New Mix of Services : A Little Help Lets Elderly Live at Home

Hobbling on two canes, Edna Armstrong, 95 and legally blind, clings to an independent life in her tiny home in the San Gabriel Valley with a little help from the state of California, which sends her housekeepers and once even arranged to repair her leaky septic tank.

Across the country in a modest New York City home, Estelle Dunham, a 106-year-old woman who brandished her cane to chase away two robbers last year, enjoys the company of a government-paid aide who helps her bathe and exercise and prepares her diet of baby food.

And in Florida, Harry Brodsky, a 76-year-old victim of Alzheimer’s disease, goes to adult day care twice a week while his wife, Rose, 70, receives much-needed counseling from a social worker sent by a local Jewish services agency.

‘Nursing Home Without Walls’

Without fanfare, a bewildering mixture of public and private services has emerged nationally to support a deeply rooted American value: the determination of the elderly to live out their lives in the comfort and independence of their own homes.

Ideally, the services can add up to a “nursing home without walls,” a combination of health care, day-care supervision, housekeeping services, counseling, meal deliveries, transportation, visits from friendly companions, home repairs and more.

Yet the cost of such services can easily strain or exceed the budgets of the 5 million elderly who need outside help in their struggle to live at home. And governments at all levels are reluctant to expand their support for fear that the demand--and the cost--will prove almost limitless.

What is at stake, declared University of Southern California gerontologist Jon Pynoos, is the very quality of existence for millions of the elderly. “It’s not just an issue of saving money,” he said, “but how we allow old persons to live out their remaining years.”

Public spending remains sharply tilted toward the elderly in institutions. The federal government, for example, funneled $8.2 billion last year to nursing homes, mostly through the joint federal-state Medicaid program for the poor. In sharp contrast, it spent less than $3 billion to assist elderly persons struggling to stay outside nursing homes.

Reagan Administration officials are not convinced that more dollars would encourage more people to stay out of nursing homes. Instead, they worry about the “woodwork effect”--the prospect that large numbers of elderly individuals who have been managing on their own would suddenly come out of the woodwork and sign up for expanded live-at-home services.

And that concern extends to the states. Even in the retirement haven of Florida, where state-paid services assist 300,000 people a year who live in their homes, the Legislature is expected to give Democratic Gov. Bob Graham just half of the $14 million in additional funds he has requested for next year.

To be sure, life in a nursing home can be the most appropriate choice for an enfeebled old person no longer able to stay at home safely. Many have no other way to contend with the dangers of dizziness and frequent falls, the embarrassment and discomfort of incontinence and the inability to remember when to take pills.

10% to 20% Demand Estimated

Teresa MacCarley, who runs a senior center in Hollywood, knows of elderly neighborhood residents whose homes became infested with insects or who failed to pay bills even though they had money. “I know we keep people from being institutionalized,” she said. “In fact, maybe we keep some people too long.”

Yet a 1985 USC study concluded that 10% or more of nursing home residents in Los Angeles County would be better off in their own homes or other settings less formal than nursing homes--and other studies have put the figure as high as 20%. Many of the elderly have difficulty “figuring out the system” of community services, the USC researchers said, and their doctors are unaware of available alternatives to nursing homes.

Medicare, the federal health insurance program for the elderly, is trying to limit the amount of time its beneficiaries can remain in the hospital. Yet it will pay the bills at home only for those getting skilled nursing care. Federal officials recognize that this creates a predicament for the elderly.

“Many of these patients need assistance in daily living activities such as bathing or preparing meals, which are not skilled services covered by Medicare,” Dr. William Roper, who runs the Medicare program as head of the federal Health Care Financing Administration, told a recent Senate hearing.

Critical of Medicare Strategy

But critics complain that Medicare is trying to restrict even more the range of in-home services it will pay for.

“The strategy is very clear to me,” said Val J. Halamanderis, president of the National Assn. of Home Care. “Having saved billions of dollars by moving people out of hospitals, the federal government is trying to trim the candle on both ends by cutting down the amount of money spent for community care.”

Already, the elderly and their families will pay an estimated $9 billion a year out of their own pockets for private services in the home, according to Janet Zhun Nasif, author of “The Home Health Care Solution,” a consumer guide. With that kind of money as a lure, an enormous and diverse industry has developed.

The Visiting Nurse Service of New York City, for 93 years a charitable agency, has launched a profit-making subsidiary to supply aides for the middle-class elderly who may need someone to clean house, cook meals, provide an escort to the doctor’s office or simply offer companionship. Major private companies, including Kelly Services and H&R; Block, have moved into the same business through subsidiaries.

Small Firms Enter Field

And smaller firms such as CHAS Inc. (Companion and Homemaker Assistance for Seniors), which provides aides for 35 clients out of offices on Wilshire Boulevard, are entering the field as well. “The potential for this type of business will grow as the number of seniors grows,” said P.J. Robinson, who started the agency in her own apartment a couple of years ago.

Many states operate special projects to help the frail elderly stay at home at little or no charge. But the programs usually are available only to extremely limited numbers of the poor--those who qualify for Medicaid and who are so frail that they otherwise would be likely to enter nursing homes almost immediately.

A typical participant, 106-year-old Estelle Dunham, suffers from hardening of the arteries and a digestive disease called cholecystitis, which makes it impossible for her to eat anything but baby food. She lives in the basement apartment of the house in Queens of her daughter, Emma Felder, who is herself 68 and suffers from severe arthritis.

After a life of plowing fields, cutting wood and picking cotton in South Carolina, Dunham has no intention of being chased out of her home and she showed her fighting spirit last year when two 16-year-olds classmates of her grandson invaded the house and tried to terrorize her grandson into giving them money. “I had my stick and I said to them, ‘Come on, I have it right here,’ ” she said. They fled and were quickly arrested.

Requires Supplemental Help

But the mundane demands of daily living have almost succeeded where teen-age hooligans failed; only because the Visiting Nurse Service of New York has supplemented the support of her own family has Dunham remained out of a nursing home. Muriel Campbell, a home health aide, spends eight hours daily at Dunham’s home, helping her bathe and dress, assisting her with exercises, reminding her to take medicine and cleaning her rooms.

Dunham does not pay Campbell herself. Instead, the bills go to the Visiting Nurse Service’s Nursing Home Without Walls program, which provides care in the community to stave off the even greater costs of supporting the elderly in nursing homes.

Similarly, in Altadena, 95-year-old Edna Armstrong is still living in her cozy, Spanish-style home because California’s Multi-Purpose Senior Services Program provides her with the services of a homemaker and a social worker. The program even paid to install railings on her porch and to make the necessary repairs when her septic tank flooded the driveway last fall.

Armstrong, who suffers from heart disease and other ailments, also relies on a younger neighbor to wash her clothes and a church member to pick up groceries. “I want to stay here till the good Lord calls me home,” said the former dressmaker, sitting on the pink couch she bought in New York in 1927. “I don’t want to be moved. In fact, to get me out of here alive, they’re going to have to call the law.”

Few Become Beneficiaries

Dunham and Armstrong are among the select few. New York’s Nursing Home Without Walls program is open to only 600 needy beneficiaries in all of Manhattan and Queens, and California’s Multi-Purpose Senior Services Program serves 4,200 persons compared with a statewide nursing home population of 107,000.

The New York and California programs are among only a handful nationwide that use Medicaid funds to pay for services that are not strictly medical. Medicaid has waived its rules because the states have demonstrated to the federal government’s satisfaction that the programs’ beneficiaries otherwise would cost the public more as nursing home residents.

Nationwide, only 53,000 frail persons are enrolled in experimental programs designed expressly to help the elderly poor remain home--a fraction of the million persons whose bills in nursing homes are paid by the government. Compared with the $8.2 billion a year that the government spends toward nursing home bills, the experimental effort diverts only $159 million to in-home services.

Whether these in-home services actually keep the frail elderly out of nursing homes remains highly uncertain, however. Perhaps Dunham would manage with the help of her grandchildren. Maybe Armstrong would find a willing neighbor to help her stay in her home.

Experiment Surprised Planners

Between 1982 and 1985, on an experimental basis, the federal Health and Human Services Department provided elderly persons living at home in Miami, Houston, Baltimore and seven other locations with a tempting array of assistance--health aides, day-care services, home companions, chore workers and home-delivered meals.

Project planners were surprised to find that participants in the experiment resorted to nursing homes just as frequently as a comparable population of elderly persons who did not benefit from the same smorgasbord of in-home services.

That does not mean the services were not worth their cost--an average of $3,900 per participant over the course of the experiment. “There were small but generally beneficial effects on social and psychological well-being,” according to an HHS report. Family members got some hours off and badly needed relief from providing round-the-clock care.

And the operators of at-home service programs are convinced that the nursing home population would grow in their absence. Marie-Louise Ansak, executive director of On Lok, a special federally financed program in San Francisco’s Chinatown that serves 300 elderly residents, insisted: “If we closed our doors tomorrow, 80% of the people would be clamoring for nursing homes because they couldn’t continue in the community.”

Patchwork of Programs

In addition to its Medicaid experiments, the federal government supports a patchwork of less comprehensive programs, including “meals on wheels” and senior centers, that are designed to help the elderly get along in the community. Old people flock to them.

“I think that people perceive the government-funded services are only for the poor and that’s not true,” said MacCarley of the Hollywood senior center. “We are here to serve everybody. We don’t turn people away. We don’t do an income test.”

But it is the needy who typically make most use of these centers, which provide such services as meals, recreation, counseling and day care. St. Barnabas senior center in North Central Los Angeles, for example, served 19,319 persons last year, 74% of them at or below the poverty line.

“Our clients don’t largely come to us for recreational needs or just to spend time,” said Idelle Cowles, the center’s development director. “They come because they have some dire emergency and they don’t know what to do about it.”

The paucity of government-supported services has left a void that the private sector is helping to fill. Under an umbrella program called Living at Home, seven private philanthropic foundations will give more than $4 million over the next three years to groups in dozens of cities that are experimenting with ways to help the elderly avoid nursing homes. “People feel the need for services, but they don’t know where to turn,” said Dr. Morton D. Bogdonoff, the program’s director.

Creating a New Profession

To fill that need, nurses, social workers and psychologists are creating a new profession of “case managers” who counsel the elderly and their families and help locate the housekeepers and aides for them. Some 200 firms have entered this field in the past few years, usually charging fees between $45 and $85 an hour, according to several of the private practitioners.

That is how Lory Glickman, a 49-year-old executive secretary in Encino, solved a problem as she awaited a visit in April by her mother, Rose Brodsky, and her father, Harry, who was losing his memory to Alzheimer’s disease. Glickman prepared for the visit by consulting with Nancy Wexler, a licensed family and marriage counselor.

During the visit, the ailing, 76-year-old Harry Brodsky kept his family awake for hours late one night, talking constantly and arguing irrationally. The next day, when he had regained his senses, Wexler and an assistant reassured him that he was not about to be sent to a nursing home. The Brodskys soon returned to their condominium near Fort Lauderdale, where, with Wexler’s help, Rose Brodsky receives counseling from a social worker from a local Jewish community center and Harry Brodsky twice a week attends an adult day-care center run by the Jaycees.

Found She Was Not Alone

Lory Glickman said of Wexler: “She represents a department store of information. . . . My own perspective is that through Nancy, my mother absorbed the information that she is not alone with the problem and that’s important.”

Glickman is fortunate not only that she found Wexler, who charges $65 to $80 a visit or even more, but that she can afford her. Not everybody could, and that’s why government-supported programs, costly as they are to the taxpayers, have become so popular.

“We’re going to pay for this one way or another, through increased taxes or increased insurance premiums or directly out of our pockets,” said Ed King, a health care analyst for the accounting firm of Arthur Young & Co. “Or else we can leave old people out on the streets, and I don’t think we want to do that.”