SOCIAL SERVICES

Funded through an array of federal, state, and local sources, social services are designed to enhance the independence and quality of life for elderly people in America. The use of public funds to support services exclusively for the elderly has become controversial as the nation’s elderly have become more financially secure, and public resources have become more scarce.

Following a brief review of early approaches to serving the nation’s elderly, this entry considers the use of social services to prevent nursing home placement and describes the range of social services available. A brief discussion of strategies for accessing public social services is followed by a review of the relationship between family care and social services. The entry closes with brief consideration of the challenges of providing services for emerging cohorts of older Americans.

Early approaches to serving the elderly

The eligibility requirements of major programs for the elderly influence our understanding of what it means to be ‘‘old’’ in America today. At sixty-two years of age an American is eligible to begin collecting Social Security benefits. Eligibility for most programs funded under the Older Americans Act begins at age sixty. Medicare eligibility begins at age sixty-five. So, for twenty-first-century Americans, ‘‘old age’’ might begin in the early- to mid-sixties.

Lacking programs and policies to define them as ‘‘old,’’ elderly people prior to the twentieth century were judged by their individual attributes. Infirmity, more than chronology, was the hallmark of old age. Services for the elderly were based not on their age but on their needs. Consequently, destitute elderly people might have been found in early nineteenth century almshouses along with children and young adults.

Beginning in the 1830s, this notion of a homogeneous class of needy Americans was challenged. Reformers who served the urban poor became interested in more efficient use of their resources and decided to focus on those most capable of reform, ‘‘the redeemable poor.’’ The elderly were not included in this category. In 1855, for example, the New York Association for Improving the Condition of the Poor resolved, ‘‘to give no aid to persons who, from infirmity, imbecility, old age, or any other cause are likely to continue unable to earn their own support and consequently to be permanently dependent’’ (italics added). Urban Charity Organization Societies (COSs) took the same position. In 1892, Amos Warner expounded on the hopelessness of work with the aged, ‘‘In work with the aged one is conscious that for the individuals dealt with there is no possibility of success’’ (Haber, p. 40).

So, while COS and other philanthropies were providing rehabilitative and educational services to the young, elderly people were confined to public almshouses. Over time they made up a growing proportion of the almshouse population and so (particularly among charity professionals) age came to be associated with destitution.

In 1902 Homer Folks, New York City’s Commissioner of Charities, announced a new name for the city almshouse, the Home for the Aged and Infirm. Folks intended to send the message that the residents of this facility were not the lazy able-bodied, but simply too old or sick to earn a living. In time, institutions like the home came to be seen as the most appropriate setting for needy elders.

As ‘‘homes’’ or ‘‘asylums’’ were populated by the elderly and infirm, they took on a more medical focus. The line between hospital and almshouse blurred and ‘‘old age homes’’ began to employ physicians and nurses, setting the stage for the expansion of facilities we now call nursing homes.

African Americans were generally denied access to these and other public sources of assistance. Using a ‘‘self-help’’ model, ‘‘benevolent societies’’ were organized to provide assistance to needy African Americans. In the antebellum era, African American elders often lived in abject poverty. Benevolent societies were formed, primarily in northern urban communities, to help them in times of need. Society members paid annual dues and in return were given sickness and death benefits. The number of these societies quickly mushroomed. Philadelphia alone had over one hundred societies serving over seven thousand members. During the latter part of the nineteenth century the resources of benevolent societies were strained by the aging of their members. Ultimately they were replaced by insurance firms with greater financial reserves. Nonetheless, the benevolent societies represented a significant resource to meet the needs of elderly African Americans (Pollard).

In sum, the nineteenth century saw an evolution in the treatment of indigent elders. They were initially grouped with other groups of ‘‘worthy poor,’’ but over time the elderly came to be distinguished from other indigents. Agencies that focused on the ‘‘redeemable poor’’ gave up on elderly people, reserving their energy and resources for young people with some hope of employment. Needy elderly people increasingly found themselves ‘‘warehoused’’ in institutional settings—precursors of twenty-first-century nursing homes.

Formal services for the elderly consisted primarily of institutional care. Informal arrangements, such as those provided by the benevolent societies, and through churches and families, constituted the primary source of services for needy elders who lived in the community. The twentieth century saw two significant social trends that were to permanently alter patterns of elder care in the United States: the widespread entry of women into paid employment, and the dramatic increase in life expectancy.

Social services to prevent nursing home placement

The twentieth century brought tremendous growth in elderly populations, not only in the United States, but throughout the world. With this growth, the cost of institutional care became a significant burden on public resources in the United States. By mid-century, the idea that social services might prevent nursing home placement contributed to the expansion of public services for older adults.

The most significant and enduring manifestation of this expansion was the Older Americans Act (OAA), signed into law by President Johnson on 14 July 1965. In his remarks upon signing the bill the president suggested the legislation would provide ‘‘a coordinated program of services and opportunities for our older citizens.’’ Through partnerships between federal, state, and local authorities, the act established a network of 57 State Offices on Aging and 670 Area Agencies on Aging that today effectively blanket the United States.

Less enduring that the OAA, but equally influential, was the Channeling Demonstration, funded through the Health Care Financing Administration in 1980. The demonstration was implemented in ten states throughout the country to test the notion that services delivered to the frail elderly in the community would reduce nursing home admissions and improve well-being. Channeling programs varied somewhat between sites, but case management was a central feature of each. Case management involves the use of a single professional, usually either a social worker or a nurse, to coordinate service delivery for an older adult. Case managers typically conduct detailed need assessments, develop a service plan designed to meet identified needs, then select providers to deliver services and monitor the process.

Programs funded through the Channeling Demonstration did meet the needs of frail elders, and they enhanced the quality of life enjoyed by their clients. But they failed to demonstrate cost-effectiveness by reducing nursing home admissions. The primary reason for this failure was what Kane and Kane referred to as ‘‘the problem of shifting targets.’’ Far more frail elderly people live in the community than in nursing homes. Approximately 5 percent of Americans over the age of sixty-five live in nursing homes. Even fewer of the nation’s elderly enter a nursing home in any given year. So, while it is possible to identify frail elderly people in need of support, it is difficult to determine who, within this pool, is most likely to enter a nursing home. As a result, services for the frail elderly serve many who would never have entered a nursing home. Thus, social services seldom reduce nursing home admissions. Nonetheless, in testimony to their positive effects on quality of life, the popularity of social services for frail elderly people continues unabated and a wide range of these services are available today.

The range of social services available today

Today professional services are offered under a variety of auspices and for a variety of purposes. Funding sources and eligibility requirements, even within a single organization, can vary tremendously. For example, an agency might provide assistance with several different funding streams, such as the Older Americans Act, the Social Services Block Grant, the Community Development Block Grant, Medicaid, and Medicare. Each of these streams might impose different eligibility requirements and require different program procedures.

The information and outreach program provided through an Area Agency on Aging (AAA) is an excellent starting point in the search for supportive services for an older adult. Under the OAA, all AAAs must provide information and outreach. Every jurisdiction in the United States provides this means of accessing needed services. Area Agencies on Aging may be housed in different types of organizations, such as local or county government, state government, or even nonprofit organizations. AAAs usually contract for services, hiring private or other governmental organizations to deliver assistance to older adults. If no other organization is available, an agency might provide the service directly. AAAs can be located by calling the national hotline (1800-677-1166) or through the Web site maintained by the U.S. Administration on Aging (www.aoa.dhhs.gov). Eligibility for assistance is based on age. Anyone over sixty years old may access services through the AAA. Some services are restricted to individuals with limited financial resources (Gelfand).

Several of the AAA services are ‘‘mandated,’’ in that the agencies are required to spend an adequate proportion of their yearly allocation for them. These include access services, which help people reach the services they need; in-home services; and community services.

Access services include outreach or information and referral programs, as well as transportation programs. The information and referral phone number for the AAA is usually listed in the government section of the phone book. By calling this number, an individual can receive information about both public and private services available in his or her community. Most AAAs provide transportation only for specific purposes, usually medical need. This might involve doctors’ appointments or visiting a family member in a nursing home. Some also provide transportation to senior citizen centers and other services such as grocery runs and trips to entertainment.

In-home services consist of homemaker services, home health aides, visiting or telephone reassurance, and chore services. Homemaker services help with light housekeeping tasks, such as vacuuming, dusting, and dishwashing. Home health aides provide personal care and limited health-related care. An aide may help with bathing or dressing, or might check blood pressure. Aides do not perform health-related tasks, such as changing a catheter. Many AAAs provide telephone and personal contacts for elderly persons by using volunteers. These individuals contact older homebound people periodically to see how they are doing and identify pressing needs. In-home services are typically restricted to individuals with limited financial resources, though some agencies offer the services to those with higher incomes using a sliding scale fee system. Chore services help with home maintenance, performing tasks such as clearing rain gutters, minor home repairs, and shoveling snow. Usually eligibility for in-home services is restricted to the financially needy.

Community services include the long-term care ombudsman program, and legal services. Each state employs a professional long-term care ombudsman. Many states also train volunteer ombudsmen. These individuals are charged with advocating on behalf of residents of long-term care facilities. They receive and investigate complaints, and maintain a record of facility compliance. These records, often called ‘‘report cards,’’ are usually available for public inspection. Legal services are usually available to people with limited incomes. Through legal services programs lawyers assist with wills and guardianships, but usually not with civil suits or criminal matters.

AAAs may also provide other services, including nutrition programs, socialization programs, protective programs, employment programs, and case management.

Nutrition programs may provide congregate meals in senior centers, and/or home-delivered meals known as Meals on Wheels. Congregate meals usually consist of a lunch, followed by a brief program of education or entertainment. These meals are available to anyone over the age of sixty. Sometimes a small donation is requested. The meals usually provide a menu that is familiar to the majority community, which may not be attractive to cultural and ethnic minorities. Home-delivered meals usually have more restrictive eligibility requirements. In most areas a physician must certify that a person is unable to prepare meals. Generally demand for home-delivered meals exceeds supply. Sometimes a nominal donation is requested. The people who deliver meals can be wonderful resources for older adults. Usually the same driver delivers the meals each day, so he or she can check on a person and secure attention for medical emergencies.

Socialization programs include the Senior Companion program, senior center activities, Foster Grandparents, and Retired Senior Volunteer Program (RSVP). The Senior Companion program provides employment for low-income seniors and help for the homebound elderly. Companions are trained and receive a small stipend for their services. They visit frail, community-living elderly people, providing company for them and respite for their caregivers. Senior centers provide a wide range of activities, including arts and crafts, discussion of current events, dancing, health promotion, and other social activities. These are available for anyone over the age of sixty. They typically reflect the cultural and social interests of the majority population in a community, so members of cultural and ethnic minorities are often under-represented in senior centers. The Foster Grandparent program was established to provide meaningful activities for elderly individuals and assistance to children. Foster grandparents work with children in a variety of settings, including schools, nurseries, Head Start programs, hospitals, and treatment centers. The RSVP program offers additional opportunities for meaningful activities. These volunteers provide services in diverse settings such as hospitals and libraries. The program offers recognition and covers volunteers’ expenses.

Protective services investigate reports of elder abuse and neglect and intervene on behalf of the victim. In most states professionals are required by law to report cases of suspected elder abuse, neglect, or exploitation to the protective services agency. Intervention may take the form of family counseling or guardianship proceedings. In some cases the AAA may become a guardian.

Employment services provide training and subsidies for older adults who are seeking employment. Most of these programs are federally funded, and some also have job-development components, with staff who work with corporations and organizations to identify jobs for seniors. The Senior Community Service Employment Program (SCSEP) provides part-time employment to low-income individuals age fifty-five and over. Typically the SCSEP program offers both training and employment in nonprofit and government agencies. Age discrimination in employment is a continuing concern. Individuals who suspect that they have been victims of age discrimination should seek assistance through their AAAs.

Caregiver services were introduced as part of the National Family Caregiver Support Program established under the 2000 amendments to the Older Americans Act. Under the auspices of the U.S. Administration on Aging, this program offers funding for a wide range of services that support family members who provide care to frail elderly people.

In addition to services available through the Area Agencies on Aging, mental health services and housing assistance often prove valuable to older adults.

Housing assistance. Federal housing assistance dates to the New Deal, when public housing was developed for low-income working families. Through incremental changes, the structure of the federal program of low-income housing has evolved. The elderly have been the greatest beneficiaries of that evolution, making up a significant proportion of those served by low-income housing facilities and rent subsidies.

Three major housing programs provide assistance to low-income elderly people; Section 202 of the Housing Act of 1959; Section 8 of the Housing and Community Development Act of 1974, and public housing. Section 202 provides low-interest construction loans to nonprofit sponsors (such as churches and civic organizations) for up to forty years. Once constructed, the Section 202 development is operated by the nonprofit sponsor, with federal oversight. Section 8 offers rent subsidies for low-income families. While some senior households do receive rent subsidies through this program, the vast majority of those in need do not, because need for housing assistance greatly exceeds the supply of rent vouchers. Public housing was developed as part of the New Deal, to house working families with children. Since then the eligible population has changed considerably. The elderly and people with disabilities are frequent residents of public housing, often sharing the same facility.

Housing developments exclusively for the elderly offer a modicum of safety, and a convenient site for the delivery of other kinds of social services. Many communities offer health promotion and other services on site at senior housing facilities.

Mental health services. Mental health services often include counseling and support groups to assist people coping with age-related changes. Growing numbers of older adults have participated in the ‘‘self-help’’ movement by joining support groups. These groups, designed for everyone from the physically ill, to the bereaved, to people suffering from addictions, often provide a sense of comradery and a source of information and advice. Support groups may be operated by a wide range of organizations or agencies, from churches to senior centers. Some are led by a professional, and others by a volunteer.

Older men are usually more reluctant than older women to participate in support groups. Participating in a support group does not match popular notions of masculinity. So, while older women may be comfortable admitting weakness and sharing emotions, older men may resist these activities and deprive themselves of the benefits of a support group. Recruiting and management strategies that are sensitive to the needs and relationship styles of older men can enhance the effectiveness of a support group for this vulnerable population (Kosberg and Kaye).

Accessing social services

Older adults who want to use public social services often encounter a hostile and demanding environment. Many public social services are underfunded, and staffed with professionals who deny services more often than they provide assistance. Older adults can find the regulations and paperwork intimidating and frustrating. Getting satisfactory service from a provider can require persistence and assertiveness. Indeed, older adults frequently benefit from having a family member or friend serve as their advocate as they seek assistance.

Before contacting an agency, it helps to spend some time thinking about the problem and what might be done to address it. In addition to a written description of the problem, older adults may want to collect the following information before contacting a potential service provider: Their latest tax return, or other information about income and assets; the potential client’s age, medical diagnoses, and functional abilities; a list of family members and friends who can provide assistance; and times and dates when they are available for an appointment.

It is rare to find the right service provider upon first contact, so it is best to begin the search for service by phone rather than in person. The caller is advised to keep a log of contacts, as the first person or agency contacted may not be the right one. The log should include the name and title of each person contacted, the date of the contact, and what the person said. This will prevent the famous ‘‘runaround,’’ in which providers focus more on referring an older adult to other providers than on what their own organizations might be able to do to help.

Most of the publicly funded services available through AAAs can be purchased in the private market. The classified sections of newspapers in any major city will reveal individuals who offer their services to care for elderly people. The dilemma, for families who have the means to purchase assistance on their own, is how to select a qualified provider. Here, too, the AAA can be of assistance. Many information and referral programs maintain files of private providers who have been screened by agency staff. Other agencies, such as visiting nurse services and hospice organizations, might also be able to provide a list of providers who have been screened. Regardless of the source of the referral, individuals purchasing care through private sources must be vigilant to prevent the abuse or exploitation of their elderly loved ones.

The relationship between social services and family care

The family is widely seen as an elderly person’s first line of defense against the risks associated with advanced age. Family members provide a tremendous amount of care for older Americans, a situation that both the elderly and their families generally prefer over professional care. Given the importance of family care, and the high cost of professional services, policy-makers and researchers in the field have been concerned about the possibility that public social services might replace family care.

Numerous studies have demonstrated that social services do not replace family care. Indeed, professional assistance may even enhance a family’s ability to provide care. Respite care is probably the best example of this. When family caregivers have access to respite care they often report being able to give more and better care to their loved ones. Similar results have been obtained with case management, personal care, and homemaker services. Despite the lack of evidence that services displace family care, this concern arises frequently when funding for social services is up for debate.

The future of social services for the elderly

Targeting of public social services has become a source of tension in recent decades. The Older Americans Act requires that services be made available to all older Americans, regardless of their income or assets. Yet today’s elderly are, on average, considerably more affluent than the aged were in 1965 when the act passed. As a result, OAA services often benefit elders who are middle-class members of the cultural majority. The recipients of programs funded under the act may not be those most in need of assistance (Barusch).

Congregate meals programs have been criticized as failing to serve cultural minorities and frail elders. The climate in most senior centers reflects the majority culture in the area. While not overtly hostile to cultural minorities, the activities, food, and atmosphere are often not familiar or welcoming. As a result, those most likely to use senior centers are typically of the majority culture. Similarly frail elders, those most in need of assistance to maintain their independence, are unable to participate in congregate meals. Yet congregate meals programs are popular, and have consistently been one of the AAA’s biggest budget items.

In response to this tension, the 1987 amendments to the Older Americans Act added Section 305 of Title III to require that states, ‘‘E) Provide assurances that preference will be given to providing services to older individuals with the greatest economic or social need, with particular attention to low-income minority individuals. . . ’’ (italics added). Subsequent appropriations have revealed an increased emphasis on cultural minorities and vulnerable individuals. So, for example, funding for home-delivered meals constituted a much greater proportion of OAA spending in the late 1990s than it had prior to the amendment. Similarly, allocations for Native American tribes increased dramatically. Programs serving frail and vulnerable elders were also initiated, including in-home and protective services and caregiver support.

As the population of America’s elderly citizens grows, it becomes more diverse. There are more women, more cultural minorities, and more extremely old, frail people. The challenge for publicly funded social services will be to maintain a strong constituency that will support their continuation, even as they target services toward the very needy—those least likely to have a voice in the political arena.

This illustrates a fundamental tension inherent in the delivery of publicly financed social services. When public resources are scarce, there is a compelling argument in favor of targeting these services toward the most needy. Yet those most in need are least likely to provide political support when funding is up for debate. A program that benefits only low-income, homebound elders is likely to have few supporters at its budget review. Social services for the elderly must demonstrate their effectiveness—not only at reducing suffering of the vulnerable—but at enhancing the quality of life for the politically active.

Amanda Smith Barusch

See also Adult Day Care; Case Management; Congregate and Home-Delivered Meals; Housing; Mental Health Services; Older Americans Act; Personal Care; Social Work.

BIBLIOGRAPHY

Barusch, A. S. ‘‘The Elderly.’’ In Foundations of Social Policy: Social Justice, Public Programs, and the Social Work Profession. Chicago: F. E. Peacock, 2002. Pages 266–300.

Gelfand, D. E. The Aging Network: Programs and Services, 5th ed. New York: Springer, 1998.

Haber, C. Beyond Sixty-Five: The Dilemma of Old Age in America’s Past. Cambridge, U.K.: Cambridge University Press, 1983.

Kane, R., and Kane, R. A. ‘‘Alternatives to Institutional Care of the Elderly: Beyond the Dichotomy.’’ The Gerontologist 20, (1980): 249–259.

Kosberg, J. I., and Kaye, L. W., eds. Elderly Men: Special Problems and Professional Challenges. New York: Springer, 1997.

Pollard, L. J. ‘‘Black Beneficial Societies and the Home for Aged and Infirm Colored Persons: A Research Note.’’ Phylon 41, no. 3 (Sept. 1980): 230–234.