LONG-TERM CARE FACILITIES

THE SPECTRUM OF LONG-TERM CARE

While the nursing home remains the most prevalent option for elderly persons requiring long-term care, in recent years there has been a great upsurge in alternative options. Changes in the spectrum of long-term care services provided have come about primarily based on changes in the demographic profile of long-term care users, in health care financing, and in policies impacting the provision of long-term care.

Nursing homes reflect the major long-term care option that has been available in the United States under Medicare and Medicaid financing. However, recent trends reflect new developments targeting self-financed long-term care, particularly in the form of assisted living, continuing care retirement communities, and special need facilities focusing on dementia or hospice care. In addition, discharge policies of acute care hospitals have resulted in the development of subacute care and rehabilitation facilities sponsored by hospitals or nursing homes. There has also been an increase in the provision of home care services to frail older adults who can forestall entry to sheltered living arrangements, including nursing homes, through the use of these services. Growing recognition of the diversity of elders requiring long-term care is leading to the diversification of settings to meet these needs, and to a blurring of boundaries between home care and residential care (R. A. Kane, 1995–1996).

In spite of the proliferation of new residential options for frail and old-old adults, those requiring extensive assistance or supervision continue to rely on nursing homes as the only viable publicly financed alternative. Consequently, this essay will only briefly touch on some of the more recent options in the spectrum of long-term care, such as assisted living facilities and continuing care retirement communities. Rehabilitative or subacute care units in nursing homes will not be addressed because they reflect mechanisms for providing short-term care. Nor will we discuss senior housing sites or retirement communities, which serve as residential options to well elders. After considering assisted living facilities and continuing care retirement communities, the major focus of our discussion will be on the nursing home.

ASSISTED LIVING FACILITIES

Assisted living facilities (ALFs) have taken over some of the original functions of nursing homes, providing services to moderately frail elders in the context of a homelike residential setting that includes less surveillance and regimentation, and more privacy and autonomy for residents than the traditional nursing home (R. A. Kane 1995). ALFs combine housing with personal support services such as meals, laundry, housekeeping, and maintenance services. Board and care homes and personal care homes may also be included under the ALF designation. Generally, residents in ALFs pay on a month-to-month basis, although financing of home health services may occur under Medicare (Pearce 1998). Assisted living facilities are an outgrowth of the group home tradition, generally reflecting small business operations. In recent years, however, assisted living facilities have increasingly been sponsored and built by hospitals, nursing homes, and large publicly traded companies (Meyer 1998).

Consistently with the model of social care (R. A. Kane and Wilson 1993), ALF services are geared toward meeting resident preferences and wishes, and consider residents to be consumers rather than patients or clients to be taken care of according to staff-based directives. Assisted living arises from a commercial model of fees for services, and its consumer-driven orientation differs from nursing home care, which generally reflects third-party payment dynamics. While these advantages make assisted living a highly attractive long-term option for frail elders with some means, potential problems include lack of regulation and inaccessibility of this type of care to the poor. Furthermore, assisted living facilities can serve only the needs of older adults with limited disabilities (R. A. Kane 1995–1996).

CONTINUING CARE RETIREMENT COMMUNITIES

Continuing care retirement communities (CCRCs) may also be termed "life care communities," and they typically offer a continuum of services from independent living to assisted living and nursing care. These facilities are appealing to well old-old persons who are still able to live independently but want to have the security of planning for increasing service needs as they arise. These older adults want to know that their changing personal and health care needs can be met within an organizational framework, which they select. Most elderly persons initially enter independent living units of CCRCs. Between 50 percent and 70 percent of entering residents eventually utilize assisted living and/or nursing home components of the CCRC (Newcomer et al. 1995).

CCRCs vary greatly in both the types and the range of services offered and in sponsorship and management. The fees may be structured as a refundable entry fee along with a monthly service fee, or it can be based on an endowment, a rental, or a condominium purchase (Pearce 1998). While fee structures differ, arrangements for these services have generally moved from exclusive reliance on entrance fees to requiring monthly maintenance fees along with fees paid at the time of initiation. With the rapid growth of CCRCs around the country, states have enacted legislation to protect older adults, particularly against bankruptcy of the organizations sponsoring the CCRC (Netting and Wilson 1994). These facilities are generally considered and regulated as insurance programs, and there has been great inconsistency in ways of implementing their regulation across different states.

CCRCs represent not only an emerging comprehensive long-term care alternative, but may constitute a new paradigm for long-term care (Vladeck 1995). Managed care CCRCs can offer flexibility and a more community-responsive paradigm for delivering long-term care. This form of care draws on the know-how of diverse industries, including housing, hospitality, insurance, and health care. This allows for a cross-fertilization of different value orientations regarding care, and different approaches to financing and management.

Large-scale national research on CCRCs finds (Sherwood et al. 1997) that such facilities tend to be utilized by well-educated, middle-class, white, elderly persons aged 75 and over, with women being overrepresented among the users. More than 85 percent had been white-collar workers (Sherwood et al. 1997). When compared with community residents, CCRC-dwelling elderly were found to be in comparable or better health and to have comparable social supports, although community-dwelling elders interact more frequently with their family members. Social research on assisted living and CCRC communities has not been extensive, and generally considers administrative and organizational dimensions of care, rather than aspects of social life and social interactions. Studies comparing CCRC residents and elderly people living in the community have noted that the former are more likely to utilize nursing units after acute hospital stays and outpatient surgery. At the same time, CCRC residents have lower rates of hospital admissions than do community-dwelling elders (Newcomer et al. 1995).

NURSING HOMES

Nursing homes are of interest to sociologists on both the macro and the micro levels. On the macro level they reflect society's orientation to financing, regulating, and delivering long-term care services to its frail citizens who are no longer capable of fully autonomous community living. Sociologists have been particularly interested in those factors affecting long-term care delivery that reflect social construction of the reality of the lives of marginal individuals such as aged persons.

On a micro level, nursing homes represent formal organizations that regulate and control the daily lives of frail elders, while providing them with medical and social care. The tension between expectations for rehabilitative or prosthetic services and actual delivery of palliative care or of dependency-inducing treatment, with iatrogenic consequences, has been a particular source of fascination and concern to gerontologists (Baltes 1996; E. Kahana, Kahana, and Riley 1989; Kane 1995–1996). Complementing this interest has been the search for understanding person-environment interactions and interpersonal and intergroup relationships involving residents, staff, and families within the institutional context (Diamond 1992; Gubrium 1975, 1993; E. Kahana, Liang, and Felton, 1980). The following discussion about nursing homes includes an introductory section outlining models of nursing home care, followed by a discussion of demographic profiles of residents and an analysis of nursing home characteristics and financing. Efforts to ensure high quality of care are discussed in terms of both regulatory efforts and formal interventions. We next consider the effects of institutionalization on the social lives of residents, and their adaptation to the nursing home. Discussion then turns to new initiatives in formal program development and effects of interventions on resident life in the nursing home. The article concludes with a discussion of emerging trends in nursing home care and the future of long-term care facilities in the United States.

Even as we aim to review sociological contributions to the understanding of nursing homes, it is important to note that information about this subject has been obtained through the research efforts of diverse disciplines, with epidemiologists, political scientists, social workers, psychologists, nurses, and physicians all contributing to the literature. In fact, medical sociologists have focused their investigation primarily on acute health care delivery in general hospitals, and many of the theoretical constructs they have developed are more applicable to acute illness than to chronic disability (Cockerham 1998; Charmaz and Paterniti 1999). Consequently, this discussion of the nursing home draws upon multidisciplinary sources.

MODELS OF CARE IN NURSING HOMES

Those requiring institutional care represent a highly select group of the most vulnerable aged persons (Hing 1987), particularly since there are now many options which can keep frail elders in the community. Any therapeutic efforts to enhance the functioning of the very frail older adults living in nursing homes thus represent a regimen of limited objectives (E. Kahana, B. Kahana, and Chirayath 1999). Nevertheless, nursing home settings can serve important therapeutic and rehabilitative functions and can enhance the quality of life of frail elders by ensuring comfort and even some measure of autonomy (Agich 1993). Moving away from an exclusive focus on poor quality of care in nursing homes, recent research has begun to consider criteria for high quality of care and even excellence in nursing home settings (Andersen 1987; Brittis 1996; Groger 1994; Looman et al. 1997).

Conceptualizations of models of care typically reflect the philosophies and traditions of the disciplines from which they originate. Sociology, medicine, nursing, the allied health professions, psychology, and social work—each has a distinct set of traditions that influence its respective conceptualizations of long-term care. Interventions arising from these diverse traditions may include therapeutic interventions (psychology), programs that enhance function (nursing or medicine), and interventions that empower patients (sociology and social work).

The medical model of care considers nursing homes as health care institutions designed to deliver high-quality chronic care to patients. As such, nursing homes are expected to provide competent and well-trained personnel to meet health care needs of patients (R. L. Kane et al. 1994). In principle, the criterion for successful care is improved health or at least minimal health decline of the patient. In practice, quality of care is generally approached by the organization through adherence to certain standards of care delivery, such as adequate staff recruitment and training, and high staff-patient ratios (Nyman and Geyer 1989; L. Z. Rubenstein and Wieland 1993).

The organizational climate of managed care has brought with it a new emphasis on managementcentered interventions and care. Management-oriented approaches often treat patients as objects of intervention who must be manipulated to achieve desired objectives. One such approach, continuous quality improvement (CQI), is an organizational management framework based on older business models such as total quality management (TQM) (Schnelle et al. 1997). The goal of CQI is to make systematic improvements by employing multiple short cycles of designing, evaluating, and implementing interventions. These cycles of continuous intervention and assessment drive long-range systematic change. Attempts at CQI in nursing homes have included interventions in incontinence and physical restraints, but have been hindered by a lack of information technology and by care standards legislated by the Omnibus Budget Reconciliation Act (OBRA) of 1987 (Schnelle et al. 1997). The social model (R. L. Kane and R. A. Kane 1978; R. A. Kane et al. 1998) considers the ideal model of long-term care to be a sheltered housing arrangement for older adults who can no longer function independently in the community. The goal of such sheltered living arrangements is ensuring a good quality of life for residents through encouragement of maximum autonomy in a homelike setting. The criterion for successful care is defined in terms of sustained psychosocial well-being, self-esteem, and life satisfaction of residents.

While medical definitions of care dictate provision of diagnostic and treatment activities, social definitions suggest emphasis on comfort, choice, and adaptation. Advocates of quality-of-life approaches have often argued for major redirection in the way long-term care is handled. They seek greater support for the home-based rather than the institution-based model of care (Leutz et al. 1992). The growing popularity of assisted living options in long-term care reflects this orientation. Empowering older clients to act as consumers provides a major mechanism for the social care model (Burger et al. 1996; Cox and Parsons 1994). Since residents living in nursing homes are typically too frail and powerless to demand active consumer involvement in their care, there is little evidence of actual empowerment-based approaches in nursing home settings (E. Kahana 1999).

The Patient-Responsive Care Model (Kahana, Kahana, Kercher, and Chirayath 1999) has been developed to recognize social, psychological, and physical needs of frail patients who are not able to function in residential settings and who require nursing home care. The Patient-Responsive Care Model is an ecological model guided by communitarian principles of sociologists (Bellah 1996; Etzioni 1993). It calls for a systematic and empathetic discernment by staff of resident perspectives and preferences. This approach is based on earlier work on person-environment fit as a determinant of resident well-being in nursing homes (E. Kahana 1973; E. Kahana 1982). Environments may be matched to resident needs by altering the physical or social environment and by enhancing staff responsiveness in an effort to improve residents' quality of life (E. Kahana, B. Kahana, and Riley 1989). This model is also consistent with recently proposed "cultural" models of nursing home care proposed by Scandinavian scholars who advocate individualized care based on "knowing the patient" (Evans 1996).

The major requisite of patient-responsive care is an understanding and an empathetic appreciation of nursing home life from the patient's perspective. Four major areas of need, loosely based on Maslow's hierarchy of needs (1970), are to be met by staff: reducing physical distress, meeting basic physiological needs, meeting emotional needs, and meeting social needs. Since cognitively impaired and frail elders are limited in their ability to articulate their needs, a major challenge of patient-responsive care is to elicit expressions of resident needs and preferences. This model is predicated on empathetic listening to the patient's lived experience (Gubrium 1993; Savishinsky 1991) as a basis for developing Patient-Responsive Care, and does not rely on need assessments based on objective test data.

Staff behaviors along dimensions of responsiveness can range from total lack of involvement (ignoring or dismissing a problem) to hearing and validating patient concerns. Staff who are responsive to patients provide reassurance and, whenever possible, take constructive actions toward resolving problems. Eliciting information about patient needs and validating those needs are proposed as concrete requisites of providing patient-responsive care. Action components of responsive care also involve communicating with family members and with other staff in advocating on the patient's behalf. Responsiveness involves three central actions by staff: eliciting the patient's definition of need, validating the need, and acting or advocating on the patient's behalf. The pattern of responsiveness thus involves observing, questioning, listening, and responding. Exemplifying this approach, aides who care for the elderly may be trained to redefine their jobs from providing custodial care to providing therapeutic measures. For example, personnel delivering meals could easily be trained to engage in conversation with residents during meals, explaining what the resident is eating and contributing to the enjoyment of the meal. Staff providing responsive care may be empowered through this very initiative. Providing responsive care can serve to enhance staff's self-efficacy and sense of competence (E. Kahana et al. 1999). While none of the models described above fully fit, the complex realities of frail older persons living in institutional settings within the constraints of managed care, each helps us appreciate the multifaceted nature of efforts to meet resident needs in the framework of long-term care.

PROFILE OF NURSING HOME RESIDENTS

In 1995, about 1.4 million American elderly persons over the age of 65 were residing in 16,700 nursing homes. While 4.5 percent of the elderly are in nursing homes at any given time, 30 percent of older adults can expect to spend some time during their lives in a nursing home. The majority of residents enter a nursing home immediately after discharge from an acute care hospital (Lewis et al. 1985). Most of these patients need ongoing medical care and some may require rehospitalization (Densen 1987). Others enter a nursing home directly from the community, due to multiple risk factors including physical and cognitive frailty and nonavailability of caregivers. Additionally, during the era of deinstitutionalization of the mentally ill, some elderly were transferred to nursing homes from mental hospitals. Among social risk factors for institutionalization, studies have identified that those elderly persons who were never married, those who are widowed, and those who do not have children nearby are overrepresented (R. A. Kane 1995–1996).

A demographic profile of nursing home residents has been provided by the U.S. Bureau of the Census (1998) based on a 1995 survey of residents in U.S. nursing homes (National Center for Health Statistics 1997). According to the report, 24.7 percent of nursing home residents are men and 75.3 percent are women.

Older women are three times as likely as older men to reside in nursing homes, both because of their longevity and because they are more likely to be widowed, and moreover without caregivers.

Nursing home placements are generally due to a combination of functional impairments, mental infirmity and unavailability of caregivers (R. L. Kane et al. 1998; Rovner and Katz 1993).

Of those elderly living in a nursing home, 8 percent were between ages 65 and 74; another 42 percent were between ages 75 and 84, and 40 percent were over age 85. Although the vast majority of nursing home residents are elderly, about 10 percent are younger than age 65 (U.S. Bureau of the Census 1998).

Although representation of minorities in long-term care facilities has been increasing over time, such groups continue to be underrepresented (Bonifazi 1998). Racial composition of nursing home residents is: 89.5 percent white, as compared to 8.5 percent black and 2.3 percent Hispanic (R. L. Kane et al. 1998; U.S. Bureau of the Census 1998). Both the greater willingness of black and Hispanic families to care for elders and barriers to the utilization of nursing home by minorities have been cited as possible reasons for these racial differences (Mui and Burnette 1994; Wallace et al. 1998).

Based on the 1995 National Nursing Home Surveys, the majority of elderly persons residing in nursing homes need significant assistance with both activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (National Center for Health Statistics 1997). The study reports that 96 percent of residents in a nursing home need help with showering, 87 percent need help with dressing, 45 percent need help with eating, 24 percent need help with transferring, and 58 percent need help with toileting. Limitations were also found in IADL function, with 78 percent of respondents needing assistance with care of personal possessions and 69 percent needing help with managing money. High levels of physical impairment in this group are also reflected in extensive use of assistive devices. Thus, 64 percent of all elderly in nursing homes utilize a wheelchair, 25 percent use a walker, and 78 percent occupy a hospital bed. Sensory and communicative impairments are also prevalent among nursing home residents, with 51 percent of residents having moderate to severe hearing loss (Garahan et al. 1992) and 24 percent exhibiting visual problems (National Center for Health Statistics 1997).

There is increasing recognition that the prevalence of diagnosable neuropsychiatric disorders in nursing homes is high, with estimates ranging up to 80 percent or greater (Kim and Rovner 1996; Rovner and Katz 1993). Elders with schizophrenia or other psychoses compose only a very small proportion of the nursing home population. The most prevalent neuropsychiatric disorders include dementia (primarily Alzheimer's disease) and depression.

Over 50 percent of elderly persons admitted to nursing homes will live out their lives in a nursing facility, with about 10 percent dying during the first year of their nursing home stay. The average length of stay of long-term care residents is two to three years. In any given year, 25 percent of residents return to the community from a nursing home (Cohen-Mansfield et al. 1999). The majority of those returning to the community have spent time in short-term, rehabilitative units of nursing homes.

CHARACTERISTICS AND DISTRIBUTION OF NURSING HOMES

The number of nursing homes in the United States has decreased from 19,100 in 1985 to 16,700 in 1995. This represents a decline of 2,400 homes over the past decade. The number of nursing home residents has increased only slightly over the same decade from 1.49 million residents in 1985 to 1.55 million residents in 1995 (U.S. Bureau of the Census 1998). In 1995, there were about 1.77 million nursing home beds. The average number of beds per nursing home increased from 85 in 1985, to an average of 106 beds per nursing home by 1995. These changes parallel organizational shifts toward the entrance of large nursing home chains into the market. At the most recent 1995 survey, 66 percent of nursing homes were proprietary, 26 percent were nonprofit, and 8 percent were sponsored by the government (U.S. Bureau of the Census 1998). Fifty-five percent of nursing homes were run by commercial organizations operating chains of facilities. Of the total nursing homes, 66 percent were certified by both Medicare and Medicaid, 20 percent by Medicaid only, 6 percent by Medicare only, and 4 percent were not certified by either Medicare or Medicaid (U.S. Bureau of the Census 1998). Nursing homes generally have high occupancy rates (87 percent) in part based on newly proliferating special units such as respite care, rehabilitative services, hospice, dementia units, and acquired immune deficiency syndrome (AIDS) special care units (U.S. Bureau of the Census 1998). Nevertheless, there are some indications that frail older adults are not entering nursing homes at the same rate they previously did. The increase in assisted living settings and other residential options is likely to contribute to this trend (Strahan 1997).

There are regional differences in both distribution and utilization of nursing homes. Older adults in the Midwest and the South have the largest number of nursing homes available to them, each with 33 percent of the total number of nursing homes in the United States. The Northeast, containing 17 percent of the country's total number of nursing homes, has the highest occupancy rate compared to the Midwest, South, and West. The West, in contrast, has a small proportion of nursing homes and has the lowest occupancy rates (U.S. Bureau of the Census 1998). Migration patterns may influence nursing home occupancy rates. Many older adults, upon retiring, move to warmer Sunbelt states seeking to improve their quality of life. This group is likely to enter nursing homes as they become frail in old-old age, thus contributing a high demand for nursing homes in the South (Longino 1998). At the same time, when they require more extensive care, significant numbers of older adults may return from the Sunbelt to the states from which they originally migrated. These countermoves may also affect the utilization rates of nursing homes in certain regions. Rural-urban comparisons of nursing home distribution reveal that metropolitan areas have a larger supply of nursing home beds per capita than do rural areas (62 versus 45 certified beds per 100 elders, respectively) (Shaughnessy 1994).

FINANCING OF LONG-TERM CARE

It has been argued that, in the United States, funding mechanisms have been largely responsible for shaping the delivery of health care in general and the delivery of long-term care in particular (R. A. Kane et al. 1998). In 1995, nursing home expenses totaled $77.9 billion, sharply up from $36 billion in 1985 (Levit et al. 1996). Medicare, a universal age-based health care program, has traditionally covered the acute and rehabilitative health care needs of older adults and reimburses only a very limited number of nursing home expenses. Medicaid, a need-based, state-administered program, on the other hand, covers nursing home expenses for older adults after their financial resources are depleted. Thus, while Medicare paid 9 percent of nursing home expenses in 1995, Medicaid paid 47 percent of the expenditures. Thirty-seven percent of nursing home expenses were paid out of pocket, whereas private insurance paid only 3 percent of nursing home expenses (Levit et al. 1996).

While private nursing home insurance is increasingly advocated as an important protection for older adults, only very few adults are currently benefiting from such coverage. This limited role played by private insurance may be attributable to high cost, limited coverage afforded by such policies, and lack of information about the availability of insurance (Cohen 1998). Most elderly individuals start their nursing home stays as privately paying patients. Nursing home care, in fact, represents the major portion (82.5 percent) of out-of-pocket health care expenses of the elderly (Rice 1989). After personal resources are depleted (usually in less than a year), patients become eligible for Medicaid financing (Lusky and Ingman 1994).

There is continuing pressure for cost containment to reduce burdens of nursing home costs. The major response to these needs has been the proliferation of assisted living facilities, CCRC facilities, and home health care. In 1995, the average annual cost of a nursing home stay was over $38,000, while out-of-pocket costs for home health care averaged $370 a month, or $4,440 annually (Cohen 1998). There have also been reductions in reimbursable nursing home services by Medicare and Medicaid. Efforts directed at cost containment through reduced payments for care pose a serious threat to the provision of high-quality services. In addition, the profit motive inherent in proprietary health care may be seen as posing a conflict of interest with the provision of high-quality care.

ENSURING STANDARDS OF NURSING HOME CARE

Ensuring high quality of care and standards for services has posed a major challenge to the nursing home industry (Vladeck 1980; R. A. Kane 1995–1996). Problems have been encountered in terms of poor staff training (R. A. Kane 1995–1996), high staff turnover rates (Banazac-Holl and Hines 1996), and limited physician involvement (Fortinsky and Raff 1995–1996). Nurses' aides, the staff members with the most limited training and education and at the lowest end of the pay scale, provide the majority of patient care in nursing homes (IOM 1996). Higher ratios of registered nurses (RNs) to patients are associated with higher patient survival rates, increased functional status, and increased numbers of patients discharged from the nursing home (IOM 1996). Nevertheless, pay differentials between hospitals and nursing homes have contributed to a paucity of RNs working in nursing homes and an overrepresentation of nurses with limited educational backgrounds working in long-term care facilities (IOM 1996). It is noteworthy that nursing assistants employed in nursing homes are also less well paid than their counterparts working in hospitals (BLS 1995). Nursing assistants have limited education, with 46 percent having high school diplomas, while nearly 18 percent have not graduated from high school (IOM 1996). In addition to morale problems resulting from low-status jobs with poor pay, many nursing assistants also face personal problems exacerbated by their low socioeconomic status (Coons and Mace 1996). These factors are related to very high turnover rates among nursing assistants, resulting in poorer quality of care (Schnelle et al. 1993).

Generally speaking, assessing quality of care involves an inquiry into three key ingredients of health care quality: structure, process, and outcomes. Structural measures gauge the presence of certain provider characteristics that are thought to produce good-quality outcomes. Process measures compare the actual care delivered to standards or norms of practice. Outcome measures serve to indicate the results of the care received (e.g., death, functional change). Reliable measures of appropriate outcomes of care are sought by quality-assurance programs in long-term care (R. A. Kane, R. L. Kane, and Ladd 1998). In the context of improvement in care quality, outcome assessments may be used to allocate resources to those areas that require remediation.

Although diverse quality assurance and enhancement programs have been advocated, regulation continues to serve as the major approach to insuring high quality of care. Until Medicare and Medicaid were enacted in 1965, nursing home regulation was each state's responsibility. Once federal programs began paying for nursing home services, the federal government became more involved in regulating nursing homes. It has been argued that Medicare and Medicaid had a major influence on delivery of care in nursing homes due to the regulations placed on facilities and the standards established for certification and for eligibility for payments (R. A. Kane, R. L. Kane, and Ladd 1998; Lusky and Ingman 1994). Lack of uniformity from state to state in care delivery arises as states decide who is eligible for Medicaid. They also impose their own diverse standards for quality care and regulation of such care through inspections.

Alternative approaches to ensuring standards for services have been advanced through regulation or free market economy (Nyman and Geyer 1989). Regulation seeks to enforce high quality of care through staffing standards, care plans, and result audits. In general, regulation aims to ensure the most basic aspects of quality of care, such as appropriate medical care, sanitary living conditions, sufficient exercise, adequate diet, and at least limited privacy for residents. Regulatory efforts are widely employed and have had at least limited success in defining and monitoring quality of health care. However, regulation is seen by many as a costly and often ineffective approach that is dependent on enforcement of a limited set of universally agreed-upon standards (Nyman and Geyer 1989).

In free market competition, consumers do the work of raising quality by making informed choices and purchasing high-quality services. Ensuring standards through the use of the free market economy rests on the assumption that the consumer can identify good-quality care and has furthermore researched the market and will choose to reside in a facility that provides the best care. However, third-party payment systems limit the effectiveness of consumers in exercising market choices. Severely impaired nursing home patients (who may also lack family or advocates) are limited in their ability to exercise sufficient rational market choice to ensure nursing home quality.

Alternative approaches to improving quality of care have been noted in addition to those of regulation or competition. For example, increased involvement by volunteers, family members, and other representatives of the community may enhance care by increasing public awareness and accountability. Community advocacy programs that encourage local citizens to press for patient rights and for improved care delivery have been found to be useful (Williams 1986). In addition, there has been increasing education of the public to have patients and families serve as their own advocates in choosing high-quality nursing homes and in seeking high-quality care through awareness of nursing home residents' rights (Burger et al. 1996). There has also been evidence of the useful roles played by nursing home ombudsmen in helping to resolve disputes involving residents (J. Kahana 1994).

In a 1986 report, the Institute of Medicine called for improvements in the quality of care in nursing homes. A landmark development following this report was the Omnibus Budget Reconciliation Act (OBRA) of 1987 setting forth guidelines by the Health Care Financing Administration for nursing home care. This act aimed to protect resident rights and improve residents' quality of life through a broad set of regulations. These included training and certification of nursing assistants, establishment of quality assurance committees, mandated resident assessments to allow for individualized care planning, reduction of physical and chemical restraints and preadmission screening for mental illness (Hamme 1991). OBRA also enforces a regulation that sets standards of care by increasing financial sanctions for noncompliance. Accordingly, noncompliant homes could be subject to fines and have Medicaid and Medicare payments withheld (Hamme 1991).

The enactment of OBRA raised high hopes about ensuring a high quality of care in nursing homes, and its implementation has resulted in improvements in quality of care. There is evidence of reduced use and overuse of drugs, in particular psychotropic medications (Borson and Doane 1997; Lantz et al. 1996), as well as a reduction in the use of physical restraints in nursing homes since the implementation of OBRA (Dunbar et al. 1996; Siegler et al. 1997). Research has also documented improvements in the accuracy of information in residents' medical records and in comprehensiveness of care plans (Hawes et al. 1997). There has also been an increase in positive programs such as presence of advanced directives and participation in activities by residents (Hawes et al. 1997). As an outgrowth of OBRA legislation, psychiatric assessments and screening programs have resulted in some improvement in matching residents to appropriate mental health services (Borson and Doane 1997). Nevertheless, many problems and challenges have remained in the wake of OBRA. Thus, for example, the OBRA-mandated freedom of residents to select their own physicians can seldom be implemented, because most physicians will not follow their patients to the nursing home to deliver care. Lack of funding for inspections allows violations to go undetected (Day 1996). There have also been only limited advances made in the treatment of the depressed elderly (Snowden and Roy-Byrne 1998).

RECENT TRENDS IN PROGRAMS AND CARE DELIVERY IN NURSING HOMES

In addition to mandated programs to enhance nursing home quality, there have also been notable developments in recent years to introduce innovative or at least new approaches to caring for older adults in nursing homes and other long-term care facilities. We will review two major approaches to such developments: special units and formal intervention programs to improve quality of care and of residential life.

Special Units. Special units within nursing homes are based on homogeneous groupings of people with special needs. The assumption underlying this movement is that specially trained staff may best meet the unique needs of specific patient groups. Segregating populations of residents with stigmatized or disruptive characteristics may also be seen as benefiting other residents by limiting their exposure to these populations.

Special programs can be targeted to unique groups such as dementia patients and patients in the final stages of life. Each of these will be discussed below. Although there is increasing recognition of the role of nursing homes in meeting the special needs of populations such as patients with AIDS (Zablosky and Ory 1995) or patients with brain injuries (Parsons 1997), programs for such individuals have been sporadic and limited. Often these special needs groups include higher proportions of younger patients and models of nursing home care geared to the elderly are poorly matched to their needs. Furthermore, research evaluating such programs is generally lacking.

Dementia Care Units Special care units in nursing homes have been proliferating for dementia patients. About 20 percent of nursing homes had dementia-specific special care units in the mid-1990s (Aronson 1994). These units are based on presumed benefits of functionally homogeneous resident groupings and generally target programs for confused but ambulatory residents.

It has been argued that dementia patients need "high-touch" rather than "high-tech" interventions (Aronson 1994). Many programs targeting dementia patients, are not reimbursable under skilled care guidelines. Special units for dementia care have been in the forefront of the development of certain innovative programs and particularly in integrating family members in patient care (Gaston 1994). Family members' prior knowledge of the older adult when he or she was functioning well can enable expressions of emotional support, which in turn facilitates maintenance of the dignity and self-worth of these elders. Effective formal programs in dementia units that involve families in the care of elders range from family stories workshops (Hepburn et al. 1997) to the inclusion of families in staff-initiated treatment programs (Grower et al. 1994).

Hospice Units As greater numbers of older adults are dying in nursing home settings, the provision of hospice care is becoming a more central function of nursing homes. Between 1992 and 1995, the number of nursing homes with hospice units increased 100 percent, although the development of such units is constrained by market forces such as Medicaid reimbursement (Castle 1998). The value of the hospice as a useful model for end-of-life care has been increasingly recognized. This approach to care emphasizes holistic patient care aimed at diminishing pain and enhancing comfort and meaning. This orientation brings both dignity and autonomy to the process of dying for the elderly resident (Hayslip and Leon 1992).

The hospice model also points the way to recognition that the nursing home often serves as the context where older adults prepare for dying. Accordingly, a much-needed and often-absent function of nursing homes is helping residents come to terms with awareness and acceptance of their finitude (Johnson and Barer 1997).

Formal Interventions to Improve Quality of Life in Nursing Homes. While sociologists have generally focused on the specification of broad social features of nursing homes that impact on the life and welfare of the resident, psychologists, nurses, and social workers have been more involved in implementing specific and circumscribed intervention efforts in nursing homes. Direct interventions to improve resident functioning and/or the quality of resident life in nursing homes have been limited by the absence of systematic theories, on the one hand, and lack of resources, on the other. Diverse efforts to improve care have generally yielded some success, suggesting that almost any type of intervention can improve the quality of life or functioning of residents (E. Kahana, B. Kahana, and Chirayath 1999). Interventions may be broadly classified into two types: those aiming to improve the physical or social environment of the setting, and those aiming to improve the coping strategies, psychosocial well-being, or cognitive functioning of residents. Interventions may alternatively be directed at the resident, the environment, family, or staff.

Interventions to improve health and physical functioning of nursing home residents typically include programs that attempt to reduce impairment and disability (e.g. nutritional problems, urinary incontinence) or the risk of falling. Some interventions aimed at improving health and physical functioning expand their scope by attempting to improve overall quality of life for the resident. Such interventions include programs which grant residents greater autonomy and locus of control (Wagner et al. 1994), and those that incorporate self-image enhancements (Plautz and Timen 1992). Intergenerational programs that promote interaction between nursing home residents and children or young adults have been found to be successful in enhancing quality of life for nursing home patients as well as young children (Gaston 1994; Newman 1985). Such programs have generally been found to improve the activities and social interactions of the elderly.

Interventions targeting cognitively impaired residents include divergent approaches. Montessori methods have also shown success in improving the cognitive functioning of demented elders (Camp and Mattern 1999). Cueing and reality orientation have been therapeutic strategies aimed at reinforcing orientation to time, place, and person among cognitively impaired elderly (Aronson 1994; Whanger 1980). Fantasy validation therapy takes a divergent view, providing staff acceptance of nursing home patients through expressing empathy in response to unrealistic beliefs or behaviors (Feil 1982).

Behavioristic approaches to the treatment of psychiatric problems in nursing homes include reinforcement of appropriate behaviors through token economies or habit training (Whanger 1980). Educational opportunities to enhance competent coping strategies have also been advocated (E. Kahana and B. Kahana 1983). Regarding the physical environment of the nursing home, prosthetically designed environments have been found to retard decline among mentally impaired elderly (Lawton et al. 1984). Milieu therapy is a systematic approach to enhancing all aspects of the social and physical environment in order to encourage social interactions among residents (Soth 1997).

As illustrated in the above discussion of systematic interventions in nursing homes, much of the empirical work relevant to person-environment transactions focuses on only one of the two related influences: the patient or the milieu. Thus, while conceptual frameworks recognize the dynamic nature of person-institution transactions, these complex interactions have not yet been incorporated in therapeutic interventions.

Focus on the Life of the Nursing Home Resident: Effects of Institutionalization. We will now consider those aspects of institutionalization that impact on the experiences, lifestyles, and well-being of the individuals who enter even the best of nursing homes. It is primarily this area of inquiry, relating social processes to the life experiences of the individual patient, to which sociologists have addressed their research on nursing homes. Considering the individual resident in the context of the physical and social milieu of a given institution, we can appreciate both the factors that induce negative reactions and those resources which facilitate positive responses to institutionalization. On this level of analysis, the sociologist moves away from considering the patient as a mere object of care and notes the interactive nature of the encounter between the institutionalized person and diverse elements within the nursing home environment.

The problems brought about by institutionalization go beyond problems of quality health care and in fact, may be inherent in the very nature of congregate care. Accordingly, sociologists have recognized that the nursing home, by its very nature, represents a unique social context with homogenizing qualities, and that there are alterations in the normal patterns of interaction and social exchange, even in facilities providing high-quality care (Linz et al. 1993). Holistic analyses of life in the nursing home have been conducted primarily in a qualitative tradition. They range from firsthand accounts to in-depth interviews and participant observations of the nursing home (Diamond 1992; Gubrium 1993; Henderson and Vesperi 1995; Laird 1979; Savishinsky 1991; Shield 1988). There have been few, if any, quantitative research projects to address the complex fabric of residents' experiences of nursing home life in the past two decades. Conceptual developments have also been limited, highlighting the seminal nature of Goffman's original conceptualizations of the total institution as the most comprehensive and best model in our field.

Goffmann's classical depiction of the total institution (1961) still serves as a standard for understanding the problems of institutional living. The total institution is described as a place where inmates are brought together under a common authority, are stripped of their normal identities, and are expected to engage in activities of daily living according to formal rules and a rational plan that regiments them. Activities of work, play, and sleep overlap and are typically conducted in the presence of others. The institution (which is often located at a distance from friends and from the previous community of the resident) also effectively cuts residents off from social ties in the outside world. It has been suggested that, among nursing home residents, isolation from society and loss of control over one's life lead to learned helplessness (Coons and Mace 1996; Baltes 1996; Baltes and Baltes 1986).

Frail older persons who typically enter nursing homes are particularly vulnerable because of physical and mental infirmities, sensory impairments, and loss of social supports that have created the need for such placement (Resnick et al. 1997; E. Kahana, B. Kahana, and Kinney 1990). Such vulnerable individuals are particularly sensitive to environmental change, and adverse living conditions (Lawton 1980). Elderly persons living in the community generally fear institutional placement and seldom plan for a move to an institution (E. Kahana, B. Kahana, and Young 1985; Schoenberg and Coward 1997). The transition to living in a nursing home is typically involuntary, with patients seldom playing major roles in the relocation decision or choice of facility (Reinardy 1992). Furthermore, the new institutional setting is unfamiliar to the resident in terms of both physical features and social expectations. Fewer than half of family members visit facilities prior to placement of an elder (Lieberman and Kramer 1991). Unpredictability and uncontrollability are major risk factors accounting for the negative outcomes of institutional relocation (Schultz and Brenner 1977). Lack of involvement in decision making has also been associated with adjustment problems (Rubenstein et al. 1992). Alternatively, positive adjustment can be facilitated where older adults participate in decision-making about relocation (Armer 1993).

It is difficult to establish conclusively which elements of institutionalization are responsible for negative outcomes among residents because the effects of morbidity, relocation, and institutionalization occur concurrently and are difficult to separate (Lieberman and Kramer 1991). Yet the negative personal consequences of life in nursing homes have been documented. Institutionalization has been described in terms of dismantling one's home with its comforts, memories, and freedoms (Savishinsky 1991). Institutionalized elders have shown loss of self-esteem and identity (Tobin 1991), and often manifest withdrawal, apathy, and depression (Gubrium 1975, 1993; R. A. Kane 1995–1996; Vladeck 1980).

Gubrium (1993) conducted qualitative interviews with nursing home residents and found great disjunctures in meaning between the workings of the nursing home as an organization and the textured realities of the "lived experience" of residents. Residents live in a rich world of subjective meaning, which is seldom recognized and validated by the nursing home. In fact, nursing homes may actively resist responding to subjective realities of residents, in an effort to introduce an organizational rationality (Diamond 1992). It has been documented that institutional environments providing limited control over the daily lives of residents result in negative resident outcomes, including diminished life satisfaction (R. L. Kane et al. 1990; Timko et al. 1993).

In spite of the evidence of adverse effects of institutionalization, there is a growing body of research and clinical observation that documents positive features and potential benefits of residential life in nursing homes (Patchner and Balgopal 1993; Pynoos and Regnier 1991). For isolated older persons who can no longer care for themselves, the nursing home can offer protection, improved living conditions, and even homelike qualities (Groger 1994). Advantages of living in a nursing home can also include behavioral expectations that are well matched to the competencies of the frail resident (Baltes and Werner 1992; Werner et al. 1994; Lawton 1980).

Nutritious meals, regular medical care, and supervised administration of medications may maximize health for frail elders living in nursing homes. Proximity to other residents may allow for social needs to be met, and organized activities can lead to meaningful social participation (Bitzan and Kruzich 1990). Indeed, there is some evidence that resident satisfaction subsequent to institutionalization exceeds expectations (E. Kahana, B. Kahana, and Young 1985). Some early studies have noted improved morale (Spasoff et al. 1978) and enhanced family relationships subsequent to institutionalization of elders (Smith and Bengtson 1979).

There are indications that elderly nursing home residents find their lives to be meaningful and that their sources of meaning do not differ significantly from those of community-living older adults (DePaola and Ebersole 1995). Well-being among residents subsequent to institutionalization may reflect not so much the positive influences of institutional life as the resilience and survival skills of residents. Accordingly, Lieberman and Tobin (1983) demonstrated that even in the face of major involuntary environmental changes such as institutionalization, many elderly persons continue to preserve a coherent and consistent self-image.

Adaptation in Institutions. There is growing evidence supporting the view that residents are active agents who attach meaning to and impact actively on their environment, continuing to take personal initiatives to remain socially engaged in the face of personal and environmental obstacles for doing so (E. Kahana, B. Kahana, and Chirayath 1999; Mor et al. 1995; Gubrium 1993).

Goffman (1961) described a range of adaptive responses among inmates of total institutions. Withdrawal refers to the resident's efforts to curtail interaction with others and to withhold emotional investment in his or her surroundings. Intransigence is a response that challenges institutional authority through noncooperation. These two modes of responding are likely to result in further alienation and to invite negative responses from staff and other residents. Colonization represents a strategy of maximizing satisfactions within the confines of the institution by accepting the rules and norms of institutional life. Conversion represents an identification with both the outward characteristics and the values of staff. Patients who opt for conversion submerge their identities into their patient roles. Although Goffman's conceptualization and description provide the earliest and possibly the richest sociological efforts to understand resident adaptation in nursing homes, there has been little follow-up research to confirm the typologies that he proposed.

Research has documented that there are active efforts even among frail institutionalized elderly to adapt to demands and stresses of institutional living and to remain socially engaged even while living in an institution (Mor et. al 1995). Instrumental coping strategies have been associated with maintenance of psychological well-being subsequent to institutionalization, whereas affective modes of coping have been related to decline in morale (E. Kahana, B. Kahana, and Young 1987).

Appraisals of life in a nursing home may contribute greatly to perceptions of stress, to coping responses, and ultimately to adaptive outcomes. In fact, an understanding of the interpretive meaning of institutional life may help integrate conflicting findings about effects of selection, relocation, and institutionalization on psychosocial well-being of elders residing in nursing homes (Gubrium 1993).

Aspects of physical frailty that create a need for institutional placement, along with perceived or real abandonment by family, require major reappraisals of both one's worldview and one's self-concept. Given a vulnerable self and loss of intimacy with significant others, the safety of one's physical and social milieu becomes a critical concern. To the extent that new residents of nursing homes can appraise their physical and social environment as safe, they will feel protected. To the extent that they feel that other residents who compose their new reference group are helpful, social integration may be possible, and depersonalization may be avoided. There is evidence that residents in assisted living facilities engage in reciprocal helping social interaction and derive satisfaction from being providers of assistance to others (Litwin 1998). This research supports earlier work (E. Kahana, B. Kahana, Sterin, Fedirko, and Brittis 1990) which demonstrated that perceptions of even minor acts of helpfulness by other residents help the institutionalized elderly reinterpret their surroundings as benign. Formation of social ties with other patients represents an important mode of positive adaptation for nursing home residents (Mor et al. 1995).

Personal backgrounds of residents as well as environmental influences affect the nature of adaptations that residents make in institutions. Lack of mental impairment and few mobility limitations and sensory deficits are associated with maintenance of close social ties within the nursing home (Bitzan and Kruzich 1990). Personality and cognitive traits such as impulse control have been found to be associated with psychosocial well-being subsequent to institutionalization (B. Kahana and E. Kahana 1976).

In order to better understand and operationalize person-environment transactions in nursing homes, several conceptual models have been articulated that take into account both personal and environmental features. Lawton's ecological model (1980) focuses on the importance of matching environmental elements to personal competencies of frail elders. E. Kahana's person-environment congruence model (1982) emphasizes the role of individual differences in needs and environmental preferences, and specifies alternative formulations for expected outcomes based on oversupply, undersupply, or congruence of environmental characteristics, such as stimulation or homogeneity, in relation to personal preferences. It is notable that there has been very limited attention to advancing conceptual models in this arena during the past two decades.

Interactionist perspectives lead to a better understanding of social influences in nursing homes by calling attention to the importance of both personal reactions and environmental presses. Environmental design and intervention approaches in nursing homes have focused on improving adjustment of residents to nursing homes by providing environments that benefit residents in general, or interventions that improve fit between the environment and personal needs of residents. Research has demonstrated that resident characteristics interact with environmental features of the nursing home to predict outcomes (Baltes et al. 1991; Timko et al. 1993). Accordingly, supportive physical features and assistive services were found to benefit impaired residents while policies permitting resident control were most likely to benefit independent residents. Furthermore, specification of salient dimensions of the institutional milieu has been one important area of progress toward designing better nursing home environments. Moos and Lemke (1996) have conducted pioneering work in providing reliable and valid indicators of social dimensions of the institutional environment.

Specific components of the institutional environment determine the demands, constraints, and benefits of institutional life for residents. They include the administrative structure, the physical environment, and the social environment. The social environment may be further subdivided into staff environment; patient environment; and community representatives such as volunteers, or friends and family, who visit the resident in the institution. There is growing evidence that the perspectives of residents, staff, and families diverge with regard to quality of life in nursing homes (Brennan et al. 1988). Research on administrative structure has focused primarily on size, financing, and type of ownership. Although it has been argued that proprietary ownership may result in poorer quality of care, the link between type of ownership and level of care has not been conclusively established. Similarly, suggested links between size of home or proportion of Medicaid patients and quality of care have not been fully documented (Shapiro and Tate 1995).

Similarities in ethnic, cultural, and social backgrounds of staff and residents appear to facilitate positive interactions, whereas discrepancies in cultural values have been found to hamper communication and mutual understanding (E. Kahana, B. Kahana, Sterin, Fedirko, and Taylor 1993; Harel 1987). Institutional norms as well as formal policies have been found to shape the impact of institutions on residents (Kiyak et al. 1978). Research also suggested that perceived social support from family not only deters institutional placement but also relates to higher self-esteem and diminished depression among elderly nursing home residents (McFall and Miller 1992).

Resident-to-Resident Interactions There has been very little research focusing on the social milieu of nursing homes in terms of resident-to-resident interactions. It is indeed noteworthy that, in one study of nursing home residents, nearly 50 percent of all residents were found never to talk to their roommates, typically because of barriers to communication such as hearing or speech problems (Kovach and Robinson 1996). Nevertheless, among those residents able to talk to their roommates, rapport with the roommate was found to be a significant predictor of life satisfaction. It is notable that communication rules about talking often inhibit communication and contribute to living in silence among nursing home residents (Kaakinen 1992).

The salience of friends appears to be limited for nursing home residents, as there are many barriers to elderly friends maintaining contact with their noninstitutionalized friends. Accordingly, perceived social support from friends did not significantly relate to positive outcomes of nursing home residents (Commerford and Reznikoff 1996).

Family-Resident Interactions Interactions with family also play an important role in social integration of residents. Research has underscored that the majority of institutionalized elderly maintain meaningful ties and interactions with family members (Schwartz and Vogel 1990; High and Rowles 1995; Smith and Bengtson 1979). Ties to children who visit most frequently appear to be closest, followed by ties to other family members and friends (Bitzan and Kruzich 1990). Proximity of family members and previous history of extensive social interactions facilitate continued contact between residents and kin (York and Calsyn 1977). In turn, visitation by families and friends has been associated with enhanced residential functioning and well-being (Greene and Monahan 1982).

Broader roles for family members for being involved in the support and direct care of patients have been discussed, particularly in the social work literature (LaBrake 1996). However, systematic investigations of the efficacy of such efforts are sparse. Some family support group activities as well as family counseling programs have reported success in bringing family and staff closer together (Campbell and Linc 1996). There have also been some educational efforts directed at assisting family members in coming to terms with psychological issues that they face regarding institutionalization of the elder relative (Drysdale et al. 1993).

Even while there is limited indication of systematic and welcoming programs initiated by the nursing home for the involvement of families in the care of residents, there are indications about naturally occurring involvement by family members in the lives and care of institutionalized older adults. Thus, for example, studies indicate that families are highly involved in assisting their relatives with decision making, and in actually making decisions when needed (High and Rowles 1995). Although researchers had expected to find less participation in decision making by families over time (since it was assumed that they would gradually defer to staff in making decisions), it was found that families do remain highly involved in their relatives' lives and well-being, even after four years. Families reported involvement in a broad range of decisions, ranging from those made during crises to those concerning the physical environment and treatment decisions.

There is also evidence, from surveys of family perspectives on nursing home care, that family members are typically sensitive and understanding about the constraints under which nursing home staff work and the difficulties posed by caring for frail elders, and particularly those with dementia (Looman et al. 1997). This research found that families also appreciate positive interpersonal ties between nursing assistants and residents.

The potential of constructive family involvement for improving resident life in nursing homes is yet to be recognized. It could have a major positive influence on helping break down barriers between the outside world and those of the institutions, addressing Goffman's classic challenge to the total institution (1961).

Future Prospects for Policy and Long-Term Care Delivery. It has been argued that, in the future, home care may evolve into a model of personal assistance services, and thus could blur the boundaries between institutional (nursing home) and community-based care (R. A. Kane 1995). To the extent that personal care and housing-related services in nursing homes could be separated, residents and families could gain greater control of their lives. With the support of flexible home care options, many frail older persons could remain in innovative community residential options, such as assisted living arrangements, for the remainder of their lives. Such potential developments are attractive, but assume major changes in the financing of long-term care and the building of private accommodations, which include baths and kitchenettes, in housing for nursing home residents. Such new trends in financing and delivery of care would have to be based on dramatic expansion of personal long-term care insurance and/or availability of savings to finance long-term care. Alternatively, they could be implemented based on major new universal services furnished through social insurance programs (Kingson 1996). However, there are no clear indications that any of these financing options is likely to materialize in the near future. Furthermore it is likely that in the future most new and even existing long-term care services will be implemented by individual states. Increasing involvement in delivery of long-term care by states is likely to lead to increasing variability in the quality of care delivered (R. L. Kane et al. 1998).

In spite of expected increases in alternative long-term care facilities, the population of old-old adults residing in nursing homes is expected to increase dramatically, due largely to the ever-increasing age structure of the U.S. population. It is notable in this regard that research projecting future nursing home use demonstrates that better health in future cohorts of the old-old will only slightly decrease the proportion of time older adults will spend in nursing homes, or the proportion of this cohort who will enter nursing homes (Laditka 1998). Thus the nursing home as an organization is here to stay for the foreseeable future.

Furthermore, it is important to recognize that all the numerous alternatives proposed to address the shortcomings in the current system involve potential problems and tradeoffs (R. A. Kane et al. 1998). Ultimately, the planning, financing, delivery, and oversight of long-term care challenges our values and ingenuity as a society. Accordingly, sociologists, who have generally opted out of the study of long-term care, are very much needed to get involved in this area, if we are to gain deeper understandings and develop systematic research based guidelines for improving services in this field.

CONCLUSION

The foregoing discussion has highlighted a series of counterpoints in consideration of nursing home care on the macro and micro levels. On the macro level, distinctions between medical and social models of care, quality-of-care, and quality-of-life issues have been discussed. Societal needs for cost containment have been juxtaposed with the need to invest greater resources in long-term care to ensure provision of high-quality care. Regulation and free market competition have been presented as alternative strategies to improve standards of care. Uncertainty about service models, along with a great concern about costs of care, have resulted in a stalemate in the field of long-term care (Vladeck 1995).

On the micro level, we have noted evidence for depersonalizing aspects of institutional living, along with data about protective features and benefits of long-term care environments. Furthermore, residents of nursing homes have been described as frail and vulnerable on the one hand, and as adaptable and resilient on the other. The ultimate well-being of nursing home residents is seen as a function of the environment, of the person, or of transactions between the two. These dualities are useful to propel dialogue and to permit a thorough examination of nursing home care. At the same time they hold the danger of oversimplification of issues that may be approached from a unidimensional framework as proponents advocate one pole of the duality or the other. In fact, a sociological understanding of nursing homes underscores the complexity and multidimensionality of the social context and the social world of the nursing home. Thus, there is great benefit in attempting to integrate insights gained from both poles of the dualities discussed.

The nursing home resident of the future is likely to be ever more frail, especially if we succeed in developing more home-based alternatives to care. Hence, we cannot reject the medical model in favor of a social model of care, or focus exclusively on quality of life rather than on quality of care. Instead, we need to complement concerns of high-quality health care with those of high standards for social care. Similarly, just as proprietary care is likely to remain a part of health care in the United States, so regulation is here to stay. Although prospective nursing home residents are likely to be ever more frail, they are also likely to be more highly educated and more conscious of their rights as consumers. Financing mechanisms that enhance the ability of the consumers of long-term care to exercise control over their lives can complement regulatory efforts to upgrade quality of care in nursing home settings. On the broadest societal level, decisions about both commitment of resources and development of creative alternatives to institution-based, long-term care are likely to shape the parameters and qualities of nursing homes of the future.

The experience of a given individual in being cared for in a nursing home must ultimately be understood in the context of the complex matrix of influences posed by institutional living. Accordingly, it is not fruitful to focus exclusively on either the ill effects or the benefits of institutionalization. Reviews of nursing homes continue to focus on normative understandings, generally highlighting poor quality of care in such facilities. As we have noted in this essay, empirical support for such negative conclusions is generally derived from qualitative research. Quantitative studies generally provide less support for expectations of decline and adverse patient reactions. In an effort to understand conflicting conclusions of different genres of research in this area, it is useful to focus on personal as well as environmental and situational influences that moderate the effects of institutional living. More carefully designed nursing home–based research, utilizing quantitative as well as qualitative approaches, is needed to specify conditions of both person and environment that maximize the well-being of the individual requiring institutional care.

Newer health care options, such as CCRCs, assisted living, and special care units, have been touted as more patient-responsive solutions to care than traditional nursing homes. Nevertheless, true consumer control and resident outcomes are still largely contingent on the resident's power to demand and advocate for appropriate care options. If an older adult becomes physically frail or mentally impaired, such options are likely to diminish, or even evaporate. Consumers are once again at the mercy of bureaucratic decision making about their best interests.

Even advocates of alternative forms of long-term care acknowledge that nursing home care will continue to be needed and utilized by the increasing segment of old-old citizens. Sanctions, incentives, and intervention programs have all been shown to be beneficial, at least to a limited extent, in improving the quality of care and the quality of life in nursing homes.

Enhancing the quality of nursing home care creates a challenge for society to commit greater resources generated by currently productive citizens to the care of those who have made previous contributions. The resources society devotes to long-term care ultimately mirror the value placed by society on its frail or dependent citizens. Thus, a devaluing of older people is likely to result in a devaluing of institutions that care for them, along with a devaluing of the providers of their care. Conversely, more positive societal attitudes toward frail elders are likely to be translated into increasing involvement by high-caliber, trained professionals in the care of the institutionalized elderly. In addition, positive societal attitudes should bring family members and community representatives into closer contact with institutions, and should help to break down barriers between the nursing home and community living.

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Eva Kahana