Book Review

The Future of Long-Term Care: Social and policy issues

N Engl J Med 1997; 337:354-355July 31, 1997

Article

The Future of Long-Term Care: Social and policy issues
Edited by Robert H. Binstock, Leighton E. Cluff, and Otto Von Mering. 300 pp. Baltimore, Johns Hopkins University Press, 1996. $38.50. ISBN: 0-8018-5320-6

This very timely book arose from a national health forum at the University of Florida in 1992, and the contributions have been written especially for the book. It provides an extremely useful and fresh analysis of this nation's attitudes toward and past attempts to formulate a policy of long-term care as well as a discussion of the future. The book is especially timely because the baby-boom generation now faces issues of long-term care because of their experiences with their parents or the realization that they themselves may require this form of care in the future. The book presents, with reasonably recent data, the projections for the need for long-term care in the next century and addresses the difficult issues associated with paying for such care, as well as the issues associated with providing care of higher quality than that now available.

The chapter authors, all respected leaders in their fields, provide their insights in discussions of the shortcomings of the current system of long-term care and analyze the many problems that must be overcome to improve it. There is also a chapter dealing with long-term care services for younger disabled persons and a useful analysis of the differences and similarities between older and younger disabled people. This analysis will be useful in considering future policies in this field, especially since there has been a tendency to view the two groups as one.

An early glimpse of the possible effect of applying technology to the delivery of long-term care is found in a single chapter. The approach needs much more extensive experimental testing. This point is made particularly clear in a chapter that emphasizes the complexities of providing care to older persons with chronic illnesses and of linking primary care, inpatient care, institutional care, and home-based long-term care in a rational system that responds to the needs and wishes of consumers and care givers. Robert L. Kane's emphasis on greater use of information technology is compelling. James J. Callahan, Jr., discusses the measurement of functional status, which has been widely used as an indicator of the types of services that are needed. He introduces two additional measures to address this important issue — namely, “professionally dictated activities of daily living” and “appreciative activities of daily living.” Unfortunately, the abbreviation for the latter term is also used for advanced activities of daily living.

The chapter on the financing of long-term care and the possibility of a combination of private and public long-term–care insurance is useful for the multiple professions involved in providing long-term care, as well as for policy makers. There is also a very useful section on ethical issues in long-term care.

The book closes with a summary of a study involving a modified Delphi method, in which a large number of experts addressed the question of what the system of long-term care might look like early in the 21st century. The results of the study suggest that an emphasis should be placed on the following: preventing disability; strengthening the informal care system; improving management and service delivery on the basis of careful evaluations; increasing and improving the training of personnel in the field; promoting technology, including the information sciences; rethinking the issue of residential care, particularly long-term institutional care; improving quality-of-care measurements by developing better methods; and creating an affordable financing system. The concluding paragraph is worth underscoring: “Long-term care should be shaped by conscious choices about future directions, rather than being fated by seemingly random and uncontrollable events. As society ponders long-term care, it should not squander the future as it has the past.”

This book will be particularly useful to professionals who provide long-term care and who influence the development of policy through their actions and words. The book will also be of enormous value to policy makers in planning a rational system, whether they work in the public or private sector. My one concern is the theme of the “overmedicalization” of the long-term–care system, which is evident in many chapters. From my perspective, a major problem in the present system, whether home-based or institutionally based, is the frequent absence of the medical contributions required to ensure the maximal quality of life.

John C. Beck, M.D.
University of California, Los Angeles, School of Medicine, Los Angeles, CA 90095-1687