Long – Term Care
The Census Bureau data released September 27, 2007, showed that 7.4 of those 75 and older lived in nursing homes in 2006. However, that is down from 10.2 percent in 1990. Today 4.4 percent (1.57 million) are still living in institutionalized settings according to the U.S. Department of Health and Human Services Administration on Aging.1
In addition to those living in institutional settings, it is estimated that 95.5 percent of older persons may be in need of varying levels of long-term care services. These services vary across the states and many in need fall through the cracks in the system.2
Many residents of long-term care facilities are moved several times through what has been termed the “spectrum of long-term care” as the resident’s condition changes or requires more care. A resident may move from independent living, to assisted living, and then on to a nursing home when the resident requires 24-hour medical care and perhaps hospice services. The continuing care model does not minimize the relocations, but restricts those relocations within the community. However, “aging in place,” a concept whereby the management of long-term care services provide a much needed opportunity for older people to live independently in their communities, can be supported by design that contributes to independence, providing safe and comfortable homes to live out the rest of their lives.
The number of Americans 85 years and older is expected to increase from 4.2 million in 2000 to 5.7 million in 2010 and then projected to increase to 12.9 million by 2020. This will represent over 23 percent of the elderly.3
Unfortunately, only 9 percent of the 3.7 million older persons enrolled in Medicare received care from service provider agencies. Most rely on families and friends to provide necessary caregiving.4
Statistics like these underscore the importance of making long-term care services available and providing design interventions to age in place and avoid institutionalization.
Furthermore, the number of children and adolescents with severe long-term health conditions and adults with physical and developmental disabilities continues to grow. Of people 6 years and older, 11 million needed personal assistance with one or more activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Among people aged 65 and older, 51.8 percent had a disability; and about 36 percent had a severe disability.5
Among the population 15 years and older, 3.4 percent had a visual impairment; while an estimated 3.4 percent of people aged 15 and older had a hearing impairment.6
Quality of Residential Long-Term Care
Research has shown that emotional stressors may influence the immune response to bacteria, thereby making the resident vulnerable to disease.7
High-quality home care may prevent the need for institutionalization and the associated stressors. Geriatric evaluation and diabetic assessment services provide in-home assessment and referral to community services. These services are offered in the home by some geriatric physicians, registered nurses, home health aides, medical social workers, and therapists. Home therapies are becoming commonplace, including provision of pain management, dressing and wound care, ventilation therapy, and phototherapy for jaundice. Physical and occupational therapy account for about 10 percent of the services in the home.
Technology also supports activities of daily living. Examples include heart monitors and glucometers; active devices that perform therapy on users (home dialysis systems, perfusion pumps, drug delivery systems, and oxygen systems); and general assistance and monitoring devices such as fall detectors and pill-minders.
Another important component supporting home care is home modification. This may include nonmedical equipment for lifting, mobility, special chairs, rails, ramps, adapted toilets, showers and baths, beds, and adapted kitchen design. Through housing design and supportive technology, individuals can function with a higher level of independence, and the demand for staff assistance may be reduced.
Consumers are increasingly demanding more options for senior housing and residential care. In most communities these choices are limited to (1) independent living, (2) assisted living, and (3) skilled nursing care. CCRCs integrate all three, moving residents from independent living to assisted living when activities of daily living become challenging, then to skilled nursing when significant medical challenges require full-time care.
In contrast, aging in place allows the resident to stay in the same place and have services delivered to the resident. However, the choice for residential long-term care is a personal one, a decision made by the individual or with family members and their medical professionals to determine the level of care needed and the type of residential living that is appropriate. Such choices might include:
1. Community-based group homes
2. Foster homes
3. Supervised apartments
5. Housing with live-in roommates
6. Host homes where the resident becomes part of the family
7. Boarding houses
8. Shared homes
9. Semi-supervised apartments (without live-in managers)
10. Subsidized support programs where individuals receive payments to follow a plan for self-sufficiency (or discounts on insurance for healthy houses and healthy habits)
These choices support all ages and financial abilities. A team of professionals can help with a seamless transition by providing a “needs assessment,” modification when necessary, and assisting devices. The team may include an occupational therapist, social worker, architect, and interior designer
The design of a residence can significantly affect care. Many long-term care services can be eliminated by making changes in a person’s dwelling.8
In addition, studies show design elements influence the ease with which long-term services can be provided in the home.9
For older people, design improves ability to adapt to and recover from stressful activity. It also maximizes the use of existing mobility as well as the auditory, visual, and tactile senses.
Forty percent of deaths from injuries to people 65 and over result from accidents at home. Tripping, fire safety, handrails, lighting, hot water temperature, HVAC (heating, ventilation, and air conditioning), kitchen safety, and security are issues that become critical for long-term care. Research confirms that the most important issues for older people involve health and security. A survey of 500 southern California seniors (over the age of 65) showed that the most requested features were 24-hour security on the premises, an arrangement with the local hospital, an attendant on the premises trained in cardiopulmonary resuscitation (CPR), emergency call systems, and a television security system in the building.10
Communication tools are truly important for those with decreased mobility. Audiovisual and communication devises can connect residents to family and friends, preventing loneliness and a connection to care providers to provide a safe feeling. Commonplace technologies like personal computers with a camera and sound can also be used by providers to monitor patients and to improve diagnosis and treatment in the home. It can provide patients and their families with access to records, and the best medical expertise and information on specific illnesses.
Smart technologies help older people and people with disabilities live independently in their homes by offering services to aging in place residents including safety monitoring, social alarming, sensor alarming (smoke, CO, housebreaking), medical monitoring (telemedicine), functional management of comfort (remote operation of lights, curtains, doors, etc.), energy management, and multimedia and entertainment.
Residential Long-Term Care in Other Countries
The argument for home care is strong. It prevents or postpones institutionalization, promotes healing, allows for freedom of the individual, and home care is personalized, tailored to meet the specific needs of each individual. The aim of home care is to meet health and social needs of individuals with high-quality home-based health care and social services. This may include formal and informal caregivers and the use of technology when appropriate.
In Europe, home health care is practiced differently around the region. Because of this, evidence about the appropriateness and effectiveness of home care is diverse and complex, making it difficult to gather and analyze data to make informed decisions. Improvements in public health to identify noncommunicable diseases have contributed to the demand for home care, especially for treatment of mental illness, dementia, and Alzheimer’s disease, and chronic illnesses more people are living with such as diabetes, heart disease, respiratory disease, stroke, and cancer. According to the World Health Organization (WHO), with the appropriate and targeted support, these illnesses could be effectively and efficiently taken care of at home.11
Home health care in France had an early start but is limited in its development. Since 1957, when home health care was an experiment to reduce the pressure on hospital beds, it has been an option, but mostly considered secondary rather than an alternative to hospitalization.12
Patients with mental illness, infectious diseases, and chronic respiratory or renal failure are not eligible for hospitalization at home. However, 60 percent of all elderly people utilize home care services either through a nurse’s aide or household help. In France, patients have direct access to national funding authorities and some control over service delivery.
In Ireland, boarding-out has been explored. Patients are placed with nonrelatives in private homes. The client and the state split the costs. However, most of their elder home care is focused on formal and informal care, but needs regulation and a framework to govern key areas of access, financing, and quality.
Demographics in Japan suggests that by 2014, the increase in the older population will reach 32 million (25 percent of the total population), creating a tremendous market for long-term care design services. In Japan today, 16 percent of the population is 65 or older, but more than 50 percent of all health-care dollars are spent on these older Japanese.13
For this reason, the government already provides preferential interest rate...