Community long-term care services: what works and what doesn't?

To establish a context, long-term care (LTC) can be provided either through institutions or in the com- munity; can include both formal (i.e., generally paid and often specialized) and informal (i.e., generally unpaid and often unspecialized) care; and that for- mal care can have either public or private funding. Within this context, a fundamental conceptual struc- ture for addressing the topic of what works and what does not in formal community long-term care (CLTC) might be reduced to four components: • Who gets something? • What do they get? • Who pays ? • What impact does it have? Concerning who receives formal CLTC, we often have two subgroups. The first subgroup of formal CLTC users comprises those who are certified by their state officials as functionally eligible for institu- tional LTC. These users are often assumed to repre- sent a type of substitution of home- and community- based services for traditional nursing home care. This assumption of substitution persists, although for at least 25 years it has been documented that there are two or three older people with the same configuration of needs and disablements living in the community for every one person residing in a nursing home (Branch, 1976, 1977, 1980), and gerontologi- cal researchers have yet to understand clearly why the one person enters the nursing home and the other two or three do not. Those CLTC users who meet nursing home admission requirements may not rep- resent substitution at all. The second subgroup of CLTC users comprises those whose frailty is substantial but not severe enough to qualify for state-funded nursing home care. The second subgroup is actually expanding the continuum of LTC clients.