The dramatic aging of the American population that will occur over the next twenty years and its implications for increased demands on health and long-term care (LTC) systems have become common knowledge. In creating this public awareness gerontologists have been successful. Less satisfactory, however, have been the proposed solutions to the impact on services and costs of the impending demographic bulge. There is a strong sense that we do not know how to control costs while adequately addressing needs. There is a widespread assumption that society will not be able to deliver on prior promises of future benefits, and leaders are increasingly reluctant to make new promises.
There is also a common perception in both the professional community and the general public that resources are too often misallocated for expensive tertiary care and life support to the neglect of primary prevention, public health, and basic social support. While Medicare will spend a small fortune on aggressive acute care for an eighty-five-year-old, and Medicaid will do the same to keep an individual alive for years in a vegetative state, help is unlikely to be available for an overburdened, aging woman who must struggle to lift her disabled husband from a bathtub. Our public and private insurance systems pay for expensive machinery that substitutes for failing kidneys, lungs, and hearts, but they are not yet ready to pay for a simple service that might substitute for a failing or absent family caregiver.
In our current health care system some of these needs are addressed at times by various benefit programs and service providers, but at other times people fall “through the cracks” into uncovered territory. Help may be available from home health agencies (for Medicare-covered skilled care), from hospitals (during discharge planning), and from nursing homes (during both short- and long-term stays); but for many, if not most, frail elders in the community, these major providers are not responsible since their needs lie outside of service and coverage definitions (Harris, 1995). Aging-network agencies funded by the Administration on Aging (AoA) may be able to help a little, and a few states also add significant funding. Still, in no state is a single agent responsible for ongoing care related to simple frailty, confusion, or medical complexity outside of acute- and skilled-care contexts.
Many of the services that are needed for community care are already available in many communities and can be purchased on a fee-for-service basis or may be reimbursed by Medicaid. Such services can include in-home assistance by nurses, therapists, personal care workers, home health aides, and homemakers. Care can also be provided in community-based settings, such as adult day-care, or through special transportation or communication systems, or even during short-term nursing home stays. But having the services available does not make a system of care: Missing are systems of financing and coverage that ensure equitable access. Missing also are standards and procedures for referral, quality assurance, access, communications, and accountability. Only when a major payer or payers are ready to consistently cover a full range of community-care services for large populations will it be possible to meet the full range of needs. Only when there are mechanisms for management and coordination of services will there be an efficient and effective system. One major question is whether community care will be a narrowly defined, independent system or a broad, integrated system.
Community care has been the focus of much research and policy attention not only because it constitutes a hole in current coverage, but also because it is such a compelling notion. Most people would strongly prefer to stay at home rather than enter institutions, whether hospitals or nursing homes. Home provides dignity, freedom, and choice, in contrast to the well-known dangers of institutions, such as iatrogenic illness and acceleration of dependence. Improved community care is attractive to policymakers because it promises to cut costs by reducing admissions and shortening stays. Costs are obviously important to individuals as well, given the clear danger of a long nursing home stay’s quickly depleting a life’s savings.
Despite the appeal of community care, as well as extensive research and numerous demonstrations showing how it works, policymakers so far have hesitated to expand benefits except in extremely limited circumstances. The predominant interpretation of demonstration results in that community care does not work very well as a substitute for current benefits, that it is very expensive (i.e., unaffordable), and that costs might be difficult to control once new benefits are introduced, as has been the case with acute care and with Medicaid nursing home coverage. Furthermore, some fear that a national service-delivery system would be much more difficult to develop and manage than a local demonstration.
The population of older persons is often called the frail elderly. In the literature frail conjures up a stereotypic image—an elusive, vaguely generalized image, characteristic of the concept itself.
The older persons who are dependent on others (i.e., those designated as “frail”) are the fastest-growing group in the older population. For them, the system has not worked nearly as well. This poor, lower- and middle-class group of older persons is the one that needs long-term care. By long-term care we mean care in home, institutional, and non-institutional settings. The numbers of older persons needing long-term care is expected to double between 1990 and 2030, while that needing nursing home care is expected to triple (Cutler, 2001). These people do not receive an adequate share of America’s bounty. For them, relief from public policy that provides insufficient income and inadequate services is difficult to achieve. A grudging societal response becomes a powerful factor influencing the quality and nature of their lives.
The need to serve this group is compelling because this population is most at risk for increased morbidity, abuse, neglect, institutionalization, and death. These vulnerable older persons, especially older women and ethnic minorities, are the specific populations to which social workers must attend. There is a pressing and clear need for leadership in social policy, in planning and the organization of services, and in direct practice with this large and growing group of vulnerable persons. Gerontology has paid greater attention to the problems of aging rather than the resiliency of aging, thereby distorting our portrait of older persons, and while we certainly are obligated to present a more accurate view, nevertheless, those in needs are the appropriate purview of the social work profession. A balance between the needs and capacities of the older person and the demands and resources of the environment is an outcome “devotedly to be wished” and striven for by social workers.
An association between being over 65 and being frail is commonly assumed. In fact, this perspective is socially constructed. Sixty-five years, though still an arbitrary benchmark should no longer bespeak the image of old age. It should no longer evoke a homogeneous picture. Human development and human accomplishment increasingly defy established stage-related designations. While there remains, for some, a homogeneous portrait with frailty as its premise, for others there is a more vigorous and diversified representation. It is now commonplace to speak of the “young-old” and the “old-old”, the “healthy-aged” and the “frail-aged” (Wandless, ; Davie, 1997). Some suggest that an age entitlement marker of 75 be substituted as the age at which specialized services should be offered. The very nature and meaning of old have been redefined. It is generally accepted that diversity increases with age and that older persons are the most diversified segment of our population. This is not to suggest that hardship is not experienced by many with increased age, particularly those in need of long-term care.
The needs of older persons, especially the vulnerable aged, are increasingly counter-posed to those of other groups, particularly children, who are viewed as a “better investment” (Cutler, 2001). Negative views of the capacities of older persons support policies that diminish opportunities for the older persons to make even the most ordinary choices about their own lives.
The belief that advanced age correlates directly with increased functional impairment prompted this group to advance 75 and over as the necessary age entitlement for increased benefits. It is the Council’s belief that the separation of social services from income maintenance has been a failure for those older persons with “a weakened voice” who have difficulty negotiating their service environment (Santell, 1994).
The views of the Federal Council on the Aging are readily understandable to social workers who work daily with older persons. In January 2000, the Department of Health and Human Services launched Healthy People 2010, a comprehensive, nationwide health promotion and disease prevention agenda. Healthy People 2010 build on similar initiatives pursued over the past two decades. Two overarching goals–increase quality and years of healthy life, and eliminate health disparities–served as a guide for developing objectives that will actually measure progress. (http://www.cdc.gov/nchs/about/otheract/hpdata2010/abouthp.htm)
Nursing homes are one of the most admired alternatives for taking care of such elderly. Some homes present complete medical care, counting rehabilitation services, for those who necessitate 24 hours management by nurses. There are quite a few things to look for when looking at a nursing home: the broad atmosphere as well as cleanliness; the approach of the staff toward the patients as well as visitors; honesty of administrators to your questions as well as concerns; soothe in addition to privacy of living quarters; quality of food; accessibility of medical care and nursing along with the emergency services; recreational as well as social programs; residents’ contribution in programs and input into administration; and modern licenses.
Nursing homes can cost as much as thirty thousand to fifty thousand dollars per year, so that even people with rational savings cannot have enough money to stay for any long period of time. Almost certainly the most unlucky feature of these homes is the focus in the information on abuse of the patients. This is the most significant thing to investigate when you are looking at a nursing home.
Today’s nursing homes are outstanding environments for elderly people. These organizations provide entertainment, health care, security, and primarily, a home for over 1000,000 American citizens who are 70+. There is no better place for a person who is gradually losing his or her faculties. During one’s golden years, one must not have to be concern concerning daily chores like washing the dishes or mowing the lawn. One should be able to rest and get pleasure from life. Nursing homes give the elderly an opportunity to do just that.
Security is the most important emphasis in most nursing homes. Curfews exist to assure the safety as well as protection of the residents. Also, busses take the senior citizens to places of general interest, for instance the grocery store as well as local shopping malls. This eases the daily pressure of driving for those inhabitants who are losing some of their essential faculties, and makes safer driving surroundings for everybody. Additionally, these older citizens are defended from those con-artists who prey intentionally on the elderly.
The main reason of today’s nursing homes is health care. Family members can rest guaranteed that their older loved ones are paid attention to all day. This eliminates a great pressure from the family of an elderly person who can not any more care for him or herself. The facility assists residents with their recommendations as well as medicines. Nursing homes are typically located near hospitals to make sure quick treatment. And in case of an emergency, trained experts are on site.
Conner, D., Erickson, G., 1996. “Drug Trends Point to Blisters,” Packaging.
Wandless, I.; Davie, J.W., 1997. “Can drug compliance in the elderly be improved?” British Medical Journal.
Santell J., 1994. ASHP national survey of hospital-based pharmaceutical services.
Inouye S., 1998. Hospitalized Older Patients: Recognition and Risk Factors. J Geriatr Psychiatry Neurol
Harris J., 1995, “Double Jeopardy and the veil of ignorance”, Journal of Medical Ethics, 21
Cutler D., 2001. “Declining Disability Among The Elderly”, Health Affairs, Vol 20