Awinding road has brought readers to this section of the text, which, at long last, addresses the specifics of intervention. Although there has been discussion throughout the book of therapeutic factors, this section places them in the contexts in which they occur.
One important consideration here is that this section is structured on the basis of health-care systems (a word that doesn't quite capture the realities of health care in the United States) as they exist in the United States. A substantial challenge for individuals needing care and the institutions that provide that care is the unfortunate lack of coordination among those systems. Although Medicare, the dominant third-party payer for health care for older adults in the United States, attempts to coordinate benefits (Centers for Medicare and Medicaid, 2014), the reality is that regulations for care and for payment remain convoluted. Gaps remain and can cause significant hardship to individuals and their families.
Furthermore, because these systems operate on different sets of regulations, with different requirements for intervention and payment, transitions can be difficult and dysfunctional. One 83-year-old man was discharged home from an acute care hospital because he no longer needed hospitalization. He did not qualify for rehabilitation, so Medicare would not cover a nursing home stay, and he had too many assets to qualify for Medicaid coverage of long-term care, even though his income was only slightly above the U.S.-defined poverty level. His adult children lived at a distance, his home did not have a first-floor bathroom (and he could not climb stairs), leaving him in a dire situation. Such stories are all too common.
Even when the transition is a smoother one, movement from one system to another requires transfer of information that may or may not happen effectively, separate evaluation to conform to system regulations, expensive transport that may not be covered by any source of funding, and adjustment by the individual—often in a weakened and confused state—to a new environment and new carers. Such transitions can, in and of themselves, result in complications and excessive stress for the individual.
Emerging trends may improve the situation somewhat. The Affordable Care Act (ACA; hhs.gov, 2015) encourages use of electronic medical records that can enhance access to information as individuals are transferred among institutions. But even with the implementation of the ACA, gaps and overlaps remain—and remain problematic.
Readers will note that there is a good bit of overlap among the following chapters; for example, occupational therapy and physical therapy in primary care may seem quite similar to their counterparts in community settings. This is not coincidental. The main difference from the perspective of the therapies is the setting, not the probable issues requiring attention. A well older adult may see a physical therapist in a primary care setting for advice and guidance about a fitness routine to maintain cardiovascular capacity. A similar ...