Chapter 7 – Profile of the Long-term Care Industry

What is Long-Term Care?

Long-term care is a variety of services that includes medical and non-medical care to people who have a chronic illness or disability.  Long-term care helps meet health or personal needs.  Most long-term care is to assist people with support services such as activities of daily living (ADL’s) like dressing, bathing, and using the bathroom. Long-term care can be provided at home, in the community, in assisted living or in nursing homes.  In fact, by far the largest percentage of the elderly needing long-term care are cared for at home and their family and friends are their only caregivers.  It is important to remember that people may need long-term care at any age.  It is estimated that 12 million older Americans need long-term care.  About 10 percent of the people who enter a nursing home will stay there five years or more.  (This information resourced from the U. S. Government Medicare website.)

As we use the term in this handbook, a “long-term care facility” refers to any institution that provides professional care (on any scale short of a hospice or hospital) to individuals, whether it be a for-profit or non-profit operation, privately run or corporately controlled, large or small, religion-sponsored or secularly managed, extended stay or acute care.  (It should be mentioned that the terms, “care center” and “nursing home” and “care facility” are often used interchangeably with “long-term care facility.”) 


The commercial industry of long-term care, as it has developed in our western culture, is unique in the history of the world. At no other time, nor in any other place, has institutionalized care been seen on the scale of what we have today. In localities where nursing homes numbered five or six just a few decades ago, today there are fifteen or twenty.  In the United States, there were 1.5 million residents living in “institutional settings” in 2016.  Of that number, 1.2 million lived in nursing homes.  (“2017 Profile of Older Americans,” page 5, published by The Administration for Community Living, April 2018 – updated regularly).  But, in addition to those in “institutional settings,” close to 5 million older adults were under the care of Home Health Agencies, receiving their long-term care in their home (“2016 Older Americans Key Indicators of Well-Being,” Federal Interagency Forum on Aging Related Statistics).  And this figure, 5 million, does not include those who are under the exclusive care of a friend or family member.  As “in-home care” becomes more and more popular, the percentage of elderly and handicapped who are able to stay in their own residence will significantly increase; but, because of the “baby boomer” phenomenon, the total number of individuals who live in long-term care facilities (especially “retirement communities”) will probably increase in the foreseeable future. 

NOTE:  Though “nursing home ministry” is focused on the elderly and infirm who are institutionalized, it is important for us, as “nursing home ministers,” to consider making adjustments in our focus to the growth of the numbers of aging, ill and handicapped Americans who are home-bound or receiving long-term care in an unconventional manner.  It is easy to see how this overwhelming majority of LTC recipients may be falling through the cracks as it relates to personal Christian ministry from within their community!  Admittedly, the logistics are complicated.  How can we find them?  How can we get an invitation to visit them in their private home?  What are the unique liabilities of in-home visits to complete strangers?  How do we relate to their care-givers?  Certainly, local Home Health Agencies would seem to be the best place to start for those who feel led by the Lord to begin investigating this segment of our field of ministry. 

In addition to the numbers, the nature of long-term care has changed too.  Seventy years ago there were two basic types of facilities: “old folks’ homes” and “convalescent homes.” Both often looked and smelled more like insane asylums than homes. As described later in this section, today there are different levels of adult care such as “nursing” care facilities, assisted living facilities, retirement homes, adult family homes, adult day-health care centers, and multi-level care complexes. Through education, community involvement and responsible regulation, these long-term care facilities are generally more clean, pleasant, and professionally managed than their predecessors.

Until recently, as the type and number of facilities has increased, so has the number of residents increased in the average facility. Where nursing homes might have housed 20 patients in old, three-story converted homes 70 years ago, today, 120 residents live in sprawling, well maintained commercial buildings designed particularly for that purpose.

We see at least five major factors in the United States affecting the population of care facilities.

Factors In Care Facility Population

1. Modern medicine is more successful in treating major illness and injury. Therefore, more people are surviving serious trauma and disease.

2. The average life-span is increasing. People are just naturally living longer than in past centuries. By the year 2020, more than 200,000 living Americans will be over the age of 100.

3. Due to the “baby boomer” phenomenon, the proportion of elderly people in the general population is increasing. Over fifty percent of our population is 50 years old or older.

4. Since 1964, Medicare and Medicaid have dramatically increased funding available for long-term care.

5. In increasing numbers, disabled people have no family or friends who are able to care for them.

Types of Facilities

The “care facility industry” is the focus of the ministry of Christian Concourse. Though the type of ministry that we do is often referred to as “nursing home ministry,” the type of facilities to which we go are actually very diverse. It is safe to say, in all cases (except Adult Day-Health Care Centers) they provide residence and care for the elderly and/or the infirm. The following list is our attempt to identify in laymen’s terms these different types of homes. [As mentioned in our discussion on the scope of this handbook, please note that the material in this manual does not address the special volunteer needs of hospitals or hospice institutions]

Augmented by our own observations, resources for this information are New LifeStyles Guide to Senior Residences and Care Options (listed in our Bibliography section) and the Federal Health Care Financing Administration.

Nursing Homes

A nursing home is a residence that provides room, meals, recreational activities, help with daily living, and protective supervision to residents. Generally, nursing home residents have physical or mental impairments which keep them from living independently. Nursing homes are certified to provide different levels of care, from custodial to skilled nursing (services that can only be administered by a trained professional).

Occasionally called convalescent centers, “nursing homes” is a term often used in general reference to long-term care facilities. Its proper technical use would be to identify facilities which provide some level of 24-hour, professional nursing services to residents. Nursing homes often serve residents needing short-term rehabilitation after accidents or illnesses. Though the same facility may house both levels, they are officially divided into two types based on the degree of nursing care they offer:

Skilled Nursing Facilities (SNF)

SNF’s provide around-the-clock nursing supervision. Many of their residents are completely or partially confined to their bed, and they are often incontinent. Medical treatment is provided under the supervision of licensed nursing professionals. At least one registered nurse must be on duty during the day. An SNF may include a special unit for residents suffering with Alzheimer’s disease and other forms of dementia.

Intermediate Care Facilities (ICF)

ICF residents are able to get out of bed and move about with or without assistance from staff personnel (whether ambulatory – able to walk – or in a wheelchair). These residents may be incontinent and will require intermittent professional care. An ICF may include a special unit for residents suffering with Alzheimer’s disease and other forms of dementia.

Assisted Living Homes

Assisted Living Homes provide an option for full-time, long-term care on a level between ICF nursing homes and retirement communities. They offer assistance with medications, bathing, dressing and usually serve full meals. These homes may include a special unit for residents suffering from Alzheimer’s disease and other forms of dementia.

Retirement Communities

Retirement Communities offer retired and elderly individuals the option of living in a community with other seniors in a fairly independent atmosphere. Residents of retirement communities are usually offered organized social programs, meal service, transportation, recreation, and assistance for shopping needs and medical services. Very often, the larger of such facilities will include an “assisted living” section on their premises.

Adult Family Homes

(Also called Residential Care Facilities, or Adult Care Residences) 

These are usually actual homes usually in residential areas having four or more beds providing care for a small group of seniors and/or mentally or physically challenged persons. Residents may be ambulatory or non-ambulatory and will be supplied room and board as well as supervision and assistance with daily activities such as bathing and dressing. Residents may suffer from Alzheimer’s disease and other forms of dementia. Programs are designed to help the residents be as independent as they can be. Such facilities are staffed around the clock.

Adult Day-Health Care Centers

Adult Day Health Care Centers are weekday, daytime-only facilities for seniors and disabled individuals who generally live with relatives or friends during non-working hours. Staff-supervised group activities of a recreational nature are provided throughout the day. Snacks and lunch are usually served. Programs vary widely, but services may also include nursing and rehabilitation.

Multi-Level Care Complexes

(Also called Continuing Care Retirement Communities, CCRC’s)

CCRC’s offer a variety of independent and retirement living options, coupled with full medical and nursing services designed to accommodate the contingencies of progressive aging disabilities. CCRC’s are usually equipped to be self-contained communities that offer a full range of activities, recreational opportunities and services for the active resident.

For more information from the U. S. government “Medicare” website about CCRC’s click here.


PACE is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility. PACE stands for Programs of All-Inclusive Care for the Elderly.

With PACE, the focus is on you — you have a team of health care professionals working with you and your family to make sure you get the coordinated care you need. Your team is experienced in caring for people like you. Usually they care for a small number of people, so they really get to know you.

When you enroll in PACE, you may be required to use a PACE-preferred doctor. These doctors are best suited to help you make health care decisions.

How does PACE work?
PACE organizations provide care and services in the home, the community, and the PACE center. They have contracts with many specialists and other providers in the community to make sure that you get the care you need. Many people in PACE get most of their care from staff employed by the PACE organization in the PACE center. PACE centers meet state and federal safety requirements.

Who can get PACE?
You can have either Medicare or Medicaid, or both, to join PACE. PACE is only available in some states that offer PACE under Medicaid. To qualify for PACE, you must:

Be 55 or older
Live in the Service area
of a PACE organization
Need a nursing home-level of care (as certified by your state)
Be able to live safely in the community with help from PACE
You can leave a PACE program at any time.
What does PACE cover?
PACE provides all the care and services covered by Medicare and Medicaid if authorized by your health care team. If your health care team decides you need care and services that Medicare and Medicaid doesn’t cover, PACE may still cover them.

Here are some of the services PACE covers:

Adult day primary care (including doctor and recreational therapy nursing services)
Emergency services
Home care
Hospital care
Laboratory/x-ray services
Medical specialty services
Nursing home care
Nutritional counseling
Occupational therapy
Physical therapy
Prescription drugs  

If you join a PACE program, you’ll get your Part D-covered drugs and all other necessary medication from the PACE program. You don’t need to join a separate Medicare Prescription Drug Plan. If you do, you’ll be disenrolled from your PACE health and prescription drug benefits.

Preventive care
Social services, including caregiver training, support groups, and Respite care
Social work counseling
Transportation to the PACE center for activities or medical appointments, if Medically necessary
. You may also be able to get transportation to some medical appointments in the community.
How to apply for PACE
To find out if you’re eligible and if there’s a PACE program near you, search for PACE plans in your area, or call your Medicaid office.

What you pay for PACE depends on your financial situation
If you have Medicaid, you won’t pay a monthly Premium for the Long-term care portion of the PACE benefit.

If you don’t qualify for Medicaid but you have Medicare, you’ll be charged these:

A monthly premium to cover the long-term care portion of the PACE benefit
A premium for Medicare Part D drugs
There’s no Deductible or Co-payment for any drug, service, or care approved by your health care team.

If you don’t have Medicare or Medicaid, you can pay for PACE privately.

This info about the PACE program taken from the Medicare Website of the U. S. Government. For the most current information click here.

Accessory Dwelling Unit (ADU)

An ADU (sometimes called an “in-law apartment,” “accessory apartment,” or a “second unit”) is a second living space within a home or on a lot. It has a separate living and sleeping area, a place to cook, and a bathroom. If you or a loved one owns a single-family home, adding an ADU to an existing home may help you keep your independence.

Space like an upper floor, basement, attic, or over a garage may be turned into an ADU. Family members may be interested in living in an ADU in your home, or you may want to move into an ADU at a family member’s home.

Check with your local zoning office to be sure ADUs are allowed in your area, and find out if there are any special rules. The cost of an ADU can vary widely, depending on many factors, like the size of the project.

This info about ADU’s taken from the Medicare Website of the U. S. Government. For more information click here.

Subsidized Senior Housing

There are state and federal programs that help pay for housing for some seniors with low to moderate incomes. Some of these housing programs also offer help with meals and other activities, like housekeeping, shopping, and doing the laundry. Residents usually live in their own apartments within an apartment building. Rent payments are usually based on a percentage of a person’s income.

This info about Subsidized Senior Housing is taken from the Medicare Website of the U. S. Government. For more information click here.

Home and Community-based Services

A variety of home- and community-based services may be available to help with your personal care and activities.

Medicaid may cover some services, including:

  • Home care (like cooking, cleaning, or help with other daily activities)
  • Home health services (like physical therapy or skilled nursing care)
  • Transportation to medical care
  • Personal care
  • Respite care
  • Hospice
  • Case management

Medicaid programs vary from state to state. Medicaid may offer more services in your state. Call your Medicaid office for more information.

These types of services may also be available through other programs, like the Area Agency on Aging, Medicare, or hospice programs. Learn more about Medicare’s coverage of hospice and home health services.

Community sources, like volunteer groups that help with things like shopping or transportation, which may be free or low cost (or may ask for a voluntary donation) are another option. Examples of the services and programs that may be available in your community are:

  • Adult day services
  • Adult day health care (which offers nursing and therapy)
  • Care coordination and case management (including transition services to leave a nursing home)
  • Home care (like cooking, cleaning, or help with other daily activities)
  • Meal programs (like Meals on Wheels)
  • Senior centers
  • Friendly visitor programs
  • Help with shopping and transportation
  • Help with legal questions, bill pay, and other financial matters
This info about home and community based services for the elderly is taken from the Medicare Website of the U. S. Government. For the most current information click here.
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