elderly. The ratio of people older than age 80 to children will peak in the year 2000, decline somewhat over the next two decades, and then soar to an even higher peak in the year 2030 (Institute of Medicine, 1989b).
These predicted trends and the mismatch between today's health and social service system and the needs of the elderly and of younger adults with chronic disease and disabling conditions should compel policymakers and service planners and providers to rethink current approaches to care. Driven by concerns about escalating expenditures, such a reappraisal is taking place, but too little attention is being paid to access to care and, in particular, to quality of care. As a result, changes implemented in the name of controlling costs are generating new issues in their aftermath. Health care practitioners, noting that the average hospital stay in the United States is shorter than in any other nation, complain that patients are being discharged from hospitals not only quicker but also sicker, although research on this issue has produced equivocal results. Also motivated largely by cost concerns, many people are placing greater emphasis on home and community care as an alternative to institutionalization. Although this shift is often viewed positively, lack of standards for home care, questions about the competency of providers, restrictions on reimbursement for services, and other concerns suggest considerable variability in the effectiveness of this approach.
Robert L. Kane contends that many of these new issues and problems are the product of an "alternatives mentality" (Institute of Medicine, 1989b). Home and community care, for example, has been advanced as a means of keeping the elderly and chronically ill out of nursing homes, but other than the goal of avoiding institutionalization, objectives have not been established for community care. "We have not addressed more fundamental questions," Kane maintains, "such as, Is community care a legitimate and important vehicle for providing care on a long-term basis" (Institute of Medicine, 1989b). Moreover, if avoiding institutionalization is the sole aim, then attention is distracted from improving the quality of care in nursing homes, which will continue to be needed.
If social and health care issues related to disability and its antecedent conditions are not addressed coherently at the policy level, it should not be surprising that current approaches to prevention lack necessary comprehensiveness, continuity, and coordination. An essential first step toward achieving the requisite "3 C's" is to redefine the standard by which we judge our efforts.
Quality of life, not just physical functioning, should guide the design, organization, and integration of services. Although quality of life is a subjective concept, valid measures exist for assessing many of its components, including physical, cognitive, psychological, and social functioning. By broadening our attention to embrace all of these determinants of individual well-being, we are more likely to