use of alternative noninstitutional settings for long-term care has increased to include home health care, personal care, residential care, and care management and other services. Within institutional settings such as nursing homes, specialized units often termed “ special care” units and “subacute care” units have emerged in an effort to meet the needs of subgroups of residents such as those with Alzheimer's disease or with relatively short-term post-acute care needs, respectively. Over the past decade, federal Medicare policies dramatically expanded and then more recently contracted coverage for home health care. Moreover, the increased use of preadmission screening for nursing homes, the expanded role of Medicaid home and community-based waivers, the introduction of Medicare and Medicaid managed care programs, the general trend toward prospective payment and more rapid discharges from hospitals, and the emergence of various long-term care provider industries, all have altered the patterns of long-term care. These arrangements also offer more alternatives for long-term care users and their family members.

This expanding range of services and service settings reflects, among other things, better understanding of the preferences and values of people needing long-term care; medical and technological advances that allow more care to be provided outside hospitals and other institutions; and pressures to cut costs by shifting more care from hospitals to other settings that are thought to be less costly. Managed care organizations have not been major participants in long-term care delivery, but their decisions about hospitalization, home care, rehabilitation, and similar matters have spillover effects to the long-term care sector.

Changing cultural perspectives about people with long-term care needs also are influencing the nature of long-term care. These individuals are being viewed as people not only with needs and vulnerabilities but also with preferences to retain some control over major elements of the care they receive. As encouraged by the 1986 IOM report and by others, assessment of the quality of long-term care increasingly includes attention to the quality of life, including satisfaction with care, experienced by those receiving such care.

LONG-TERM CARE NEEDS

The implications of the aging of the population for the demand for long-term care and for the widespread public and policy focus on the elderly population in discussions of such care are a long-standing concern. The U.S. population is aging and the elderly population is growing older. The population aged 85 years and older is the fastest-growing age group in the United States, and it is the most rapidly growing age group among the elderly population. Most of the increase in demand for long



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