esirable if not outright dangerous6. When the widespread popularity of homeopathy began to seriously threaten the livelihood of allopathic physicians, allopaths throughout the country joined together to the form the American Medical Association (AMA) in an attempt to limit the ability of homeopaths to practice their alternative medicine6. Their efforts failed, however, and by 1900, with approximately 15% of all US physicians having graduated from one of the homeopathic medical schools then located in almost every major city, the AMA granted recognition to the homeopathic movement6. But the victory for homeopathy was short-lived6. With the discovery of antibiotics and vaccines, more barbaric medical practices fell out of favor and mainstream medicine became much more palatable to the public6. As a result, homeopathy all but died out, with fewer than 100 homeopathic physicians practicing in the US in 19706.
Although homeopathy has been used to treat such diverse conditions and symptoms as allergic asthma, hay fever, migraines, childhood diarrhea, rheumatoid arthritis, and fibromyalgia and to decrease the duration of labor and the time required to recover from trauma, studies on the perceived benefits are difficult to conduct6. Meta-analyses, published in well-respected journals such as The Lancet and the British Medical Journal, however, have shown some benefits over placebo6.
The FDA regulates the manufacturing and marketing of the over 2,000 different homeopathic medications available for sale in the US6 . Approval of these medications, however, tends to be a formality, since manufacturers are rarely required to provide evidence of safety and efficacy and most of these preparations can be purchased without a prescription6. Furthermore, only four states provide licensure15 whereas the standards by which homeopathic providers are regulated in the reamining 46 states are quite variable. The Council of Homeopathic Education has, however, stated that five universities — three on the West Coast, one in Canada, and one in Europe — meet their standards for providing adequate training in homeopathic medicine6.
An initial visit to a homeopath averages $137 with follow-up visits costing around $55 each6. Medications, however, are significantly less expensive at $3-7 a bottle, and refills are rarely required6. Although insurance reimbursement may be available when individuals consult mainstream practitioners who also practice homeopathy6, Eisenberg’s study found that no insurance coverage whatsoever was provided to those individuals who sought homeopathic services14.
Naturopathy is the branch of alternative medicine dealing with “anything ‘natural’” including herbal medications, dietary supplements, acupuncture, dietary and/or lifestyle modification, stress management, and detoxification6. From the diversity of the components involved, it is evident that naturopathy is more a philosophy than a given set of techniques; a philosophy which draws heavily from the other conventional and alternative medicine practices, including Asian, Indian, and Greek medicine, which believe in the healing power of nature and the body’s ability to heal itself6. Also inherent to this philosophy of “natural medicine” are the previously discussed concepts of the holistic individual, the active role of the patient in attaining spiritual and physical health, the role of the physician as teacher, and the importance of preventive measures6. Another important component of naturopathy is an attempt to find and change the cause of disease which it believes lies in the environment — either internal or external6.
The profession of naturopathy was brought to the US in 1895 by a German immigrant named Benedict Lust who founded the New York City’s American School of Naturopathy in 1902 and the American Naturopathic Association in 19196. It has been used to treat such diverse conditions as allergies, asthma, arthritis, gastrointestinal illnesses, depression, insomnia, nausea, high blood pressure, labor pains, gynecologic problems, stress, and chronic pain6. Naturopathy emphasizes the prevention of illness and, like many alternative therapies, may work best in situations where conventional treatments have failed6.
In many ways, training for the degree of Doctor of Naturopathic Medicine (ND) parallels the training of allopathic and osteopathic physicians6. Four years of college precede four years of naturopathic medical school where much of the curriculum overlaps with allopathic medicine but includes training in acupuncture, physical manipulation, and massage therapy6. There are currently four such colleges in North American, three on the West Coast of the US (in Seattle, Portland, and Scottsdale) and one in Toronto, Canada6. Although licensure is currently granted to NDs in 12 states throughout the US as well as the District of Columbia15, the West Coast, particularly the Pacific Northwest, is the best with regard to regulation, licensure, and reimbursement, and in the state of Washington naturopaths are considered primary care providers6. In general, naturopaths’ fees run about half the cost of an allopathic visit6.
Massage Therapy was used by 11.1% of the population in Eisenberg’s study, with the majority going to a therapist for an average of 8.4 visits per year14. This translates into 113,723,000 total visits in the US in 199714. Massage therapy, however, is a frequent component of other types of alternative medicine practices and schools of thought and many different kinds of alternative medicine practitioners are taught massage techniques as part of their training.
Massage therapy involves the “systematic manipulation of the soft tissues of the body” via nearly 100 different techniques (and combinations of techniques) such as rubbing, kneading, slapping, tapping, rolling, pressing, and many others6. The two most popular types in the US are the Swedish and contemporary Western forms6. Swedish massage was developed in the early 1800s and brought to the US in the 1850s where it is currently the most popular6. It falls into the broader category of traditional European massage with a goal of improving blood flow in the muscles, relaxing the muscles by mimicking both active and passive exercise, improving circulation throughout the body, and increasing the body’s range of motion6. Also popular is contemporary Western massage which takes a holistic approach to the therapy with the hope of improving the function of the body and mind, thus bringing about a greater sense of well-being6.
Other common forms include: deep tissue massage, manual lymph drainage massage, myofascial release, neuromuscular massage, trigger point massage, myotherapy, and sports massage6.
Massage therapy has been used to treat high blood pressure, asthma, burns, chronic pain (back and neck pain, arthritis, migraines), rashes and other skin conditions, labor pains, addiction, depression, anxiety, attention deficit hyperactivity disorder, eating disorders, symptoms of premenstrual syndrome, chronic fatigue syndrome, sore muscles, and muscle sprains and strains6,14,17. It has also been used to reduce swelling, enhance relaxation, boost immune function, improve diabetic control, and improve general well-being6,14,17. Regulation and licensure of practitioners varies by location, although the Commission on Massage Therapy Accreditation recommends a minimum of 500 hours of education and the National Certification Board for Therapeutic Massage and Bodyworks administers a national certifying exam6.
A one-hour massage therapy session costs between $30 and $60 (although more specialized techniques will cost more) with most sessions lasting 30-90 minutes6. Insurers tend not to cover the cost of massage therapy, but a referral from a physician may increase the likelihood of reimbursement6. In Eisenberg’s study, insurance plans provided complete coverage for 11.8% of the individuals who saw a massage therapist, partial coverage for 16.7%, and no coverage for 71.5%14.
Hypnosis places an individual in a trance-like state during which time he or she is barely aware of the surroundings and is susceptible to the power of suggestion 6. It was used by 1.2% of the respondents polled by Eisenberg’s, et al14. With the majority of these individuals going to a practitioner an average of about 3 times per year, it is estimated that, nation-wide, Americans made 4,171,000 visits to hypnotists that year14.
The practice of hypnosis was begun in France in the late 1700s by Franz Mesmer6. Originally a fraudulent practice more often than not (Mesmer was later expelled from France for medical fraud), hypnosis has been accepted as a genuine medical therapy in the US since 19586. Many medical practitioners from a wide variety of backgrounds have since attained adequate training and experience in the techniques of hypnosis6. However, obstacles to its widespread acceptance remain. The mechanism(s) through which hypnosis works are unknown, and the techniques are only effective in a selected population of individuals6. While hypnosis can only work for those people who believe in it and have clear goals for their therapy in mind, even among the highly motivated individuals 25-30% remain minimally susceptible to the techniques while 60-80% are moderately susceptible and 5-10% are highly susceptible6.
For those individuals in whom hypnosis works, it seems to be a reasonable approach to take in attempting to get rid of bad habits, irrational or overwhelming fears, pain, and addiction to drugs or cigarettes6. Hypnosis has also been found effective in weight loss programs and for the treatment and management of skin conditions, asthma, nausea, irritable bowel syndrome, fibromyalgia, cerebral palsy, and migraine headaches6,19.
No licensure requirements currently exist for the practice of hypnosis. However, the American Board of Hypnosis and the American Council of Hypnotist Examiners issue guidelines to assure minimal competency among practitioners6. And while the cost of a hypnosis session may, theoretically, be covered if performed by a healthcare provider licensed in a conventional medical field, Eisenberg found that complete coverage was only available to 5.1% while a lack of any partial coverage left 94.9% of those surveyed to pay the entire bill out-of-pocket14.
Biofeedback links the mind with the body in a way that allows the mind to control certain bodily functions. In this alternative medicine technique used by 1.0% of the population in Eisenberg’s survey14, an individual is hooked up to a monitoring device which provides an indication of how a specific part or system of the body is functioning6. Examples of these devices include machines which monitor brain waves, breathing patterns, muscle stimulation and response, sweat gland function, pulse, skin temperature, and blood pressure6. The output from the machine is continuous and nearly instantaneous. Thus, as the patient focuses on the physiologic response output and attempts to change it through mind-body exercises such as relaxation, the machine provides the feedback which guides future attempts at modification6. While significant changes may take a number of sessions (the individuals who reported using biofeedback in Eisenberg’s study scheduled an average of 10 visits a year) as well as a great deal of practice between sessions, this therapy has been shown to be effective6, 14. Biofeedback is now widely accepted throughout the healthcare field for the treatment of such conditions as anxiety, asthma, tension headaches, chronic pain, high blood pressure, stress, and Raynaud’s disease6. Additional investigations are now underway to determine if it may have an adjunct role in the treatment of diabetes and epilepsy and rehabilitation following a stroke6.
The majority of individuals who use biofeedback see a trained practitioner, accounting for an estimated 3,871,000 visits in 199714. Although no licensure is available for these practitioners, who are usually traditional healthcare providers as well, the Biofeedback Certification Institute of America does provide certification for those individuals who meet their minimal standards of training and competency6.
Often approaching $150 per session6 and typically requiring many sessions before the desired effect is achieved, biofeedback tends to be quite costly as far as alternative therapies go. The good news, however, is that this therapy is frequently covered by insurance plans for a cause which is “mainstream” or upon the recommendation of a physician6. Eisenberg, for example, found that insurers provided complete coverage for 30.5%, partial coverage for 43.7%, and no coverage for 26.0% of individuals14.
Community Clinics were designed to provide free or low cost medical care and preventive health services to those individuals without insurance who are unable to pay high out-of-pocket fees. Begun in the 1960s, they have, for the most part, grown out of grass-roots efforts to provide healthcare for the working-poor, thus enabling them to stay off welfare5. Depending heavily on community support and the effort of hundreds, if not thousands, of local volunteers, these clinics have become well-respected facilities in the many communities which they serve fostering pride, encouraging voluntarism, and building a strong sense of community5. In 1990, there were over 1500 community clinics in the US, over 200 of which were considered to be “free clinics”, including the Free Medical Clinic of Greater Cleveland; and the states of Virginia and North Carolina both had laws freeing clinic volunteers of liability for services donated5.
Despite receiving no financial support from the federal government, these facilities have found the means to provide rather costly services such as laboratory tests, x-rays, and prescription medications to their patients5. Although some community clinics rely on limited funding from their local government, all have found alternative means of financing their budgets while keeping their overhead expenses low5. These mostly volunteer-run organizations have very few, if any, salaries to pay and they often utilize donated space and products5. Their funding and supplies come from such diverse sources as: local hospitals, pharmaceutical and medical/dental equipment companies, health departments, private community organizations, individual donors, interest from endowments, the United Way, and local businesses5. In addition, many community clinics, even those which are “free”, charge their patients at least a nominal fee, not only as a means of generating revenue, but, more importantly, to encourage these individuals to invest in their well-being and to become active participants in their healthcare5.
Because they have remained flexible throughout the years, community clinics have been able to identify creative, locally-based solutions to not only meet their financial needs but to solve the healthcare problems unique to their communities5. Their strength in providing much needed healthcare lies in their ability to eliminate many of the barriers which make it difficult for the working poor to seek medical care anywhere else5. These include not only large costs but also transportation and inaccessible hours5. Community clinics are usually located in the heart of the community, eliminating transportation problems for those at greatest need5. In addition, this closeness-to-home provides a sense of familiarity, intended to encourage increased use5. Many community clinics have also altered their hours of operation, opening only in the evenings or on weekends when more of their patients, and volunteers, are likely to be off from work5. And by becoming intimately familiar with the communities they serve, these clinics have been able to identify and address specific healthcare concerns which they feel are being overlooked5. Many community clinics have educational programs addressing hygiene, nutrition, prenatal care, and safe sexual practices and provide their patients with lists of social services and other valuable community resources5.
Healthcare is also provided to the community through School-Based Health Services which range from a nurse in the school to a school-based clinic or health center. All of these varying services are designed with the notion that school children of all ages, and adolescents in particular, have unique physical, mental, and social health needs which are not being met by the conventional healthcare system which they underutilize20. This may stem from the fact that one out of every seven US adolescents lacks health insurance while many others have only limited coverage which prevents them from accessing frequently-needed services such as preventive health, mental health, and drug and alcohol treatment20. Because of these and other concerns, many state and local governments nationwide are trying to improve the health programs in their schools21.
School nursing, “a specialty branch of professional nursing [which] seeks to identify or prevent student health problems, and intervenes to remedy or modify these problems” 21 has been in existence in the US for over 100 years21. It began in the late 1800s with attempts to prevent the spread of communicable diseases but serves today to “bridge the gap between health and education”, combining the objectives of providing health education, performing direct services, and improving the school environment21,22. Specific tasks of the school nurse include triaging students who are ill or injured, conducting screening and early intervention programs, educating and counseling students, providing mental health services, fostering healthful behaviors geared towards health promotion and disease prevention, and providing public health services to the greater community21,22. From this extensive list, it is evident that many of the services are provided on a group level via classroom education and intervention programs22.
In an attempt to provide comprehensive healthcare to students on an individual basis, school-based clinics and health centers have recently been developed. First started in secondary schools, these programs are now being expanded into the elementary schools of many communities as well20,22. With only two such programs in the US in 1970, the number had exploded to over 700 in 41 different states by 199520 and was approaching the 1000-school mark by 1998 with many more under development22.
With a multidisciplinary professional staff consisting of NPs, PAs, part-time physicians, and social workers these clinics offer a wide variety of services including those which address the preventive, mental, and sexual health of their young patients20,22. Specific services include: physical exams, immunizations, diagnosis and treatment of minor injuries and sexually transmitted diseases, laboratory tests, management of chronic illnesses, prescriptions and supplies, gynecologic services including family planning, prenatal education, developmental assessment, and counseling on a wide range of topics such as nutrition, drugs and alcohol, and HIV/AIDS20,22. When they are unable to provide services directly, as is often the case with prenatal, specialist, and dental care, school-based clinics offer referrals and help in ensuring that the barriers to obtaining these services are overcome20,22. Like the school nurse has always done, these clinics are also beginning to integrate education into their long list of services, with projects ranging from individual classroom presentations to the development of comprehensive health education curricula20,21,22. As a result, many school nurses, who once saw the school health education domain as exclusively theirs, are now partnering with these health centers to achieve mutual goals while sharing from the same limited resource pool22.
The funding for these clinics, which were initially born out of grass-roots efforts, now comes from public as well as private sources20. Sponsors of these projects include county and city health departments, community clinics, local hospitals, and even HMOs20. Additional finances come from reimbursements by Medicaid and some private insurers, although HMOs and other managed care plans which require in-network utilization have been reluctant to pay20.
Short-term evaluations of these clinics and health centers have shown some success in improving the overall health of the students including reductions in risk-taking behaviors, decreases in school drop-out rates, increases in the rate of promotion to the next grade, and improvements in the consistent use of contraception during sexual intercourse20. More importantly, these studies indicate that students will utilize these services if they are readily available20. In order to use the services offered by school-based clinics and health centers, students must first enroll, a process which requires parental consent20. Typically, 60-70% of all students in a school with an existing program will in fact enroll, and 50-70% of these will utilize the services during the course of the school year20. In one study, 31% of those who used the school-based clinic went for acute care, 26% for preventive services, 20% for mental health counseling or treatment, 18.5% for reproductive services and sexual health needs, and 8.5% for the management of one or more chronic illnesses20. Parents have the right to limit the extent of services their child is to receive, although this rarely happens in practice20.
Perhaps these clinics are so popular among both students and community leaders because of the many advantages they offer. They are convenient to students because they are readily accessible and easy to use, freeing them from reliance on adults when it comes to seeking much-needed care20. Located on school grounds, they eliminate the transportation barrier to access, and with their nearly-universal policy of providing care without regard to insurance status, they are available to all students regardless of ability to pay20. Furthermore, these clinics and health centers have been designed to be user-friendly for their young patients, stressing confidentiality, educating them about the services offered, and making care easy to obtain20. With appointments scheduled around school hours, loss of classroom time is dramatically reduced20. And for the many adolescents who are spontaneous in seeking medical care, large blocks of time set aside for walk-in appointments make it easy to “drop by” 20. With the implementation of such programs, many communities have realized reductions in the number of ED visits, which translate into decreased costs20. Cost savings also occur when sexually transmitted diseases and teen pregnancies are prevented, screening and immunization programs are implemented in a timely manner, and better follow-up for chronic disease management occurs20. Furthermore, these clinics and health centers have been shown to provide cost-effective primary care by centralizing utilization thus eliminating the duplication of services between multiple providers in the community20. Perhaps most important, however, is the benefit to the entire community when the health of its children improves. They are then more likely to become better learners, remain in school longer, and become productive members of adult society20.
A more loosely defined community is the workplace, where innovations in healthcare are also taking place. Traditionally limited only to the treatment of work-related injury and illness, Healthcare in the Workplace is now expanding in a limited number of corporations to include primary care and preventive health services as part of “24-hour coverage”23,24. A study published in 1995, looking at four such pilot programs in California, showed that these plans are effective in reducing healthcare costs24. Savings stem from the fact that the additional services use pre-existing on-site facilities and support and administrative staff23. Furthermore, when the worker-patient is being evaluated by one well-coordinated healthcare team, duplications of expensive services such as diagnostic tests and referrals can be minimized23. And since it is not always clear which conditions stem from work-related injuries and exposures and which do not, having access to both primary care and occupational medicine providers in one facility helps ensure that a wider variety of diagnoses can be made more rapidly and accurately23. An additional advantage to both worker and corporation is the convenience of having more medical services on-site, resulting in less time away from the job when seeking care as well as an increased use of preventive services23. When these result in the improved overall health of employees, job-performance and productivity increase while absenteeism decreases23.
However, the consequences of merging work-related healthcare with other medical services are not all positive. Health records which track illnesses not related to the workplace can interfere with workers’ privacy rights and could potentially lead to discrimination23. And healthcare providers who are paid by the company but serve its employees may find themselves in the uncomfortable position of trying to determine to whom they are accountable and whose best interests they are trying to serve23. Additional problems stem from the fact that the physicians staffing the employee health clinics are trained in occupational medicine, with a background focusing on preventing, recognizing, and treating work-related injuries and illnesses23. They are not trained in primary care and are thus not adequately qualified to provide such services to patients23. This means that a company wishing to expand its employee health clinic to provide primary care would need to hire additional physicians who have the appropriate expertise23,24. This would not only take funding and other resources away from the occupational health services which may be more essential to the corporation but would require multiple physicians to work closely together to maintain the continuity of care which such programs are striving to achieve23. The financial burden will be particularly great for those companies which did not, in the past, pay for the primary care insurance of some or all of their employees but which now wish to expand their clinics to provide comprehensive healthcare benefits to all workers23.
Forming a very different category of community healthcare organization are Support Groups. Defined as “self-governing groups whose members share a common health concern and give each other emotional support and material aid, charge either no fee or only a small fee for membership, and place high value on experiential knowledge in the belief that it provides special understanding of a situation” 25, the number of these organizations, also known as self-help groups, has increased dramatically since their inception in the 1960s25,26. Over 500,000 such groups were in existence across the US at the end of the 1980s, and it is estimated that 10 million people attend an average of almost 20 sessions annually while at least 25 million individuals have tried support groups at some point in their lifetime14,25,26. Focusing on a variety of diverse topics, a group exists for virtually every type of morbidity and mortality, and just about every aspect of medicine and public health is addressed26. Some well-known examples include: Alcoholics Anonymous, Mothers Against Drunk Driving, the Association for Retarded Citizens, the National Black Women’s Health Project, the National Alliance for the Mentally Ill, Take Off Pounds Sensibly, and Overeaters Anonymous25,26. Other support groups exist for those recovering from addictions, parents of premature infants, widows and widowers, and those with illnesses such as post-traumatic stress disorder, chronic fatigue syndrome, multiple sclerosis, and a variety of cancers, to name just a few17,25,26.
Perhaps self-help groups are so popular throughout the country because they work25. By allowing people with similar problems to come together, these groups provide individuals an opportunity to learn from each other by sharing experiences and ideas25,26. Often people find not only support and companionship in the midst of these groups but also role models who have overcome their adversity and teach and encourage others to do the same25,26. These factors combine to give many support group members a regained sense of control over their lives and a feeling of empowerment25,26. They are also able to serve as a political venue for voicing concerns and advocating for change at both the local and national levels25,26. And they themselves maintain the ability to evolve and adapt to meet the ever-changing needs of a dynamic local community26. Amazingly enough, all of this happens at little or no financial cost and without a reliance on healthcare professionals, making the services accessible to all while taking a significant burden off a community’s formal health care system25,26.
The number of Americans over the age of 65 is climbing, with the most rapid growth occurring in that category of elderly — over age 85 — who are known as the “oldest old” 27. As the volume of senior citizens continues to expand, so does the demand for services to assist and take care of these individuals27. Often-times, when family support systems prove no longer adequate and the burden of care to the community becomes too great, Nursing Homes are called upon to provide the needed care.
In 1996, nearly 1.5 million Americans over the age of 65 resided in 17,208 nursing homes across the country (1020 of which were in the state of Ohio), occupying 83% of the nearly 1.9 million beds available nationwide1. At an average monthly cost of $3,135 per resident, nursing home expenditures totaled over $78.5 billion in 1995, compared to only $0.8 billion spent in 19601. Government funds paid for nearly two-thirds of all nursing home residents that year, while roughly one-third were supported by their savings or their family’s income, and private insurers contributed only 5% to the total pool of funds1. In looking ahead, it has been estimated that 40% of all individuals who had turned 65 by 1990, can expect to reside in a nursing home for at least some portion of their life, with nearly 1 out of 4 spending one year or longer in such a facility and 1 out of 11 living there for over 5 years27. Based on these figures, the demand for nursing home beds is expected to approach 5 million by 2025, at an annual cost of $700 billion27.
In increasing numbers, nursing home residents are older and more functionally dependent, unable to care for themselves27. Currently, about half of all nursing home residents are over 85 years old1. And a large majority, nearly two-thirds, are cognitively impaired, suffering from dementia, delirium, and other mental illnesses27. Many are also immobile, confined to a bed or a wheelchair, with multiple medical problems requiring many medications27. In 1995, it was reported that 79.0% of all nursing home residents required assistance with mobility, 63.8% were incontinent, 44.9% needed help eating, while 36.5% fell into all three categories1. However, as the push to decrease the duration of hospital stays continues, nursing homes are, with increasing frequency, being asked to deal with more acute and subacute medical issues by providing services to younger patients who need extra help recovering from a major illness, surgery, or accident3. Thus, the duration of a nursing home stay does not have to be long-term, with approximately 25% of the residents returning home after less than 6 months of rehabilitation3,27. However, nearly 50% of residents do spend 6 months or longer in a nursing home while 25% receive fewer than 6 months of end-of-life care27.
Obviously the sicker, older residents require the highest level of care. With around-the-clock nursing care and physicians available to manage many active medical issues on-site, skilled nursing facilities are called upon to provide a full range of medical, personal, and residential care services to their highly-needy residents3. Medications are administered, rooms are cleaned, meals are prepared, and clothes are laundered3. Social activities and physical and occupational therapy sessions are provided as is assistance with eating, dressing, bathing, and ambulating3. This is the only level of nursing home, when mandated by a patient’s medical condition, that is covered by Medicare3. The needs of less disabled individuals, however, may be met by the lower-level of services offered at an intermediate-care facility3. These less costly alternatives are more likely to be used by those seeking short-term rehabilitation3. The final type of nursing home, frequently referred to as “assisted living”, provides only a very limited number of personal care and homemaking services in a “sheltered” or “custodial” setting that does not offer any medical care3.
In addition to level-of-care categories, nursing homes can also be divided on the basis of ownership. Proprietary facilities are owned by an individual or a corporation3. Driven by competitive market forces, these establishments may provide better services at a lower cost3. In 1995, 63.6% of all nursing home residents were paying an average of $3,047 per month to live in one of these facilities1. The other 36.4% of residents were living in non-profit facilities operated by community organizations, religious groups, or the government at an average monthly cost of $3,2881.
All nursing homes are highly regulated, licensed by state governments and certified for Medicare/Medicaid payments by federal authorities3,27. They are held accountable for the care they provide and are required to conduct periodic, comprehensive assessments of all residents, enforce standards for employees, attempt reductions in the use of physical and pharmacologic restraints, and review quality assessment measures on a regular basis3,27.
But while nursing home care may be the only viable solution for some, a large number of elderly individuals with significant healthcare concerns turn to other options, and it has been estimated that “for every elderly person living in a nursing home, at least two persons living in the community have the same disease and disability burdens” 27. One such option, gaining increasing popularity, is that of Home Care. In 1992 over 1.2 million patients nationwide were receiving home healthcare services1. By 1996, this number had nearly doubled1. And while cheaper than hospitalization, this sector of the healthcare market consumes a significant portion of the federal Medicare budget. In 1992 alone, Medicare spent $8.2 billion (or 6% of its budget) on home care, a number estimated to be increasing by 10% annually3. Medicaid and many private insurers will also cover the cost of home care when medically indicated, prescribed by a physician, and delivered by a certified home care provider3. In 1993, 6,497 home health agencies were on Medicare’s certified provider list and an additional 5,714 agencies offered services3.
Although categorized here as an “elder care” service, home healthcare is not reserved solely for the elderly. Home care can be provided to a qualified younger individual who is either chronically ill or recovering from an acute hospitalization3. In fact, while in 1992 nearly 76% of all individuals receiving home care were 65 and older, by 1996 this number fell slightly to 72.5%1. The main diagnosis leading individuals to seek home care are (in descending order): heart disease, arthritis and other musculoskeletal diseases, diabetes, stroke, lung disease, cancer, and fractures1. Services provided by home care nurses, doctors, health department workers, and lay employees include: nursing care, health assessment, hospice care (see section below), social services, respiratory therapy, physical therapy, occupational therapy, speech therapy, and intravenous antibiotics3. Help with cooking, cleaning, shopping, and household chores, although not covered by Medicare funds, are also frequently considered to be home care services3. These are usually offered by local community volunteer organizations, social service agencies, and church groups through popular programs such as Passport and Meals-on-Wheels3.
Including both nursing home facilities and home care as part of their multi-level elder care model are Continuing Care Retirement Communities (CCRC). Sometimes referred to as “lifecare communities”, approximately 1000 such facilities currently exist in the US, serving an estimated 250,000 individuals between the age of 70 and 9028. Ranging in size from 200 to 2500 beds, they offer housing in an apartment, assisted living, and nursing home setting to meet an individual resident’s changing level of need28. Medical and self-care services provided include home healthcare, skilled nursing facilities, and, often, subacute short-term facilities to care for those recently discharged from the hospital28. Many CCRCs also hire full- or part-time primary care providers (physicians as well as NPCs) while others provide transportation to nearby facilities28. And most contract with one or more local hospitals to facilitate and control costs for resident admissions as well as dealing with the insurance paperwork and medical bills on the residents’ behalf28.
To enter such a community, an individual (77% of all CCRC residents are single) must sign a lifecare agreement and pay a rather steep entrance fee which entitles them to life-long care28. Monthly service fees are assessed to cover the cost of apartment maintenance, common area upkeep, social activities, security, local transportation, and one or more meals per day28. The entry fee serves as insurance for the increased costs which would be incurred if an individual were to require a higher level of care and is highest in those communities classified as Type A by the American Association of Homes and Services for the Aging (AAHSA). CCRCs of this category are all inclusive, providing skilled nursing and home care, as needed, at no extra charge28. Type B communities offer the full range of services as well, but limit their amount so that residents needing care beyond the extent specified will incur an additional fee28. Type C communities operate on a fee-for-service basis, charging the smallest entry fee but requiring residents to pay out-of-pocket for any care in excess of the amount covered by their monthly assessment28. Communities of the A and B type are also more likely to pay the medical or pharmaceutical bills not covered by the resident’s Medicare and Medigap insurance, although they usually require the residents to use their preferred providers in order for such coverage to apply28. But because they are all inclusive in the services they offer, they not only charge more but set rather stringent entrance requirements, limiting admission to higher-functioning residents predicted to be less likely to require extensive care in the future28. Attempts are currently underway to make these communities, originally founded by nonprofit charities but now marketed to only the wealthiest 10% of the elderly by for-profit development groups, more affordable and accessible to the middle-class28.
Another type of service available to qualified individuals of any age but utilized primarily by the elderly is Hospice. Established by Dame Cecily Saunders in London, England in 1967 to provide end-of-life care for the terminally ill, the first US hospice program was started by Florence S. Wald in 1977 providing home-based care for those with a predicted life expectancy of under six months3,29. Hospice programs currently provide care through in-patient facilities, in the home, and at free-standing clinics to nearly 60,000 individuals each year1,3.
The mission of hospices nationwide is to ensure death with dignity by optimizing pain control and minimizing suffering3. The services provided extend not only to the patient but the family as well. Aiming to allow individuals to remain at home surrounded by their family and friends rather than extensive hospital equipment, hospice workers and volunteers provide education to help the patient and family prepare for death and ultimately lend support to the survivors3. Although 58% of hospice patients have cancer, heart and lung disease also accounts for a large proportion of individuals receiving care, 78% of whom are at least 65 years old1.
As of 1982, Medicare (as well as many private insurers) covers the cost of hospice care if the patient is Medicare eligible, has a terminal illness with an expected survival of less than six months, has given informed consent, and seeks care from a certified agency29. In 1993, 1,223 hospice programs nationwide were certified by Medicare and an additional 477 programs were in existence3. In the state of Ohio, 51 different hospice programs were available in 19992.
For the Healthcare Manager, the question “where do Americans go for health care?” is an important one to consider. The answers are numerous and diverse. Although this discussion has attempted to provide a comprehensive overview of the types of services which exist, both traditional and alternative, in the community and for the elderly, it has only begun to scratch the surface of a rapidly evolving marketplace.
The important lesson for the manager to keep in mind is that the array of services is broad and the settings in which they are found are also varied. Thus, the role of a manager can vary considerably, often involving a wide variety of different tasks. This may range from no involvement in a solo office practice to the gargantuan task of ensuring that the wide variety of services and large number of employees comprising a large medical center or an extensive Continuing Care Retirement Community are smoothly and efficiently integrated. Somewhere along this continuum of management complexity lie the many other practice environments and styles described. Today, many complementary medicine practitioners from a variety of different schools of thought are joining together to provide their patients with multiple options in alternative care within the confines of a single office. This parallels the recent evolution in the traditional group practice model. It is not uncommon to find, in a large group practice today, a number of allopathic and osteopathic physicians, trained in several different fields of medicine, working side by side with non-physician clinicians to provide higher-quality and more efficient care to their patient-consumers.
From this discussion, it should be apparent that the key to surviving in this changing healthcare system is to be open to change. Will the new services and structures which continue to develop blend in smoothly with the existing models of care? Or will they be better served by finding a more innovative method of bringing care to the community? Only time will tell.
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