Institutional Care

Long-term care of older persons in the United States is provided in either institutional or community-based residential settings. Institutional long-term care settings include primarily nursing facilities. Community-based residential long-term care settings include care provided in someone's home and group shelter and care residences such as assisted-living facilities. Most long-term care now occurs in community-based residences rather than in nursing facilities.

Nursing facilities and assisted-living facilities have several similarities. Any resident of a long-term care setting has some degree of physical and/or cognitive disability that prevents the resident from attending to many of his or her own daily functions. These functions are known as activities of daily living (ADLs), including getting out of bed, bathing, dressing, toileting, walking across a small room, and eating, and instrumental activities of daily living (IADLs), including taking medicines, driving, preparing meals, doing laundry, and managing finances. Residents of both settings may receive services from multiple providers (e.g., physicians, nurses, social workers, physical therapists, nursing aides and assistants). The multidisciplinary team attempts to assist long-term care residents in reducing the impact of their functional limitations.

[Page 306]The distinction between the two settings lies in the amount of supportive care required by their constituents and the physical structure or environment in which that support is provided. Each setting is staffed to deliver varying aspects of care at differing levels of intensity. Nursing facilities are equipped to meet all of the functional needs of individuals who cannot live independently and who do not have the functional support they require to continue living in their own homes or with their families. Nursing facilities provide functional support while delivering a higher level of continuous nursing care 24 hours per day. The goal of nursing facility care is to restore or preserve the highest attainable level of independence for each resident. Care in nursing facilities also aims to prevent disease progression in their chronically ill populations and to treat the acute complications and illnesses that arise.

The nursing facility culture in the United States is highly institutionalized. Regulations and safety standards set by the federal and state governments, along with physicians' and nurses' orders, guarantee rigorous oversight of residents' environment, activities, and bodily functions. To comply with regulations and safety standards, nursing facilities impose rules and a certain amount of control over residents' personal space. Most residents live in rooms shared with one other person, further compromising personal space and privacy.

Although variable in the amount and intensity of nursing and supportive services they offer, assisted-living facilities generally provide less health-related services, such as meals, housekeeping, and assistance with getting dressed, to a constituency that is not as functionally impaired as are residents of nursing facilities. Assisted-living residents generally live in their own apartments, or residences, within a building that has a nurse on-site for some amount of time during the day. Regulation of assisted-living settings is less uniform and is applied with less rigor and punitive oversight than nursing facilities face. Although not as institutional as nursing facilities, assisted-living facilities usually impose some rules on the use of residential space. Also, assisted-living staff are involved with some aspects of every resident's daily routine. Albeit less formal, observation and monitoring of residents' activities do occur. The remainder of this entry focuses on institutional care in nursing facilities.

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