As entitlement programs—social security, Medicare, and Medicaid—consume a larger and larger percentage of the nation’s budget, discretionary programs—the source of most public arts and aging dollars—receive a smaller and smaller percentage. The costs of healthcare and long-term care are increasing as providers struggle to serve a growing population that demands more programs, better services, and up-to-date infrastructure. At a conference of the U.S. Administration on Aging in December 2006, speakers reported the following:
The long-term care system relies heavily on public funding. According to Matt Salo, director of the Health and Human Services Committee at the National Governors Association, Medicaid averaged 20 percent of states’ budgets in 2006—more than the amount spent on K-12 education.42 “By 2030, spending for Medicare, Medicaid, and social security alone will reach almost 60 percent of the federal budget.”43
Trends in policy and funding favor home- and community-based care over long-term care provided in facilities. Several new initiatives from the Administration on Aging support the transfer of individuals from nursing homes to community settings and allow Medicaid enrollees to participate in cash and counseling programs in which they purchase long-term care services in the community using a predetermined budget. Another federal initiative is the Medicaid Home- and Community-Based Services Waiver for Older Adults. Administered by states, its goal is to enable older adults to remain in a community setting by allowing services typically covered by Medicaid only in a long-term care facility to be provided to eligible persons in their homes or in an assisted living facility.
Aging and Disability Resource Centers are one-stop shops that simplify information gathering for older adults, family caregivers, professionals seeking assistance on behalf of their clients, and adults planning for future long-term care needs. Center programs are also the entry point to publicly administered long-term support funded under Medicaid, the Older Americans Act, and state revenue programs. Most states have these centers up and running.
Annual turnover among most paraprofessional long-term workers is about 50 percent. With a median hourly wage of $9.20 in 2003, they earn nearly one-third less than all U.S. workers.44 Insufficient benefits, inadequate training, limited involvement in decision making, few opportunities for promotion, heavy workloads, and a high rate of injury also contribute to turnover. In addition, workers suffer from the widespread public perception that caring for older adults is unpleasant and unappealing. Not surprisingly, research has consistently demonstrated a relationship between staffing and quality of care in nursing homes.
Efforts to recruit and retain staff center on changing the workplace environment, increasing wages and benefits, and creating opportunities for career advancement and training. Long-term care facilities that have a person-centered approach have reorganized their caregiving process and management practices, resulting in lower turnover and higher-quality care. Though a number of states have attempted to implement policies or pass laws that increase wages and benefits or mandate more training, there are few systems in place to monitor compliance. Several states also support initiatives such as team building and peer mentoring.
Caregiver burnout is a state of physical, emotional, and mental exhaustion that may be accompanied by a change in attitude—from positive and caring to negative and unconcerned. Burnout can occur when caregivers don’t get the help they need, or if they are physically or financially overextended. They may experience fatigue, stress, anxiety, and depression. Many caregivers also feel guilty if they spend time on themselves rather than on their older family members.
The aging service field addresses this issue primarily by offering support and information resources. Some residential communities, senior centers, and hospitals have caregiver support groups where family members share successes, challenges, and tips. Clearinghouses such as Aging and Disability Resource Centers direct caregivers to help, including facilities that provide respite services where an older adult lives for a weekend or a couple of weeks.