The vast majority of older patients reside in their own homes. These patients, either on their own or with the support of family, manage their own needs, and are independent in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)—see Table 7.2.

Patients should have primary care practitioners and make office visits; many areas of the country have house call practitioners who can visit homebound seniors to provide ongoing primary care [1]. The American Academy of Home Care Physicians has a website with access listings for house call providers (http:\\www.aahcp.org).

Older patients with temporary needs for nursing oversight following a hospitalization or outpatient procedure can be referred to a visiting nurse agency. These multi-service organizations provide short-term skilled nursing services (wound care, medication monitoring and adjustment, home assessment, and teaching), rehabilitation services from physical, occupational, and speech therapy, social work, and some specialty nursing services such as wound care and ostomy care. Some agencies have expanded to provide home intravenous support and nutrition support; these agencies are often hospital owned and managed. For residents who require ADL support, temporary home health aides can be provided for short periods. The costs of care are usually covered by Medicare, but may require pre-authorization in Medicare managed care. The duration of care extends as long as the skilled care needs can be documented: as long as progress towards goals of care is being made. Once the patient has stabilized or reached a plateau in status, services are withdrawn. Visiting Nurse Agency episodes of care rarely exceed 6 weeks.

For patients who require long-term supportive care services at home, some special programs have been developed. Patients and families may privately pay companions or home health aides to provide care. In many areas of the country, assistance is available to help support patients and families in need of services at home. These programs are supported mainly through Medicaid programs of the states and vary widely. The programs are coordinated by a network of Area Agencies on Aging which are located in every county and provide information and access to state and federal programs available in a region. Local agencies can be accessed through the website of the National Association of Area Agencies on Aging: http:\\www.n4a.org

An interesting innovation in the care of the frail elderly has been the development of Programs of All-Inclusive Care of the Elderly (PACE) programs throughout the nation [2]. These programs offer to Medicare/Medicaid eligible seniors a coordinated menu of medical and social programs at specialized sites. Because PACE sites are equivalent to managed care and are capitated for each member, sites often develop specialized referral networks for their patients.

Seniors who find the maintenance of their homes too difficult can opt for senior housing in specialized buildings which also offer increased security. Rent may be income-linked; many of these buildings are built with federal support for low-income elderly. Larger facilities may offer some social work access, but no health or social services are mandated in these buildings, and the residents are expected to be independent in their apartments.

The fastest growing segment of housing for older people is the Assisted Living Facility ( ALF ). These often “for-profit” buildings offer apartments of various sizes as well as dining rooms providing daily meals, and often some program of activities. Residents are expected to be independent within their apartment (ADL independent). Many offer housekeeping, laundry, and medication oversight as additional charges. Some facilities offer “memory” programs with additional activities and oversight—these specialized areas are usually more expensive. Residents or families are responsible for obtaining medical care which is usually provided in an outside physician’s office. State regulation of these facilities ranges from nonexistent to nascent; services may vary widely from state to state, and even county to county. Costs are generally covered by patients and families themselves; some states are beginning to allow Medicaid payments to ALFs. While these facilities are generally attractive physically (resembling apartments rather than nursing homes), these sites generally cannot meet the life-long requirements for care for residents with progressive illnesses such as dementia. Residents will need either to relocate again to a nursing home when they become ADL dependent, or purchase increasingly expensive amounts of care in the ALF.