How to Help Older Americans Age in Place — Without Weakening Care or Wearing Out Family Caregivers

The number of older Americans residing in long-term care facilities is steadily increasing — but such facilities are often not the first choice for aging Americans who need care. Long-term care facilities are defined as overnight facilities, including nursing homes and residential care communities, which provide a broad range of health care, personal care, and supportive services for adults who have limited self-care capabilities. Yet even when they suffer from poor health, almost all older adults prefer to remain at home and in their community.

Public policies like the Affordable Care Act have promoted options that align with older adult’s desires for in-home care. That is good — yet sweeping recommendations that promote aging-in-place may leave vulnerable populations with more unmet health care needs and place excessive burdens on family caregivers. As the U.S. population rapidly ages, policymakers, advocates, and health care professionals must account for the particular needs of older Americans and their caregivers.

Who is Most Vulnerable?

White adults are more likely to enter nursing homes than older Latino/a and Black adults, despite the fact that non-white adults are, on average, in worse health and more likely to have a disability than their white counterparts. Yet older minority adults who age at home often have many unmet health care needs because their family members lack the training, experience, and support required to provide adequate care.

Research suggests that differences in long-term care by race and ethnicity can be partially explained by cultural preferences — like the desire for family care. But the differences also result from discrimination, segregation, and other institutional and policy factors that make it harder for nonwhites to use long-term facilities.

Long-term care facilities in racial and ethnic minority neighborhoods are typically much lower quality and have fewer staff than facilities in majority white neighborhoods. Latino/a adults who do not speak English have often desire to find a nursing home with Spanish language proficiency or struggle to discuss health care options with health care providers physicians who only speak English.

Unmarried older adults — especially men — are much more likely to enter long-term care facilities and much less likely to remain in their communities, mostly because they have fewer family supports than married adults and unmarried older women. Unmarried adults face unique health vulnerabilities because of social isolation and economic disadvantage, yet their numbers are growing thanks to longer life expectancies, rising divorce rates and less remarriage. People in this group often cannot manage to age in place, and policies which promote aging in place often assume support from family members. Without providing adequate alternative supports, these policies do not help unmarried adults.

What about the Caregivers?

In-home care for older adults is typically provided by family members — spouses and adult children — with some assistance from paid home health aides. But declining fertility, increases in women’s labor force participation, and geographic mobility, may make family members less able or willing to provide care for older relatives.

Family caregivers are an important resource for older adults who need help, but these caregivers pay significant financial, physical, mental, and emotional costs. In-home care is physically and emotionally taxing and family members providing care often experience mental and physical health problems, especially those in older married couples who care for one another while experiencing illness or functional limitations themselves.

Policy Suggestions for Aging at Home

Social policy efforts should continue to take into account the desires of older adults and their family members for aging at home. In order to make this type of care workable, policymakers, advocates, and health care providers should cooperate to:

• Tailor efforts to expand care to the unique needs of vulnerable populations — including racial-ethnic minorities and unmarried older adults.

• Extend the Family and Medical Leave Act coverage to smaller employers and expand Medicaid services to facilitate long-term care by friends and extended family members.

• Make formal health care support available as a supplement to family care.

• Develop no-cost trainings for informal caregivers to ensure that older family members are receiving the best possible supports.

• Create legal mandates to support family caregivers. If older adults wish to age in place, skills and supports for caregivers cannot be overlooked.

• Encourage care from a wide range of sources — not just family members but also intimate partners, neighbors, friends, and other community members. Such multi-sided care must be supported and encouraged, with oversight from nurses, social workers, and other professionals, to ensure no abuse is occurring and that no one falls through the cracks.