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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