hospital stay following PPS should in theory have had the practical consequence of a greater need for home health services. Other factors in this leveling may be a strict interpretation of the homebound provisions and an inability of the home care market to expand sufficiently to meet the immediate demand.

A detailed examination of 1986 home health statistics (Table 3.11) shows that service use increases with age, measured as visits per 1,000 enrollees; visits per elderly person are about the same at every age (visits per nonelderly person are considerably higher than for elderly). The proportion of females using home health services is 29 percent higher than that of males.

In 1985, 80 percent of the elderly who required assistance with activities of daily living (ADLs) lived at home. Women outnumbered men 2 to 1 in this population (GAO, 1988).

Formal community-based services help address the needs of persons with activity limitations and include a broad range of health and social services such as home health care, rehabilitation programs, homemaker and chore services, personal care services, adult day care, and meals on wheels. Some nursing home patients do not require the level of care provided in an institutional setting and could remain at home assuming that appropriate services could be provided (Rice and Estes, 1984). Community-based services, therefore, are intended to help the elderly (among others) cope with independent or community living, so as to improve the quality of individuals’ lives and forestall institutionalization.