changing demographic, economic, and sociological characteristics of the elderly population in the United States.

EMERGING TRENDS

Both federally funded programs and private payers are evaluating innovative ways to provide services across the continuum of care while attempting to use the least expensive and least intensive care that is appropriate (Cohen, 1998). Examples of such innovation include privately funded social health maintenance organizations (SHMOs) and programs of all inclusive care for the elderly (PACE). SHMOs are demonstration projects that combine community care services and short-term nursing home care with Medicare’s basic services. PACE is a new Medicare benefit; these programs accept the risk of providing all forms of care needed by nursing home-eligible clients for a capitated Medicare fee. When possible, these services are provided while recipients remain in their homes (HCFA, 1998).

Another trend is that traditional nursing homes are expanding “up” to include more complex services, such as subacute care, and “down” to provide less complex services, such as home care and assisted living (Evashwick et al., 1998; Lehrman and Shore, 1998). However, the largest number of elders are still being cared for by informal caregivers such as family and friends (AoA, 1998; Cutler and Sheiner, 1993).

Both federally and privately funded health insurance plans are moving from a fee-for-service system to a partially or fully capitated (PPS) in all areas of care, including skilled nursing, home care, and outpatient services.

Future trends will be affected by longer lifespans and the desire of older people to remain independent as long as possible (Economics and Statistics Administration, 1995; Hawes et al., 1999; Manard and Cameron, 1997). Increased longevity has significant cost implications. The precise impact on Medicare expenditures is unknown and depends on evolving Medicare policies and social practices, changing medical technology, and the prevalent morbidities within the older population.

As health care shifts from acute care to community and home-based programs, provided by a mix of health professionals, paraprofessionals, and informal caregivers, effective nutrition services and food assistance programs are likely to become especially important. However, the present system of including nutrition services in overall administrative costs, rather than direct reimbursement, creates a financial disincentive to address the nutrition problems of older people. If nutritional status and food security diminish as a result of this inattention, the older person may develop subsequent illnesses that require more acute and expensive care



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