Nursing Homes and the Elderly--An Evaluation of Avoidable Admissions

This article appeared in the GAO Review, Vol. 15, Issue 2, Spring 1980. Entering a nursing home has become an irreversible costly decision. Many who enter these facilities could have remained in their homes or community if appropriate support systems could have been obtained. The major burden of illness in the United States has shifted from acute infectious disease to chronic and degenerative conditions. The United States faces the dilemma of designing a humane yet affordable system of providing long-term health and social services to the chronically ill and disabled population. Under an optimal long-term care system, an individual would be assured of receiving essential health and social services in a setting which fosters independent functioning. Nursing homes would be used only when community living is not a viable option. At present, 93 percent of all public funds for long-term care services goes to nursing homes and institutions, while only 7 percent finances community based care. Medicaid paid for 87 percent of all public expenses for nursing home care, because most private health insurance plans exclude long-term care from their coverage. Many elderly poor are ineligible for Medicaid benefits while living in the community, but upon entering a nursing home different standards apply. Many low or moderate income elderly enter nursing homes as private pay patients and become impoverished or transfer their money to relatives in order to become eligible for Medicaid coverage. Once institutionalized, far more medical services are covered by Medicaid than are by Medicare. There is limited or no public financial or social support available to family caretakers of the elderly. A comprehensive assessment is needed to assure appropriate nursing home placement. Medicaid's assessment mechanisms have not been effective measures to control avoidable institutionalization. They occur too late, and focus on medical conditions and not the other factors involved. GAO proposed a program of preadmission screening to provide all applicants to nursing homes with community-based services based on a Federal/State cost sharing arrangement comparable to the Medicaid Program. Current congressional interest would expand the opportunities of the elderly to receive care in their own homes or communities rather than force them to impoverish themselves to qualify for public support and nursing home care.