There's No Place Like Home

Think about growing older. Where do you see yourself? Surrounded by the lush, rolling hills of the countryside? An energetic cityscape, dotted with taxi cabs, storefronts and restaurants? Or simple sidewalks, connecting neighbor to neighbor in the suburbs? Chances are everyone's vision has one thing in common; it's a place called home.

Few of us dream of leaving our homes, but many of us will be faced with that possibility when we can no longer live independently.

Long-term care is a subject most of us don't like to contemplate. But every day, millions of Americans are confronted with agonizing choices about long-term care. And overwhelmingly, older Americans want to get that care at home.

Jennie Chin Hansen, AARP national officer and board member, moved her father, tube fed and confined to bed, to her home in San Francisco. There, On Lok Senior Health Services provides elderly and frail residents of Chinatown with services to help keep them living in their community. Through On Lok, Jennie's father received medical care, regular visits from a physical therapist, and nursing supervision along with a variety of social services. He gained strength, began painting again and soon found he could dress himself without help. When he died five years later, he was a resident in a thriving, familiar community with friends and loved ones only steps away.

Across the country in Boston, several neighbors wanted to grow old in the homes they have lived in for years. They moved beyond dreaming and talking and created Beacon Hill Village of Boston, an all-encompassing concierge service. The Village links members to carefully-reviewed, fee-for-service house cleaners, home repair services, errand runners, transportation, computer advisers, and more. And the Village offers them a number of included benefits such as weekly car service to the grocery, monthly lectures by notable Bostonians, exercise classes, special health clinics, dining clubs and links to volunteer opportunities. Membership costs $580 a year for an individual, $780 a year per household and $100 to $150 a year for lower-income residents, who also get a $250 credit toward services. In many cases remaining at home and using the Village's a la carte services is much cheaper than assisted living. If, however, someone becomes ill enough to need 24-hour care or other expensive services, the total costs probably will equal those of a nursing home, but with one big difference: People are in their own homes.

These communities are lucky, but not everyone has access to the array of supportive services that enable them to get the assistance they need at home. Medicaid, the largest payer of long-term care, has a bias - individuals who meet eligibility criteria are entitled to nursing home care, but not necessarily to home and community-based services. Those services could keep many people living at home, comfortable among familiar surroundings, family and friends.

The way to start making sure those services are available in more American communities is by rebalancing Medicaid funds, increasing the share of long-term care dollars destined for home and community-based services. It's encouraging that some steps have been taken in that direction. Nationwide, about six in 10 Medicaid dollars spent on long-term care in 2006 went to nursing homes. Ten years earlier, nursing homes consumed about eight in 10 of those dollars. But with nearly 90 percent of older Americans wanting to stay in their communities, the proportion of Medicaid dollars going to skilled nursing facilities versus home and community-based services remains out of sync.

If you can get quality services in the setting of your choice, then you are really fortunate. But even then, the cost can be overwhelming. Medicare and private health insurance generally do not cover long-term care. Medicaid only assists those with low incomes. People should have access to affordable long-term services that provide financial protection and choice - and don't require you to spend all your savings before you get the help you need.

When one's health begins to decline, the familiarity of home, family and friends becomes even more important. Long-term living, at the maximum level of functional ability, in the setting of one's choice is what's needed in this country. It is time to start investing in the desires of older Americans and a place called home.