Care for Elders with Chronic Disease and Disability

Abstract

The main characteristics of long-term care are chronicity and a multidisciplinary and multisectorial involvement where professionals interact with lay caregivers. Long-term care goes beyond the traditional boundary of medicine and single-sector responsibility, thereby creating confusion and ambiguity among providers and policymakers about its proper place.[1] Should it be part of health care, to be included in the basic package of medical services, or is it merely a welfare problem? What is the proper balance between medical and nonmedical needs? These questions are not easy to answer. The need for long-term care among elderly individuals is almost always medicosocial. The medical conditions are often multiple and chronic and thus important, but it will be the level of disability or dependency together with psychosocial factors that will determine the need for societal help and services. The medical goals in long-term care are to control disease and prevent its progression, to provide palliation, and to maintain or improve self-sufficiency. A more general goal, which cannot be achieved by medical intervention alone, is to promote well-being in the presence of chronic disability. In this context, the harmful effect of the medicalization of chronic care has been recognized. It has increased the cost of care through greater consumption of more expensive and highly professionalized medical services--while often, at the same time, leaving the nonmedical psychosocial needs of the recipient unmet. This danger could be overcome by a new trend in long-term care: demedicalization. The rationale for encouraging this trend is that it will lead to both a higher quality of care and to decreased spending. Yet acceptance of demedicalization as a leading principle could bring about just the reverse danger: that the recipient of care, chronically ill and disabled, would be deprived of necessary medical interventions and skilled nursing care. The proper response to that danger is to target services carefully, tailoring them to individual needs and variations. The process of targeting and individualizing services needs more attention. It is a stepwise process, encompassing case findings, screening, assessment, the planning and monitoring of care, and outcomes evaluation.[2] While there is a general acceptance of those steps, individual countries differ in their models of case management and only a few have structured their systems to encompass the whole process. Many studies have confirmed that there is a hierarchy of service use according to disability status of the recipient. Generally speaking, the higher the disability level, the more extended and personal is the needed range of services. However, the full range of services has been developed in only a few countries, and the availability of nontraditional services (such as day care, respite care, and apartments) is limited. Even in countries with well-developed systems of care, the spectrum and distribution of services and access to them are still under discussion and are subject to policy changes and trends in innovation. Moreover, actual use of services is shaped more by economic possibility, historical tradition, political climate, and the culture's welfare philosophy than by objective needs and individual choice.[3] The estimated numbers of elderly people who need some kind of societal help are very similar throughout Europe and North America. About 5 to 7 percent of the elderly are heavily dependent or medically unstable and thus in need of institutional placement. Another 5 to 10 percent of the disabled are cared for at home, while a further 15 percent require home help or community services. Nonetheless, despite these similar needs, consumption of services varies extensively. In the Netherlands, Sweden, and Norway, the rate of institutionalization approaches 10 percent, while in Japan and the Czech Republic it is as low as 3 to 4 percent. …