A mericans, and people throughout the world, are living longer and healthier than at any time in...
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Americans, and people throughout the world, are living longer and healthier than at any time in human history. Nevertheless, the human body and mind often become compromised at some point in life and can lose functional capacity due to accidents, disease, or accumulated wear and tear. When people face difficulties with personal care or otherwise living independently, they usually come to depend on the help of others. About 12.5 million persons of all ages in the United States need this type of assistance, almost half of whom are under age sixty-five (Kaye, Harrington, & LaPlante, 2010).
The set of health and social services delivered over a sustained period to people who have lost (or never acquired) some capacity for personal care is called long-term care (LTC) or long-term services and supports (LTSS). The latter term is increasingly being used because it emphasizes the fact that most of the care is supportive and collaborative. Ideally, LTSS enable recipients to live with as much independence and dignity as possible in the least restrictive environment that they desire. LTSS can be provided in institutional, community, or home settings and can involve assistance with such daily activities as walking, bathing, cooking, managing medications, and overseeing finances. It can be furnished by paid providers (formal care), unpaid family and friends (informal care), or by a combination of the two. LTSS can also include creating conditions that facilitate independent living, such as home modifications, accessible transportation, and special equipment like a motorized wheelchair. LTSS differs from most topics discussed in this volume because it depends heavily on social services and less on medical services.
The demand for LTSS will grow rapidly in the coming years due to the aging of the population overall, as well as increased lifespinstitutional care (such as nursing homes), home and community care, informal unpaid care, and the workforce in those sectors. It highlights how financial considerations have framed the dominant policy debates and research agenda. Policymakers frequently consider community services and family care as less expensive substitutes for nursing home care, making quality-of-life issues a secondary priority. Older adults and disability advocates, however, prioritize independence and quality of life over costs. Complicating the debate between independence and the costs of care is the diversity by gender, race or ethnicity, and income among older Americans.
When most people think about long-term care or LTSS, the first service that comes to mind is nursing home care. But only 4.2 percent of older adults live in nursing homes, with an additional 2.7 percent living in community housing that offers supportive services (Federal Interagency Forum on Aging-Related Statistics, 2012). Nevertheless, the high cost of nursing home care, averaging $73,000 per year for double occupancy and $81,030 for a private room (Genworth Financial, 2012), make it a top policy priority.
Institutions that deliver long-term care services can be classified by the extent of medical or nursing care they provide. At one end are subacute facilities and skilled nursing homes that provide intensive posthospital care, twenty-four-hour skilled nursing, and often rehabilitation. At the other end are residential facilities with little or no medical or nursing care, but that offer assistance for functional activities like cooking and bathing, typically in board-and-care or assisted-living facilities. Regardless of the level of medical care, institutionalized populations have some level of disability that require care and supervision.
Public policy first encouraged the establishment of private long-term care institutions when Old Age Assistance (public aid for low-income elderly) was established in 1935 and specifically barred residents of publicly owned facilities from receiving this aid. The program allowed local governments to close their unpopular almshouses for the poor and ill, transferring the care of the ill and dependent elderly to private facilities, and shifting the costs to the states and federada (Stevenson & Grabowski, 2010