The country is rapidly aging. The longevity of a significant part of the population is a direct result of advances in medicine and changes in lifestyle. But longevity is not without its costs. With longevity comes the increased prevalence of chronic diseases and accompanying disabilities. Chronic diseases and disabling conditions result in impairments to a person’s inability to perform the activities of daily living (ADLs), increasing the number of people who need extended (as opposed to acute) care as well as the time that they need to recover. Today almost 50 million people in the United States, many of them are elderly and disabled, currently need assistance completing basic ADLs (e.g., eating, bathing, dressing). Most of these people remain at home, receiving help from caregivers who are family and friends. The number of elderly and disabled will grow significantly adding significantly to the system.

Accelerating the need for concern is that caregivers who provide many of these services are aging themselves, and the number of caregivers as a percentage of the populations is declining. These caregivers provide complex care often administering relatively complicated medication regimes and exercise programs. As they become unable and incapable of caring for impaired relatives and friends, the pressure for services form the healthcare system will increase.

Much of the recent emphasis has been on home care and home services as well as the financing through Medicaid. Much of it is well directed and intentioned.  Advocates base their position on the assumption that home always represents the least restrictive and appropriate environment. When compounded with the fear that many people have of residential facilities, there is a risk of not properly providing resources not only to a part of the health care system that provides post-acute care but also a critical component of the safety net. Home- and community-based care advocates seek a total rebalance of care. They want the care dollars to be shifted to home- and community-based care, which has been historically short-shifted. However, shifting one group of care against another does not achieve the needed balance.

In his 1980 book, Unloving Care, Bruce Vladeck concluded that U.S. nursing home policy was the by-product of broader social welfare legislation. He did not mean it as a compliment, but then again it was thirty years ago. Given the current reality, skilled facilities have developed both as healthcare facilities and at the same time essential part of the social welfare system. They developed in the absence of other situations that are safe and secure and capable of providing care to very vulnerable and compromised persons. In many ways, the home care industry, in its efforts in its own interests to secure funding has demonized residential care that it threatens to jeopardize its ability to provide a safe and secure environment for those who cannot live at home. Home-based care needs good nursing home care. They are entirely dependent on one another.

Rather than a defined system of care, the safety net is a patchwork of institutions, clinics, and physicians’ offices supported with a variety of financing options that vary dramatically from state to state and community to community. Further, even within the skilled nursing community, the level of commitment to “safety net” programs varies and many may not be fully aware of the function that some provide. The structure and strength of safety net programs likewise often vary, depending on the general political environment of a state or community, as well as according to the number of people and the types of health care institutions in the area. In the emerging reform of healthcare, skilled facilities will have a crucial if not critical role in providing safety net services.

James Lomastro, Ph.D., has worked in acute, community based and long-term care for 33 years. He has held an administrator license since 1991. Prior to involvement in administration, he held academic and research appointments at Boston University School of Medicine and Northeastern University.