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Issues in Long-Term Care of Elderly Individuals

With the growing number of individuals joining the ranks of mature adulthood, never has it been more important for long-term care plans to be in place. As the baby boomer generation ages, more and more people leave the role of the caretaker and begin seeing their adult children take on this role. According to Beverly Goldberg of the Century Foundation (2007), “By 2010, the population aged 20-65 (that is, those who make up the potential workforce) will comprise 60% of the total population, whilst the oldest old will make up only 2%; in 2030 those numbers change to 53.2% and 2.6% respectively…” Goldberg goes on to report the growing number of the oldest old population in succeeding years, warning gerontologists and aging individuals of the corresponding issues and concerns of such growth. One of those issues, and a very prominent one at that, is the issue of long-term care.

The term “long-term care” used to only with the connotation of nursing home placement, however, in today’s day and age the term “long-term care” means a good deal more. As Hooyman and Kiyak (2002) note in their textbook on social gerontology, long-term care now deals with a wider array of services and assistance programs for mature adults (pg. 539). While this wider selection of options for long-term care is certainly beneficial to both the elderly and their families, it also poses a decision for families that can sometimes be stressful.

Choosing Long-Term Care

Due to the options available today, just putting grandma or grandpa, mother or father, into any old nursing home simply isn’t acceptable. Determining the needs and desires of the elderly individual and matching them with the correct type of care is now the goal and responsibility of caretakers, social workers, and medical professionals. Of course there is also the option of sole charge at home care, but this section will only discuss alternatives to this traditional option and concerns of caretakers will be discussed later.

Following with the P-E Congruence Model of gerontology, one concern in choosing a long-term care plan is to take into account the person-environment congruence. The P-E Congruence Model takes into account a person’s compatibility with their environment and “assumes that the impact of the environment is mediated by the individual’s level of abilities and needs” (Hooyman, Kiyak, 2002). As such, it becomes an issue to ensure that the elderly individual being placed in a long-term care facility is in equilibrium with the environment. In order to ensure such things it’s important to look at the location of the facility, the rules and regulations, and the services provided. For example, and elderly individual who grew up and grew old in New York City may not be comfortable or able to fully adjust to quiet country living in a secluded nursing facility. Instead, said individual may desire a more connected and centrally located facility with easy access to the city and familiar surroundings. In such a facility it is more likely that this individual will be able to adjust and find equilibrium in the environment. Failure to do so can cause unnecessary stress that may in turn bring on mental or physical illness; not to mention unhappiness in later life.

A second factor to consider in choosing a long-term facility, and achieve P-E congruence is to take into account an individual’s needs. While the ideally located facility in NYC may look great, perhaps it doesn’t offer sufficient care for the physical impairments your loved one is experiencing.

ADLs are the activities of daily living and consist of basic activities like brushing one’s teeth, bathing, dressing, etc. IADLs are instrumental activities of daily living and including secondary activities for life such as shopping, and cleaning (Hooyman and Kiyak, 2002). Both ADLs and IADLs are a basis for evaluation for entry into most any long-term care facility. Should an individual have lost their mobility and be unable to dress or perform other basic actions of daily life, their need to assistance is higher than an individual with one or no ADL impairments. Said individual would then need to seek out a more comprehensive and attentive (to physical impairments) facility.

Cognitive impairments are also taken into account. An individual with dementia would need a different type of care than an individual with an ADL impairment or a chronic illness such as cancer. Similarly, individuals with chronic illnesses must be placed in facilities operating on a medical model as opposed to a social model where medial care is often limited, if offered at all.

Home based care, and home based care assistance is also readily available for family primary caregivers. This sort of aid is also assessed based on ADLs, IADLs, cognitive function, and health status.

Financing Long-Term Care

One of the biggest issues to hit long-term care recently is the growing financial need of caregivers, long-term care facilities, and the elderly individuals receiving care. According to the Wiener and Stevenson (1997), “Nursing home and home health care accounted for almost 12 percent of personal health expenditures in 1995, and they were approximately 14 percent of all state and local health care spending.” Furthermore, 60% of medical care for the 65 and over cohort is paid through Medicare in addition to a private source (Komisar, Niefeld, 2000). The same research also showed a firm 20% of this same cohort using Medicare and Medicaid, and 16% using Medicare only. A very slight 4% pay through an “other” source (Komisar, Niefeld, 2000).

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For many government agencies and private awareness groups, the heavy reliance on Medicare and Medicaid raise concern over the financial resources available through the government, private sectors, and individual savings for the costs of health care later in life. Clearly Social Security benefits, although never truly meant to, do not cover the costs of living for elderly individuals, let alone their health care needs. According to Hooyman and Kiyak (2002), 14% of all individuals who are placed in a long-term care facility begin paying out-of-pocket and end as Medicare users due to the exhaustion of initial financial resources. This is in contrast to the 27% that “start and end their time in the facility as Medicaid recipients.” It’s not hard to see why residents of long-term care facilities have become so dependent on Medicare and Medicaid, both of government funding origin, when one considers the costs of residency and the fact that it is rising and continuing to do so. Goldberg (2007) notes that the expected cost of long-term care in 2050 will be as high as 390 billion dollars.

Unfortunately, alternatives such as home health care don’t seem to pose any financial relief. Such care in 2005 averaged 19 dollars an hour for a licensed agency’s aid (Goldberg, 2007). If the government is going to be able to meet the growing needs of elderly individuals, the approach for health care and retirement planning will need a swift make-over. Those of the baby boomer generation make up a significant percentage of the population and are making their way into the upper years of life; their eventual dependence on Social Security and some form of government health care funding seems inevitable.

Issues Within Care Facilities

Issues in choosing and funding a long-term care option aren’t the only issues in long-term care. In fact, care facilities have a great deal of concerns that must be met internally. Two of these issues are nutritional concerns and requirements and risk management.

Nutritional concerns stem from the wide variety of individuals present in the facility. Some elderly individuals are plagued with nutritional related illnesses such as diabetes, some may have problems with their weight (over or under), and others still may have allergies to certain foods. According to Morely and Silver (1995), “Protein energy undernutritionis endemic in nursing homes, with a prevalence ranging from17% to 65%. Protein energy undernutrition has beenassociated with decubitus ulcers, cognitive problems, posturalhypotension, infections, and anemia.” Obviously, due to the major health impairment implications, proper nutrition within a long-term care facility is extremely important. Other deficiencies such as mineral or vitamin deficiencies are also responsible for a number of illnesses, poor immune system performance, and bone strength issues.

Similarly, home health care providers need to take action to prevent the aforementioned deficiencies and educate families on the risks of them, and prevention measures to be implemented with or without a health care professional present.

Risk management is another internal issue that must be addressed with sincerity by long-term care employees and management. The biggest reason for this concern is the rise in litigation against long-term care facilities. This rise in litigation has resulted in decreased medical services in nursing homes and insurance carriers ceasing services to nursing home facilities (Weinberg, Levine, 2005). Both insurance coverage and availability of licensed physicians in nursing care facilities are things that families must look for in a nursing home, most specifically for patients with chronic illness and/or cognitive impairment. The unavailability of the these two things can cost a nursing home patients and thus money putting nursing homes at risk for closure resulting in too few nursing homes in the U.S. As such, risk management and nutritional awareness need to be addressed internally in order to ensure a high quality of care, better government funding (if application), better resources available to patients, and applicability for insurance.

Caregiver Concerns

The last long-term care issue to be discussed is the needs of long-term care providers. While what is to be addressed applies to some extent to employees of long-term care facilities, it is mainly addressed to those families that take on the long-term care of their elderly loved ones.

Caregiver well-being is an extremely important issue in long-term care as it can determine the amount of care and time an elderly individual may receive before having to rely on a nursing home or other long-term care facility. Often times the costs, psychological stressors, and physical demands of primary care for en elderly individual can drive families to admit elderly family members to long-term care facilities. According to Hooyman and Kiyak (2002), “The decision to seek institutionalization is often precipitated by the family caregiver’s illness or death, or by severe family strain” (pg. 322). Hooyman and Kiyak (2002) also state that institutionalization is generally sought after a family has used up their own resources (pg. 322). These resources are exhausted faster when a caregiver is without supportive services both physical and emotional.

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Stresses affecting the caregiver are financial (costs of care, conflicts between job and care, excessive absences at work), physical (headache, weigh changes, sleep disturbances, self neglect), and emotional (depression, anxiety, loneliness, resentment, anger, strained family relationships).

While there are supportive services available to caregivers (adult day care, respite care, volunteer help, at home medical aid, community support groups, among others) few utilize these resources or can find them available in their area. If at-home caregiving is to continue and give nursing homes and other long-term care facilities the back seat, caregivers will have to be more educated on the availability of resources. Moreover, supportive services need to be implemented in wider variety and in greater abundance. With more community support for at-home care provided by the family, in conjunction with medical services, it is possible that this sort of care can reduce the large financial strain currently on the government for elderly care. However, caregivers will also need more financial support in one form or another in order to fully take on and successfully carry out the primary caregiving role.

To make the situation worse, the role of family as a primary caregiver is expected to decline in the future. According to Goldberg (2007), “20% of baby boomers have no children, and 25% have only one child.” This data forebodes of a significant amount of extra responsibility on community members and local governments, as well as the federal government, to cover the costs of long-term care. Furthermore, this cohort is anticipated to be highly reliant on long-term care facilities because of lack of family. Data given by Hooyman and Kiyak (2002) states that “living alone is a major predictor of institutionalization (pg. 322).


Clearly there are a large number of issues currently plaguing long-term care of the elderly and are, at present, bound to worsen in the future. With the increasing number of baby boomers working their way into the young-old category and fewer children borne during young adulthood, it seems that without better incentives it will be impossible to physically reduce the strain on American nursing homes. Furthermore, financial burdens on the Medicare and Medicaid systems, along with Social Security deficits forecast serious problems in elderly individual’s ability to meet health costs and/or the government’s ability to allot enough money to the respective budget. To make matters worse, poor nursing home quality of care and/or management can cause major problems in long-term care facility placement decisions, as well as funding, insurance availability, and service offerings. This, in conjunction with the wide variety of considerations one must take into account when choosing a long-term care facility, creates an extremely frustrating and stressful situation for both the elderly individual and their family only further complicating the issue of long-term care.

Elder care services and government financing have a long way to go before they will be able to meet the aforementioned growing needs in the area of elderly long-term care. Until then, the issues plaguing long-term care of the elderly must be taken into account by all involved in their care and well-being including their retirement plans, health care plans, social support systems, and financial management.


Congressional Budget Office. (2004, April). Financing Long Term Care for the Elderly. Retreieved June 26, 2007, from http://www.cbo.gov/ftpdoc.cfm?index=5400&type;=0

This is an online pamphlet from the Congressional Budget Office which addresses the

government’s financing for elderly care in 2004. This booklet details the financing

and the need for financing in long term care of elderly individuals. Financing is one

of the many issues affecting long term care of elderly individuals, and one of the

ways in which individuals determine what care they are able to obtain.

Feder, J., Komisar, H.L., Niefeld, M. (2000). Long Term Care in the United States: An Overview. Health Affairs, 19 (3), 40-56. Retrieved June 27, 2007 from http://content.healthaffairs.org/cgi/reprint/19/3/40

Published in the health journal Health Affairs, this article gives an overview of long

term care as it is provided and needed in the United States. It deals with the

problems of the current system, along with the needs of long term care, and the

consequences for not meeting these needs. This article provides a solid backbone

for my paper on long term care of elderly individuals.

Goldberg, B. (2007). Facing the Problems of Providing Long-Term Care for the Oldest Old. Retrieved June 27, 2007, from http://www.tcf.org/publications/economicsinequality/goldbergbrief.pdf

This online booklet is offered by the Century Foundation and written by Beverly

Goldberg. The booklet addresses the problems and concerns in providing long term

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care for the oldest old in the community. Most specifically it deals with the special

needs, the costs of care and where the money comes from, the needs and concerns of

the caregivers, and ways in which to address each of the aforementioned.

Hegner, B., Needham, J. (2002). Assisting in Long Term Care, 4th Edition. Clifton Park, NY. Thomson Learning Inc.

Assisting in Long Term Care is an alternative look at long term care, and deals with

the caregivers and how they deal with providing long term care. Caregivers are an

integral part of providing long term care, so the issues they confront and the

hardships they face add to the issues and concerns facing long term care of the


Hooyman, N., Kiyak, H.A. (2002). Social Gerontology: A Multidisciplinary Perspective, 6th Edition. Boston, MA. Pearson Education Company.

In chapters 11 and 17 of Hooyman and Kiyak’s textbook, various types of long term

care are discussed, as well as long term care policies which affect the quality and

forms of long term care that the elderly receive. The section on nursing homes

address what is available, and what is needed in caring for the elderly on a long term


Institute of Medicine. (2001). Improving the Quality of Long Term Care. Washington D.C. National Academy Press.

As the title of the work suggests, this book provides a look at what is needed to

improve the quality of care in long term facilities such as nursing homes and

retirement facilities. In order to do this, the book addresses the needs of the elderly,

especially those with severe ADL and cognitive impairments.

Moody, H. (2006). Aging: Concepts and Controversies. Thousand Oaks, California. Pine Forge Press.

This book by Harry R. Moody contains a detailed discussion of long term elderly care.

Moody addresses the type of care needed, the impact on the community and

economy, and the types of care needed by those in the long term care facilities. I

intent to use the discussions of necessary care needed as well as its impact on

society in order to create a well rounded view of long term care.

Morely, J., Silver, A.J. (1995). Nutritional Issues in Nursing Home Care. Annals of Internal Medicine, 123 (11), 850-859. Retrieved June 26, 2007 from http://www.annals.org/cgi/content/full/123/11/850

This internet journal article deals with the nutritional issues affecting the nursing home

community, both residents and their caregivers. Long term care providers are

charged with the well being of their patients, and nutrition is one of those concerns.

This article addresses the issue of providing adequate nutrition to patients, as well as

other nutrition related concerns that long term care presents.

Pratt, J. (2005). Long Term Care: Managing Across the Continuum, 2nd Edition. Sudbury, MA. Jones and Bartlett Publishers.

This book, in chapter twelve, addresses the quality of long term care, and what is

needed to achieve “quality” care. It also deals with the concerns in providing long

term care, and the advocacy groups that make it their mission to ensure good quality

long term care is available to those in need of it.

Senior Solutions of America. (2007). Aging Patients and Elder Care. Retrieved June 26, 2007, from http://www.aging-parents-and-elder-care.com/

This site, provided by Senior Solutions of America, details what it takes to care for the

elderly as they age. The source is a good walk through from early old age care to

the more demanding later stages of old age. As this paper deals with long-term care

issues, the needs and concerns of caretakers need to be addressed. Senior Solutions

of America addresses the various concerns and “to-dos” as one cares for an elderly

individual over a long period of time.

Weinberg, A., Levine, J. (2005). Clinical Areas of Liability: Risk Management Concerns in Long Term Care. Annals of Long-Term Care, 13 (1), 26-32. Retrieved June 27, 2007 from http://www.annalsoflongtermcare.com/article/3564

This article, found in the Annals of Long-Term Care, addresses the risk management

concerns of long term care. It discusses the increasing litigation against long term

care facilities, which is a huge concern for those providing long term care.

Litigation against long term care facilities can affect their performance and

environment, and thus holds a key place in the issues affecting long term care.

Wiener, J., Stevenson, D. (1997). Long Term Care for the Elderly and State Health Policy. Retrieved June 26, 2007, from http://www.urban.org/publications/307048.html

The Urban Institute discusses the issues related to long term care, more specifically

the expenditures which can be a huge issue for the institution, the family, and the

government. This website provides a look at the costs of keeping elderly individuals

in nursing homes, and providing nursing homes with the items and financing they

need to remain open and providing care.