Faced with the loss of a spouse or the need for help with meals or housekeeping, many of the nation's elderly sometimes find that moving into a nursing home is just the easiest way to meet their needs.
Recent studies indicate that often it is not health but a shift in marital status or the need for some personal care that prompts the move. An estimated 25 percent of all nursing-home patients are considered physically able to take care of themselves in their own home setting -- if they just had access to occasional help.
These facts, the skyrocketing cost of nursing-home care, and the rapid growth of America's senior citizen population are forcing experts in the field to take a fresh, hard look at alternatives to institutionalizing the elderly who need some form of long-term care. New service and financing possibilities and the government's role in them were the focus of a regional conference recently in Chicago, sponsored by Washington's Administration on Aging. The regional meeting was a prelude to next fall's White House Conference on Aging.
"The problem is that nursing homes have really been the only alternative for those needing some support over the long term," explains Dr. Harold Richman, a University of Chicago professor in the School of Social Service Administration and co-chairman of the conference. "As a solution it's expensive, medically oriented, and not that responsive to the needs of many elderly . . . . We can't afford to wait for the ideal. We need to decide what kind of public policy we want to follow for long-term care and try some experiments."
In an effort to find a more balanced approach to care for the elderly, several US senators have cosponsered legislation that seeks to meet the combined health and social service needs of the elderly through government-supported homemakers, nurses, and other aides.
Initially, the measure calls for a six-year experiment in 10 states. Teams of health aides in these states would screen senior citizens entering nursing homes to decide whether the person could remain at home if they had access to some help with daily tasks. Although home health care is not considered high on the Reagan administration's list of priorities, the bill has strong bipartisan support ranging from Sen. Bob Packwood (R) of Oregon to Sen. Daniel Patrick Moynihan (D) of New York.
Almost everyone now agrees that helping America's elderly stay as independent as possible and encouraging them to manage their own affairs in the freest possible environment are desirable goals. Most citizens and experts also would agree that there is a need for more and better coordination of cummunity-based services such as home nursing care and adult day care.
There also is a need for more flexible living arrangements, such as adult foster care and group homes for the elderly. Such services exist in some areas -- Michigan, for instance, has 3,000 adult foster care homes. But these services tend to be scattered, overlapping, and offered through such a maze of agencies that many elderly don't know how to take advantage of them.
There remains widespread disagreement as to how much responsibility the public sector should assume for providing long-term care for those needing help. Though many Americans may assume that the majority of older citizens are in nursing homes, some 60 to 80 percent of those needing care receive it from friends and relatives.
Defenders of the status quo argue that large increases in community services will tend to undermine and replace such help. They also believe that government should not take a role in compensating or recognizing families for the extra financial and mental burden related to caring for the elderly.
But proponents of a larger public role in long-term care argue that the family-friend network of help tends to be fragile. Often husband and wife both have demanding jobs, and they say the added home chores make them perform less well on the job and cut heavily into their social or recreational activities.
Some experts in the field say the strains involved could easily shift the caretaker job entirely to nursing homes and the federal bureaucracy if more goverment help is not forthcoming. As things stand, a mere 2 percent of all medicaid dollars is channeled into home health services. By contrast, medicaid pays about half of the nation's nursing home bill.
Donna McDowell, acting director of Wisconsin's Bureau of Aging, argues that tax incentives and expanded community services would nourish and strengthen familial caretaking efforts. In her view, the effect would be no more damaging than help parents now receive in child care from schools, baby sitting, and the Boy Scouts.
"To argue that government home care services would supplant family care is as ridiculous as saying that schools undermine motherhood -- in fact they help keep mothers sane," she says. "We should be concerned with whether or not negative pressures on caretaking families, if unresolved, will work against the natural sense of obligation. I believe we have to consciously develop a concept of social recognition and rewards and positive reinforcement for caregiving."
One form such rewards could take, some experts at the conference suggested, would be a broadening of the current tax deduction and credit system. For instance, property tax reductions offered elderly homeowners in some states could be extended to families supplying their home and care as well. Similarly, deductions for dental and medical expenses could be broadened to include in-home supports from attendant care to transportation costs. A voucher system, by which older citizens can purchase the services they need, is the focus of an experiment in illinois. California has been trying a flat monthly allowance for care to achieve the same end.