WEBVTT 1 00:00:00.330 --> 00:00:02.880 Hi, everyone, and welcome to this week's module, 2 00:00:02.880 --> 00:00:06.120 where we will be discussing global demographic shifts 3 00:00:06.120 --> 00:00:09.750 and the management of long-term services and supports. 4 00:00:09.750 --> 00:00:12.330 Global healthcare delivery systems in the 21st century 5 00:00:12.330 --> 00:00:13.710 face serious challenges related 6 00:00:13.710 --> 00:00:15.630 to the aging of the population, 7 00:00:15.630 --> 00:00:18.210 the prevalence of chronic disabling conditions, 8 00:00:18.210 --> 00:00:20.700 and the growing demand for long-term services and supports 9 00:00:20.700 --> 00:00:23.280 across a variety of care settings. 10 00:00:23.280 --> 00:00:25.350 In this module, we will provide an overview 11 00:00:25.350 --> 00:00:27.630 of the demographic, historical, and culture forces 12 00:00:27.630 --> 00:00:29.880 that affect the demand for long-term care. 13 00:00:29.880 --> 00:00:31.770 We'll also explore key issues related 14 00:00:31.770 --> 00:00:33.993 to the supply of long-term care services. 15 00:00:38.130 --> 00:00:39.450 Healthcare systems throughout the world 16 00:00:39.450 --> 00:00:41.520 are facing mounting pressures from growing numbers 17 00:00:41.520 --> 00:00:44.010 or older adults, many of whom have complex care needs 18 00:00:44.010 --> 00:00:46.950 associated with chronic or disabling conditions. 19 00:00:46.950 --> 00:00:48.240 As people live longer, 20 00:00:48.240 --> 00:00:50.460 they're more likely to require long-term services 21 00:00:50.460 --> 00:00:52.380 and supports, whether in home 22 00:00:52.380 --> 00:00:54.570 or in various care settings, 23 00:00:54.570 --> 00:00:56.853 to help manage their regular life activities. 24 00:00:58.170 --> 00:01:00.690 Long-term services and supports are defined 25 00:01:00.690 --> 00:01:03.210 as the care, services, and assistance provided 26 00:01:03.210 --> 00:01:06.390 across various settings to help people address difficulties 27 00:01:06.390 --> 00:01:09.633 in performing their activities of daily living. 28 00:01:13.500 --> 00:01:15.270 So what are some of these demographic 29 00:01:15.270 --> 00:01:17.250 and cultural forces affecting demand 30 00:01:17.250 --> 00:01:21.900 for the supply of long-term supports and services? 31 00:01:21.900 --> 00:01:26.100 Well, population aging is a global demographic shift 32 00:01:26.100 --> 00:01:28.740 whereby older adults are making up an increasing proportion 33 00:01:28.740 --> 00:01:30.040 of the overall population. 34 00:01:31.320 --> 00:01:33.420 This trend reflects both increased longevity 35 00:01:33.420 --> 00:01:35.520 and lower fertility across the various regions 36 00:01:35.520 --> 00:01:36.353 of the world. 37 00:01:37.247 --> 00:01:39.600 Between 2025 and 2050, in fact, 38 00:01:39.600 --> 00:01:42.780 the older adult population is expected to almost double 39 00:01:42.780 --> 00:01:45.060 to 1.6 billion globally, 40 00:01:45.060 --> 00:01:47.280 whereas the total global population will increase 41 00:01:47.280 --> 00:01:49.223 by just 34%. 42 00:01:51.360 --> 00:01:53.643 So what are some types of population aging? 43 00:01:54.810 --> 00:01:56.760 Population aging is a global trend, 44 00:01:56.760 --> 00:02:00.150 although the speed with which the process occurs is uneven 45 00:02:00.150 --> 00:02:01.500 from one region to another. 46 00:02:02.490 --> 00:02:04.170 Many low- and middle-income countries, 47 00:02:04.170 --> 00:02:07.530 like China and Turkey, are considered aging societies, 48 00:02:07.530 --> 00:02:09.930 meaning that their older adult populations 49 00:02:09.930 --> 00:02:13.230 are growing rapidly, to the point where people aged 65 years 50 00:02:13.230 --> 00:02:16.353 or older make up between seven and 14% of the population. 51 00:02:18.000 --> 00:02:20.400 A number of higher-income countries, 52 00:02:20.400 --> 00:02:23.430 including the United States and many European nations, 53 00:02:23.430 --> 00:02:25.530 are regarded as aged societies, 54 00:02:25.530 --> 00:02:27.300 meaning that the population of older adults 55 00:02:27.300 --> 00:02:29.853 has already reached 14 to 21% of society. 56 00:02:31.080 --> 00:02:33.540 Some countries, like Japan, 57 00:02:33.540 --> 00:02:36.330 are categorized as hyper-aged societies, 58 00:02:36.330 --> 00:02:38.790 meaning that older adults make up more than 21% 59 00:02:38.790 --> 00:02:39.693 of the population. 60 00:02:40.890 --> 00:02:44.130 Growth among older populations in high-income countries 61 00:02:44.130 --> 00:02:46.470 is expected to continue in the coming years, 62 00:02:46.470 --> 00:02:48.150 but at a slower rate 63 00:02:48.150 --> 00:02:49.770 than in low- and middle-income countries, 64 00:02:49.770 --> 00:02:51.963 especially those in Asia and Latin America. 65 00:02:53.370 --> 00:02:54.960 This epidemiological transition 66 00:02:54.960 --> 00:02:57.480 towards older populations is largely a result 67 00:02:57.480 --> 00:02:59.190 of declining fertility rates, 68 00:02:59.190 --> 00:03:01.140 as well as lower mortality rates stemming 69 00:03:01.140 --> 00:03:03.240 from medical advances in the 20th century. 70 00:03:07.920 --> 00:03:09.870 Another factor driving the increased demand 71 00:03:09.870 --> 00:03:12.180 for long-term services and supports is the growing number 72 00:03:12.180 --> 00:03:15.120 of adults with chronic and disabling conditions. 73 00:03:15.120 --> 00:03:17.100 In considering this factor, 74 00:03:17.100 --> 00:03:19.950 let's first define some key terms. 75 00:03:19.950 --> 00:03:21.600 Chronic health conditions are conditions 76 00:03:21.600 --> 00:03:23.340 that last three months or longer 77 00:03:23.340 --> 00:03:26.370 and affect an individual's health or independence. 78 00:03:26.370 --> 00:03:29.670 A disability can be a physical, sensory, cognitive, 79 00:03:29.670 --> 00:03:33.150 or intellectual impairment, or a type of chronic disease. 80 00:03:33.150 --> 00:03:35.640 A disability reflects a combination 81 00:03:35.640 --> 00:03:37.920 of an individual's health and social circumstances 82 00:03:37.920 --> 00:03:40.710 that determines one's ability to function 83 00:03:40.710 --> 00:03:43.203 within a given social context. 84 00:03:44.130 --> 00:03:47.730 Levels of disability can be analyzed based 85 00:03:47.730 --> 00:03:51.060 on several different factors, including: 86 00:03:51.060 --> 00:03:52.410 the individual's ability to function 87 00:03:52.410 --> 00:03:55.890 and carry out activities of daily living, or ADLs, 88 00:03:55.890 --> 00:03:58.290 which include routine and fundamental life activities, 89 00:03:58.290 --> 00:04:00.960 like eating, bathing, and dressing, 90 00:04:00.960 --> 00:04:03.960 instrumental activities of daily living, or IADLs, 91 00:04:03.960 --> 00:04:06.960 including cleaning, shopping, and managing finances 92 00:04:06.960 --> 00:04:09.483 that enable people to live independently. 93 00:04:12.990 --> 00:04:16.440 Other measures include active life expectancy, or ALE, 94 00:04:16.440 --> 00:04:18.570 which is the portion of total life expectancy 95 00:04:18.570 --> 00:04:21.420 during which an individual is not affected by disability, 96 00:04:22.710 --> 00:04:25.170 or healthy life years, or HLYs, 97 00:04:25.170 --> 00:04:26.490 which are the estimated number of years 98 00:04:26.490 --> 00:04:27.330 that an individual will live 99 00:04:27.330 --> 00:04:31.260 without disability-related limitations on daily activities. 100 00:04:31.260 --> 00:04:35.040 And finally, health-adjusted life expectancy, or HALE, 101 00:04:35.040 --> 00:04:38.160 which is a measure of life expectancy adjusted 102 00:04:38.160 --> 00:04:40.510 for the severity of an individual's disability. 103 00:04:42.750 --> 00:04:44.700 So with this increased need 104 00:04:44.700 --> 00:04:47.460 for long-term supports and services, 105 00:04:47.460 --> 00:04:49.510 there are several supply issues 106 00:04:50.610 --> 00:04:54.390 which are challenges or barriers 107 00:04:54.390 --> 00:04:56.313 to the provision of these services. 108 00:04:57.150 --> 00:05:00.060 So in the US and other high-income countries, 109 00:05:00.060 --> 00:05:02.460 the importance of long-term supports and services 110 00:05:02.460 --> 00:05:07.460 is well-recognized, though many models of long-term care 111 00:05:07.680 --> 00:05:10.410 in these nations are focused on the role of acute care 112 00:05:10.410 --> 00:05:11.700 or the curative sector, 113 00:05:11.700 --> 00:05:13.830 where individuals receive assistance from professionals 114 00:05:13.830 --> 00:05:16.080 in hospitals or other institutional settings. 115 00:05:16.920 --> 00:05:18.180 In lower-income nations, 116 00:05:18.180 --> 00:05:20.010 long-term services and supports have remained 117 00:05:20.010 --> 00:05:21.420 the responsibility of family members 118 00:05:21.420 --> 00:05:23.340 and informal caregivers. 119 00:05:23.340 --> 00:05:25.710 Some countries have passed laws and regulations 120 00:05:25.710 --> 00:05:27.504 to formally establish the responsibilities 121 00:05:27.504 --> 00:05:29.463 of family caregivers. 122 00:05:30.840 --> 00:05:33.330 The US and many other high-income countries 123 00:05:33.330 --> 00:05:35.130 have experienced a trend towards independence 124 00:05:35.130 --> 00:05:37.980 in family relationships across the lifecycle. 125 00:05:37.980 --> 00:05:41.820 As a result, many older adults in those countries live alone 126 00:05:41.820 --> 00:05:43.143 or just with a spouse, 127 00:05:44.160 --> 00:05:47.580 so that their care needs are not a burden on family members 128 00:05:47.580 --> 00:05:50.850 who might be supporting younger dependent children. 129 00:05:50.850 --> 00:05:52.770 The number of, quote, elder orphans, 130 00:05:52.770 --> 00:05:54.780 or individuals living alone without a family member 131 00:05:54.780 --> 00:05:57.630 available to provide care, in the US is likely 132 00:05:57.630 --> 00:06:00.693 to increase as the baby boomer generation ages. 133 00:06:04.980 --> 00:06:07.500 The textbook provides this informative example 134 00:06:07.500 --> 00:06:08.883 of global dementia care. 135 00:06:10.260 --> 00:06:12.450 Dementia care and the need for it is expected 136 00:06:12.450 --> 00:06:16.263 to increase significantly in the 21st century. 137 00:06:19.680 --> 00:06:21.310 Part of this is 138 00:06:23.850 --> 00:06:28.850 due to the increase in memory care units, 139 00:06:29.910 --> 00:06:32.643 that is the existence, 140 00:06:35.760 --> 00:06:37.680 in many countries, the traditional model for caring 141 00:06:37.680 --> 00:06:41.163 for people with dementia has emphasized care provided 142 00:06:41.163 --> 00:06:44.043 in the home by unpaid, family caregivers. 143 00:06:45.330 --> 00:06:47.700 Memory care units are units in nursing homes 144 00:06:47.700 --> 00:06:50.400 that focus specifically on dementia care 145 00:06:50.400 --> 00:06:52.000 and are secure areas 146 00:06:53.310 --> 00:06:56.463 where individuals receiving such care reside. 147 00:06:57.540 --> 00:06:59.940 There's an example this week in the reading materials 148 00:06:59.940 --> 00:07:02.613 about a dementia village in the Netherlands. 149 00:07:05.880 --> 00:07:09.453 So there are also workforce challenges in long-term care. 150 00:07:10.440 --> 00:07:12.240 Long-term care is highly labor-intensive, 151 00:07:12.240 --> 00:07:15.270 and the global delivery of long-term care depends 152 00:07:15.270 --> 00:07:17.700 on both formal, trained professionals 153 00:07:17.700 --> 00:07:19.443 and informal, unpaid caregivers. 154 00:07:20.310 --> 00:07:22.140 Direct care workers, especially aides, 155 00:07:22.140 --> 00:07:23.490 represent the largest component 156 00:07:23.490 --> 00:07:24.840 of the long-term care workforce, 157 00:07:24.840 --> 00:07:26.460 and the development of this workforce segment 158 00:07:26.460 --> 00:07:29.100 has been identified as a key concern 159 00:07:29.100 --> 00:07:31.000 facing healthcare in the 21st century. 160 00:07:32.190 --> 00:07:34.470 A direct care worker is defined as an individual 161 00:07:34.470 --> 00:07:36.090 in the health workforce who provides care 162 00:07:36.090 --> 00:07:38.700 and personal assistance to individuals who are frail, 163 00:07:38.700 --> 00:07:41.370 sick, or injured, or who have physical 164 00:07:41.370 --> 00:07:42.663 and mental disabilities. 165 00:07:44.370 --> 00:07:46.100 Globally, however, the majority of long-term care 166 00:07:46.100 --> 00:07:48.000 is provided by family members, friends, 167 00:07:48.000 --> 00:07:50.553 and other informal caregivers. 168 00:07:53.490 --> 00:07:55.110 There are also, in some settings, 169 00:07:55.110 --> 00:07:58.350 there's been an emphasis on individuals aging in place. 170 00:07:58.350 --> 00:08:00.420 That is, the practice of remaining in one's own home 171 00:08:00.420 --> 00:08:02.043 and community during old age. 172 00:08:03.120 --> 00:08:05.550 As a result of this, home and community-based services 173 00:08:05.550 --> 00:08:07.200 provided by direct care workers have come 174 00:08:07.200 --> 00:08:09.690 to encompass increasingly broad and complex array 175 00:08:09.690 --> 00:08:12.270 of physical and mental health needs 176 00:08:12.270 --> 00:08:15.450 requiring skills in such areas as medication management, 177 00:08:15.450 --> 00:08:17.403 palliative care, and dementia care. 178 00:08:20.940 --> 00:08:24.720 So how can technology help to address some 179 00:08:24.720 --> 00:08:25.833 of these challenges? 180 00:08:27.210 --> 00:08:30.540 Well, one example is the delivery of long-term care 181 00:08:30.540 --> 00:08:32.640 can be enhanced by telehealth capabilities 182 00:08:32.640 --> 00:08:33.660 and other health-enabling 183 00:08:33.660 --> 00:08:36.450 and ambient assistive technologies that collect data 184 00:08:36.450 --> 00:08:38.350 and provide communication in the home. 185 00:08:39.240 --> 00:08:42.660 Robotic devices may also provide some basic services 186 00:08:42.660 --> 00:08:44.163 at affordable prices. 187 00:08:45.630 --> 00:08:46.740 In high-income countries, 188 00:08:46.740 --> 00:08:48.300 technology has helped to extend life 189 00:08:48.300 --> 00:08:50.460 through a variety of devices and services, 190 00:08:50.460 --> 00:08:53.970 as well as through the use of high-technology medicine. 191 00:08:53.970 --> 00:08:55.500 In low- and middle-income countries, 192 00:08:55.500 --> 00:08:56.910 portable technologies have enabled 193 00:08:56.910 --> 00:08:58.890 the inexpensive collection of healthcare information 194 00:08:58.890 --> 00:09:01.980 and improved communication between healthcare providers 195 00:09:01.980 --> 00:09:04.290 and people living in remote areas. 196 00:09:04.290 --> 00:09:06.540 Personal response systems can benefit individuals 197 00:09:06.540 --> 00:09:08.520 affected by serious health conditions, 198 00:09:08.520 --> 00:09:10.830 enabling faster emergency response, and therefore, 199 00:09:10.830 --> 00:09:13.113 reduced hospital utilization and mortality. 200 00:09:15.900 --> 00:09:17.790 So now let's discuss some of the main models 201 00:09:17.790 --> 00:09:19.983 for care management and care transitions. 202 00:09:20.820 --> 00:09:23.460 Throughout the world, long-term services and supports 203 00:09:23.460 --> 00:09:26.370 are provided by a wide variety of models, 204 00:09:26.370 --> 00:09:28.770 from institutional and well-defined residential settings 205 00:09:28.770 --> 00:09:30.720 to people's own homes in the community. 206 00:09:32.820 --> 00:09:35.400 These models are also influenced 207 00:09:35.400 --> 00:09:38.220 by the healthcare system in a certain country. 208 00:09:38.220 --> 00:09:40.020 So under universal coverage systems, 209 00:09:40.020 --> 00:09:41.610 national and local governments fund 210 00:09:41.610 --> 00:09:44.850 and administer long-term care coverage for all citizens. 211 00:09:44.850 --> 00:09:46.560 Under mandatory insurance programs, 212 00:09:46.560 --> 00:09:48.330 the government requires people of certain age groups 213 00:09:48.330 --> 00:09:50.790 or employment statuses to pay premiums towards insurance 214 00:09:50.790 --> 00:09:51.903 for long-term care. 215 00:09:52.890 --> 00:09:54.660 Some countries have mixed systems, 216 00:09:54.660 --> 00:09:56.610 in which public means-tested elements 217 00:09:56.610 --> 00:09:59.010 and private insurance both play important roles. 218 00:10:00.060 --> 00:10:02.070 In other countries, services may be provided 219 00:10:02.070 --> 00:10:04.473 with few public funds or with no formal system. 220 00:10:07.470 --> 00:10:10.980 The table on this slide and in your textbook helps 221 00:10:10.980 --> 00:10:12.780 to summarize these different models. 222 00:10:14.280 --> 00:10:17.070 Now, we will briefly go over some vignettes 223 00:10:17.070 --> 00:10:19.710 of different countries and how they manage 224 00:10:19.710 --> 00:10:21.663 their long-term supports and services. 225 00:10:23.430 --> 00:10:26.160 So to begin with, Japan, as we mentioned, 226 00:10:26.160 --> 00:10:28.050 is a hyper-aged society. 227 00:10:28.050 --> 00:10:30.840 It stands at the forefront of the population aging trend, 228 00:10:30.840 --> 00:10:34.800 and in 2015, people aged 65 or older represented 26.6% 229 00:10:34.800 --> 00:10:35.850 of Japan's population, 230 00:10:35.850 --> 00:10:38.730 making it the oldest country in the world. 231 00:10:38.730 --> 00:10:40.380 Additionally, Japanese culture 232 00:10:40.380 --> 00:10:42.900 has traditionally emphasized filial piety, 233 00:10:42.900 --> 00:10:45.330 with the idea that younger family members have an obligation 234 00:10:45.330 --> 00:10:47.190 to take care of their elders. 235 00:10:47.190 --> 00:10:48.780 As a result, families have taken on 236 00:10:48.780 --> 00:10:51.000 significant caregiving responsibilities, 237 00:10:51.000 --> 00:10:53.190 and care throughout the hospital systems has been used 238 00:10:53.190 --> 00:10:54.783 for more serious illnesses. 239 00:10:56.010 --> 00:10:57.750 In recent years, however, 240 00:10:57.750 --> 00:10:59.700 family structures have begun to change, 241 00:10:59.700 --> 00:11:03.090 and older adults now sometimes live separately 242 00:11:03.090 --> 00:11:06.600 from their families, which has necessitated a restructuring 243 00:11:06.600 --> 00:11:07.893 of service networks. 244 00:11:11.400 --> 00:11:14.790 In 2000, Japan introduced a national long-term care policy 245 00:11:14.790 --> 00:11:16.230 that redefined the role of government 246 00:11:16.230 --> 00:11:18.840 in providing care for older adults. 247 00:11:18.840 --> 00:11:19.740 The country established 248 00:11:19.740 --> 00:11:21.630 a national long-term care insurance program, 249 00:11:21.630 --> 00:11:24.840 known as Kaigo Hoken, that is administered separately 250 00:11:24.840 --> 00:11:26.550 from the national health insurance policies 251 00:11:26.550 --> 00:11:28.230 and is funded by general tax revenues, 252 00:11:28.230 --> 00:11:30.960 as well as insurance premiums. 253 00:11:30.960 --> 00:11:32.400 These policies are mandatory. 254 00:11:32.400 --> 00:11:35.490 All citizens older than age 40 must contribute. 255 00:11:35.490 --> 00:11:37.650 This insurance covers long-term care services 256 00:11:37.650 --> 00:11:41.043 for people aged 65 or older with severe disabilities. 257 00:11:42.960 --> 00:11:45.000 Now, let's turn to Sweden. 258 00:11:45.000 --> 00:11:46.890 So Sweden has long been recognized 259 00:11:46.890 --> 00:11:49.740 as the first European country to have a long-term care plan 260 00:11:49.740 --> 00:11:51.450 and a publicly funded welfare state. 261 00:11:51.450 --> 00:11:53.700 And it ranks among the top European nations 262 00:11:53.700 --> 00:11:55.743 in investment in long-term services and supports 263 00:11:55.743 --> 00:11:57.843 as a percentage of GDP. 264 00:12:00.360 --> 00:12:02.760 Swedish municipalities planning housing 265 00:12:02.760 --> 00:12:04.410 and residential areas are required 266 00:12:04.410 --> 00:12:05.670 to ensure that they meet the needs 267 00:12:05.670 --> 00:12:07.830 of all kinds of individuals with disabilities, 268 00:12:07.830 --> 00:12:09.660 regardless of age. 269 00:12:09.660 --> 00:12:11.010 These accessibility requirements 270 00:12:11.010 --> 00:12:12.960 have been given greater prominence in legislation 271 00:12:12.960 --> 00:12:15.450 over the years, and a growing number of older adults 272 00:12:15.450 --> 00:12:17.610 want to live in, quote, senior housing, 273 00:12:17.610 --> 00:12:19.650 ordinary homes for people aged 55 and older 274 00:12:19.650 --> 00:12:21.303 where accessibility's a priority. 275 00:12:24.690 --> 00:12:26.790 Now, let's turn to China. 276 00:12:26.790 --> 00:12:28.950 So China is an aging society 277 00:12:28.950 --> 00:12:30.750 with changing social structures, 278 00:12:30.750 --> 00:12:33.030 and it faces daunting challenges in meeting the demand 279 00:12:33.030 --> 00:12:35.430 for long-term services and supports. 280 00:12:35.430 --> 00:12:37.980 China's older adult population's growing rapidly, 281 00:12:37.980 --> 00:12:41.343 up to 136.9 million in 2015. 282 00:12:42.450 --> 00:12:45.327 Older adults represent 10.1% of China's total population, 283 00:12:45.327 --> 00:12:47.910 and the percentage is projected to increase 284 00:12:47.910 --> 00:12:49.983 to 17.2% by 2030. 285 00:12:50.940 --> 00:12:52.890 Additionally, the number of Chinese adults 286 00:12:52.890 --> 00:12:55.140 aged 85 or older is expected to grow at a rate 287 00:12:55.140 --> 00:12:57.213 of one million per year until 2025. 288 00:13:01.140 --> 00:13:03.180 China has two broad systems that provide care 289 00:13:03.180 --> 00:13:05.610 to older adults: a social welfare system 290 00:13:05.610 --> 00:13:07.140 of community-based elder clinics, 291 00:13:07.140 --> 00:13:09.660 residential facilities, and nursing homes, 292 00:13:09.660 --> 00:13:11.820 and a medical system consisting of physicians, 293 00:13:11.820 --> 00:13:14.310 hospitals, and primary care clinics. 294 00:13:14.310 --> 00:13:17.040 The services provided include long-term institutional care 295 00:13:17.040 --> 00:13:19.050 in non-acute settings with significant levels 296 00:13:19.050 --> 00:13:21.720 of medical and support services, 297 00:13:21.720 --> 00:13:25.290 as well as non-institutional senior care services 298 00:13:25.290 --> 00:13:27.150 encompassing a wide range of home 299 00:13:27.150 --> 00:13:28.773 and community-based services. 300 00:13:31.790 --> 00:13:33.810 When we look at the example of Turkey, we see that, 301 00:13:33.810 --> 00:13:35.580 like many other low- and middle-income countries, 302 00:13:35.580 --> 00:13:37.410 Turkey faces a variety of concerns related 303 00:13:37.410 --> 00:13:40.113 to population aging and sociodemographic transition. 304 00:13:42.660 --> 00:13:44.490 Historically, elder care services 305 00:13:44.490 --> 00:13:46.680 in Ottoman Turkish society evolved in parallel 306 00:13:46.680 --> 00:13:50.400 to Western experience over the course of four periods: 307 00:13:50.400 --> 00:13:52.683 the traditionally Ottoman period, 308 00:13:54.030 --> 00:13:57.423 the period of stagnation and the opening of nursing homes, 309 00:13:58.440 --> 00:14:01.110 nursing homes becoming alternative to home-based care, 310 00:14:01.110 --> 00:14:03.840 ushering in a transitional period, and finally, 311 00:14:03.840 --> 00:14:06.000 the modern period, which began in 1980, 312 00:14:06.000 --> 00:14:08.160 in which institutional care became prevalent 313 00:14:08.160 --> 00:14:09.273 in large cities. 314 00:14:12.720 --> 00:14:15.030 So finally, let's turn to the US. 315 00:14:15.030 --> 00:14:18.180 The US, like other countries discussed in this module, 316 00:14:18.180 --> 00:14:20.040 is undergoing significant demographic shift 317 00:14:20.040 --> 00:14:21.630 with major implications for the delivery 318 00:14:21.630 --> 00:14:24.240 of long-term services and supports. 319 00:14:24.240 --> 00:14:27.330 I encourage you all to review the textbook chapter 320 00:14:27.330 --> 00:14:30.540 for more information about the demographic shifts going on 321 00:14:30.540 --> 00:14:31.443 in the US. 322 00:14:32.490 --> 00:14:35.850 But some key developments in common residential arrangements 323 00:14:35.850 --> 00:14:38.580 available in the US include assisted living facilities, 324 00:14:38.580 --> 00:14:40.590 skilled nursing facilities, 325 00:14:40.590 --> 00:14:45.383 and medical homes, or CCRCs, 326 00:14:47.730 --> 00:14:50.790 which we've discussed earlier in this module, 327 00:14:50.790 --> 00:14:52.080 that are related to independent living, 328 00:14:52.080 --> 00:14:54.393 assisted living, and skilled nursing. 329 00:14:56.340 --> 00:14:59.523 And finally, here are some conclusions from this module.