Abstract
As the population ages and individuals express the desire to remain in the community, versus transitioning to an institutional setting, there is a need to understand the complexities of home- and community-based services. Moreover, efforts to support an older adult’s desire to age in place often require support from caregivers (paid or unpaid) as well as a network of medical and social services. The overarching objective of the book is to provide an introduction to these home- and community-based services, including the settings and services, policies, and the barriers and facilitators to home- and community-based care. This goal is achieved by examining the topic of home- and community-based services from multiple perspectives, including family caregivers, professional caregivers (e.g., interdisciplinary teams), and policymakers. The authors provide examples from the U.S. and global context as they depict innovations in how to foster aging-in-place through home- and community-based services.
In an effort to situate the discussion of home- and community-based services, Chapters 2 and 3 provide an overview of policies, court cases, and programs associated with supporting an older adult in the community, including clarifying the difference between Medicare and Medicaid. Furthermore, the authors provide an overview of the trajectory of efforts to support older adults in the community. Chapter 2 highlights two historical events that laid the foundation for individuals to age in place. Specifically, they describe the 1981 Reauthorization of the Social Security Act, which rebalanced public funding to support both community and institutional care. The second seminal event that is discussed is the 1999 Olmstead decision, which supports an individual’s ability to live in the least restrictive environment. Moreover, this clarifies that unnecessary institutionalization is a civil rights issue and a violation of the Americans With Disabilities Act. Chapter 3 summarizes the history of the Older Americans Act, its reauthorization, and an overview of the services and networks supported by this legislation.
Chapters 4, 5, and 6 address the essential role of paid and unpaid caregivers as well as the services involved in home- and community-based services. The authors emphasize the importance of a team approach to support the health and well-being needed to foster aging-in-place in Chapter 4. Within this chapter, the authors describe interprofessional education and practice, including the 10 core principles of this care approach, as well as the conceptual framework for interdisciplinary care. The pivotal role of the family caregiver(s) is addressed in Chapter 5 as the authors provide a brief history of caregiving, the need to assess caregivers, and interventions to support family caregivers to ensure that older adults can remain in the community. Chapter 6 describes home health care eligibility requirements, costs of services, and how home health care services are funded.
Where services can be provided as well as innovative models of home- and community-based services are described in Chapters 7 to 11. Chapter 7 introduces the reader to the Village concept and naturally occurring retirement communities, referred to as “NORCs.” Chapter 8 describes the evolution of home-based primary care, which aims to address the medical care needs of an individual who wants to age in place. For individuals who want to remain in the community but need services to support them, Chapter 9 describes the evolution of Assisted Living Facilities. The authors present five models in which older adult housing can be categorized (i.e., hybrid, hospitality, housing, health care, and social). Chapters 10 and 11 discuss adult day services and hospice care.
Chapter 12 capitalizes on an international perspective to compare and contrast demographics in the United States with other countries around the world, as well as highlight differences in care models and the funding approaches for these home- and community-based services. The authors explore the life expectancy of various populations as well as the proportion of individuals who are 65 years of age or older. The reader is provided with a brief overview of key demographic terms, such as the introduction of the dependency ratio.
The emergence of technology in home- and community-based services is explored in Chapter 13. The authors introduce the concept of gerontechnology and highlight the emerging home-based technology that is intended to optimize safety and health. Finally, the authors talk about the potential use of robots. The authors conclude the book with a projection on what the future may hold for home- and community-based services, describing the potential rebalancing of care to shift toward the community, methodology for facilitating high-quality research in this care context, and how to better align acute medical care with home- and community-based services (e.g., supporting transitional care).
This book is ideally situated for individuals who are looking to gain a broad understanding of home- and community-based services, for example, those studying to have a career in gerontology health and social care fields who will be working with older adults to ensure they return to or remain in the community. More specifically, entry-level health care providers (e.g., occupational, physical, and speech therapists; nurses; and social workers), as well as public health and health administration students, would benefit from this text.
The book is structured so that each chapter includes learning objectives and a series of Fact or Fiction statements, which are addressed in the subsequent text. Each chapter includes case studies and perspectives from the field, where experts share their perspectives on a given topic. A limitation of the book is that it focuses on identifying and describing concepts, yet there is limited reflection and synthesis on the evolution of topics over time as well as gaps in situating topics in the broader U.S. context. For example, Chapter 2 summarizes legislative actions, but there is limited reflection on the evolution of the legislation within the broader political climate. The authors assert that funding for home- and community-based services needs to be expanded at federal, state, and local levels (p. 24), yet these recommendations are not situated in the context of the current national funding challenges and other factors impacting national finances (e.g., demographics, state budget challenges, and political pressures to limit government spending). Chapter 9, which focuses on Assisted Living, acknowledges at the onset that most of these facilities are private pay. However, the connections between payment models, long-standing disparities in health and social care, the low-income status of minorities, and access to Assisted Living are not addressed. More specifically, there is no link between the requirement to have substantial assets necessary to pay privately for Assisted Living and the racial disparities in the utilization of Assisted Living. Authors explicitly state that they purposely excluded a discussion of nursing home care; thus, for those readers looking for a perspective of the various institutional and community-based long-term service and support options, this book does not address the individual’s choice to reside in a nursing home. That being said, the strength of this home- and community-based services text is that the authors included a wide variety of viewpoints that range from consumers, to researchers, to providers as they explore the topic of home- and community-based services.
