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General Principles in Older Adults

Older adults, more than any other age group, reside in a variety of settings. Particularly as physical and cognitive function decline, older adults require increasing levels of assistance for their care. In addition, functional decline following serious illness or injury affects the ability of older adults to return directly from hospital to home, leading to a need for institutional rehabilitation prior to return to the community. This chapter describes the variety of living situations available to older adults, including both short-term and long-term nursing home care (Figure 18–1).

Figure 18–1.

Sites of long-term care. A diagrammatic representation of the locations in which elders live (circles), with thick arrows showing the directions in which elders move from location to location. The thin arrows identify those medical services available to elders living in different sites and the medical/service centers to which elders travel (squares).

Long-Term Care in the Community

The overwhelming majority of caregiving takes place in the community, with more than 7 million individuals receiving agency home health care and an estimated 10.9 million who need assistance. Although the nursing home census has now risen to 1.8 million, most older adults continue to live at home throughout their lives, with family members and friends providing care as needed. Within the community, elders can receive services ranging from custodial care (assistance with activities of daily living and light household chores) to the Hospital at Home model.


Models of care range from single-family dwellings, to apartments, to “intentional communities,” to the Residential Care Facility for Elders (RCFE), also known in many states as the Assisted Living Facility (ALF) or Board and Care Home. Unlike nursing homes, ALFs are considered social models of care, regulated by a variety of state agencies across the United States, and providing a range of services. In the most basic Board and Care Home, an elder can expect to receive help with laundry, housekeeping, and meal preparation. In the larger ALFs, there may be assistance with medication administration, and even dementia special care units. Some ALFs are built adjacent to nursing homes and marketed as continuing care communities. At all of these residential settings, older adults may be able to receive the following:

  • Home medical care: Medical services from clinicians who make house calls

  • Home health agency care: Skilled nursing, social work, rehabilitation services and, assuming the ALF has a hospice waiver, interdisciplinary home hospice services

  • In-home social services: Custodial assistance with activities of daily living (bathing, toileting, transferring, feeding), light housekeeping, shopping, and food preparation (also called Home Health Aid and Attendance)

  • Private case management services

In addition, home-dwelling elders have the option of attending adult day health centers (ADHCs), where they ...

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