RESEARCH TO PRACTICE
Rethinking the Future of Long-Term Care
Basler, B. (2004), Suing to get out in the world. AARP Bulletin, (June), 3-12.
Chappell, N., Havens, B., Hollander, M., Miller, J., & McWilliam, (2004). Comparative costs of home care and residential care. The Gerontologist, 44, 389-400.The author of the AARP article points out that many people who qualify for a nursing home that would be fully paid for by Medicaid would rather stay on a wait list for Medicaid’s home and community services (HCBS), even if it means doing without the care that they need. She sites Indiana as an example where 30,000 people are wait-listed for HCBS while 15,000 nursing home beds lie empty. “People would rather be No. 30,000 on a list for community care than go into a nursing home” (p.12).
Another manifestation of this perception of nursing home care has recently occurred in California. In 2000, a class action suit was filed against a nursing home, Laguna Honda, siting the 1999 U.S. Supreme Court decision that ruled that if a disabled person prefers to live in the community, and care services would cost the same or less than a nursing home, making him/her stay in the nursing home would be isolating and discriminatory. Last year the U.S. Justice Department’s Civil Rights Division estimated that for the price of two beds in Laguna Honda for one year, five people could be served in the community with full support. Last year, several Laguna Honda residents were released to the community after being assessed for their ability to live on their own.
A number of studies that date back to the eighties have had mixed findings about cost comparisons between home care and nursing home care. The most recent of these was conducted in Canada by Chappell et al (2004) and was reported in the June issue of The Gerontologist. Their research computed the costs of formal care and informal care in both residential and home settings comparing groups of residents/clients who needed the same level of care.
Their results showed that care for clients in the community was significantly lower than for facility residents, regardless of whether costs to only the government were taken into account or whether both formal and informal costs were taken into account. Past studies have not considered informal caregiving at either a minimum or replacement wage. These authors were quick to point out that informal caregiving frequently must increase in order to make up for the loss of full-time care within the nursing home situation.
Implications: Laguna Honda was recognized as a home that provided exceptionally good care. The message behind this story may be not that we continue to refine and improve the current model but that in addition to changes in nursing homes, long-term care organizations must find ways to diversify their product. Perhaps instead of playing an adversarial role to forces that would allow older persons to remain in their home, long-term care organizations could find ways to actively encourage older adults to do just that. Potential exists in the home health field but also in assessing physical and cognitive functioning in community-dwelling older adults and then implementing individualized strategies to help older people retain remaining abilities.