Correspondence
Long-Term Care for the Frail Elderly
N Engl J Med 2000; 342:823-824March 16, 2000
- Article
To the Editor:
Bodenheimer's article on long-term care for the frail elderly (Oct. 21 issue)1 extols the Program of All-Inclusive Care for the Elderly (PACE) for its cost effectiveness, for its excellence as a model of care for the frail elderly, and as an alternative to placement in a nursing home. There is great potential for improvement in the care of elderly people residing in the community through the use of programs such as PACE and On Lok. I disagree, however, with Bodenheimer's implication that PACE is a valid alternative to nursing home care. The people participating in PACE are quite different from those living in nursing homes, and both require and deserve superior care.
Bodenheimer states that in order to qualify for On Lok services (the model on which PACE is based) one must be “sufficiently disabled to be eligible for nursing home care.” Despite the fact that PACE clients may qualify for nursing home care, it is doubtful that the average PACE client has the same degree of disability as the average nursing home applicant or resident. As of 1995, Eng and colleagues2 found that the average PACE patient was 80 years of age and needed assistance in 2.7 activities of daily living. By contrast, the National Nursing Home Survey (conducted in 1995)3 found that the mean age of nursing home residents at the time of admission was 82 years, with 40 percent over the age of 85. In the later stage of life, every additional year has a major effect on function, independence, health, and mortality. Moreover, the functioning of the average nursing home resident was more impaired than that of the average PACE participant, with 33.1 percent of nursing home residents needing assistance in three activities of daily living, 32.9 percent needing assistance in four activities of daily living, and 8.6 percent needing assistance in five activities of daily living. Only 25.4 percent of nursing home residents needed help in fewer than three activities of daily living.
My colleagues and I are establishing a PACE-like program in three culturally diverse areas of New York City and will provide care for about 900 frail elderly persons. We will study the cost effectiveness of the program, as well as the effectiveness of the services provided and the effect on postponement of or substitution for nursing home placement.
In this day of “sicker and quicker” transfer of patients from hospitals to nursing homes, it is rare to find a nursing home resident who does not need nursing home care. I have never met a malingerer living in a nursing home.
3 ReferencesLeslie S. Libow, M.D.
Jewish Home and Hospital of New York, New York, NY 100251
Bodenheimer T . Long-term care for frail elderly people -- the On Lok model. N Engl J Med 1999;341:1324-1328
Full Text | Web of Science | Medline2
Eng C ,Pedulla J ,Eleazer GP ,McCann R ,Fox N . Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc 1997;45:223-232
Web of Science | Medline3
Dey AN. Characteristics of elderly nursing home residents: data from the 1995 National Nursing Home Survey. Advance data from Vital and health statistics. No. 289. Hyattsville, Md.: National Center for Health Statistics, 1997:3. (DHHS publication no. (PHS) 97-1250.)
Author/Editor Response
Dr. Bodenheimer replies:
To the Editor: Dr. Libow's letter is a helpful addition to my article. The preferred sites of care for severely disabled elderly people should be the home (with adequate assistance) and the community. But there will always be some people for whom nursing home care is the only alternative.
Thomas Bodenheimer, M.D.
