Letters Alternatives to Institutional Care In the February 1978 issue of HEALTH AND SOCIAL WORK, Gary A. Fashimpar and Richard M. Grinnell, Jr. presented the results of an empirically based research project that noted the effectiveness of homemakerhome health aides in improving the quantity and quality of home-care services. The authors recommend that social workers utilize these services more frequently when working with clients who could benefit from such services in order to remain in their own homes and out of institutions. It is this issue of "alternatives" that I would like to explore further. The phrase "alternatives to institutional care" has become very fashionable in recent years, in both the lay and scientific press. It appears, however, that the real issue is not necessarily one of alternatives but one of offering the aged a choice of services providing different levels of support, including that of skilled nursing facilities. Study after study has shown that most of our elderly go into institutions not for health reasons but for lack of community support systems. This issue of choice has been raised by (1) governmental leaders, (2) the elderly persons themselves, (3) the families of 200

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elderly persons, and (4) the health care personnel who are charged with providing health and social services to the elderly. Among the choices being considered is that of home health care services. The Department of Health, Education, and Welfare (HEW) administers the principal federal programs that provide home health care. The main home health care programs that are medically oriented are Medicare and Medicaid. HEW is also responsible for administering various home-care or in-home service programs that are authorized under the Social Security Act and the Older Americans Act. During recent Senate hearings on the "alternatives" issue, Congressman Claude Pepper of Florida, Chairman of the House Select Committee on Aging, voiced the need for some order to be brought to the "crazyquilt" arrangement of home health services at the federal level. Presently, some form of home care is being provided under at least nine federal authorities. There is a need for a national policy to assure that any of these services are actually delivered to those who need them. According to HEW, the various federal home health programs under current legislation defy coordination. This indicates the need for an overall federal policy for home health care with legislative changes enacted before these programs can be consolidated. There is a need for the elderly themselves to become involved in home health care advocacy. In addition, doctors and institutional discharge planners need to be informed of the home-care resources available in their own communities. We need to develop a model for home care that brings together under one umbrella all of the services rendered in the home: the attendant, the chore worker, the professional, the paraprofessional,

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the social worker, the non-health-related people, the meals-on-wheels services, the friendly visitor program, the drug delivery program, the janitorial and laundry services, and many others. Once this is accomplished, there will be less need to use the institution inappropriately. We need one federal and one state agency to assume responsibility for all home care, including the development of reasonable standards to which local communities can relate. We need a national policy shift in reimbursement patterns to a home-care focus rather than one of institutional care that we now have. The prescription for home health services ought to come out of an assessment that includes the entire range of human functioning in order to avoid the fragmented care that frustrates us now. We need a philosophy of continuity of care so the elderly are served where, when, and how they need service with reimbursement available. This is not presently the case. In order to obtain sufficient funding for these recommendations, there needs to be either expansion of current titles of the Social Security Act or changes in the type of services and reimbursement that are available through Title XVIII (Medicare), Title XIX (Medicaid), and Title XX (which provides for social service needs in order to reduce, eliminate, or prevent dependency). Silver Spring, Maryland

AYELIFFE A. LENIHAN

Alternatives to institutional care.

Letters Alternatives to Institutional Care In the February 1978 issue of HEALTH AND SOCIAL WORK, Gary A. Fashimpar and Richard M. Grinnell, Jr. presen...
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