As the population ages, the need for home and community-based care is expected to rise. This chapter discusses public and private funding sources to help older adults with dependencies in their activities of daily living stay in their homes or find alternate community residential options. It explains the basics of the Older Americans Act, Medicaid waivers, the limited Medicare support for care at home, care of special populations such as veterans, Native Americans, and Native Alaska Elders, older adults with dementia, and those with mental health challenges. Residential housing options, assisted living communities, continuing care communities, and newer models for residential support including villages and naturally occurring retirement communities are discussed. Workforce challenges in providing care to the aging population are presented as a key factor in creating successful service programs.

This chapter takes an historical perspective in describing and analyzing the first 6 months of the COVID-19 pandemic in nursing facilities in the United States. Optimal institutional infection control practices in nursing facilities in the pre-COVID-19 era are described, as are many of the challenges faced by nursing facilities in response to the COVID-19 pandemic. The role of the nursing facility medical director is described within the historical context. The structure and content of medical care within the post-acute and long-term care institutional setting are presented. Resources are presented to assist clinicians practicing in nursing facilities.

QUALITY NURSING HOME CARE: REFORM AND UTOPIA

The American nursing facility is an important community resource, a refuge of last resort for those among us whose needs exceed the capacities of our families to provide care at home. Although often feared and reviled, the American nursing home is a dynamic microcosm, a subculture within the broader community. Nursing homes reflect the values of the communities of which they are a part. The call for “culture change” within the nursing home is really a call for an examination and evolution of the parent culture that created the nursing home in the first place. If the nursing home neglects its residents, the blame in part may be placed at the feet of the community. Although a corporation may own the nursing home, it belongs to the community in a moral sense. In America today, however, we are more apt to adopt a highway than a nursing home or the nursing home resident without any family of her own.

The best nursing homes are likely to be those staffed by local men and women who take pride in their work and are respected for helping their neighbors care for family members who are infirm and disabled. They are likely to be those facilities in which: families, including children, remain actively involved in the lives of their loved ones entrusted into institutional care; organizations such as faith communities, schools, and clubs are routinely present to enrich and enhance the quality of life for the residents; and frail older people can remain spiritually alive and engaged in relationships, celebrations, and community life.