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by Robert Jawitz
Eldercare is quickly becoming one of the most vexing issues
confronting the culture of the 20 th and 21 st centuries. Before
the 1 st world war, the care of the elder generation took place
within the family homestead. This is true in the USA as well
as in Europe and Asia. In Asia, the elderly were revered for
their wisdom and were given a dominant position in the society
and the family. But this is changing. It is changing because
Asia, particularly Japan and China, have been following the
American economic model. Now, because both spouses in a young
or middle-aged family must work, there is no time to provide
care for the elderly. Even Japan is looking to the USA for ideas on how to
address this issue.
The way the USA addresses the issue is to institutionalize
its elderly. Whenever a family feels that Mom or Dad is no
longer capable of living alone, the first reaction is to institutionalize
her or him. Originally, it was in rest homes or nursing homes
depending on the severity of their incapacity. The nursing
homes of about 50 years ago had wards of 4 to a room. Later
it was improved to 2 to a room. Nursing homes were considered
hospitals and residents were considered patients with very
few rights. They had no independence. They could not leave
unsupervised. They could not have their own furniture. Sending
a loved one to a nursing home is a death sentence. The care
there is vastly inferior to a real hospital and, without independence,
the will to live quickly evaporates. The cost of nursing homes
is so high (in the East about $250/day) that a long term resident
quickly loses the value of their house, their savings and other
assets and then becomes a ward of the State. Currently between
70 and 90% of long term nursing home patients are on public
welfare. The average life expectancy in a skilled nursing home
is about 3 years.
The elderly community rebelled and the concept of the Continuing
Care Retirement Community (CCRC) was born. The concept was
that elderly moved in when still independent but when a judgment
is made that the elderly individual cannot lived independently
any longer (or that the spouse cannot manage the care) the
resident is sent to an on-site nursing home. This decision
is made by a group including the Director of the facility,
the Director of Nursing, the facility’s Physician and
the responsible member of the family. The resident has no say
in the matter. Supposedly, the on-site nursing home was preferable
to an out-sourced situation because friends in the independent
section could visit and the “patient” could be
returned “home” when deemed to be independent.
CCRC’s were and are very expensive. Not only must the
fee (entrance fee or rent) carry the physical cost of the building,
but it must support 24 hour/7 day per week supervision and
security, full administration, building and grounds maintenance,
a food and dietary program, transportation and “hotel
services” such as linens. Typically, the entrance fee
and maintenance charges or rent took the full value of the
house and whatever savings, social security and pension income
the resident could muster.
Because CCRC’s were so expensive, they soon became
less desirable and families chose to “institutionalize” their
elderly only when they were no longer independent. Because
nursing homes are such dreadful places, the concept of the “assisted
living facility” was born. This is basically congregate
housing (apartments with food service) with a limited home-health
care component. Typically, the resident now can have a full
apartment with his, her or their own furniture, and keep a
modicum of independence. They may not need to get permission
to leave, but the facility (because of its liability) will
need to know when they leave and when they are expected back.
Aides can manage the requirements of physical disabilities
(bathing, dressing) and home-health nurses can manage medications,
but when the resident becomes mentally incompetent, the resident
is moved to a nursing home in a similar process as with the
CCRC.
Assisted living facilities are still institutions. While
some of the trappings of independence are restored (furniture,
living without a roommate, coming and going), one is still
forced to live with people who care not about you or who you
do not care about and one must follow the rules of the institution.
For many who lived much of their lives in apartments, this
is not as much an issue, but for those who come from single
family houses, it is a big step down in life.
But even if assisted living facilities worked (and most don’t
because the nursing and aide component quickly strips the resident
of his or her ability to pay and he or she is sent to a nursing
home to go on public assistance), it still means selling the
house to get the income. In fact, all of the institutional
alternatives eventually mean selling the house to get the income.
All of the institutional alternatives mean relying on strangers
for the assistance-in-living elderly need.
The better alternative is to return to the concept of having
the family taking care of its elderly. In this model, it is
loved ones that provide the care. In the model where 4 generations
live together in one compound, we have the son/daughter of
the elderly take primary responsibility for the care with support
from the younger generation. In this model, the wisdom, experience
and friendship of the elder generation are not discarded and
is a resource for the children. In this model, the family provides
the “administration expense, building and grounds
maintenance, a food and dietary program, transportation and “hotel
services” such as linens” but does it in a
non-institutional and loving way. The elder doesn’t feel
useless in this society and can contribute to the requirements
of living of the family to its best abilities (whether it’s
in the garden, in food preparation, or with the laundry). In
this model, the family can help the elder self-administer medication
and can provide the services an aide would such as bathing
and dressing. In this model, the elder keeps a more than a
modicum of independence. In this model, the elderly do not
have to sell the family estate including the house, their heirlooms
or their assets and has it to assist the newer generations.
Today, with the advances in the curing of disease, our elderly
have the ability to live much longer. We can address most physical
disabilities and, hopefully soon, we can address the devastation
of Altsheimers Disease and other forms of mental incompetence.
If we can address the desire to live, it is reasonable to expect
our elderly to live to 100 years and beyond. In our model, our
elderly can live these years, at home, with family, in a satisfying
and fulfilling life-style.
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