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LTSS Roadmap - Facility-based care

Guidance for the LTSS Roadmap planning model, which can guide communities through the planning process if they need to establish long-term services and supports or improve its current program. This module provides information on facility-based care.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 03, 2016

Facility-Based LTSS Models

Facility-based LTSS care is provided in and structured around institutions such as skilled nursing facilities (nursing homes) and, to a lesser extent and depending on State determination, assisted living residences and adult family homes.

Overview of facility-based LTSS care from Longtermcare.gov

Eligibility Requirements

State Medicaid requirements and restrictions apply. See State resources to learn more.

Examples of Facility-Based Care

Types of Facilities

Skilled nursing facility
Nursing home
Assisted living residences - (depending on State guidelines - See State resources.)
Adult family homes - (depending on State guidelines - See State resources.)

Services Offered

Skilled nursing care (not always offered, but required for Medicare licensure)
Occupational therapy, physical therapy, and speech therapy
Dietary management
Hospice and palliative care (not always offered)

Benefits and Challenges of the Facility-Based Care Model

Benefits

Comprehensive care
24-hour care
Secure living environment
Support for patient’s family
Some facilities provide culturally competent care

Challenges

High costs
- Initial investment
- Operating expenses
Family separation
Minimum occupancy level
Must open service to non-AI/ANs if licensed through Medicare

Transitional Care

Transitional care is the process of maintaining quality of care while elders and persons with disabilities transition to or from hospital or nursing home facilities and residential or home settings.

The purpose of transitional care is to stabilize the individual moving from one care system to another to ensure the transfer is successful. The process includes review of health status, medication management, and follow-up care.

Note: Transitional care occupies an increasingly important role as HCBS replaces facility-based care as the LTSS delivery mechanism of choice.

There are different models for transitional care: See an overview of 4 common models, including:

Care Transitions Intervention (CTI, or "Coleman Model")
Transitional Care Model (TCM, or "Naylor Model")
Better Outcomes for Older Adults through Safe Transitions (Boost)
The Bridge Program
GRACE (Geriatric Resources for Assessment and Care of Elders)
Guided Care

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.