According to a 2018 survey conducted by the American Association of Retired People (AARP), more than three quarters of over-50s would prefer to stay in their homes and communities as they age, rather than being admitted to a nursing home or assisted living facility.
The survey, which gathered data from 2,287 adults across the U.S., found that 76% of Americans age 50+ wish to remain in their current residence, while 77% would like to live in their community for as long as possible. Nearly one-third of the cohort is open to considering alternatives like home sharing or building accessory dwelling units connected to the family home.
With a rapidly aging population and rampant inequality in healthcare access, many advocates believe the time has come for Americans to develop a more compassionate, inclusive approach to elder care. In California, where the over-65 population is projected to double in the next ten years, policymakers have committed to ‘building an age-friendly state’ that will allow all citizens to age ‘with dignity and independence.’ Aging in place, with access to treatment services and community support, could hold the key to facilitating a revolution in the way we care for people during their final years of life.
We’re still some way off achieving this lofty aim. Elder care remains dominated by a profit-first residential care model beset by internal problems and under fire from critics who claim it’s not fit for purpose and is showing unmistakable signs of failure.
In California, which has the biggest nursing home population (100,000) of any state, alarm is growing about the chaotic nature of this business model, which allows operators to build huge property portfolios (often paid for by private equity interests) while running each facility on perilously thin margins. Low paid, poorly motivated staff bear the brunt of day-to-day operations, while the residents they’re entrusted to care for are put at risk of infection, neglect, and abuse. The dire situation at two Pasadena nursing homes prompted an extraordinary decision by state public health officials to take control of the facilities.
It’s not hard to see why many people skeptical about spending massive amounts of money on accommodation and caregiving solutions that put them at an increased risk of eviction, infection and abuse are beginning to ask themselves: will I really be better off in a long term residential care facility than I would be at home?
Elder care advocates say no, you will not. Not when nursing home operators can legally continue running facilities after they’ve been denied a license. Not when 82% of nursing homes have been cited for infection prevention and control deficiencies, or when proposed reforms to minimum staffing requirements are beholden to market incentives rather than patient welfare. Not when a third of the country’s COVID-19 fatalities have occurred in facilities that were totally unprepared for an outbreak of this scale — facilities incapable of preventing and managing the localized infections that procured their violation citations in the first place. And not when the other epidemic assailing our most vulnerable citizens – that of elder abuse – continues to plague the nursing home industry.
Dangerous conditions in U.S. nursing homes existed long before the pandemic — especially in the for-profit sector. But the deaths of tens of thousands of elderly residents have drawn widespread public attention to systemic problems like staff shortages and high turnover, and the abuse and manipulation of Medicare ratings by operators looking to inflate their market value and attract lucrative admissions.
Some advocates are optimistic that the public perception of residential care settings is beginning to line up with the reality.
Tony Chicotel of the California Advocates for Nursing Home Reform, quoted in a New York Times piece in May, contends that families who ‘ended up agreeing to a nursing home without giving it a lot of deliberation’ revised their opinions on caring for older relatives at home after trying it during the pandemic. Many now see aging in place as a viable alternative to long term residential care. As Chicotel puts it:
“What’s happened is a welcome sort of market correction for nursing homes.”
This re-evaluation of home care is undergirded by technological advancements which make it easier to monitor the physical and mental well-being of vulnerable people at home. Remote devices and web tools can help families with medication reminders, schedule management, communication with caregivers, and responding to emergencies.
The benefits of home care are largely intuitive. Remaining in a familiar, comfortable setting with loved ones close by can ease the stress and anxiety associated with cognitive impairment and dementia. Maintaining a semblance of independence while building a one-on-one relationship with an in-home caregiver is an obvious boon — not just for elderly patients, but for family members who only have to vet and monitor one care worker.
Less obvious, perhaps, are the relative financial burdens of nursing home care vs. home care. In both scenarios, the cost will be determined by a number of factors such as the specific healthcare needs of an individual, location, insurance, etc. But generally speaking, the cost of in-home care is lower, and especially so for the many seniors who don’t require the round-the-clock care that nursing facilities purport to offer.
According to a Cost of Care survey run by insurers Genworth, the median monthly cost of a semi-private room in a nursing home is $9,247, rising to $11,437 for a private room. For in-home care, the median is $5,529. There is a similar trend nationally, with the monthly median for a private room ($8,821) almost double the cost of a home health aide ($4,576). Annually, that’s a difference of $50,000.
Fortunately, policymakers are increasingly turning their attentions to managing our aging population with home-based solutions. The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare/Medicaid initiative expressly designed to provide ‘preventive, primary, acute and long-term care services’ to over-55s who would otherwise reside in nursing facilities.’ It covers everything from in-home care and checkups, to hospital stays and training and support for familial caregivers. The ultimate goal of the PACE model is to support eligible individuals to remain independent and in their homes for as long as possible – which is what an overwhelming majority of Americans want for themselves and their loved ones.
Home care won’t completely replace residential settings. Nor should it. But many people are waking up to the advantages in-home caregiving has over the profit-first nursing home industry. And with 10,000 baby boomers a day turning 65 between now and 2030, aging in place programs like PACE will have a major role to play in staving off a looming crisis.