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informal meeting, contact, and social support. Adult day care, variously titled, is a communitybased provision that provides health, social, and related support services in a protective setting but for less than 24 hours on a daily or less frequent basis. Such facilities are becoming increasingly important in the spectrum of LTC services. Adult day care may follow the medical model or the social model or some combination of both. Day care is sometimes provided in a clinic or hospital, where it may have a specific clinical or rehabilitation aim; it may also be provided in a residential home, a day center, or a club. Purpose-built and converted day centers or clubs often provide social contact, recreation, and education. Some offer meal service, and they may act as a base for home delivery of services such as meals on wheels. Many adult day care centers provide transportation, and some have medically trained staff members. Day care is often helpful in relieving relatives from the care of an elderly person or a disabled adult for a few hours a day; recent innovative services provide care in the evenings or at night. An extension of this is respite services (see below) which may be based in the community or in an institution.

Family and Informal Caregivers. The majority of informal caregivers are family members, of closer or more distant relationship, but some are friends and neighbors. While increasing attention is paid to the professionalization of communitybased LTC in most developed-world countries, informal caregivers undoubtedly provide the major portion of care at all levels of need at home. Ironically, ideological shifts from hospital to community in the process of deinstitutionalization have, as a by-product, increased the importance of informal and family caregivers, but often in the absence of full-fledged community care systems. In some societies, especially in the developing world, the family is popularly and sometimes officially regarded as the main and only source of long-term care. Considerable shame and disapprobation can descend on the family that neglects the care of its elderly members, in more traditional societies. Indeed, even in highly developed societies, there is often popular pressure or at least an assumed expectation that the family will take responsibility for LTC of its immediate members, even if this is provided with paid assistants. This can hold true even when the individual is resident

in formal LTC settings and family members have visiting or care-providing roles.

Informal caregivers in LTC are predominantly female. American studies show that family caregivers are wives (23 percent), daughters (29 percent), other females (20 percent), husbands (13 percent), sons (8 percent), and other males (7 percent). This pattern holds true in many cultures. In China, for example, it provides an underpinning for the strong belief in the importance of having a son: Once a daughter marries, she traditionally lives with her husband and his parents, thus depriving her own parents of her potential future LTC help and domestic or financial assistance. Research in the United Kingdom and elsewhere indicates that family care is central to the lives of a substantial proportion of older people. In many countries, however, social change—includ- ing smaller families; women increasingly in the workforce; greater longevity; and social factors such as divorce, remarriage, and migration—all render the caring potential of the family more difficult. In developing countries, there is often very strong rural-to-urban migration of young work- ing-age people. This can often render rural elders bereft of children who would provide day-to-day help, especially in the absence of formal LTC provision.

The reciprocal nature of family care is increasingly recognized—care flowing from parents to children, grandparents to grandchildren, and in reverse. This is often intricately bound up with exchange relationships, duties, and inheritance patterns. Elderly people themselves also have key roles as caregivers and, as noted above, among retired couples, the principal LTC provider is generally a spouse, often as old as or older than the recipient. Elderly parents often shoulder great responsibility for the LTC of their adult children with developmental disabilities. Indeed, the aging of children with mental retardation and severe physical disabilities has become an acknowledged research and policy issue only over the last two decades, with the shift from an emphasis on early childhood concerns to those of life-span issues. The progressive aging of almost all societies has increased the average age of caregivers of both elderly people and disabled adults. This necessitates important shifts in policy toward, for example, rendering housing more amenable and providing aging generations with greater frequency

and variety of support, including respite care (see below).

In spite also of the strong emotional preference for being cared for by family members, many older people and their families, as well as the families of disabled younger adults, increasingly favor the support of professional caregivers when there are extensive care needs. This can be a recognition of caregiver burden—the stresses placed on family members by their caring responsibili- ties—but it is also a practical recognition of the limitations of families and informal caregivers. Researchers are increasingly focusing on the problems of family caregivers, especially those coping with physical and mental illness and especially those associated with disorders such as dementia. The impacts of providing LTC on family life, privacy, and on other members of the family besides the primary caregiver are also increasingly being recognized.

Respite Care. Respite care is temporary, shortduration, usually residential care with supervision and/or nursing provided for dependent adults, who typically cannot be left alone to live. The purpose is to provide caregivers (usually family members but often formal live-in caregivers) with temporary relief or respite from their caring roles. This clearly recognizes the family context within which much LTC is provided and acknowledges the burden that can be placed on caregivers. It is also a pragmatic recognition that, given appropriate breaks and holidays, family members may be able to continue to provide LTC support that would otherwise not be possible.

Respite care has the explicit aim of relieving the primary caregivers of impaired elderly persons, and its use has been extended to other caregivers of handicapped nonelderly adults. Many caregivers report that the main service they would like is to be given ‘‘a break’’ from caring duties and the chance for a holiday or participation in social activities. While this is undoubtedly the case, evidence is not conclusive that these services significantly reduce caregiver stress. In addition, a range of other services, such as meals on wheels, transport services, befrienders, and home help services might provide some of the functions of short-term respite care, yet they are not classed as such and are not really in this category. The major problem with respite care is that it is only as a rule available

on a local basis; it has not generally received high funding priority, and caregivers therefore often feel they cannot rely on it to be available if and when they require it. In addition, there is evidence that, for various reasons, respite care places are often not fully occupied, a feature which renders the service vulnerable when budget reviews are undertaken.

FUNDING OF LTC

Sources of financial support for and cost of LTC vary considerably internationally and are likely to become even more variable as many countries undertake health sector reform and reassess public expenditure on welfare. Classically, LTC falls between health and social care; by its very nature, it lies at the interface between the two. Many public or insurance schemes have been able or willing to pay only for eligible clients who are in the residential or nursing home medical end of the LTC spectrum. By contrast, community-based LTC services for individuals and client groups have emerged piecemeal and have often been excluded from private insurance or public welfare payments. They can be very much a patchwork, dependent on local historical provision and the evolution of national programs. Care by the family, neighbors, and volunteers have also been of extreme importance for LTC recipients in the community, so individual resources and funding remain critical in many systems. At least five public policy options (other than total private reliance) exist for funding LTC. These include means-tested public funding; private insurance; public-private partnerships; social insurance; and funding from general taxation. Increasingly, there is an international focus not purely on value for money or efficiency and quality of LTC (as these are notoriously difficult to define) but on the concept of ‘‘best value.’’

Funding of LTC is fraught with emotion among the public and politicians in many countries, and the moral panic (excess concern about future numbers of elderly people, in particular, and escalation of costs) has frequently made rational debate difficult. The issue is of major concern in the United States, where policies and, by implication, funding, are under considerable debate (O’Brien and Flannery 1997). Welfare states such as the United

Kingdom have in the past been based on a combination of free National Health Service provision for health care aspects and social welfare payments for the social care aspects. Increasingly until the early 1990s, there was assistance from local authorities and from generous publicly underpinned funding of private sector homes for elderly people. Private LTC homes flourished during the 1980s. Much of this has changed in the mid-1990s since an extensive review of the nature and funding mechanisms of community care and the retrenchment of more or less automatic public sector support for residents of private old people’s homes. A new approach to privatization has resulted in more stringent assessment of residents in private homes who are to receive public support to target the most needy with care packages. Many private old people’s homes have subsequently gained vacancies following this policy shift (Bartlett and Phillips 1996).

Comparative analysis of international systems of LTC can be valuable. A study of the evolution of the United Kingdom’s LTC policies and those of Israel, which are based on a system of national insurance, attempts to draw some lessons for the United States (Cox 1997). Israel’s 1988 Community Long Term Care Insurance Law sought to ensure that all of the state organizations involved in LTC of elderly people would be integrated into one system. Israel attempted to calculate of costs of alternatives to institutionalization. It was estimated that some 60 percent of disabled elderly people on waiting lists for institutional care could, through a basket of services, home care, day care, and personal care to relieve the burden on families, be cared for in their homes at substantially lower costs than those of the institutions. This is a thorny issue, rarely adequately addressed. Modeling exercises have suggested that, in the case of the United States, for example, efficient allocation of home care services can produce some net LTC cost savings. Greene et al. (1998) estimated that reducing nursing home use and using an optimal allocation of home care services could achieve savings of around 10 percent in the overall LTC costs for an identified frail elderly population. However, this involved targeting and a more medically oriented mix of services than has been implemented to date. It appears that the expansion of personal care services may not be significantly

justified in terms of cost containment or potential to reduce nursing home use.

Some countries have addressed the philosophy and financing of LTC systematically. The United Kingdom appointed a Royal Commission to review the long and short-term options for a sustainable system of funding LTC for older persons, both in their homes and other settings (Royal Commission on LTC 1999). They recommended coverage by ‘‘risk pooling,’’ rather than private insurance, and services underwritten by general taxation. The report of the Commission provides useful sources of costs and means of delivery. Japan, for example, likely in the next two decades to become proportionately the most elderly country in the world, demonstrates the social, economic, and political importance of LTC. Japan has experienced increased lengthening and seriousness of LTC, with one out of every two bedridden persons being bedridden for two years or more. More than half the care attendants are themselves aged 60 or older. The percentage of elderly people living with their children has fallen to just over one-half, and the proportion of women working is increasing. The Japanese Ministry of Health and Welfare estimates that the percentage of people aged 65 and over who need care will rise from 11.8 percent in 1993 to 14 percent in 2010 and even 16 percent in 2025.

As a result of these pressures, in December 1997, legislation was passed for a new public LTC insurance scheme—Kaigo Hoken—to be fully operational from 2000. This makes Japan only the third country, after Holland and Germany (see below), to provide such insurance. These proposals are very significant because they depart radically from the Japanese tradition that families are primarily responsible for long-term care. Eligibility criteria will no longer take into account the extent of informal care available to patients; and ultimate responsibility for care will lie with the state rather than with families. The scheme separates LTC services from medical care insurance and will pay for institutional and home-based care not only for those aged 65 or more, but also for people over 40 years old with ‘‘age-related’’ diseases such as dementia. Each municipal government is deemed a provider, and levels of services are decided by the patients’ impairment. Half the

funding is from monthly premiums levied on people over 40, with a 10 percent co-payment at the point of service; rates are altered for those on low income. The rest of the funding comes from general taxation.

The scheme has two potential drawbacks. First, health and social services professionals in each municipal government will have to assess eligibility and decide on care plans, skills that have long been neglected in Japan. Second, the mechanism of quality assurance has not been clearly defined. The scheme nevertheless is a major departure in Japanese social policy (Arai 1997). It aims to underpin the development of a more diverse system in which users have more choice and may use the services they wish. It also hopes to promote the change from the excessive reliance on geriatric hospitals to sanatorium-type wards with suitable environments for long-term recuperation.

Germany introduced a new LTC insurance program in 1995. This required a considerable shift in focus from traditional rights to curative medical procedures toward long-term residential and home care, which previously had to be paid privately or from means-tested social assistance. There was political agreement that LTC costs threatened ordinary citizens with impoverishment in later life, a contrast with high levels of social expenditure available for health and pensions. After extensive public debate, a public insurance system was chosen, which requires equal contributions from all employers and employees; pensioners also contribute. Benefits from the LTC insurance may be taken in kind or in cash for home care and in kind for institutional care. Benefit payment levels are graded according to fairly narrow dependency definitions: dependent, seriously dependent (in need of extensive care), and very seriously dependent (needing extensive twenty-four-hour care) (Evers 1998). The cash alternative for home care is designed to allow private family-based arrangements to be made. Various additional benefits include short-term respite care to allow family caregivers four weeks’ holiday, subsidized housing improvements, and contributions to the social security system. The new scheme, ostensibly a simple extension of the German insurance-based welfare approach, does create reliable rights for everyone in serious need of care as opposed to

means testing. However, there have been discussions about the appropriateness of linking care costs to employer and employee payments. In addition, the LTC fixed-sum payments are likely to meet only part of the total costs of care. Residents of nursing homes in particular still have to spend individual resources, albeit at a slower rate. Due to the high proportion of recipients of home care initially opting for cheaper cash reimbursements, the system went into early profit and has amassed a surplus. This preference for cash has been taken to indicate the importance of the family in Germany’s LTC, but some higher-cost medical care services can still be reimbursed from health insurance.

By contrast, even in some countries with advanced approaches to welfare, full-fledged support for long-term care remains highly dependent on local variations. In Canada, for example, what is regarded as continuing care has been called a ‘‘patchwork quilt’’ of long-term care, mainly institutional, and home or community care, mainly noninstitutional. The institutional components are widely provided across the country, with public and private funding. The noninstitutional components are developing, unevenly provided and also funded publicly and privately. While access to acute care is guaranteed, this is not the case for continuing care. The amalgam of services that compose continuing care involve the communitybased and residential LTC services outlined above. Funding varies by province in Canada, with decreasing federal support, and is typically still complicated by the situation of LTC at the interface of health and social welfare. Various types of continuing care are cost-shared between province and municipality of residence. Ownership of facilities nationally falls under three categories, and the relative balance varies considerably between provinces: public (49 percent), private for-profit (26 percent), and private nonprofit (25 percent) ownership. For illustration, Quebec has 78 percent and Nova Scotia 36 percent publicly owned facilities on average, but 100 percent of care facilities for advanced chronic mental and physical conditions are publicly owned in Nova Scotia. While funding comes from a variety of sources, there is a move toward universal rather than means-tested benefits, and cost sharing with users is the norm. In most provinces, people are not required to spend down their assets to receive public support,

though they will usually have to co-pay daily rates for lower levels of care. Community-based nursing services are virtually universally supplied in Canada, although home care and support vary considerably. The picture is evolving, with increasing emphasis on noninstitutional care and budget reallocation to this sector.

QUALITY ISSUES

Quality of provision in LTC is of increasing international interest and revolves around standard setting, regulation, inspection, and ethics. It can require legislation and a mature and sensitive appreciation of care needs on the part of LTC providers and the many professions involved. Service quality in LTC residential settings has at least five dimensions (Duffy et al. 1997): tangibles (physical facilities, equipment); reliability (ability to perform promised services); responsiveness (willingness and promptness); assurance (conveyance of confidence and trust by personnel); empathy (caring, individualized attention provided by the facility). There is also an important economic aspect to quality related to costs of services delivered: value and satisfaction.

In addition to broader quality issues, specific features such as the use of restraints also give indications of the quality and respect for individuals in a LTC system. In this and other respects, international standards vary. For example, an eightcountry study of use of restraints in nursing homes (Denmark, France, Iceland, Italy, Japan, Spain, Sweden, and the United States) found considerable variation. Total use of restraints was less than 9 percent in Denmark, Iceland, and Japan; between 15 and 17 percent in France, Italy, Sweden, and the United States; but almost 40 percent in Spain. The intensity of use of restraints and the types applied varied. In all countries, there was a constant increase in the use of restraints with increasing ADL difficulties and cognitive dysfunction (Ljunggren et al. 1997). It is clear that financial factors concerned with staffing levels, staff culture and training, the balance between better and less well trained staff, and the physical nature of facilities influence levels of use of restraints. Cultural variations and the thresholds for applying restraints also vary greatly internationally. The same is undoubtedly true of many other facets of LTC.

LTC–ISSUES OF POLICY AND PRACTICE

LTC systems have generally emerged as a series of incremental responses to a growing problem or set of problems, over a number of political eras and in many jurisdictions. The result is often a medley of noncomplementary and even conflicting programs for people with chronic disability, which are typically ineffective and inefficient. In many countries, especially in the developing world, there is still enormous emotional and even official attachment to care by the family. At the extreme, placing one’s parents or relative into an LTC residential facility can be anathema. Even in countries such as the United States, with expensive health care systems and an established range of community-based programs, LTC does not work well.

It is doubtful whether a universal blueprint for LTC can be devised. The development and financing of long-term care services in many countries has been at best haphazard. Until the Japanese and German experiences, and perhaps those in Australia and the United Kingdom at present, elsewhere it has rarely been asked what the ultimate LTC system should look like. Most systems have evolved piecemeal and have suffered from being at the interface of technically expanding and expensive health care and lower-technology, but fragmented, social care.

Basic policy issues and questions arise. What should LTC encompass? How can the role of housing policy in LTC be recognized? Is LTC an individual, a family, an employer, or a state responsibility, or is it (increasingly) some complex combination of all of these? What is the role of the family, and how can it be supported? Should LTC be provided to various disability groups and ages? If so, how? What is the ideal balance and relationship between LTC and the acute health care sector? What should be the balance between the various residential, social care, nursing, ancillary services, and informal care? What resources should be devoted to home care, assisted living, and other options? Underpinning many of these questions is the basic philosophy within specific countries regarding collective and individual responsibility for vulnerable citizens.

Housing is clearly crucial to the success of LTC. The internal home environment and its interaction with the local external environment adds to the challenge of life for many people with

chronic disabilities, and their ADL are compounded by their environment. Initiatives have appeared such as sheltered housing (assisted daily living), with wardening and support services, residential homes, and various schemes to assist adaptation of existing dwellings, but, in most countries, there has been little coherent policy development in this area. Ironically, many initiatives to build specialist housing for elderly or handicapped people have come from private sector developers, who have identified a new and underserved market segment for specialist housing. Aging in place and care in the community can often be enabled by relatively minor housing improvements. These may be administrative; for example, in public housing, there may be provision for flexibility enabling residents to exchange current units for more appropriate, often smaller ones. Many academic disciplines, including sociology, gerontology, planning, geography, environmental psychology, and architecture, can contribute to this important aspect of policy development.

What will future LTC look like? It can be provided in a number of different settings, by a range of personnel, and to people with varying types and levels of disability. Nevertheless, in many systems, institutional care such as nursing homes still represent the majority of expenditure on LTC. Residential and nursing homes do indeed often represent an important care option, but they would be unlikely to occupy such an important position in a newly designed LTC system. As many systems have gradually emerged piecemeal from a range of initiatives, they do not meet the needs of the recipients or providers of LTC today, nor the needs of those who pay for care. Internationally, there is little agreement about potential policy solutions. In many countries, thoroughgoing debate and reappraisal need to be initiated.

REFERENCES

Arai, Yumiko 1997 ‘‘Insurance for Long-term Care Planned in Japan.’’ The Lancet 350(9094):1831.

Bartlett, Helen, and David R. Phillips 1996 ‘‘Policy Issues in the Private Health Sector: Examples from Long-Term Care in the U.K.’’ Social Science and Medicine 43(5):731–737.

Binstock, Robert H., Leighton E. Cluff, and Otto von Mering 1996 The Future of Long-Term Care: Social and

Policy Issues. Baltimore, Md.: Johns Hopkins University Press.

Cox, Carole 1997 ‘‘Long-Term Care: A Comparison of Policies and Services in Israel and the United Kingdom and Implications for the United States.’’ Journal of Aging and Social Policy 9(2):81–99.

Dearborn Financial Publishing 1997 Long-Term Care, 2nd ed. Chicago: Dearborn Financial Publishing.

Duffy, Jo Ann, Michael Duffy, and William Kilbourne 1997 ‘‘Cross National Study of Perceived Service Quality in Long-Term Care Facilities.’’ Journal of Aging Studies 11(4):327–336.

Evers, Adalbert 1998 ‘‘The New Long-Term Care Insurance Program in Germany.’’ Journal of Aging and Social Policy 10(1):77–98.

Greene, Vernon L., Jan Ondrich, and Sarah Laditka 1998 ‘‘Can Home Care Services Achieve Cost Savings in Long-Term Care for Older People?’’ Journal of Gerontology: Social Sciences 55B(4):S228–238.

Hutten, Jack, and Ada Kerkstra (eds.) 1996 Home Care in Europe: A Country-Specific Guide to its Organization and Financing. Aldershot, England: Arena Publications.

Katz, S., A. B. Ford, R. W. Moskowitz, B. A. Jackson, and M. W. Jaffe 1963 ‘‘Studies of Illness in the Aged: The Index of ADL: A Standardized Measure of Biological and Psychosocial Function.’’ Journal of the American Medical Association 185:914–919.

Ljunggren, Gunnar, Charles D. Phillips, and Antonio Sgadari 1997 ‘‘Comparison of Restraint Use in Nursing Homes in Eight Countries.’’ Age and Ageing 26(S2):43–47.

Mahoney, F. I., and D. W. Barthel 1965 ‘‘Functional Evaluation: The Barthel Index.’’ Maryland State Medical Journal 14:61–65.

Novak, Mark 1997 Issues in Aging: An Introduction to Gerontology. New York: Addison Wesley Longman.

O’Brien, Raymond C., and Michael T. Flannery 1997

Long-Term Care: Federal, State and Private Options for the Future. New York: Haworth Press.

Peace, Sheila, Leonie Kellaher, and Dianne Willcocks 1997 Re-evaluating Residential Care. Buckingham, England: Open University Press.

Ribbe, Miel W., Gunnar Ljunggren, Knight Steel, Eva Topinkova, Catherine Hawes, Naoki Ikegami, JeanClaude Henrard, and Palmi V. Jonnson 1997 ‘‘Nursing Homes in 10 Nations: A Comparison Between Countries and Settings.’’ Age and Aging 26 (S2):3–12.

Royal Commission on Long Term Care 1999 With Respect to Old Age: Long Term Care—Rights and

Responsibilites. Report by the Royal Commission on LTC. London: The Stationery Office.

Tinker, Anthea 1992, 1997 Elderly People in Modern

Society. London: Longman.

DAVID R. PHILLIPS

LONG-TERM CARE FACILITIES

THE SPECTRUM OF LONG-TERM CARE

While the nursing home remains the most prevalent option for elderly persons requiring longterm care, in recent years there has been a great upsurge in alternative options. Changes in the spectrum of long-term care services provided have come about primarily based on changes in the demographic profile of long-term care users, in health care financing, and in policies impacting the provision of long-term care.

Nursing homes reflect the major long-term care option that has been available in the United States under Medicare and Medicaid financing. However, recent trends reflect new developments targeting self-financed long-term care, particularly in the form of assisted living, continuing care retirement communities, and special need facilities focusing on dementia or hospice care. In addition, discharge policies of acute care hospitals have resulted in the development of subacute care and rehabilitation facilities sponsored by hospitals or nursing homes. There has also been an increase in the provision of home care services to frail older adults who can forestall entry to sheltered living arrangements, including nursing homes, through the use of these services. Growing recognition of the diversity of elders requiring long-term care is leading to the diversification of settings to meet these needs, and to a blurring of boundaries between home care and residential care (R. A. Kane, 1995–1996).

In spite of the proliferation of new residential options for frail and old-old adults, those requiring extensive assistance or supervision continue to rely on nursing homes as the only viable publicly financed alternative. Consequently, this essay will only briefly touch on some of the more recent options in the spectrum of long-term care, such as

assisted living facilities and continuing care retirement communities. Rehabilitative or subacute care units in nursing homes will not be addressed because they reflect mechanisms for providing short-term care. Nor will we discuss senior housing sites or retirement communities, which serve as residential options to well elders. After considering assisted living facilities and continuing care retirement communities, the major focus of our discussion will be on the nursing home.

ASSISTED LIVING FACILITIES

Assisted living facilities (ALFs) have taken over some of the original functions of nursing homes, providing services to moderately frail elders in the context of a homelike residential setting that includes less surveillance and regimentation, and more privacy and autonomy for residents than the traditional nursing home (R. A. Kane 1995). ALFs combine housing with personal support services such as meals, laundry, housekeeping, and maintenance services. Board and care homes and personal care homes may also be included under the ALF designation. Generally, residents in ALFs pay on a month-to-month basis, although financing of home health services may occur under Medicare (Pearce 1998). Assisted living facilities are an outgrowth of the group home tradition, generally reflecting small business operations. In recent years, however, assisted living facilities have increasingly been sponsored and built by hospitals, nursing homes, and large publicly traded companies (Meyer 1998).

Consistently with the model of social care (R. A. Kane and Wilson 1993), ALF services are geared toward meeting resident preferences and wishes, and consider residents to be consumers rather than patients or clients to be taken care of according to staff-based directives. Assisted living arises from a commercial model of fees for services, and its consumer-driven orientation differs from nursing home care, which generally reflects third-party payment dynamics. While these advantages make assisted living a highly attractive long-term option for frail elders with some means, potential problems include lack of regulation and inaccessibility of this type of care to the poor. Furthermore, assisted living facilities can serve only the needs of older adults with limited disabilities (R. A. Kane 1995–1996).

CONTINUING CARE RETIREMENT

COMMUNITIES

Continuing care retirement communities (CCRCs) may also be termed ‘‘life care communities,’’ and they typically offer a continuum of services from independent living to assisted living and nursing care. These facilities are appealing to well old-old persons who are still able to live independently but want to have the security of planning for increasing service needs as they arise. These older adults want to know that their changing personal and health care needs can be met within an organizational framework, which they select. Most elderly persons initially enter independent living units of CCRCs. Between 50 percent and 70 percent of entering residents eventually utilize assisted living and/or nursing home components of the CCRC (Newcomer et al. 1995).

CCRCs vary greatly in both the types and the range of services offered and in sponsorship and management. The fees may be structured as a refundable entry fee along with a monthly service fee, or it can be based on an endowment, a rental, or a condominium purchase (Pearce 1998). While fee structures differ, arrangements for these services have generally moved from exclusive reliance on entrance fees to requiring monthly maintenance fees along with fees paid at the time of initiation. With the rapid growth of CCRCs around the country, states have enacted legislation to protect older adults, particularly against bankruptcy of the organizations sponsoring the CCRC (Netting and Wilson 1994). These facilities are generally considered and regulated as insurance programs, and there has been great inconsistency in ways of implementing their regulation across different states.

CCRCs represent not only an emerging comprehensive long-term care alternative, but may constitute a new paradigm for long-term care (Vladeck 1995). Managed care CCRCs can offer flexibility and a more community-responsive paradigm for delivering long-term care. This form of care draws on the know-how of diverse industries, including housing, hospitality, insurance, and health care. This allows for a cross-fertilization of different value orientations regarding care, and different approaches to financing and management.

Large-scale national research on CCRCs finds (Sherwood et al. 1997) that such facilities tend to

be utilized by well-educated, middle-class, white, elderly persons aged 75 and over, with women being overrepresented among the users. More than 85 percent had been white-collar workers (Sherwood et al. 1997). When compared with community residents, CCRC-dwelling elderly were found to be in comparable or better health and to have comparable social supports, although com- munity-dwelling elders interact more frequently with their family members. Social research on assisted living and CCRC communities has not been extensive, and generally considers administrative and organizational dimensions of care, rather than aspects of social life and social interactions. Studies comparing CCRC residents and elderly people living in the community have noted that the former are more likely to utilize nursing units after acute hospital stays and outpatient surgery. At the same time, CCRC residents have lower rates of hospital admissions than do community-dwell- ing elders (Newcomer et al. 1995).

NURSING HOMES

Nursing homes are of interest to sociologists on both the macro and the micro levels. On the macro level they reflect society’s orientation to financing, regulating, and delivering long-term care services to its frail citizens who are no longer capable of fully autonomous community living. Sociologists have been particularly interested in those factors affecting long-term care delivery that reflect social construction of the reality of the lives of marginal individuals such as aged persons.

On a micro level, nursing homes represent formal organizations that regulate and control the daily lives of frail elders, while providing them with medical and social care. The tension between expectations for rehabilitative or prosthetic services and actual delivery of palliative care or of depend- ency-inducing treatment, with iatrogenic consequences, has been a particular source of fascination and concern to gerontologists (Baltes 1996; E. Kahana, Kahana, and Riley 1989; Kane 1995– 1996). Complementing this interest has been the search for understanding person-environment interactions and interpersonal and intergroup relationships involving residents, staff, and families within the institutional context (Diamond 1992; Gubrium 1975, 1993; E. Kahana, Liang, and Felton, 1980).

The following discussion about nursing homes includes an introductory section outlining models of nursing home care, followed by a discussion of demographic profiles of residents and an analysis of nursing home characteristics and financing. Efforts to ensure high quality of care are discussed in terms of both regulatory efforts and formal interventions. We next consider the effects of institutionalization on the social lives of residents, and their adaptation to the nursing home. Discussion then turns to new initiatives in formal program development and effects of interventions on resident life in the nursing home. The article concludes with a discussion of emerging trends in nursing home care and the future of long-term care facilities in the United States.

Even as we aim to review sociological contributions to the understanding of nursing homes, it is important to note that information about this subject has been obtained through the research efforts of diverse disciplines, with epidemiologists, political scientists, social workers, psychologists, nurses, and physicians all contributing to the literature. In fact, medical sociologists have focused their investigation primarily on acute health care delivery in general hospitals, and many of the theoretical constructs they have developed are more applicable to acute illness than to chronic disability (Cockerham 1998; Charmaz and Paterniti 1999). Consequently, this discussion of the nursing home draws upon multidisciplinary sources.

MODELS OF CARE IN NURSING HOMES

Those requiring institutional care represent a highly select group of the most vulnerable aged persons (Hing 1987), particularly since there are now many options which can keep frail elders in the community. Any therapeutic efforts to enhance the functioning of the very frail older adults living in nursing homes thus represent a regimen of limited objectives (E. Kahana, B. Kahana, and Chirayath 1999). Nevertheless, nursing home settings can serve important therapeutic and rehabilitative functions and can enhance the quality of life of frail elders by ensuring comfort and even some measure of autonomy (Agich 1993). Moving away from an exclusive focus on poor quality of care in nursing homes, recent research has begun to consider criteria for high quality of care and even

excellence in nursing home settings (Andersen 1987; Brittis 1996; Groger 1994; Looman et al. 1997).

Conceptualizations of models of care typically reflect the philosophies and traditions of the disciplines from which they originate. Sociology, medicine, nursing, the allied health professions, psychology, and social work—each has a distinct set of traditions that influence its respective conceptualizations of long-term care. Interventions arising from these diverse traditions may include therapeutic interventions (psychology), programs that enhance function (nursing or medicine), and interventions that empower patients (sociology and social work).

The medical model of care considers nursing homes as health care institutions designed to deliver high-quality chronic care to patients. As such, nursing homes are expected to provide competent and well-trained personnel to meet health care needs of patients (R. L. Kane et al. 1994). In principle, the criterion for successful care is improved health or at least minimal health decline of the patient. In practice, quality of care is generally approached by the organization through adherence to certain standards of care delivery, such as adequate staff recruitment and training, and high staff-patient ratios (Nyman and Geyer 1989; L. Z. Rubenstein and Wieland 1993).

The organizational climate of managed care has brought with it a new emphasis on managementcentered interventions and care. Management-ori- ented approaches often treat patients as objects of intervention who must be manipulated to achieve desired objectives. One such approach, continuous quality improvement (CQI), is an organizational management framework based on older business models such as total quality management (TQM) (Schnelle et al. 1997). The goal of CQI is to make systematic improvements by employing multiple short cycles of designing, evaluating, and implementing interventions. These cycles of continuous intervention and assessment drive long-range systematic change. Attempts at CQI in nursing homes have included interventions in incontinence and physical restraints, but have been hindered by a lack of information technology and by care standards legislated by the Omnibus Budget Reconciliation Act (OBRA) of 1987 (Schnelle et al. 1997).

The social model (R. L. Kane and R. A. Kane 1978; R. A. Kane et al. 1998) considers the ideal model of long-term care to be a sheltered housing arrangement for older adults who can no longer function independently in the community. The goal of such sheltered living arrangements is ensuring a good quality of life for residents through encouragement of maximum autonomy in a homelike setting. The criterion for successful care is defined in terms of sustained psychosocial well-being, selfesteem, and life satisfaction of residents.

While medical definitions of care dictate provision of diagnostic and treatment activities, social definitions suggest emphasis on comfort, choice, and adaptation. Advocates of quality-of-life approaches have often argued for major redirection in the way long-term care is handled. They seek greater support for the home-based rather than the institution-based model of care (Leutz et al. 1992). The growing popularity of assisted living options in long-term care reflects this orientation. Empowering older clients to act as consumers provides a major mechanism for the social care model (Burger et al. 1996; Cox and Parsons 1994). Since residents living in nursing homes are typically too frail and powerless to demand active consumer involvement in their care, there is little evidence of actual empowerment-based approaches in nursing home settings (E. Kahana 1999).

The Patient-Responsive Care Model (Kahana, Kahana, Kercher, and Chirayath 1999) has been developed to recognize social, psychological, and physical needs of frail patients who are not able to function in residential settings and who require nursing home care. The Patient-Responsive Care Model is an ecological model guided by communitarian principles of sociologists (Bellah 1996; Etzioni 1993). It calls for a systematic and empathetic discernment by staff of resident perspectives and preferences. This approach is based on earlier work on person-environment fit as a determinant of resident well-being in nursing homes (E. Kahana 1973; E. Kahana 1982). Environments may be matched to resident needs by altering the physical or social environment and by enhancing staff responsiveness in an effort to improve residents’ quality of life (E. Kahana, B. Kahana, and Riley 1989). This model is also consistent with recently proposed ‘‘cultural’’ models of

nursing home care proposed by Scandinavian scholars who advocate individualized care based on ‘‘knowing the patient’’ (Evans 1996).

The major requisite of patient-responsive care is an understanding and an empathetic appreciation of nursing home life from the patient’s perspective. Four major areas of need, loosely based on Maslow’s hierarchy of needs (1970), are to be met by staff: reducing physical distress, meeting basic physiological needs, meeting emotional needs, and meeting social needs. Since cognitively impaired and frail elders are limited in their ability to articulate their needs, a major challenge of patientresponsive care is to elicit expressions of resident needs and preferences. This model is predicated on empathetic listening to the patient’s lived experience (Gubrium 1993; Savishinsky 1991) as a basis for developing Patient-Responsive Care, and does not rely on need assessments based on objective test data.

Staff behaviors along dimensions of responsiveness can range from total lack of involvement (ignoring or dismissing a problem) to hearing and validating patient concerns. Staff who are responsive to patients provide reassurance and, whenever possible, take constructive actions toward resolving problems. Eliciting information about patient needs and validating those needs are proposed as concrete requisites of providing patientresponsive care. Action components of responsive care also involve communicating with family members and with other staff in advocating on the patient’s behalf. Responsiveness involves three central actions by staff: eliciting the patient’s definition of need, validating the need, and acting or advocating on the patient’s behalf. The pattern of responsiveness thus involves observing, questioning, listening, and responding. Exemplifying this approach, aides who care for the elderly may be trained to redefine their jobs from providing custodial care to providing therapeutic measures. For example, personnel delivering meals could easily be trained to engage in conversation with residents during meals, explaining what the resident is eating and contributing to the enjoyment of the meal. Staff providing responsive care may be empowered through this very initiative. Providing responsive care can serve to enhance staff’s selfefficacy and sense of competence (E. Kahana et al. 1999).