislative initiatives have been instrumental to increasing coverage and access of behavioral health care, but there are some limitations to be noted. For instance, the MHPA and MHPAEA both have limitations in that insurance providers have found methods of circumventing these acts, including the implementation of non-quantitative treatment limitations (NQTLs) to limit the scope or duration of benefits for treatment. In addition, the rate of children with private insurance that does not cover behavioral problems continues to increase, and private insurance companies continue to place subtle restrictions on coverage for behavioral health treatments (Mental Health America, 2019). In addition, 16 states have chosen to opt out of Medicaid expansion and the use of Medicaid federal waivers has left a significant number of people without coverage for behavioral health problems. Lower income individuals in these states fall into a coverage gap, with too much income to be eligible for Medicaid but too little income to purchase insurance on their own.

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Recommendations for improvement include:

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  • stronger public effort to drive their government representative to close loopholes

  • more clarification and enforcement of the MHPAEA within states

  • removal of or restrictions on NQTLs

  • expansion of Medicaid to all states

  • restricted use of Medicaid waivers

References:

Mental Health America. (2019). Access to care data. Retrieved from https://www.mhanational.org/issues/mental-health-america-access-care-data


SAMSHA-HRSA. (n.d.). Integrating behavioral health into primary care. Retrieved from https://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care


Sultz, H. A., & Young, K. M. (2018). Health care USA: Understanding its organization and delivery. Burlington, MA: Jones & Bartlett Learning.

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