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Will We Really Be Able to Age in Place?

New models of support for aging Americans show promise

By Beth Baker and SCAN Foundation

How will we access and pay for the support and services we’ll need as we grow older? There is a growing sense of urgency around that question, as more of us are determined to remain as independent as possible throughout our lives.

Many states are shifting away from requiring people who need long-term care to be in a nursing home in order to receive Medicaid. In Ohio, for example, nine out of 10 older people on Medicaid received long-term services in a nursing home in 1993; today, half that population receives such care at home, according to a study by the Scripps Gerontology Center at Miami University.

More Help Needed

While that trend is welcome news, professionals in the field of aging say our system needs a huge course correction in order to adequately meet older people’s desire to stay at home.

Supportive services, both volunteer and paid, need to be expanded. Payment must better align with the individual, both to give people what they want and to save the health care system money, according to a new report by the Long-Term Care Financing Collaborative, a group of experts and stakeholders.

In the past, “what we have had is what I and others call the over-medicalization of aging,” says Collaborative member Stuart Butler, senior fellow at the Brookings Institution. People often ended up in institutions regardless of their wishes, simply because they ran out of resources and Medicaid would only cover care in a nursing home. Other older people moved to more institutional settings rather than burden their families.

Nevertheless, family caregivers continue to provide the vast majority of long-term care. But turning to family members is less and less an option. A 2013 AARP study found that the ratio of family caregivers (aged 45 to 64) per older relative will decline from seven to one in 2010 to three to one in 2050, when the boomers are in their 80s.

“Comparatively speaking, we’ve had an abundance of potential family caregivers,” says independent consultant Don Redfoot, who co-authored the study and serves on the Collaborative. “But that dramatically changes over the next couple of decades.”

At the same time, few older people can afford much paid home care, which can easily cost $20 an hour.

Meeting the Caregiving Shortfall

To fill the gaps, community supports will increasingly be a critical piece of the long-term care puzzle, the report found. Although most volunteers can’t provide hands-on care, “There’s an awful lot they can do that may not prevent, but could delay, the time people have to go to an institution,” says Collaborative member Howard Gleckman, senior fellow of the Urban Institute and author of Caring for Our Parents.

“That in itself would be very important both for the person receiving care and the people worried about costs,” he says.

New models such as The Villages, a neighbors-helping-neighbors membership organization, are one way to deliver that support.  Among the other promising alternatives highlighted by the Collaborative:

Fraternal Organizations

Ohio Masonic Home is a nonprofit that serves older members of the Ohio Masons, a fraternal organization with 500 lodges and 90,000 members.

In addition to retirement communities, nursing home, assisted living, and a paid home care agency, the Ohio Masonic Home operates an 800-number call center. The center is staffed by “aging service representatives” who link older members or their widows to local resources of all kinds, including volunteer assistance.

Masons help their fellow members with anything from repairing a broken toilet to meal preparation or transportation.  The organization will also help with emergency funds for things like lapsed utility bills. In one case, a member needed a wheelchair ramp.  Volunteers built the ramp, and when the member could not afford to pay for the supplies, Ohio Masonic Home covered the cost.

“If you can’t get these things done, you run the risk of falls, of depression, of not eating well,” says CEO Tom Stofac. “Those kinds of issues start to escalate, and they might go to the hospital because they’re malnourished.  What we haven’t done a good job of in the aging field is to look upstream at these little things. That’s what I'm finding is really helpful.”


A home care model that is spreading globally is called Grand-Aides, now operating at 20 sites in the U.S.

Grand-Aides, who are employed by health systems at no charge to patients, have the temperament of kindly grandparents and the skills of specially-trained certified nursing assistants, according to program founder Dr. Arthur (Tim) Garson.

Armed with computer tablets, Grand-Aides provide home care to people at risk of hospital admission or an emergency room visit.


“Everybody is pushing towards trying to manage patients with ‘apps,’” says Garson. “It turns out that some people just need people.”

A typical patient is someone discharged from the hospital with congestive heart failure. Such patients are most at risk of readmission within the first 30 days.

A Grand-Aide will visit the patient several times that first week. Using her computer tablet, she will video the patient and his medications, with a registered nurse on the other end viewing the encounter and double-checking the meds.

By troubleshooting problems and offering clear guidance and reassurance, Grand-Aides affordably provide home health care and may reduce readmissions, a major goal of hospitals and of Medicare.

Faith and Health

In Memphis, Tenn., Methodist Le Bonheur Healthcare partners with local churches, predominantly African-American, to promote wellness and manage chronic illness. Some 600 churches have forged a “covenant” relationship with the hospital system to promote good health in their congregations and surrounding neighborhoods.

Hospital navigators link to volunteer liaisons within the congregations. When church members are admitted to the hospital, the liaison alerts the navigator who looks out for the patient and, along with the church, makes discharge arrangements.

“We try to see what needs [the churches] can meet when they go back to their community,” says Rev. Dr. Harry Durbin, senior vice president for Faith and Health at the hospital. “Maybe transportation to visit their doctor, or someone who is a ‘pill pal’ to remind them about their medicine — any range of activity.”

The hospital also holds physician-led classes in the community for church members about prevention, wellness and chronic disease management, such as diabetes.

The health system invests $700,000 a year in the program.

“We think it’s consistent with our mission, which is to care for the whole community without ability to pay,” says Durbin. “If we’re going to be a health care organization committed to good health, we have to be in the community.”

And by helping attend to wellness and prevention, he adds, the hospital can better direct its resources to handling more acute and difficult illnesses.

Dr. Gary Gunderson, who founded the Memphis Model, is now at Wake Forest Baptist Medical Center. There, he leads a learning group of hospitals wanting to adapt and expand it.

“As we approach decades when there are more and more elders, we simply must work on building the broad community strengths to balance those in our more formal programs of government,” Gunderson says.


Beth Baker is a longtime journalist whose articles have appeared in the Washington Post, AARP Bulletin, and Ms. Magazine. She is the author of With a Little Help from Our Friends — Creating Community as We Grow Older and of Old Age in a New Age — The Promise of Transformative Nursing Homes. Read More
By SCAN Foundation
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