WALTHAM, Mass. -- Despite the graying of the American population, the percentage of Americans residing in traditional nursing homes has declined significantly since the mid-1980s, according to a new report from Brandeis University. Increasingly, its author says, older Americans appear drawn to newer long-term care options, including assisted living and care provided within their own homes. While it bodes ill for the struggling nursing home industry, the trend may hearten those who have long fought the institutionalization of elders with disabilities.
The report, based on the most recent National Nursing Home Survey, appeared in the journal Health Affairs. It indicates that the percentage of Americans age 65 and older residing in nursing homes fell from 4.6 percent in 1985 to 4.2 percent a decade later, with the sharpest decline among those 85 and older. If the 1985 rate had held, the number of elders in American nursing homes in 1995 -- actually 1.4 million -- would have been closer to 1.7 million.
"Nursing homes are no longer as prominent among long-term care options as they were a decade ago," says Christine Bishop, a professor in the Schneider Institute for Health Policy at Brandeis's Heller Graduate School. "While nursing homes were the dominant long-term care option as recently as the early 1990s, new options that provide lower-level care -- such as adult daycare and assisted living -- have grown in prominence. Nursing homes have become more narrowly specialized, catering to those requiring the greatest assistance."
One result, says Bishop: residents of nursing homes are increasingly older and sicker, as elders with fewer needs seek services elsewhere. The facilities are generally now the choice of only the most severely disabled elders, signaling an about-face from the concerns of the 1980s over "misplaced elders" -- people of widely divergent disability levels who found themselves funneled into one-size-fits-all nursing homes -- to the roughly 300,000 "missing elders" cited in Bishop's report, those who have most likely abandoned government-regulated facilities in favor of less formal varieties of long-term care.
Bishop says that falling rates of disability among the elderly may account for some of the "missing elders." But more likely, she says, alternatives such as home-delivered care and assisted living -- apartment complexes with access to limited care -- have filled the gap left by declining nursing home use.
"Family members continue to provide most long-term care," Bishop says. "Informal, unpaid support continues to sustain many older people living in their own homes."
Bishop says her findings are the latest herald of a period of great instability for nursing homes, one that could lead to financial crisis in many facilities. "This is a time of rough waters for the nursing home industry," she says, noting that the institutions' financial health has worsened to the point that one in seven nursing home beds in Massachusetts is owned by a company that has filed for bankruptcy. In addition to demographic changes, recent policy shifts on government payments to nursing homes -- most notably those enacted under the Balanced Budget Act of 1997 -- have also been unfavorable to the industry.
In addition, Bishop found that by 1995 nursing homes were increasingly serving a group of patients barely in evidence a decade earlier: those seeking temporary, Medicare-funded care after hospitalization for surgery or illness. Bishop says this revolving-door group, which occupied an average 11 percent of nursing home beds on any given night in 1995, siphoned away slots that formerly might have gone to patients in need of genuine long-term care.
Journal
Health Affairs