Academic journal article Generations

A Key Piece of the Integration Puzzle: Managing the Chronic Care Needs of the Frail Elderly in Residential Care Settings

Academic journal article Generations

A Key Piece of the Integration Puzzle: Managing the Chronic Care Needs of the Frail Elderly in Residential Care Settings

Article excerpt

Although families continue to be the major source of long-term care, a variety of residential settings with supportive services have emerged to supplement their efforts. These arrangements support those families whose members need more care than the family can provide and the elderly and disabled who have no family. Indeed, other than nursing homes, the most common form of residential setting with services for people with disabilities is board and care homes. As such, they must receive serious consideration in any efforts to achieve integration of care services for older people. Such settings are thought to offer significant potential for meeting the needs of frail elders in residential settings that are more homelike than those found in psychiatric hospitals and most nursing homes. At the same time, prior research has raised questions about the ability of many such facilities to meet the needs of people with chronic diseases. Such questions are particularly worrisome, given the increase in acute conditions one sees among residents in all levels of long-term care, a trend that spills over to residential care.


Residential care facilities have traditionally referred to nonmedical community-based residential settings that house two or more unrelated adults and provide some services such as meals, medication supervision or reminders, organized activities, and transportation or help with bathing, dressing, and other activities of daily living (ADs). However, in recent years, this definition has blurred as such facilities have expanded the range of services they offer and residents they serve.

Residential care facilities that serve a predominantly elderly population are known by more than thirty different names across the country, including adult congregate living facilities, personal care homes, homes for the aged, residential care facilities for the elderly, shelter care homes, adult care homes, family care homes, community residential facilities, and assisted living facilities.

Under the generic name "board and care" in 1991 there were an estimated 34,000 to 36,000 such facilities, with more than 600,000 beds, based on estimates generated from the National Health Inventory. These facilities housed an estimated 540,000 elderly people who were physically frail or had cognitive or functional limitations (Clark et al., 1994).

In addition, an unknown number of unlicensed homes were providing similar services; estimates of the number of such unlicensed facilities have ranged from 10,000 to more than 40,000. One ten-state study estimated only about a 12 percent increase in unlicensed homes over the states' licensed bed capacity in 1993 (Hawes et al., 1995a). This study found that, contrary to expectations, these homes were not small "mom and pop" endeavors but, rather, were large retirement homes and assisted living facilities. In some states, licensure was not required for facilities in which residents lived in apartments, even though they received the same types of services as in licensed board and care homes. In other places, facilities avoided licensure by providing health and personal care services through home health agencies (Hawes et al., 1995a; Hawes, Wildfire, and Lux, 1993).

Since 1991, there has been tremendous growth in this long-term- care sector, primarily among facilities that describe themselves as "assisted living" Indeed, from its start in the United States in the late 1980s, mainly in Oregon, assisted living has become the most rapidly growing form of residential care for the elderly (American Seniors Housing Association, 1998). This pattern of rapid growth has been particularly striking among larger assisted living facilities (those with more than 25 beds) and among high-profile, publicly traded multi-facility systems. Assisted living is thought to differ from traditional board and care homes in terms of its philosophy and willingness to provide a more expansive range of services that allow residents to "age in place," receiving different services as their needs and preferences change (see box, this page). …

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