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In 2007, an estimated 7 million older Americans needed long-term care due to functional impairment, usually as a result of chronic medical conditions and illnesses. Most of these people choose to remain in the community, and require services to help them stay in their homes rather than enter an institution. These services constitute what is generally known as community-based long-term care (CBLTC). As the population ages and the number of functionally impaired older adults increases, so will the need for CBLTC. Unfortunately, no coherent national policy drives CBLTC in the United States, which leaves a “system” that is inconsistent, decentralized, difficult to access, bewildering to navigate, and unable to fully meet the needs of many patients. Much of what is actually done to meet these needs is provided by unpaid family caregivers at great personal and economic cost. This chapter addresses CBLTC for older adults in the United States. We outline the semantic challenges in understanding the scope and nature of CBLTC and the heterogeneity of care models that comprise CBLTC, describe who receives, provides, and pays for it, and review the evidence for its effectiveness. We also discuss important public policy issues and identify emerging innovations and trends in CBLTC delivery.

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The term “community-based long-term care” overlaps with several other terms in the medical and social sciences literature, including home care, personal care services, home and community-based services, home visits, and house calls. In general, these terms refer to nursing, personal care, or social services provided to older persons, with an explicit goal of filling unmet needs or maintaining them in the community. Most of this kind of care is provided by unpaid family members or friends, sometimes with support from a variety of formal caregivers. Home care may mean home-based rehabilitation or disease management after hospital discharge, preventive health interventions, geriatric assessment, primary care physician visits, or highly technological care provided in individual patient homes. These services often overlap to such an extent that important aspects of a given intervention are not accurately reflected in a single label. For example, a program in which an interdisciplinary team provides comprehensive geriatric assessment followed by primary care home visits, inpatient management as needed, and continuing longitudinal care after hospital discharge does not fit neatly into any one category. Several forms of CBLTC integrate housing arrangements with personal and medical care, further blurring the distinction between CBLTC and institutional long-term care. Table 22-1 depicts the heterogeneity and scope of services and settings that fall under the rubric of community-based long-term care.

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Table 22-1 Types of Community-Based Long-Term Care and Home Care

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