Often home-based caregivers, either a spouse or adult child, rely on institutional care only as a choice of last resort, and this is often reported only after their own health and well being begins to be perceived as degraded by caring for the individual in the home, relevant to supplemented home care services as well. (Ducharme et al. 2007, p. 3-31) Researchers in fact contend that individuals will employ a vast variety of coping mechanisms to attempt to remain independent, and though these mechanisms should be supported in the community, when they are productive and effective rather than destructive but that alternatives should be better, in a number of fundamental ways. (Robichaud & Lamarre, 2002) What this trend of last resort means, according to Clemmitt, is that those with dementia and other functionally debilitating and progressive chronic diseases, i.e. The most vulnerable of populations are those who end up in LTC facilities. (2010, pp. 345-346) Caron, Griffith, & Arcand stress that the importance of caring for dementia patients in particular in an ethical and collaborative manner is fundamental to quality of care. To respond to this growing trend and the needs of staff and family to collaborate regarding care decisions, the long-term care facilities of the future should redirect attention of creating systems and standards for collaborative practice, where family and staff are in constant communication regarding care needs of their loved ones, as their loved ones are not usually in a position to make those decisions independently. (2005, pp. 231-234) Collaborative, family/caregiver care plans need to not only be developed but enforced, with regard to how and what a patient unable to make his or her own decisions receives in the way of care as well as in the way of autonomous decision making power. (Lambert et al., 2005)
Another reality associated with Long-Term Care in both largely unregulated assisted living centers and in traditional nursing home like care facilities is lack of trained staff and this issue has paramount impact on both quality of care and systems associated with that care. (Clemmitt, 2010, p. 346) Understaffed facilities, often because of pay scale must run in a far more efficient manner than those with adequate staff, everything must be done on schedule to meet even the most basic needs of residents on a daily basis, if any deviation in the schedule occurs, due to patient special requests being honored or for any other reason the limited time resource of the staff will not be able to recover and provide care to the rest of the patients. Additionally, when certain events occur, such as meal times and several staff are then taken off the floor to assist with the meal and provide medication during the meal the remainder of the facility is left even shorter staffed. The result is poor quality of care. (Kane, 2001)
Staffing and staff development must therefore be paramount to the development of a long-term care center of the future. Creative payment schedules, possibly based on quality of care and a new investment in continuing education as well as better benefits and higher wage scales need to be demanded, by staff and offered to staff to adequately resolve quality of care and short staffing issues. To do this a real stand must be taken in the way that LTC is paid for, so that earnings from care reimbursement can be funneled into better staffing and other quality of care programs. According to Clemmitt the only real way to do this is to expand the currently flat LTC insurance coverage, marketing it within traditional medical care insurance rather than alone, which will force the financial burden to be shared across the market, i.e. among those who need or may need the care and those who do not, as it is with medical coverage in general. (2010, p. 349) if there is no real change in the way that Medicare/Medicaid structure payment for long-term care the previous response is the only viable way that the community will be able to shoulder the burden of an increasingly elderly population, such as will be found with the baby boomers in the very near future, a population that by the way is more likely to have fewer children than individuals in the past and are more likely to be geographically separated from those children than previous generations. (p. 350) Staffing has been on the forefront of concern regarding LTC for decades and yet the prevailing wisdom has been to continue to offer the same payment structure and resolve the problem by putting a bandage on a gaping wound, in part by continuing to run understaffed and ineffectually on a daily basis. No real resolution will be offered the industry unless the industry itself responds by increasing the pay scale and to do so the broader community must begin to seek to advocate for this change, as well as the funding changes that would be needed to do so. In short the LTC community and licensing agencies cannot continue to advocate for unfunded mandates, like demanding continuing education without funding it driving willing and capable staff out of the industry for very logical reasons. What it really comes down to is that if we would like to have better skilled staff we must reward them for their service by paying them better and to do that the broader community needs to respond with changes in payment sources for LTC.
Though this work has briefly touched on the issue of collaborative care, regarding caregivers and family, these structures also need to be expanded to a picture that more broadly develops the idea of holistic care. In general this issue has been dealt with in the literature in the case of specialization, such as follow up care and collaboration between institutions and caregivers from hospital and surgical settings. Yet, the continuity of care issue needs to be addressed in a more formal way. The discussion of the desire of previous care providers, such as hospital staff and physicians having follow up information as well as to influence future care needs to be addressed in the future long-term care setting. The days of LTC being an oasis of its own should end as more and more previous care givers seek to have at least a minimal understanding of the future well being of patients they have treated and families as well as patients tend to seek the same connectivity. Some caregivers are in fact so concerned about this disconnect that they present the idea of creating better outcomes if intermediate care offerings were provided in hospital, rather than in separate LTC facilities. (Raj, Munir, Ball, & Carr, 2007) This call for research on this subject likely has as much to do with the overall disconnect that exists between previous care providers and LTC rehabilitative service provisions as it has to do with the medical community, as well as the public having serious and enduring questions about the quality of care offered in such facilities, i.e. real and fear poor patient outcomes. (Kane, 2001) (Torres et al., 2006)
Reinardy & Kane contend that decisions made about future care are often associated with many factors and autonomy is one of the most important to most. Many often stress the choice of an unregulated assisted living facility, even if they could benefit from more skilled care because they perceive that their privacy as well as their autonomy will be better protected in such as situation. The system of future long-term care must address this issue with regard to autonomy and privacy likely by building on more private room structures and better individualization options for individuals. The days of the stark white institutional flooring and a single hospital bed, arm chair setting may very well be over and for good reasons. Long-term care centers of the future need to integrate the ideation, physical, social and emotional aspects of each cohort, i.e. those who are primarily concerned with rehabilitative care and those who are primarily concerned with privacy and autonomy, to create an environment that would meet the needs of both cohorts, possibly improving physical/medical offerings in assisted living and improving issues of privacy and autonomy in nursing homes. (2003)
Finally, and last but certainly not least LTC facilities of the