Expanded Home Care
Most disabled elderly are at home and want to stay there. Home care services, such as home health care, homemaker help, personal care, meals-on-wheels, respite care, and adult day care, enable them to do so. Only a small minority of the chronically disabled elderly, however, receive any paid home care services. In 1982 only 25 percent of the 4.65 million disabled elderly living at home used any paid in-home care. 1 Public expenditures for long-term care are overwhelmingly for nursing home rather than home care. Less than 5 percent of medicaid long- term care expenditures for the elderly in 1984 went for home care. 2 An obvious approach to reforming long-term care is to increase public finding for home care.
Supporters often justify expanded home care services by arguing that these will substitute for nursing home care and thus actually reduce public long-term care expenditures. Evaluations of community care programs, however, tend to show not only that expansion of community care has little effect on nursing home use, but that it raises, rather than lowers, total expenditures. 3 One reason for the cost increase is that the expanded home care goes primarily to people who were not receiving paid services. Another is that home care services do not keep disabled people out of nursing homes. They are almost always a complement to, not a substitute for, nursing home care in the overall system of long-term care.
Saving public money may be the most popular way to justify an expansion of home care, but there are other reasons to expand home care. One is that the elderly strongly prefer home care and that their demands for that care are unmet. Others are to establish a more