Long-Term Care Around the Globe

The nature of residential eldercare has once again begun to change. A newer model emphasizing the availability of personal-assistance services, rather than nursing, was promoted and the balance between these types of facilities and medically oriented nursing homes shifted. In Europe and Australia, these residential care settings are being developed primarily under public auspices (both with respect to financing and service delivery). The terminology varies; in Europe, they were often described as supportive housing arrangements and often consist of specially designed (handicapped accessible) complexes of private rooms and apartments, along with congregate dining facilities, multiple communal areas for socialization, and locations where nurses and other care personnel are permanently stationed. In the United States, the growth of what are called assisted-living facilities developed primarily in the private-pay marketplace when for-profit and not-for-profit developers identified and responded to an emerging consumer demand for this service from affluent elders and their families.

As governmental authorities above the local level (i.e., national, state, and provincial governments) have assumed a greater share of the costs associated with eldercare provided in inpatient facilities (especially long-stay hospital or nursing-home care), the societal visibility of residential care increased. The complex and changing roles of poverty, family relationships, chronic illness, and functional disability in explaining the use of residential eldercare has resulted in a great deal of confusion in the minds of policymakers, professional experts, and the public about when, if ever, care in such settings is truly necessary or appropriate. In opinion surveys, most respondents readily agree that disabled elders prefer to, and should be able to, obtain the long-term care they need at home.

There is also a private-pay market developing for the newer social models of residential eldercare in some countries (e.g., assisted living in the United States, hostels in Australia). These facilities appeal to elders and families when it is clear that it is no longer possible for an elder to live alone safely, even with substantial amounts of formal and informal help. Governments in many countries are responding to this phenomenon by differentiating between payments for care and payments for accommodation. Increasingly, the care component is publicly funded, without means-testing, but residents are expected to pay room and board costs out of their own income and savings. However, low-income elders who cannot afford to pay all of the accommodation fees can apply for means-tested public assistance to cover the shortfall. This pattern now prevails in Germany and France for all forms of residential long-term care and in Australia for social model facilities (hostels, as distinct from nursing homes). Another common pattern is to require residents of care facilities to contribute most of their Social Security pension income toward the cost of care (in Canada, this is referred to as the user fee) with the remainder of the cost being borne by public programs (although residents may also have to pay supplemental charges from private income and savings for private rooms and other amenities and services). In the United States, there is growing interest in states to cover the care component of assisted-living facilities for low-income individuals under Medicaid, but not the room and board component, which federal Medicaid law prohibits.

Nevertheless, most disabled elders who need long-term care continue to receive it at home, and most functional assistance is still being provided by family caregivers. Institutionalization rates for older adults in eight developed countries (United States, United Kingdom, Australia, Canada, New Zealand, France, Germany, and Japan) are estimated to range between 5 and 7 percent of the total elderly adult population. Since the 1960s, the use of formal home care (primarily as a supplement to family care) has increased. Use rates of formal home care among the population age sixty-five and older in these same eight countries are estimated to range from a low of 5 to 5.5 percent in Japan and the United Kingdom to a high of 16 to 17 percent in Canada and the United States. In the United States, data from the 1982, 1989, and 1994 National Long-Term Care Surveys on use of formal home care by older Americans with chronic functional disabilities residing in the community show an increase from 25 to 35 percent. Virtually all of the increase was in use of paid care to supplement informal care; the percentage of disabled elders who relied exclusively on paid home care remained at about 5 percent.