Provision of Services

Overview

The US experts strike a theme when they cite the phrase “alter natives to institutionalization”. The phrase refers to community based and home services. The US should think of institutions as “alternatives”, say the experts.

Some champions of the elderly would argue that care of the chronically ill occurs primarily in the home with assistance of family members, neighbors, friends, and others who come together as an informal support network.

This is not to say that professionals in health and social care serve in minor roles. Clearly, they play major roles in the formal delivery of services, as do the institutions of the hospital and nursing home. However, a balanced view would accord the informal elements their rightful place in public policy considerations concerning the substance, financing, and organization of assistance to individuals in need.

Moreover, it is impossible in many instances to distinguish between health and social factors as influences on an individual’s ability to maintain independence. French law implicitly recognizes this. While there may be organizational, historical, and financial reasons for the separation of health and social services, the provision of one without the other may be counter-productive or ineffective. Consequently, an ideal system delivers both.

In more developed nations, with high concentrations of professional manpower in institutions like the hospital, resources tend to be allocated more to health servi es than to social services, and more to acute care than to chronic care. One result is a tendency to ignore or minimize chronic care needs. Indeed, a vivid example is furnished by the medical dramas of US television, which are overwhelmingly dramas of acute illness; chronic care receives a relatively small share of public attention.

The goal of assisting a disabled individual to make adaptations and to preserve lifestyle may lack the immediate glamor of heroic efforts in acute care, but it may be equally important. The key types of assistance for the chronically ill person may take the mundane form of chore services (someone comes into the dwelling to clean, cook, and make repairs for safety and health purposes), shopping services, friendly visiting (to counter loneliness and monitor someone who may need help), and simple nursing (to change dressings and give assistance in bathing, toileting, and taking medications, in following an exercise regimen, or in using equipment).

With a spectrum of supports by the Informal network and by organizations providing medical, nursing, counseling, home-health, home-maker, meals-on-wheels, friendly visiting, and other services, an elderly patient may progress through a growing burden of chronic illness — and remain at home. Senior centers, day-care centers, and other community-based services may contribute to the goal of maintaining the individual’s desired living arrangements and participation in society for the longest feasible duration.

Achievement of this goal may depend also on appropriate housing. For example, consider the individual living alone in a detached house better suited to the large family of his or her earlier years. Such a person may be at more risk of mental and physical deterioration than his or her counterpart in an apartment house containing communal dining facilities and served by health and social caregivers. Such living arrangements are scarce.

For some individuals, progressive deterioration may make it necessary to live in a nursing home in which skilled nurses, therapists, and other professional care-givers are on hand. Consequently, in an ideal system of chronic care, a wide spectrum of services should be tailored to diverse and changing needs. Institutionalization may be essential to survival. Unfortunately, in many areas, the principal chronic care institution, the nursing home, is poorly developed as a site of professional care. It is isolated from centers of research and academic training. Physicians may visit irregularly. Poor working conditions may contribute to high rates of staff turnover. Scandalous conditions have been linked far more often with for-profit than other auspices.

A vocabulary for chronic care and the organized and informal delivery of services in a variety of settings is being developed in response to awareness of a growing elderly population. For want of better terms, “nursing home” stands for a wide variety of institutions, some offering little more than custodial service while others may approximate rehabilitation hospitals. “Community-based and home services” may be unclear to the public.

This chapter covers the breadth of formal chronic care services -health and social, and home, community, and institutional. Although some introductory reference is made, the subject of informal networks is reserved primarily for discussion in the chapters dealing with supports by family and community.