More care at home: the challenge of creating viable community alternatives to nursing home care.

Creating a national long-term care (LTC) delivery "infrastructure"-one that would make home-based care more accessible to people with extensive needs-will be a major undertaking. It will require new service organizations that have the authority to provide and coordinate an appropriate array of services. Medicaid Managed Long-Term Care (MLTC) and the Programs of All-Inclusive Care for the Elderly (PACE) offer two promising examples of what the service organizations of the future might look like. The history of how these plans developed illuminates challenges that others will encounter. Further expansion of these types of organizations requires resolution of resource, staffing, and operational issues. Keywords: Medicaid; Medicaid Managed Long-Term Care (MLTC); Programs of All-Inclusive Care for the Elderly (PACE); Medicaid reform; workforce How often do you receive a panicked call from a friend whose mother or grandmother needs help? Maybe she doesn't hear or see all that well anymore, the caller tells you. Maybe she forgets things, such as how to get home from the supermarket, or maybe she fell and broke her hip, or had a stroke. The details vary, but the bottom line is always the same: It's getting much harder for someone you care for to manage on her own. What are the options? Is there anything the family can do besides moving loved ones into a nursing home? With many people now living well into their 80s and 90s, families are increasingly faced with the need to make elder care arrangements. At the state and national level, meanwhile, policy-makers are talking more seriously about the need to create viable alternatives to nursing home care. But what does a "viable alternative" to nursing home care look like? People who are "nursing home eligible" have a host of complex and interrelated conditions-functional, cognitive, and healthrelated-that require different kinds of care and, as a result, a delivery system in which the caregivers are able to communicate effectively, coordinate their strategies, and provide the appropriate scope of services. Experts agree that a national long-term care (LTC) delivery "infrastructure"-with the required scope of services, staffing, expertise, information systems, and operational support to make home-based care more accessible to people with extensive needs-will be a major undertaking for policy-makers in the next decade. Like the national investment in roads, bridges, and tunnels during the 1930s, such an effort would require meticulous planning and wellcoordinated strategies. However, the kinds of organizations best suited to this task are rare, as are the professionals specifically trained to coordinate complex and extensive care in the home setting. Creating these kinds of organizations-and staffing them-will require a focused and sustained effort over the course of many years. Moreover, what is most needed to build an infrastructure of this magnitude is a clearer vision about what the organizations providing care should look like as well as reasonable expectations about the resources and time needed to create them. Two service-delivery models in New York-Medicaid Managed Long-Term Care (MLTC), and the Programs of All-inclusive Care for the Elderly (PACE)-offer promising examples of what the service organizations of the future might look like. The history of how these plans developed illuminates the challenges that others will ultimately encounter, and the kinds of policies and practices that might speed and strengthen the growth of viable community alternatives to nursing home care. LTC CONSUMERS IN THE COMMUNITY Nearly 10 million people in the United States need some help in order to perform basic activities of daily living (ADL), such as bathing, toileting, and eating. The majority (7.9 million) of them reside in the community. It comes as no surprise that seniors are most at risk of needing help or that the need for help increases with age. …