The Future: How to make long-term care better

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Long-term care has become an increasingly urgent policy issue. The number of elderly Americans and their proportion of the nation's population are growing, and Americans who reach age 65 are living longer. Debate over long-term care by policymakers and members of the public has ebbed and flowed during the past three decades. More and more Americans and their leaders face the dilemma of how to meet the needs of elders with chronic disabilities in the United States.

Policymakers now face three significant questions:
• Who should pay for long-term care, and how?
• How should services to elders with disabilities and their families be designed, and who should deliver them?
• How can the labor force delivering that care be recruited, trained, and maintained? For long-term care policymakers in the United States, this is the triple knot. Each of these three strands demands equal attention if sound, appropriate policy is to be developed.
The question of financing has received periodic attention from federal policymakers since the early 1970s. The potentially high cost and the lack of political will, however, have impeded serious debate about access to long-term care and about the "right" balance between the roles of the public and private sectors. Except for some federal demonstration initiatives, policy development related to the delivery of services has occurred primarily at the state and local levels.
At every level, the availability and quality of the current and future long-term care labor force –– both professional and paraprofessional –– have received the least attention of all.
Long-term care encompasses a broad range of help with daily activities that chronically disabled individuals need for a prolonged period of time. These primarily low-tech services are designed to minimize, rehabilitate, or compensate for loss of independent physical or mental functioning. The services include assistance with basic activities of daily living (ADLs), such as bathing, dressing, eating, or other personal care.

Coming to terms
One reason for the blurred boundaries between long-term care and various stages of medical care -- acute, post-acute, and subacute –– is the confounding of settings with services. (Post-acute care is care directly after a hospital intervention; subacute refers to a vague treatment modality that may bypass hospitals altogether or that focuses on longer-term rehabilitation, ventilation care, and the like.) More acute care and high-tech rehabilitation formerly provided in hospitals is being provided in nonhospital settings traditionally used for long-term care, such as skilled nursing facilities, and private homes.
It is difficult to know where medically oriented care stops and long-term care begins. Should medical interventions such as intravenous drug therapy, ventilator assistance, and wound care that are delivered in a nursing facility, residential care facility, or the home be considered acute care, subacute care, or long-term care? Should medication management for elders with chronic disabilities, including the administration of injections and the monitoring of adverse drug interactions, be considered long-term care or ongoing medical care?
In the future, a number of factors will converge to shape the magnitude, scope, and nature of the demand for long-term care: changing demographics and the health and functional status of the population; the availability of family members and other unpaid, "informal" caregivers; the financial status of various generations and how much they plan for long-term care; and the availability and cost of institutional care and community-based alternatives.
The coming years will bring an unprecedented increase in the size of the elderly population as the large baby boom generation ages. While most elderly people are not disabled, the likelihood of their needing long-term care increases with age.
Several elements are essential to the design and implementation of a long-term care system for the future.
First, the system should address the long-term care needs of people of all ages, recognizing that services and other accommodations must be tailored to people with varying degrees of physical and mental impairment. Second, the long-term care system must be sensitive to the needs of the family as well as those of the person who needs long-term care. Although formal care should not, and probably will not, replace the efforts of family and friends, the repertoire of services should build the famil