A. Home and Community-Based Services


Home and community-based services will be increasingly important in assuring quality health care for older persons in the future. Such services are generally strongly preferred by older persons because they foster maximum independence in least restrictive settings. Many individuals will need such services after discharge from a hospital or a nursing home. Often the availability of such support will make it possible for older persons, including individuals with multiple disabilities, to maintain themselves at home for extended periods.

In 1985 more than 90 percent of the elderly population with long-term care needs were residing in the community. According to the 1982 National Long Term Care Survey, about 40 percent lived with their spouses, 36 percent lived with their children, 11 percent lived alone, and 14 percent lived in other arrangements. About 33 percent were poor and 62 percent had low to middle incomes.

The largest share of services in the home will probably continue to be provided on an "informal" basis by spouses, other family members, and friends. As discussed in Chapter II, more than 80 percent of current caregivers for older disabled persons living in the community with activity limitations are now from these groups, and about 70 percent of these elderly adults receive all their care in this way. Although societal changes may reduce these percentages, informal services are likely to remain major and key components of in-home arrangements. The provision of guidance, training, and support to such "primary caregivers" is one of the most important activities of professional health and social services personnel.

Services to persons in their homes that are provided on a formal, organized basis may include a comprehensive mix of preventive, supportive, therapeutic, rehabilitative, and related services aimed at maintaining and improving health status and functional independence. These services should be able to respond effectively to the diverse needs of the older population, including acutely ill patients and persons with chronic conditions.

In-home services may be classified into three levels:

• The basic level, which consists primarily of housekeeping services for individuals who require assistance with the instrumental activities of daily living--e.g., cooking, shopping, laundry, transportation, and financial management;
• The intermediate level, which involves both housekeeping services and personal care assistance with activities of daily living--e.g., eating, bathing, grooming, toileting, and other self-care activities; and
• The intensive level, which includes skilled nursing services, skilled therapies, and other medically oriented support services. Basic and intermediate level care is usually required for relatively long periods. Intensive level care may be short-term to stabilize post-acute patients or extended for persons with severe and chronic medical problems. There are no general standards for staffing such services.

The basic level of services is usually provided by housekeepers, home attendants and managers, and chore aides. The intermediate level may be provided by personal care aides with the assistance of housekeepers or by homemakers with training as personal care aides. Home health aides contribute to the third level of care, assisting professional health personnel.

Housekeepers, personal care aides, and home health aides need to be prepared not only to provide appropriate and sensitive care but also to be alert to changes in health conditions that may call for the attention of health professionals.

Care management activities can guide and target older persons and their families to the appropriate level and location of services. The activities include screening, assessment, care planning, coordination of services to carry out care plans, follow-up, and monitoring. Effective care management can achieve more prompt and responsive care to older persons and more coordinated and efficient utilization of resources.

Care managers must be educated to carry out their responsibilities in close contact with older persons, informal and formal care providers, and a variety of community resources. Usually these personnel have a nursing or social work background but they may be from a variety of other disciplines. Supplementary training to deal with the complexities of the needs of many older persons is generally indicated but is often unavailable. Older persons themselves and family members should also be assisted to participate in care management activities.

The elderly population is already the principal user of organized home care services. Estimates indicate that 75 to 90 percent of home visits are for persons 65 years of age and older. More than 45 million home health visits to older persons are estimated to have been provided in 1984. These services are being financed by private and public funds from multiple sources.

A number of federal programs assist the delivery of some form of home care services. They include Medicare, Medicaid, Social Services Block Grants, and grants from the Administration on Aging and the Public Health Service. In addition, in-home services for their specific clients frequently are provided on a limited basis through mental health programs and mental retardation and developmental disabilities programs.

Home health benefits under the Medicare program are only supported on a limited basis for post-acute care, not for long-term maintenance of persons with chronic conditions. Patients must be homebound and need skilled nursing care on a part-time or intermittent basis. The services have been expanding rapidly in recent years; the number of persons served increased to more than 1.5 million in 1984 (from fewer than 1 million in 1980), and the number of visits financed by the program increased to more than 40 million in 1984 (from about 22 million in 1980). In 1984 there were more than 1,300 visits per 1,000 Medicare enrollees. About one of every 30 Medicare enrollees used such services--about one of every 75 between the ages of 65-66 and more than one of every 10 who were 85 years and older. The average number of visits per user was 27 in 1984.

The growth in home health services is likely to continue in future years. Not only will earlier hospital discharges contribute to the expansion, but so will expanded capabilities to carry out more technical procedures in the home and the increasing number of older persons with chronic disabilities.

Home health services can also be expected to increase substantially in areas where there is a relatively low level of such services at present. For example, within the Medicare program, the number of persons served in 1983 varied from more than 70 per 1,000 enrollees in Vermont to about 20 per 1,000 in Arizona. The number of visits per 1,000 enrollees ranged from more than 3,000 in Mississippi to fewer than 500 in Arizona and Minnesota.

An analysis of a sample of persons utilizing Medicare-financed home health care in 1982 found that patients could be grouped into five types. Two groups, accounting for about half of Medicare payments for these purposes, needed extensive assistance in regular and instrumental activities of daily living. The average number of visits increased from about 20 among those with the least problems and to about 100 among patients with the greatest difficulties.

Data from the 1982 National Long Term Care Survey indicate that, among the 3.2 million older persons reporting one or more limitations, about 5 percent lacked needed assistance in one or more activities of daily living and more than 35 percent lacked needed assistance in one or more instrumental activities of daily living. About half of the former group and a third of the latter had five or more limitations. The greatest need appeared to be assistance to improve mobility. More than half of those with unmet needs were receiving support from informal caregivers only.

Home health personnel need to be well prepared to carry out their responsibilities. Such training is critical to high quality care. Persons providing care in the home should have orientation, education, and continuing in-service training in line with their specific duties and tasks.

However, the supply and training of home health aides as well as personal care workers and housekeepers are very uneven and are generally seriously deficient. For example, because the work can be stressful and isolating, leading to very high rates of employee turnover, some employers have endeavored to train aides to anticipate and defuse difficult interpersonal situations; such efforts tend to be few and far between, however. To ensure appropriate direction and guidance of direct care personnel, the preparation of care managers, administrators, and supervisors with respect to the special needs and problems of older persons also needs to be substantially expanded.

Nursing personnel have major responsibilities in the planning, administration, and provision of home health services. As discussed in Chapter III, the full-time equivalent number of registered and licensed practical nurses required in various types of community health programs (serving persons of all ages) was projected to increase to about 380,000 in the year 2000 in the Fifth Report on the basis of the historical trend-based model, most of whom would be registered nurses. This number is more than double the number employed in such activities in the 1980s. The expert panel that considered needs for future nursing in 1984 (whose composition and work was described in Chapter III) projected larger requirements for nursing services in the community. The panel called for from about 650,000 to 980,000 FTE nursing personnel for these types of services in the year 2000; about 50 to 65 percent would be registered nurses and most of the others would be home health aides. The estimates anticipate that about 25 percent of hospital discharges should receive home visits (averaging about 9 RN visits a year), and that home visits should be provided to 2 percent of the population 65-74 years of age (averaging 7 RN visits), 5 percent of the population 75-84 years of age (12 RN visits), and 10 percent of the oldest old (15 RN visits).

The potential need for homemakers and home health aides has been estimated by the National Association for Home Care on the basis of experiences in European countries where there is broad financing of long-term care services. Their estimate is that at least 500,000 homemakers and home health aides are needed at the present time to provide one aide for each 100 persons 65 years old and over, and one aide for each 1,000 younger persons. This number is about twice the current workforce of these personnel.

An estimate of needs for home health aides to serve older persons, based on data from Medicare and the 1984 National Long Term Care Survey, identified a requirement for about 200,000 home health aides in 1985. The estimated need for the year 2000 is about 250,000 home health aides and for the year 2020 about 370,000 such aides. If improvements in the health status of older persons are assumed, the estimates might be reduced by about 25 percent. If shifts from informal care by relatives and friends to more formal care by paid aides is assumed, the estimates might be increase by 10 percent or more.

The Bureau of Labor statistics expects the employment of homemakers and home health aides to grow very rapidly in the next few decades. Its analysis notes that the extent of this expansion will depend upon such factors as trends in informal caregiving by families and friends, the availability of private and public funds to purchase in-home services, and the availability of alternative arrangements, including adult day care and lifecare communities. Other analyses of personnel needs for home health services have estimated that, on the average, about 9 percent of the population 65 years old and over are at high risk of needing such services. This percentage would equal about 3 million persons in the year 2000 and 5 million in 2020.

Adult day programs are another important form of community-based services. There are already more than 1,200 such centers and additional programs are being developed in many communities to provide various supportive services. These facilities provide opportunities for offering many health promotion and disease prevention activities that are discussed below, as well as other health-related services. Leadership in the development and conduct of such activities can include voluntary as well as paid staff, which may require more attention to the training of volunteers.

Other community-based services are provided by various health professional and associated personnel, such as physicians, dentists, social workers, occupational and physical therapists, pharmacists, and optometrists, and nutritionists. Activities and prospective needs in these areas were reviewed in Chapter III. Needs for home and community-based services are closely related to trends in the availability and utilization of institutional services. In 1986, about a third of hospital discharge planners reported that the supply of nursing home beds was the most important barrier to discharges and that the supply of home health care services was a serious problem. About half of the planners in the Northeast reported such difficulties. The supply of homemaker and hospice services was reported to be inadequate or marginally adequate in all areas of the country.

As discussed in Chapter II, future projections of service needs for the older population have anticipated a substantial expansion in the number of nursing home beds--from 1.3 million in 1980 to more than 2 million in 2000 and more than 3 million in 2020. Such an expansion would require nursing home construction to exceed a rate of 2 percent a year. If the rate of nursing home development is only half that rate, then there will be about 500,000 more disabled persons in the community in the year 2000 and one million more in 2020. Under these conditions, a further expansion in the availability of various types of home and community-based services will be necessary.

B. Services in Nursing Homes


The personnel and training needs for caregivers who work with residents of nursing homes are among the most critical issues concerning the health care of older persons in the future. There are already more patients in nursing homes (including skilled nursing and intermediate care facilities) on a daily basis than in acute hospitals; in 1985 there were 1.4 million residents 65 years old or older. These numbers are certain to grow in coming years.

The median age of nursing home patients exceeds 80 years. More than 70 percent are female and more than 60 percent are widowed. Almost 5 percent of the elderly population is in nursing homes at one time. About 8 percent is estimated to be in such facilities during a year.

More than 20 percent of persons 85 years old and older are in nursing homes; they make up about one third of the residents. The oldest old are likely to comprise 40-50 percent of nursing home patients in the next few decades. The increase in mean age is likely to result in a greater proportion of heavy-care residents, including many with some form of mental disability, particularly Alzheimer disease.

Minority groups have tended to utilize nursing homes to a lesser extent. For example, the 1985 National Nursing Home Survey found that about 3.5 percent of the black population 65 years of age and older were in nursing homes, compared to 4.8 percent of the white population. The comparable rates in 1977 were 3.1 percent and 5.0 percent.

Nursing home utilization includes two broad categories of patients. More than 50 percent have relatively short stays (under 3 months); this group generally requires short-term recuperative nursing and rehabilitation services or terminal care. The remainder tend to stay for extended periods, usually until death, and need long-term maintenance and support. For the latter group the facility becomes their "home," encompassing both living and treatment arrangements.

The mix of patients varies greatly in different nursing homes. In general, the intensity of care needs is increasing. As discussed in Chapter III, this trend is due to earlier hospital discharges, prolongation of life because of more effective and complex technologies, and the higher average age of patients. In many cases a larger number of "semi-acute" patients requires a high level of care. More than half of nursing home residents are estimated to have some type of mental or behavioral problem. Further, many residents experience frequent changes in health and functional status and need continuing attention as well as sophisticated diagnostic and management technologies.

There are increasing needs for rehabilitative services in these facilities. Some nursing homes, especially skilled nursing facilities, have begun to plan and develop such services far more intensely than before. These capabilities can make it possible for more patients to be discharged to assisted living arrangements in the community and to their homes.

There are great variations in the availability of nursing home beds across the country. In 1985 there were about 15,000 nursing home beds certified for participation in Medicare and Medicaid programs, and about 1,000-2,000 other beds licensed by States. In 1983 the number of persons 65 years of age and over per bed varied from about 11 in Wisconsin to 45 in Arizona; the national average was about one bed for each 18 elderly persons. State Medicaid programs are a critical factor in the development of these resources; on a nationwide basis, they support more than 40 percent of expenditures for these purposes.

Personnel staffing within nursing homes also varies greatly. Medicare rules require only that skilled nursing facilities provide 24-hour service by licensed (not necessarily registered) nurses, and that a registered nurse be present during the day tour five days a week. Current regulations permit nurse aides to deliver all resident care in intermediate care facilities without supervision of a licensed nurse from 3 p.m. to 7 a.m. daily. The 1986 Institute of Medicine (IOM) report, Improving the Quality of Care in Nursinq Homes, pointed out that care in nursing homes is staff-intensive. The IOM committee concluded that it was inappropriate to prescribe detailed staffing standards in view of the heterogeneity of residents. They emphasized the broad range of knowledge and skills necessary to meet the multiple needs of nursing home populations. The committee urged that all professionals serving these facilities be trained in geriatric care and gerontology.

The IOM report further recommended that every new nursing home resident receive a comprehensive assessment. Additional assessments should be made periodically and when there is a change in status. Reviews should include each resident's functional status, medical and dental conditions and needs, mental and emotional status, social interactions and support, personal activity preferences, and financial circumstances.

A registered nurse who has received appropriate orientation should usually be responsible for assessments. As a minimum, the assessment team should also involve a physician, social worker, and physical therapist. Other personnel such as dentists, psychologists, nutritionists, audiologists, speech therapists, occupational therapists, and podiatrists should be drawn on as needed.

Physicians are responsible for providing medical services in nursing homes. Less than 20 percent of general and family medicine practitioners and internists are reported to make visits to these facilities, however. The average primary care physician, it is estimated, spends less than 1.5 hours per month in nursing homes. Less than 8 percent of registered nurses work in nursing homes. Only 15 percent of nursing homes staffs are registered nurses; 14 percent are licensed practical nurses. The current staffing level equals about one RN for each 100 residents. Few nurses employed in nursing homes have advanced gerontologic nursing education. Less than one-tenth of Medicare-certified nursing homes have one registered nurse for each 10 beds. About 90,000 additional RNs--more than twice the existing number in such facilities--are needed to achieve that ratio.

There are wide variations among the States in staffing of nursing homes by licensed nurses. In 1981 there was one nurse for every 19 Medicare certified nursing home beds in Oklahoma, compared to about one nurse for every 5 such beds in Alaska. In New Hampshire there were about two registered nurses to every licensed practical nurse, while in Texas there were five LPNs to every RN.

Aides and other nonlicensed personnel deliver the majority of direct care in nursing homes. More than 70 percent of the nursing personnel in long-term care facilities are nurse aides, and as much as 90 percent of the resident care in a nursing home may be delivered by these types of personnel. Most aides have little or no formal education and training in health care or the needs of older persons and are often poorly supervised. The 1986 IOM report recommended that new standards for the training of nurse aides be included in the conditions of participation for the Medicare and Medicaid programs (17 States already have such requirements). The IOM committee concluded that the benefits to nursing home residents of increasing the ratio of better-prepared staff to patients far outweighs the cost of increased staff. They urged that--

"...nursing homes should place their highest priority on the recruitment, retention, and support of an adequate number of professional nurses who are trained in gerontology and geriatrics to ensure an adequate number and appropriate mix of professional and non-professional nursing personnel to meet the needs of all types of residents in each facility."

Social workers in nursing homes not only work with residents and their families but also help prepare and assist other staff to positively influence the psychological and social status of patients. The 1986 IOM report pointed out that such staffing is uneven, often very minimal. They proposed that, for each 100 beds, facilities have at least one full-time professional social worker, and that smaller and rural facilities arrange at least one day of consultation per week.

Ombudsman programs help nursing home residents and their families negotiate with nursing homes and State regulatory agencies. Virtually every State has such a program; there are about 1,000 paid staff and more than 5,000 volunteers engaged in this work. The IOM committee found that programs vary widely in effectiveness and recommended that stronger national leadership foster the development of effective training programs for these personnel as well.

The 1983 IOM report, Nursing and Nursing Education, also emphasized that upgrading the skills of nursing home personnel is urgently needed. The committee concluded that nursing service staffs in nursing homes often lack necessary knowledge and skills to meet the clinical challenges presented by the residents. They urged that such facilities, in collaboration with nursing education programs and other private and public organization (including State higher education and vocational programs), develop and support programs to upgrade the knowledge and skills of aides, licensed practical nurses, I, and registered nurses who work with elderly residents in such facilities.

As discussed in Chapter III, projections of nursing personnel through the year 2000 anticipated increased needs in nursing homes of about 260,000 FTE registered nurses and 300,000 FTE other licensed nursing personnel on the basis of the historical trend-based model. These estimates are about three times the staffing levels in 1983-84.

A more extensive level of staffing within nursing homes was projected by the expert panel that met in 1984. The panel called for expansion to at least 838,000 FTE registered nurses, 339,000 other licensed nurses, and about 1 million nursing aides by the year 2000. The panel emphasized that professional nurses, particularly those with special education in geriatric nursing, can make significant differences in the quality of care and the quality of life in nursing homes.

Examples of important innovations in some nursing homes are the utilization of geriatric nurse practitioners and nurse clinicians, educational upgrading for LPNs and RNs, continuing education for directors of nursing, and increased reliance on professionally trained long-term care administrators. In some cases linkages are being developed with other service providers and with various educational institutions (as discussed in section 8 below). These actions not only strengthen the resources available to operate facilities but also enhance capacities for improving the supervision and training of staff personnel.

A 1986 report prepared by the Office of Technology Assessment pointed out the potential contributions of nurse practitioners (NPs) and physician assistants (PAs) in improving the quality of services in nursing homes. The report noted that these types of personnel have the demonstrated ability to provide care for a population with chronic problems and functional disabilities and they can enhance services that many nursing homes find difficult to supply. If coverage were extended, NPs and PAs would most likely provide nursing home visits as employees of physicians' practices or as team members in group practice; if NPs were paid directly, they could function as independent practitioners. The OTA report noted that total costs to third-party payers would probably decrease because visits to nursing homes by teams of physicians, NPs, and PAs could decrease the use of hospital facilities. (As noted in Chapter III, the Omnibus Budget Reconciliation Act of 1986 authorized coverage of PA services under Medicare in nursing homes in states where they are legally authorized to perform such services, beginning January 1, 1987.) The 1986 IOM report also urged that well-designed studies be carried out to determine the most effective staffing of nursing homes, relating nursing staff requirements to the varying mix and needs of patients. Such analyses should also clarify desirable requirements for related education and training. The report also noted that further studies are especially needed concerning the appropriate content and length of the most effective training programs for nurse aides.

C. Health Promotion and Disease Prevention


Health promotion and disease prevention opportunities need to receive greater attention in both education and service programs. Primary and secondary prevention approaches can contribute substantially to furthering the well-being and continued independence of many older persons. These benefits are likely to be recognized and valued increasingly by health personnel as well as by older adults themselves.

A series of health promotion and disease prevention measures have been identified to be of great potential benefit to older persons. Among the most important are actions relating to smoking, exercise, hypertension control, immunization, and dental health. Other valuable interventions are related to injury control, osteoporosis, mental health, nutrition, and the appropriate use of medications. Advances in knowledge during the coming years can be expected to add to these opportunities.

Many of these issues can be addressed most effectively by various health care practitioners as part of the provision of personal health care. As discussed in Chapter III, many associated health personnel as well as physicians, nurses, and dentists can have important roles in providing these types of services. Other approaches can be developed on a community basis, involving leaders from many different backgrounds, including older persons themselves and volunteers.

Incentives to encourage health promotion and prevention practices may be included in more health care financing and insurance programs in the future. Such policies can encourage more widespread interest and more positive attitudes among both caregivers and older people.

The 1979 Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention stated:

"The long-term goal of a health promotion and disease prevention strategy for our older people must not only be to achieve further increases in longevity, but also to allow each individual to seek an independent and rewarding life in old age, unlimited by many health problems that are within his or her capacity to control."

In 1984 the Public Health Service, in cooperation with the Administration on Aging, undertook a nationwide program specifically focused on healthy older people. The initiative had three broad purposes:

• To enhance the quality of life for older Americans through the improvement of their health status and preservation of their independence;
• To educate older persons about health practices which can reduce their risks of disabling illness and increase their prospects for more productive and active lives; and
• To curtail health costs caused by preventable conditions.

State coordinators were appointed by Governors and Statewide coalitions were established in 35 States to help carry out the Healthy Older People program. Consumer materials have been developed on a variety of topics and disseminated through mass media, training programs, and local efforts. Corporate sponsors have distributed educational products and national organizations--including the American Association of Retired Persons, the American Hospital Association, and the American Optometric Association--have joined in dissemination and training activities. Information on program activities and pertinent research findings are shared throughout the Healthy Older People network. Examples of 50 exemplary local projects are available to assist individuals at the community level.

In order to prepare all types of health personnel to contribute appropriately and consistently to health promotion and disease prevention activities, information and techniques concerning these issues need to be integrated within their education and training programs. The available opportunities should be emphasized as part of basic and graduate professional curricula and in-service and continuing education courses. Faculty members to guide such programs should be up-to-date concerning the latest state of the art and should serve as effective role models. Students should have practical experience in developing such activities with older persons in various settings, including senior centers and day programs.

Similarly, education and training concerning health promotion and disease prevention should be widely available to other interested individuals, such as informal caregivers and older persons. Voluntary health agencies, senior citizen groups, and private companies as well as local educational institutions, public health agencies, and health professional associations may often provide critical leadership in planning and conducting such programs. These activities can extend health educational efforts beyond the traditional health care system when carried out in accessible locations throughout the community.

The effectiveness of educational activities in these areas can influence significantly the duration and quality of life of many older persons. They can also help reduce needs for other, more costly services. Thus, such activities warrant priority emphasis in both education and service delivery programs.