able investment will have to be made in undergraduate and graduate programs if appropriate services and care are to be available. Finally, the scope of "health care services" for the elderly is broad. Curative services remain important, but as the burden of chronic diseases increases with age, maintenance of function and satisfaction with care loom large as the primary outcomes in assessing the appropriateness and effectiveness of health care services. Critical services will be diverse, including clinical and personal care, functional assessment, education and social services, transportation, housing, social support, income supplementation, and others. Further, it is possible that social investments outside clinical geriatrics (e.g., in lay care giver training or in housing or social environments) will, in the end, be more effective in improving elder health than those in the medical care sector. Even within the domain of clinical activities, some critical services for sustaining elder health (e.g., annual influenza vaccination) may be the "product" of multiple providers such as the public health department or senior citizen centers, as well as the responsibility of clinical organizations.


Given the size of the elder population, its political salience, and importance to medical care expenditures, many stakeholders would see the health status and effectiveness of services provided to this population as important, including providers, insurers, and state and local public health authorities. The frail elderly are an at-risk population in head-to-head competition with education of youth in state budget plans. Even employers and local industry, to the extent that they are committed to medical care for their retired employees and are concerned about current employees' obligations to care for elderly relatives, have a stake in the health of the elderly.

By using the domains of the field model, it is possible to identify a variety of measures that might serve as performance indicators for a community's efforts to improve the health of the elderly. Because of the nature of aging, both the medical and the social needs of elders must be addressed.

Health Care and Disease

An extraordinarily diverse set of performance indicators could be considered for use as part of a monitoring system that ad-

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