Social Services

The twentieth century brought tremendous growth in elderly populations, not only in the United States, but throughout the world. With this growth, the cost of institutional care became a significant burden on public resources in the United States. By mid-century, the idea that social services might prevent nursing home placement contributed to the expansion of public services for older adults.

The most significant and enduring manifestation of this expansion was the Older Americans Act (OAA), signed into law by President Johnson on 14 July 1965. In his remarks upon signing the bill the president suggested the legislation would provide ‘‘a coordinated program of services and opportunities for our older citizens.’’ Through partnerships between federal, state, and local authorities, the act established a network of 57 State Offices on Aging and 670 Area Agencies on Aging that today effectively blanket the United States.

Less enduring that the OAA, but equally influential, was the Channeling Demonstration, funded through the Health Care Financing Administration in 1980. The demonstration was implemented in ten states throughout the country to test the notion that services delivered to the frail elderly in the community would reduce nursing home admissions and improve well-being. Channeling programs varied somewhat between sites, but case management was a central feature of each. Case management involves the use of a single professional, usually either a social worker or a nurse, to coordinate service delivery for an older adult. Case managers typically conduct detailed need assessments, develop a service plan designed to meet identified needs, then select providers to deliver services and monitor the process.

Programs funded through the Channeling Demonstration did meet the needs of frail elders, and they enhanced the quality of life enjoyed by their clients. But they failed to demonstrate cost-effectiveness by reducing nursing home admissions. The primary reason for this failure was what Kane and Kane referred to as ‘‘the problem of shifting targets.’’ Far more frail elderly people live in the community than in nursing homes. Approximately 5 percent of Americans over the age of sixty-five live in nursing homes. Even fewer of the nation’s elderly enter a nursing home in any given year. So, while it is possible to identify frail elderly people in need of support, it is difficult to determine who, within this pool, is most likely to enter a nursing home. As a result, services for the frail elderly serve many who would never have entered a nursing home. Thus, social services seldom reduce nursing home admissions. Nonetheless, in testimony to their positive effects on quality of life, the popularity of social services for frail elderly people continues unabated and a wide range of these services are available today.