the challenge of community long-term care: the dependent aged

12
THE CHALLENGE OF COMMUNITY LONG-TERM CARE: The Dependent Aged PATRICIA M. KIRWIN ABSTRACT: By r~~w~g both the h~to~ of the recent ~eo~g~al shift towurd community long-term care for the dependent aged and the role played by key actors, and based on the literature, this article suggests strategies for coordinating community long-term care services to the institutionally diverted Both recent demonstration pro- jects and the literature appear to suggest coordination through (I) case management; (2) a systems approach; andlor (3) a single agency at the community level The phrase “long-term care” is relatively new in the vocabulary of professionals, researchers, the public, and government agencies. It has in the past referred primarily to care in institutions of various types. More recently, it is being used in a broader sense to encompass various styles of care and service provided on a long-term basis. The individu- als receiving care may reside in their homes, with relatives or friends, or in group facilities such as housing for the efderly and boarding homes. Brody f i977, p. 14) PURPOSE This article will (1) review the recent ideological shift toward community long-term care for the dependent aged from a historical perspective; (2) consider the role of key actors in this ideological shift; and (3) suggest strategies to coordinate community services for the institutionally-diverted aged if they are not to suffer the plight of former deinstitutionalized citizens. As voiced by Estes and Harrington (198 1): “A major con- cern of aging advocates is that states may move to curtail, limit, or reduce the number of nursing home services, while at the same time failing to assure alternative services at the local level” (p. 822). The problems of institutional diversion derive not so much from the alternative concept of community care as from its nai’ve implementation, as evidenced by the emptying of mental institutions in the sixties. In addition, an array of community-based services necessary to the support of frail elders cannot possibly come without Direct all correspondence to: Patricia M. Kink, 634 Knox Rat, Wayne, PA 19087. _ -..._____ JOURNAL OF AGING STUDIES, Volume 2, Number 3, pages 255-266. Copyright 0 1988 by JAI Press, Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.

Upload: patricia-m-kirwin

Post on 31-Aug-2016

214 views

Category:

Documents


2 download

TRANSCRIPT

Page 1: The challenge of community long-term care: The dependent aged

THE CHALLENGE OF COMMUNITY LONG-TERM CARE:

The Dependent Aged

PATRICIA M. KIRWIN

ABSTRACT: By r~~w~g both the h~to~ of the recent ~eo~g~al shift towurd community long-term care for the dependent aged and the role played by key actors, and based on the literature, this article suggests strategies for coordinating community long-term care services to the institutionally diverted Both recent demonstration pro- jects and the literature appear to suggest coordination through (I) case management; (2) a systems approach; andlor (3) a single agency at the community level

The phrase “long-term care” is relatively new in the vocabulary of professionals, researchers, the public, and government agencies. It has in the past referred primarily to care in institutions of various types. More recently, it is being used in a broader sense to encompass various styles of care and service provided on a long-term basis. The individu- als receiving care may reside in their homes, with relatives or friends, or in group facilities such as housing for the efderly and boarding homes. Brody f i977, p. 14)

PURPOSE

This article will (1) review the recent ideological shift toward community long-term care for the dependent aged from a historical perspective; (2) consider the role of key actors in this ideological shift; and (3) suggest strategies to coordinate community services for the institutionally-diverted aged if they are not to suffer the plight of former deinstitutionalized citizens. As voiced by Estes and Harrington (198 1): “A major con- cern of aging advocates is that states may move to curtail, limit, or reduce the number of nursing home services, while at the same time failing to assure alternative services at the local level” (p. 822).

The problems of institutional diversion derive not so much from the alternative concept of community care as from its nai’ve implementation, as evidenced by the emptying of mental institutions in the sixties. In addition, an array of community-based services necessary to the support of frail elders cannot possibly come without

Direct all correspondence to: Patricia M. Kink, 634 Knox Rat, Wayne, PA 19087. _ -..._____

JOURNAL OF AGING STUDIES, Volume 2, Number 3, pages 255-266. Copyright 0 1988 by JAI Press, Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.

Page 2: The challenge of community long-term care: The dependent aged

256 JOURNAL OF AGING STUDIES Vol. ~/NO. 311988

considerable financial cost. That is, deinstitutionalization is not a cheap alternative, particularly if the community-based resources integral to the welfare of the deinstitu- tionalized are implemented. The fiscal retrenchment of government has left the con- cept of community care ominously incomplete. The fate of a noble, humanizing idea may fail to sustain life through a poorly designed concept of community care, under- fleshed by a diet woefully short of financial resources and service coordination.’

FACTS AND FIGURES OF COMMUNITY LONG-TERM CARE

From the early 1900s to the present, there has been a steady increase in the institu- tionalization of the aged in the United States. The population of the elderly residing in institutions and group quarters of one type or another increased 267% between 19 10 and 1970 (Supplement to the Encyclopedia of Social Work 1983, p. 22).

By 1970, 1.1 million elderly were living in institutions, of whom 72% were residing in nursing homes, 12% were in group quarters, and 10% were in mental institutions (Supplement to the Encyclopedia of Social Work 1983). The total proportion of the elderly living in institutions by 1970 was 5.5% as contrasted to 4.1% of the total population in 1940 (Estes and Harrington 198 1, pp. 8 1 l-826). The increase in the proportion of the aged that are institutionalized may reflect the added rehabilitation capability of modern nursing homes, a service previously performed by hospitals. It was projected by Estes and Harrington (198 I) that the 1977 population of 1.3 million in nursing homes would grow to 1.95 million by the year 2000 and to 2.95 million by the year 2030. However, growing federalism, increasing deficits, and the fact that between 1973 and 1979 the increase in totat public and private nursing home expenditures was 148% versus a 63% increase in the consumer price index has provided impetus toward increasing community programs and decreasing institutionalization of the aged. Recently, nursing home care has been the fastest-growing cost in the health system, increasing in recent years in the neighborhood of 18 to 20% annually (Crystal 1982).

The use of nursing home care as the preferred solution to the long-term care needs of 5 percent of the over-65 population and 25% of the over-85 population has come on hard financial times in the eighties (Wood 1985).2 Community long-term care has emerged as a national policy goal to replace the previous bias, through funding mecha- nisms, for institutional long-term care.

While it is true that the aged population has been affected by the structural move toward deinstitutionalization~ with this population perhaps Warren’s (1972, p. ‘726) use of the term “transinstitutionalization” is more precise. Elderly patients were relo- cated from mental institutions to nursing institutions, not to the community.

Long-term care difficulties have been produced, in part, by the evolution of a new situation in American society-the survival of large numbers of disabled persons at a time when the economy draws most able-bodied adults, including women, into paid employment, which diminishes the family-care resources. Imperfections in the organi- zation and funding of long-term care programs, both in health and welfare, are embedded in and may result in part from difficulty in controlling these two basic social developments. Attempts to control and structure expenditures more effectively are offset by changing pressures that are not well predicted. At a minimum, control of costs and improved equity are contending goals (Callahan and Wallack 198 1, p. 25).

Page 3: The challenge of community long-term care: The dependent aged

The Challenge of Community Long-Term Care: The Dependent Aged 257

HISTORICAL PERSPECTIVE

Nursing Home Development

The initial growth of the nursing home industry may be directly linked to the wording of the Social Security Act of 1935 that indirectly accelerated the deline of the poor- house and the rise of the nursing home (Achenbaum 1978, p. 15 1). The authors of the Act, who by and large rejected the almshouse method of providing for aged depen- dents, drafted and successfully defended a provision denying direct assistance to poor- house inmates. A previously unnoticed private institution, the “rest home,” benefited from the situation because it could offer a residence with care for old people on public assistance without contravening Title I of the Act. Many former (or potentially) poor residents relocated to proprietary homes (U.S. Social Security Board 1937, p. 189; McClure 1968, pp. 169, 234-239). The federal prohibition against payments to per- sons in public institutions was withdrawn in 1953 for institutions licensed by the state (Eustis, Greenberg, and Patten 1984, p. 17).

By the late 1950s the shortage of beds in general hospitals created pressure to move chronic patients from hospitals into nursing homes to make room for acute cases (Supplement to the Encyclopedia of Social Work 1983). Federal funds authorized under the Hill-Burton legislation that paid for hospital construction became available at this time to build nursing home facilities (Eustis, Greenberg, and Patten 1984, p. 17). This source of funding linked institutional long-term care with provision of medical and nursing care.

The enactment of Medicare and Medicaid funding for nursing home resident care in the 1960s gave further stimulation to the growth of commercial nursing homes. It may not have been altruism but rather the promise of a good return on investment that created the nursing home boom of the late 1960s and later.

By the late sixties, 70% of nursing home care was publicly funded through Medicare and Medicaid. Public funding fell to 42% in 1972 after Medicare nursing home benefits were cut back. The proportion of public funds used to finance nursing home care again rose to about the 55% level in the late seventies, with Medicaid as the main source of funding (Crystal 1982; Health Care Financing Administration 1979). Medicaid, unlike Medicare, is means-tested and descends from “welfare medicine” programs for public assistance recipients administered by the state.

Once a resident’s assets are spent, both resident and Medicaid contribute to the cost of care, the resident “spending down” Social Security or other income while Medicaid pays the rest. The changes in the Medicare reimbursement system effective in 1983- the introduction of the Prospective Payment System (PPS) and its Diagnostic Related Groups (DRGs)-have significantly shortened stays and reduced hospital occupancy. Many of these patients are discharged to nursing homes, thereby increasing nursing home occupancy (Wood 1985).

Community Social Services Development

Community services for the elderly, with particular emphasis on the frail and poor, received substantial federal support in 1965 with the enactment of the Older Americans

Page 4: The challenge of community long-term care: The dependent aged

258 JOURNAL OF AGING STUDIES Vol. ~/NO. 311988

Act. Title III of this act funded local projects (sponsored by nonprofit agencies) to provide some long-term care services: information and referral, transportation, home- maker/home health aide services, and day care (Tobin, Davidson, and Sack 1980; Gelfand and Olsen 1980).

The 1973 Amendments to the Older Americans Act created a network of approx- imately 660 Area Agencies on Aging mandated to plan, administer, coordinate, and advocate programs and services within the community to assure the availability of resources promoting the well-being of residents aged 60 and over. There is a special emphasis in these amendments on serving those who are frail, isolated, low-income, and minority. However, the funding necessary to achieve these worthy ambitions has continued to be insufficient to meet the goal: $1.26 billion in 1985 compared to $6 billion for Medicare in 1965 (Ficke 1985).

Recent Developments

By 1980, long-term care was pronounced a priority domestic policy issue with extensive emphasis on reducing the institutional bias of federal and state financing programs. All the reasons usually cited in the literature for deinstitutionalization of other populations contributed to this pressing impetus toward a community long-term care continuum for the aged. However, the most forceful pressure came primarily from the federal government’s desire to relieve itself of the ever-increasing cost of funding Medicare and Medicaid. The desire to contain costs has included an effort to shift more of the burden of long-term care to individuals and families (Wettle 1985, p. 32). The stress this places on families has been well documented (Scull 1977; Eustis, Greenberg, and Patten 1984; Springer 1984). Is it necessary to add that our growing national consensus for providing care for the frail aged within the commun- ity, outside of large institutions, brings joy and relief to this population whose over- whelming wish is to remain in their homes, in the community, maintaining the maxi- mum degree of independence (Butler 1982)?

KEY ACTORS WHO CAN’T IMPLEMENT THEKEYROLESTHEYNEEDTOPLAY

Whereas it is true that dependent, frail elders prefer to remain in the community, there continues to be a lack of commitment to defining and implementing a true continuum of community long-term care. A discouraging aspect of care for chronic patients is that even successful programs require continuing efforts over many years. This costly care is an activity that just won’t quit.

Today, caregivers are the ones absorbing the brunt of indecision and lack of co- ordination between the federal, state, and local levels. While long-term care is every- one’s problem, it is no one’s clear responsibility (Callahan and Wallack 1981). The lack of a coherent national aging policy is evident in the multiplicity of federal policies and programs affecting the aged. Estes (1979) counted eighty such pro- grams.4 Caregivers, therefore, are left to cope on their own, to bridge the gap between national and state policies, and to actually provide the total, often 24-hour, care needed by the chronically dependent.5

Page 5: The challenge of community long-term care: The dependent aged

The Challenge of Community Long-Term Care: The Dependent Aged 259

Action at the federal level is paramount, since major changes in the long-term care system and in the current patterns of care necessitate some changes in the way the long-term care system is financed and coordinated. The federal government, because of its income and health programs, will undoubtedly continue to be the major finan- cier; the states, because of their control of social-service programs, will continue to have responsibility for coordinating the federal and state efforts; and the actual deliv- ery of services will continue to involve local governments and private providers (Cal- lahan and Wallack 198 1, p. 8). Fragmented funding has frequently been cited as a cause of fragmented service delivery .6 A national policy to establish clear lines of responsibility for financial and service provision and coordination is urgently needed.’ With such a policy in place, the State Units on Aging may provide a national resource for implementing coordination.

State Units on Aging established under the 1973 Amendments to the Older Americans Act include State Advisory Councils to engage in statewide policy development; coordi- nation, monitoring, and evaluation of programs; and advocacy on behalf of the service needs of the elderly (FallCreek and Gilbert 198 1). State Units also distribute federal and state funds to the Area Agencies on Aging. Area Agencies on Aging, as stated above, are mandated to serve as advocates and focal points for the elderly within the community by monitoring, evaluating, and commenting upon all policies, programs, hearings, levies, and community activities that will affect the elderly (P.L. 95-478).

MEETING THE CHALLENGE OF COMMUNITY CARE

Each new generation of reformers and each new change in political administration tends to

grab that easy problem-solving device known to bureaucrats as “recognizing’‘-to give the

impression of progress (change names and titles, shift personnel, start new programs, aban-

don old ones, move patients around: into institutions, back to communities, into nursing and

foster homes, or back to institutions with new names) (Butler and Lewis 1982, p. 256).

Butler and Lewis add that the actual provision of care is rarely improved by all this shuffling. Each decision concerning home care versus institutional care must be based on the older person’s needs. Butler and Lewis believe home care offers the best treat- ment location, except when people are physically dangerous or require inpatient treat- ment. But it is beneficial only when the home is an adequate place to begin with or can be made adequate by selected interventions.8

History demonstrates that American policy changes are incremental. This is with good reason. Any shift in policy, as we have learned in the relationship between hospital bed and nursing home placement rates, is apt to cause a shift in another part of the structure. Change often has ramifications that cannot be known before the change is made. Perhaps the results of recent demonstration projects involving both service coordination and new community strategies will help guide developing federal long- term care policy.9

Strategies for coordinating community long-term care services for the institutionally diverted aged appear to narrow to three often-cited alternatives involving a systems approach, case management and/or single agency coordination (Callahan and Wallack 1981; Eustis, Greenberg, and Patten 1984; Benjamin, Lindeman, Budetti, and Newa- check 1984).lO

Page 6: The challenge of community long-term care: The dependent aged

260 JOURNAL OF AGING STUDIES Vol. ~/NO. 311988

Callahan and Wallack (1981, p. 163), in asserting that perhaps a single agency could resolve the long-term care problem, point out that one needs to ask to what extent existing problems are the result of underlying factors that have to date pre- vented the nationwide creation of comprehensive long-term care agencies within local communities.

However, in considering the coordination of community long-term care for the elderly using an incremental approach, there may be support for using the Area Agency on Aging as the single agency (Callahan and Wallack 1981; Benjamin et al. 1984). At the community level, Area Agencies on Aging are already designated to be responsible for the coordination of social services and community resources needed by the fastest- growing segment of our population (Lowy 1980). Using the case management approach of assessment and care planning, Area Agencies provide service through contraction. Area Agencies do not provide direct services unless quality community service contractors cannot be identified.

Case management, often called service management in the Aging Network, is the process through which needed services are secured for the elderly in a coordinated manner. Case management is designed to provide access to the entire spectrum of community services and to ensure effective and coordinated service delivery. Basic to case management is an initial broad-based assesssment of the client’s needs. Together, the case manager and the client construct a written service plan. This plan coordinates informal resources that may currently or potentially be available with formal commu- nity resources to meet the case manager’s assessment of the client’s needs. In the Aging Network, as the Area Agencies on Aging are known, case managers or service manag- ers are most often social workers.

The federal government is currently supporting, through separate funding streams, three uncoordinated case management systems: (1) Area Agencies on Aging through Older Americans Act dollars; (2) hospital discharge planners through Medicare reim- bursement of home services (some observers see this growing enterprise as mainte- nance of a firm grip on future patient in-hospital funded days)-DRG’s activated the hustling instincts of the health business community;” and (3) the Veterans Administra- tion, which funds case management for its population. These three parallel case man- agement systems may be difficult to coordinate into a single community long-term care continuum. There must be a clearly perceived beneficial reason for each of these interests to cooperate in service coordination. In some areas, Older Americans Act dollars are provided at the state level to the community mental health system or to the Department of Public Welfare for case management, with actual services being pro- vided through Area Agencies on Aging. This unwieldy division of case management from service provision appears to lead to the duplication of case management and client assessment functions. Private corporations are also contracting with State Departments of Health Services to provide case management. Connecticut Community Care, Inc. is an example. A model for the single-agency provision of services through case management is the Massachusetts system of Home Care Corporations. Home Care Corporations contract with the state’s Executive Office of Elder Affairs.

The Executive Office of Elder Affairs (EOEA) in Massachusetts was established in 1974 as one of the nation’s first cabinet-level agencies serving senior citizens. While the EOEA mandate is broad, the majority of the state’s resources for the aging are

Page 7: The challenge of community long-term care: The dependent aged

The Challenge of Community Long-Term Care: The Dependent Aged 261

devoted to helping frail elders live independently. The community care network oper- ates in 27 service areas. EOEA contracts with nonprofit Home Care Corporations in each area. The Home Care Corporation staff determines client eligibility for services, assesses service needs, authorizes and monitors services, and coordinates with other community agencies to meet client needs. Actual services are delivered through sub- contracts between the 27 Home Care Corporations and local agencies. In 20 of the 27 areas, the Home Care Corporation is also designated as the Area Agency on Aging (AAA). In three areas covering seven Home Care service areas, the AAA is a separate agency from the Home Care Corporation (Dukakis and Rowland 1985, p. 3).

The core service of the Massachusetts Home Care Program is case management. Therefore, a single agency, as the literature suggests, is using case management to coordinate community services for frail elders. Evaluations of the Massachusetts Home Care Corporation may be expected to provide information for federal long-term care policies. Ninety-two percent of Massachusetts’ Department of Elderly Affairs proposed 1987 budget will fund home care (Aging Action Alert, Feb. 14, 1986, p. 4).

Citing organizational theory, Callahan (Callahan and Wallack 198 1, chap. 9) makes a strong case for using the systems approach to coordinate service.12 A systems view enables an analyst to uncover gaps, inefficiencies, and inequities that exist (Eustis, Greenberg, and Patten 1984, p. 139). In particular, it has been shown that most long-term care dollars are attached to means-tested programs, almost all of these dollars are spent on institutional care, and, at present, virtually no private insurance exists for long-term care. This awkward state of policy affairs ensures that those who are not on Medicaid to begin with will, after a few months or more of paying for nursing home costs, also be considered eligible for Medicaid through means-testing. This situation encourages an unavoidable slide into poverty for those unfortunate enough to require long-term institutional care for themselves or a relative. The government is applying fiscal brakes to this situation. This doesn’t mean community long-term care programs are in place. This doesn’t mean dependable, financially responsible supports are available for caregivers. It means eligibility for nursing home placement has been further restricted. It means that as our citizens over 85 become the fastest-growing segment of the population, nursing home construction and expansion of nursing home beds has been curtailed through the Deficit Reduction Act of 1984 and by the “certificate of need” process instituted in 49 out of 50 states, whereby no new or expanded facility may be constructed without first obtaining a certificate of need from the state agency. Such certificates are increasingly more difficult to obtain (Wood 1985). This produces an explicit structural stress.

CONCLUSION

Frail aged members in community settings face formidable problems in coping, includ- ing the acquisition of appropriate personal care services, nutrition, housing, transporta- tion, and other services, as well as sustained social contact. While in the community, these physically dependent citizens are often isolated, neglected, and out of touch with an established system of services that is organized to respond realistically to their needs. Surviving the years is not seen as an achievement, but rather as a stigma! Families, with all their loving strength, cannot meet their obligations for the care of

Page 8: The challenge of community long-term care: The dependent aged

262 JOURNAL OF AGING STUDIES Vol. ~/NO. 311988

frail elders without either the support of the community or becoming victims them- selves (Kirwin 1986). A well-organized community program based on principles of care could prevent much needless caregiver burden and expensive nursing home placement. Such a system would promote and maintain each individual’s maximum level of functioning, independence, and healthful life. Perhaps, as demonstration mod- els appear to be indicating, the time has come for a single funded authority or agency at the local level to assume responsibihty through a case management and a systems approach for the total array of community long-term care services, including assess- ment for nursing home placement for the chronically dependent aged population. Social workers, as case managers, are an integral component in delivering a coordi- nated continuum of care in the community to those growing in dependence through the aging process.

The need for institutional care will not be erased by the presence of community- based alternatives. That need will continue to grow simply by the weight of growing numbers of elderly, especially the old-aid. But we should retain the hope that only those who want that option, or those for whom a community-based care plan is not reason- able in terms of quality and cost, will be institutionalized. At issue is the need to assure quality of care in both settings. Personal choice and real need should be deciding factors.13

A further and important issue to study is the translation of these concepts to funding and policy-making bodies at the federal and state levels. Because long-term care for the chronically ill and our frail elders is a national problem that cuts across state lines, policy solutions should be a federal priority. History has demonstrated that the private marketplace alone cannot solve human problems of a national scale. Similarly, state and local governments lack the resources and national leadership to tackle the prob- lems of community long-term care themselves. In the end, it must be acknowledged that long-term care is the responsibility of the federal government. This is not to suggest that the federal government can meet this challenge on its own; it needs the cooperation of state and local governments and private enterprise to translate its commitment to reality.

NOTES

1. While some authorities have suggested that community care is more expensive than institu- tional care (Weissert 1978; Weissert, Wan and Livieratos 1979, Weissert et al. 1980), others conclude that the reverse is true (Virginia Department of Aging 1985; Saltz et al. 1984).

2. The need for functional assistance increases sharply with age. In 1982, about 4.8 million older persons living in the community needed the assistance of another person to perform one or more selected personal care or home management activities. This figure represented 19% of noninstitutionalized older persons, but the percentage ranged from 13% for persons 65-74 to 25% for persons 75-84 and 46% for persons 85+ (American Association of Retired Persons 1985).

3. Since the early 1950s national policy has gradually come to reflect the search for an alternative to institutional care and control as the preferred solution to social problems. There developed and extensive system of public aid that allowed for the replacement of the in-kind, room-and-board, restrictive, iong-term care insurance programs. This development, in particu- lar, created a state-subsidized market for the local provision of care by the private sector (Warren 1981).

Page 9: The challenge of community long-term care: The dependent aged

The Challenge of Community Long-Term Care: The Dependent Aged 263

In contrast to the nobility of the rationales often cited for deinstitutionaiizdtion, Scull (19771, Mechanic (1969), Rose f 1979), and Warren ( 198 1) argue that such changes were made when structural pressures developed to curtail the cost of institutionalization and when public policies generated welfare payments to the private sector. In other words, populations became “problem populations” not by inherent characteristics but by a shift in government policy. For the reader interested in more depth on the issue of deinstitutionalization beyond the cited sources, see Estes and Harrington ( I98 1) and Scull (198 1); see also Rothman and Rothman (1972).

4. Estes contends that policies for the aging fait to ameliorate the disadvantaged condition of the elderly in the United States. She cites the Older Americans Act as a reflection of the new federalism principal of decentralization. Callahan (Callahan and Wallack 1981) sees the federal decentralization as a possibility for coordination at the local level.

5. Crystal (1982) is quite correct: “It is not completely clear how many of the impaired elderly in the community actually receive the help they need with personal care and how many simply suffer” (p.79). In Chapter 4 Crystal describes the present lack of a clear relationship between government and family roles. Family care is seen as violating expectations of independence on the part of both generations and creates conflicts around issues of dependency. When combined with the genuine concern and the sense of obligation that most children feel for their aged parents, this creates a difficult, emotional, and anxiety-producing dilemma in the families of the aged. Both Elaine Brody and Ethel Shanas have written extensively on this point. See especially Brody (1982, 1985), Callahan (1985) and Kane (1985).

6. For greater understanding of the need for financial service c~rdination within home health care, the reader is encouraged to see Kaye (1985).

7. While beyond the direct scope of this article, for further discussions on the options for financing long-term care the reader is encouraged to read Callahan and Wallack (198 1) who discuss three options in detail: block grants, compulsory long-term care insurance, and the voucher program used in Western Europe. Chapter 5 in Eustis, Greenberg, and Patten (1984) raises issues in regard to the current system of ~nancial care. Congressional studies of cata- strophic health insurance are frequent news items. While the number of elderly people who would benefit from such a plan is relatively small-an estimated 13,000 out of 29 million beneficiaries- Health and Human Services Secretary Dr. Otis Bowen said he saw “no immediate solution” to the problem of paying for long-term care for chronic illness, which is the major problem faced by most sick elderly people. But as a “first step toward a long-term solution,” Bowen suggested allowing people to open tax-free individual Medical Accounts, patterned after Individual Retirement Accounts (IRAs), to save money for health costs later in life (Older A~e~~~ Reports, Capital Publications, February 7, 1986). See also Victor Fuchs (1974). Another perspective is offered by George Beall (1984).

8. There is a growing body of recent literature on the prevalence of elder abuse. “Elder Abuse: A Review of the Literature” by the Giordanos in Social Work, 29(3), May/June 1984 is a good place to begin to study this issue. A more extensive coverage of the resources is Tanya Johnson’s Elder Negfecf and Abuse: An A~~orate~ ~jb~~grup~y, Connecticut: Greenwood Press, 1985.

9. Examples of long-term care demonstrations include: (1) Triage, a cooperative personal care service arrangement among seven towns in central Connecticut; (2) Wisconsin Community Care Organization, operating in three cities, providing comprehensive social services to individ- uals discharged from area hospitals and nursing homes; (3) Monroe County Long-Term Care Project in Rochester, NY, offering a single entry assessment and case management for individ- uals over 65 regardless of income status; (4) Social HMOs funded by the U. S. Department of Health and Human Services (the most recent demonstration models include considerable varia- tion in meeting community needs); (5) National Long-Term Care Channeling demonstrations, begun in 1980-an attempt to test the cost-effectiveness of new service management systems

Page 10: The challenge of community long-term care: The dependent aged

264 JOURNAL OF AGING STUDIES Vol. ~/NO. 311988

without necessarily expanding services. Other initiatives include New York State’s Nursing Home Without Walls program, the Massachusetts system of Home Care Corporations, and various programs in Minnesota, Georgia, California, and Pennsylvania. Details are to be found in Callahan and Wallack (1981); Eustis, Greenberg, and Patten (1984); Birnbaum et al. (1984), Sommers (1985), Emlet (1984), McAnky and Bleizner (1985), and Yordi and Waldman (1985), a review of the renowned On Lok program in San Francisco. See also Kane and Kane’s (1985) A Will und a Way for an understanding of the Canadian system of long-term care.

However, there are serious problems in interpreting the array of studies evaluating alternative settings and programs for long-term care of the elderly. There are major methodological weak- nesses and substantial ambiguities in the results. For an overview of these weakenesses and ambiguities see Gurland, Bennett, and Wilder (198 1).

10. In 1975, Robert Morris and Delwin Anderson suggested that social workers could at last achieve a distinct professional identity through the delivery of personal care services (Morris and Anderson 1975). This separation of a categorical service would serve dependent children, the physically and mentally handicapped or disturbed, and the frail elderly. In Diamond and Berg- man (1981) Morris’ idea resurfaces as a community care organization (PCO) “offering single entry access to comprehensive personal and social services for elderly individuals at risk of institutionalization.. . ”

11. For more on this, see “Charting Health Care Delivery Through Case Management in Business and Health,” 2(8), 1985, pp. 5-35.

12. At least three reasons for pursuing coordination have been identified in organizational literature: (1) coordination develops because organizations operate under conditions of scarce resources and require additional resources to meet their goals. In this context, “interorganiza- tional exchanges” are seen as essential to goal attainment; (2) organizations may establish relationships in order to influence the priorities and activities of other organizations (Gilbert and Specht 1977); and (3) coordination may occur primarily because some superordinate body establishes a mandate calling for it (O’Brien and Bushnell 1980). See also Scott (1983); and Aldrich (198 1).

13. Nursing home residents (or their visitors) who may have a complaint that the nursing home administrator is not responding in a satisfactory manner may bring the matter to the attention of the Nursing Home Ombudsman in their state through the Department on Aging or the local Area Agency on Aging. However, those with a complaint about in-home services received as part of the continuum of community long-term care do not have an ombudsman. In-home service workers usually are paid minimum wage and are part-time employees of short duration. “It is hard to find people to do this type of work at what we are able to pay them.. Ho- ward Johnson’s is now paying more,” according to “The New Old Age,” part 3 by Sandra Evans

( 1986). See also Susan Sheehan ( 1984).

REFERENCES

Achenbaum, A.W. 1978. Old Age in the New L.und. Baltimore: Johns Hopkins University Press. Aging Action Alert 86(2). February 14, 1986. Washington, D. C. American Association of Retired Persons. 1985. A Projile of Older Americans. Beall, George. “Long Term Care Cost Crisis: Can Private Insurance Bail Us Out?” Perspective on

Aging 20-23. Benjamin, A. E., et al. 1984. “Shifting Commitments to Long-Term Care: The role of Coordina-

tion.” The Gerontologist 24(6):598-603. Birnbaum et al. 1984. “Implementing Community-Based Long-Term Care: Experience of New

York’s Long-Term Home Health Care Program.” The Gerontologist 24(4):380-386. Brody, E. 1977. Long-Tern Care of Older People: A Practical Guide. New York: Human Sciences

Press.

Page 11: The challenge of community long-term care: The dependent aged

The Challenge of Community Long-Term Care: The Dependent Aged 265

1982. “How America Treats Its Elderly.” Newsweek (November l), pp. 60-65.

~. 1985. “Parent Care as a Normative Family Stress.” The Gerontologist 25( 1): 19-29.

Butler, R.N. and M.I. Lewis. 1982. Aging and Mental Health. St. Louis: The C.V. Mosley Company.

Callahan, Daniel. 1985. “What Do Children Owe Elderly Parents?” The Hastings Report 15(2): Callahan, J.J., and Stanley S. Wallack, eds. 198 1. Reforming the Long-Term Care System. Lexing-

ton, MA: D.C. Heath and Company. Crystal, S. 1982. America’s Old Age Crisis. New York: Basic Books. Dukakis, M., and R. Rowland. 1985. Creating Opportunities for Elder Independence In a Long

Term Care System. Boston, MA: Executive Office for Elder Affairs.

Emlet. 1984. (January/February). “Coordinating County Based Services for the Frail Elderly: A Tri-Departmental Approach.” Journal of Gerontolotical Social Work 5- 13.

Estes, C.L. and C.A. Harrington. 198 1. “Fiscal Crisis, Deinstitutionalization, and the Elderly.” American Behavioral Scientist 24(6): 8 1 l-826.

Estes, C. 1979. The Aging Enterprise. San Francisco, CA: Jossey-Bass. Eustis, N.N., J.N. Greenberg, and S.K. Patten. 1984. Long-Term Care for Older Persons: A Policy

Perspective. Monterey CA: Brooks/Cole Publishing Company. FallCreek, S., and N. Gibert. 1981. “Aging Network in Transition: Problems and Prospects.”

Social Work 26( 3): Ficke, S.C., ed. 1985. An Orientation to the Older Americans Act. Revised Edition. Washington,

D.C.: National Association of State Units on Aging. Fuchs, V.R. 1974. Who Shall Live? New York: Basic Books. Gelfand, D. and J.K. Olson. 1980. The Aging Network Programs and Services. New York:

Springer Publishing Co.

Giordano, N., and J. Giordana. 1984. “Elder Abuse: A Review of the Literature.” Social Work 29(3):232-236.

Health Care Financing Administration. 1979. Duta on the Medicaid Program Eligibility, Services, Expenditures. Baltimore: Medicaid/Medicare Management Institute.

Johnson, T. 1985. Elder Neglect and Abuse: An Annotated Bibliography. Westport, CT: Green- wood Press.

Kane, R.A. 1985. “Long Term Care Status Quo Untenable? What is More Ideal?” Perspectives on Aging 14:(5):23-26.

Kane, R. and R. Kane. 1985. A Will and a Way. New York: Columbia University Press. Kaye, L. 1985. “Home Care for the Aged: A Fragmented Partnership,” Social Work 30(4): Kirwon, P.M. “Adult Day Care: An Integral Model.” 1986. pp. 59-71 in Socicrl Work and

Alzheimer’s Disease, edited by Rose Dobrof. New York: Haworth Press.

Lowy, L. 1980. Social Policies and Programs on Aging. Lexington, MA: D.C. Heath and Co. McAnley and Bliezner 1985. “Selection of Long-Term Care Arrangements by Older Commun-

ity Residents,” The Gerontologist 25(3):188-193. McClure, E.E. 1968. More than a Roof. St. Paul: Minnesota Historical Society. Mechanic, D. 1969. Mental Health and Social Policy. Englewood Cliffs, NJ: Prentice-Hall. Morris, R. and D. Anderson. 1975,“Personal Care Services: An Identity for Social Work.” Social

Service Review 49(2):157-174.

1983-I 984 Supplement to the Encyclopedia of Social Work. 1983. 17th Edition. Silver Spring, MD: National Association of Social Workers.

Older Americans Report. 1986 (February). Washington, DC: Capital Publications. P.L. 95-478. October 18, 1978. Comprehensive Older Americans Act of 1978,92 Stat I. Returning the Mentally Disabled to the Community: Government Needs To Do More. January 1977.

Washington, D.C.: General Accounting Office. Rothman, D. and S. Rothman, eds. 1972. On Their Own: The Poor in Modem America. Reading,

MA: Addison-Wesley.

Page 12: The challenge of community long-term care: The dependent aged

266 JOURNAL OF AGING STUDIES Vol. ~/NO. 311988

Rose, S.M. 1979. “Deciphering Deinstitutional Complexities in Policy and Program Analysis.” Health & Society 57~429-460.

Rothman, D. and S. Rothman, eds. 1972. On Their Own: The Poor in Modern America Reading, MA: Addison-Wesley.

Saltz, C. Corley, E.B. Palmore, R. Valez, R. Whlig. 1984. “Alternatives to Institutionalization: Estimates of Need and Feasibility.” Journal of Applied Gerontology 3(2): 137- 149.

Scull, A.S. 1977. Decarceration: Communig Treutment and the Deviant. Englewood Cliffs, NJ: Prentice-Hall.

I98 1. “A New Trade in Lunacy.” American Behuviorcrl Scientist 24(6). Sommers, T. 1985. “Long-Term Care: Biggest Dilemma, Toughest Problem, Greatest Chal-

lenge,” Perspective on Aging (July/August): 99- 1 I 1 Springer, D. and T. Brubaker. 1984. Furnish Curegivets and Depe~ent Exerts. Beverly Hills, CA:

Sage PubIications, Tobin, S.S., S.H. Davidson, and A. Sack. 1980. Effecrive Suciaf Servicesfor Older Ameticuns. Ann

Arbor, MI: University of Michigan, Institute of Gerontology. Trager, B. 1980. Home Health Cure und National Health Policy. New York: Haworth Press. U.S. Social Security Board. 1937. Social Secutit;v In Americu. Washington, DC: Government

Printing Office. Virginia Department of Aging. 1985. “Study of the Public and Private Cost of Institutional and

Community-Based Long-Term Care.” Richmond, Va. Warren, C. 198 I. “New Forms of Social Control: The Myth of Deinstitutionalization.” Americun

Behaviorul Scientist, 24(6X724-740. Weissert, W.G. 1978. “Costs of Adult Day Care: A Comparison of Nursing Homes.” ln~uj~

15(1):10-19 Weissert, W.G., T. Wan and B. Livieratos. 1979. Effects and Costs ofDu~ Care and Home~naker

Services For the Chron~ai~~ Ilk A ~an~rni~ed Experiment. Hyattsville, MD: National Center for Human Services Research.

Weissert, W.G., et al. 1980. “Effects and Costs of Day Care Services for the Chronically Ill: A Randomized Experiment.” Medical Care 18(6):567-584.

Wettle, T. 1985. “Long-Term Care: A Taxonomy of Issues.” Generations 10(2):30-34. Wood, S.F. 198.5. “Growing Opportunities.” Mortgage Buzking 46(3):26-32. Yordi and Waldman 1985. “A Consolidated Model of Long-Term Care: Service Utilization and

Cost Impacts,” The Gerontologist (25(4):389-397.