Long-Term Care

In 1994 nearly 80 percent of older persons who reported needing assistance with one or more daily activities lived in their own home or another community setting. Just over 20 percent lived in nursing homes. Of those living in homes and communities, an estimated one million lived in supportive housing that provided some long-term care services, such as assisted living facilities (GAO, 1998).

The bulk of long-term care, however, is provided by unpaid family members or friends (GAO, 1994). Between 1987 and 1997 the proportion of U.S. households involved in unpaid caregiving activities for a person over the age of fifty jumped from approximately 8 percent (seven million households) to 22 percent (more than twenty-one million households).

Caregivers varied in the amount of time they spent caregiving and in the scope of care provided. While the average unpaid caregiver provided eighteen hours of care per week, nearly one in five (18 percent) provided forty or more hours of care per week (NAC/AARP, 1997). Nearly all caregivers surveyed (98 percent) said they helped with at least one household management activity, such as transportation, grocery shopping, housework, preparing meals, or managing finances, or giving medication. More than four in five (81 percent) helped with three or more of these activities. Over half (51 percent) helped with at least one personal care activity, such as getting in or out of chairs, dressing, bathing, toileting, or feeding. Over a fourth (29 percent) helped with three or more of these activities. In 1996 more than seven in ten unpaid caregivers (73 percent) were women, and 12 percent were age sixty-five or older (NAC/AARP).

Because many members of the baby boom generation have remained single longer and have had fewer children than their parents, a smaller proportion of this generation will have a spouse or adult children available to provide unpaid caregiving when they are older. In addition, families are more likely to be geographically dispersed, and women are more likely to work outside the home than they were formerly. As a result of these demographic changes, it is predicted that older persons of the future will have fewer unpaid caregivers available and will be more dependent on paid long-term care services (GAO, 1998).

Individuals who need more assistance than unpaid caregivers can provide may receive long-term care in a range of settings, including home care, adult day services, supportive housing, and nursing homes. Home care refers to a range of services, including nursing care, personal care, assistive devices, meals, and home modifications, provided to people with disabilities in their own homes. Many unpaid caregivers use one or more home care services to help with caregiving. For example, 47 percent of caregivers reported acquiring a wheelchair, walker, or other assistive device. In addition, many caregivers reported purchasing personal or nursing care services (38 percent), home modification (28 percent), home delivered meal services (16 percent), assistance with housework (16 percent), and respite care (14 percent) (NAC/AARP 1997).

Adult day centers provide a range of services to physically impaired or mentally confused adults who live at home, thus allowing caregivers to have respite or go to work during the day. Adult day centers provide less than twenty-four-hour care and typically operate during normal business hours five days a week. As of 1996, there were an estimated four thousand adult day centers operating in the United States (NADSA).

Supportive housing refers to care in a homelike setting in the community for people in need of assistance with daily activities or protective oversight. Supportive housing can be an alternative to nursing homes for some. Typically, however, supportive housing offers only very limited nursing care. The major types of supportive housing settings include assisted living, adult foster care, congregate housing, and continuing care retirement communities (Blanchette).

Assisted living is a rapidly growing option for individuals with long-term care needs who prefer to live in the community and who generally do not require the level of skilled nursing or custodial care provided in a nursing home (GAO, Assisted Living, 1999). While definitions of assisted living vary, the term generally refers to a residential, homelike setting that provides or coordinates personal care services, twenty-four-hour supervision, social activities, and some health-related services. Although the lack of consensus on a definition precludes an exact count of assisted living residents, states reported a total of 32,886 licensed assisted living facilities with 795,391 units or beds in 2000, a 30 percent increase since 1998. These numbers include board-and-care homes, which are often similar to assisted living but usually provide no health-related services (Mollica).

Nursing homes are the most easily recognized form of long-term care, although far more people receive long-term care in their own home or in other community settings. The National Nursing Home Survey defines nursing homes as "facilities with three or more beds that routinely provide nursing care services." In 1997 approximately 1.5 million persons sixty-five years and over lived in nursing homes (Bishop).

As opportunities have expanded for care in the community (often termed home and community-based care), the proportion of older people residing in nursing homes has declined. Between 1985 and 1995 the number of nursing home residents per thousand individuals age sixty-five and older fell from 46.2 to 42.4, an 8.2 percent decline. In 1995 nursing home residents tended to need more intensive care than did their counterparts in 1985, because individuals with fewer impairments were more likely to receive care in the home or another community setting, such as an assisted living facility (Bishop).