every nursing home resident. While he appears to envision
an army of guardians ad litem, he does not address the
social and financial costs of this proposal.
Marin et al. recognize the competing claims of beneficence and autonomy but misunderstand the similar tensions in immediate versus long-range autonomy. Surprisingly, the authors contend that, for mental health
professionals, long-term autonomy — actions to promote
future freedom — has primacy over the more immediate
choices the client makes. In contrast, Collopy (1988) highlights the inherent tension between these choices and
cautions that paternalistic interventions can be wrongly
pursued in the name of long-term autonomy. In seeking to
ensure safety, these authors recommend rather heavyhanded strategies of intervention in their analyses of the
cases. For example, in a case centered on the problems of
neglect and self-neglect, they suggest that if the client
failed to cooperate, guardianship would be sought. Guardianship may or may not be appropriate in this case: the
client's willingness to cooperate should not drive the decision. In another instance, the authors suggest that a resident's expressed desire to leave a nursing home setting
would trigger a competency evaluation. Again, competency determination should be based on the individual's
ability to make reasoned choices rather than on the
choices made. As reflected in other chapters, and in the
other two books, vigilance is required to ensure that care
does not become control or coercion.
Where Do We Go From Here?
These books represent very different approaches and
traditions, illustrating the breadth of the field. The critical
question, however, is to what extent do they advance the
policy and practice of protective services?
For me, their major contribution lies in identifying some
of the trees in several larger and less settled jungles. I
found them to be most effective when they recognized
that they were wandering in a thicket and least so when
they attached a clarity and finality or nostrum to concepts
that are to some degree unresolvable.
For example, one of the deepest and darkest areas in the
protective service wilderness is competence. Readers will
find an array of opinions expressed about this construct,
including what to call it, how to measure it, and who
should determine it. A similar dilemma is found with autonomy. Under what conditions does it trump other values? What are the characteristics of situations that override
autonomy? When autonomy has been rescinded, should
we rely on ensuring the best interest of the client or should
we act as an advocate, using the substitute judgment
standard to make the decision that we believe the client
would want for him- or herself?
At their best, these books suggest that we recognize and
tolerate inherent tensions rather than accepting a more
comfortable resolution. As Schmidt reminds us, the concepts are still evolving as is our notion of what constitutes
enlightened protective service policies. Where do we go
from here? Holstein points the way. Rather than searching
for one solution, we need a process; rather than specific
rules, we need flexible guidelines.
In sum, the contributions of these three books suggest
that protective service research is no longer in its infancy.
During the last decade, the field has blossomed into early
adolescence with all the potential for growth and conflict
which that stage of development portends.
Kathleen H. Wilber, PhD
Associate Professor of Gerontology
and Public Administration
Andrus Gerontology Center, MC 0191
University of Southern California, University Park
Los Angeles, CA 90089-0191
References
Associated Press. (1987). A special report: Guardians of the elderly. New
York: Associated Press.
Collopy, B. J. (1988). Autonomy in long-term care: Some crucial distinctions. The Cerontologist, 28, (Suppl.), 10-17.
Kane, R. A., & Kane, R. L. (1987). Long-Term care: Principles, programs, and
policies. New York: Springer.
Schmidt, W. C , Miller, K. S., Bell, W. C , & New, B. E. (1981). Public
guardianship and the elderly. Cambridge, MA: Ballinger.
LONG-TERM CARE MOVES INTO THE MAINSTREAM
The Continuum of Long-Term Care: An Integrated Systemsgroup of individuals with severe and lasting disabilities,
and references to an aging Baby Boom population are
Approach, edited by Connie J. Evashwick. Delmar Pubbeginning to appear with regularity in newspaper editorial
lishers, Albany, NY, 1995,445 pp., no price listed (cloth).
cartoons and health sections.
Long-term care is conceptually and operationally comHome Care: Current Problems and Future Solutions, by
plex, as those with experience as providers, researchers,
Warren Balinsky. Jossey-Bass Publishers, San Francisco,
or consumers know. Under this rubric are found children
1994, 252 pp., $29.95 (cloth).
with developmental disabilities, elderly people with physiHome Care and Managed Care, edited by Eric B. Linne. cal disabilities as well as those with Alzheimer Disease, and
adults with AIDS. Services range from intravenous adminAmerican Hospital Publishing, Inc., Chicago, 1995, 231
istration of medicine and devices for mechanical ventilapp., no price listed (paper).
tion to meal preparation and bathing. Providers include
New Developments in Home Care Services for the Elderly: skilled nurses, technicians and therapists, family memInnovations in Policy, Program and Practice, edited by bers, and low wage, part-time workers. Evashwick's The
Continuum of Long-term Care takes on the full complexity
Lenard W. Kaye. The Haworth Press, Inc., Binghamton,
and
breadth of long-term care, with contributions from
NY, 1995, 290 pp., $45.00 (cloth).
many well known researchers in the field. The other three
volumes reviewed here choose a narrower target, home
care, with emphasis on particular populations (in Kaye, the
Long-term care is moving steadily into the mainstream of
elderly; in Balinsky technology-dependent children, AIDS
American health care. Medicare home health is the fastest
patients, and the elderly), models of care, and managegrowing component of the Medicare program, Medicaid
ment issues.
restructuring is focusing attention on the high-cost sub274
The Gerontologist
for research, and challenges for health care delivery, associated with long-term care. Evashwick and Branch note in
passing that "long-term care was once equated with nursing home care" (pg. 17). Those days, as this volume attests,
are long gone.
An Integrated Systems Approach
Evashwick's definition of long-term care, following an
established trend in the field (Doty, Liu and Weiner, 1985;
Kane and Kane, 1987), encompasses any health or support
services tied to the continuing care needs of persons with
functional disabilities. This focus on the person rather than
the service or service setting to define the content of longterm care is a perspective that is permeating mainstream
health care. It is congruent both with the notion that
individuals move across components of integrated health
systems and with a person-based payment system (i.e.,
capitation) as opposed to a fee-for-service approach.
As Part 2 of Evashwick's book makes clear, today "longterm care" services are provided in every conceivable
setting — hospitals, single-family or group homes, nursing
homes, housing with linked services (e.g., assisted living),
and specialized day centers. She proposes conceptualizing long-term care services as a continuum that, ideally,
should be integrated at several levels — patient care,
financing, information systems, and the organization and
management of service delivery. In the two chapters on
financing, both the complex mix of funding streams that
often characterize long-term care and current efforts to
integrate funding are described. The other topics, with the
addition of ethical issues, are similarly presented.
Sections five and six of the volume deal with systems of
long-term care for specific populations and case studies, a
useful attempt to balance theory with real world examples
of working programs. Included are programs in mental
health, mental retardation, and rehabilitation as well as
those directed at older people and veterans. The rationale
for including rehabilitation as a system is not clear, and a
more explicit treatment of the role of rehabilitation services in the spectrum of long-term care would have been
useful. For example, are rehabilitation efforts primarily an
intervention that occurs early on in an effort to prevent
disability — as the patient profile of clients with stroke,
joint replacement/repair, and job injury suggests — or is
there an ongoing role for those with long-term care needs?
In addition, while it is gratifying to see mental health and
mental retardation considered in a volume on long-term
care, these service systems are sufficiently well developed
and distinct to make them deserving of separate chapters.
The case studies provide real world examples of what it
means to implement a "continuum" of long-term care
services but, breaking the pattern set earlier in the book,
they are heavily weighted toward programs that serve
elderly people (4 out of 5 examples.)
Managed Care
Linne's book is intended as "a broad-based, practical,
multidisciplinary source for those home care organizations that wish to succeed in the predominantly managed
care environment of the future" (p. 19). As such, it is a
nuts-and-bolts treatment written by people engaged in
marketing and financial management, developing methods for effective cost accounting, and building home care
networks. I suspect this is a useful volume for those in the
trenches of health care management and administratorsin-the-making. For researchers, it provides a window on
concerns and decisions that confront home care organizations as they move from a service model based on the
Medicare home health benefit to managed care, with its
attendant changes in payment systems, services, and quality assessment. The client of these services, however,
makes few appearances in this volume.
The final section takes on the risky business of peering
into the future, with chapters indicating the issues we are
likely to continue debating into the next century — patient
rights, public dollars, and intergenerational equity — as
well as specific predictions. Among the more interesting
predictions are the rise of preventive gerontology and the
demise of current-style nursing homes in favor of specialized subacute and chronic disease facilities.
Evashwick' volume is part of a series aimed at the health
administration/public health field and the preface identifies the target audience as administrators. With this audience in mind, in addition to conclusions, each chapter
ends with a short section summarizing the main points
entitled "What the Administrator Needs to Know." However, the audience for this book is conceivably much
broader, including those in degree programs involving
gerontology, health services research, health policy and
management, and related fields. The first two chapters
provide an excellent grounding in current definitions and
paradigms in long-term care. The scope of the book is
impressive and reading it makes clear the many avenues
Policy, Program and Practice
Kaye's book focuses on home care for the elderly in
three sections entitled policy, program, and practice innovation. The first covers home care benefits under various
programs and legal and ethical issues; the second, various
organizational models, high-tech care, information systems, quality assurance, and marketing; and the third,
client counseling, clinical assessment, case management,
and the role of the home care supervisor/case manager. A
final chapter provides an international perspective drawing largely on the Scandinavian countries and England.
These chapters were published simultaneously in the Journal of Gerontological Social Work (Vol. 24, No. 3/4,1995),
and two themes predominate: 1) various aspects of organizing, marketing, and evaluating home care services, and
(2) the role of care providers who have case management
or clinical responsibilities. Issues of financing and the
implications of an increasing managed care presence in
home care are largely overlooked. This book, like Linne's,
Vol. 37, No. 2,1997
Legal Issues in Home Care
The three volumes on home care provide very different
perspectives on this growing service area, although there
is overlap in content. All, for example, include a chapter on
legal issues, but the "take" in each volume is distinctly
different. Balinsky's Home Care devotes considerable
space to informed consent and patient rights, but also
covers liability for patient care and some of the legal issues
around referrals (e.g., steering patients to certain providers, kickbacks, and similar antitrust/fraud issues). The
chapter in Kaye's New Developments in Home Care Services for the Elderly focuses on the legal context within
which home care providers operate — the family's role in
decision making, liability issues, and legal aspects of decisions to limit treatment or use physical or chemical restraints. The chapter in Linne's Home Care and Managed
Care on the other hand, is geared to the concerns of a
home care agency executive about to enter into a contract
with a managed care organization. The topics covered
include oral versus written agreements, basic terms and
definitions, reporting requirements, liability, and antitrust
issues.
275
is mostly concerned with home care from the provider's
perspective. While Linne focuses on how to succeed in
managed care relationships from the administrator's viewpoint, Kaye's volume concentrates on how to organize
home care services and effectively interact with clients.
Multiple Home Care Populations
Balinsky's stated purpose in writing about home care is
"both to advocate and to educate" (pg. xiii). Like Linne and
Kaye, he hopes to reach practitioners and administrators in
home care, but aims to contribute to the policy literature
as well. Of these three volumes, Balinsky provides the
most comprehensive view of home care, using
technology-dependent children, AIDs patients, and elderly people in adult day care to convey the range of
individuals and needs that are served. A section on models
of care focuses on a few in depth, including the sharedaide program and high-tech home care, while a section on
management considerations deals with quality assurance
and legal issues. Costs of care and financing are discussed
throughout, in connection with both particular populations and care models. The client and his/her family are a
strong presence in Balinsky's volume. As he notes, "home
care is structured around the assumption that there are
informal caregivers at home who can continue functioning
in their normal life pattern with the assistance that home
care provides," (pg. 73). (Evashwick also includes a chapter
on Informal Caregiving in long-term care which provides a
concise description of who caregivers are, what they do,
and their well documented key role in long-term care.)
Balinsky's book has the additional advantage of a single
author, which contributes to a more tightly organized and
well-written volume than can be achieved in a collection of
individually-authored papers.
Trends in Research and Practice
Of these four volumes, those by Evashwick and Balinsky
have the broadest scope and will inform both the newcomer to long-term care and the experienced practitioner
or researcher. For future authors, however, the field is still
wide open. Further evidence that long-term care is no
longer an isolated outpost within the health care system is
found in Balinsky's observation that two important developments in health care generally are also being felt in
home care — the importance of patients' rights and the
shift from quality assurance with its focus on structure and
process of care, to evaluating outcomes. Whether
couched in terms of consumer empowerment or patientcentered care, patient involvement in decisions about care
and evaluating treatment is a growing force in health care.
This perspective still is not well represented in the longterm care literature, however. This may change with the
dissemination of results from various research and demonstration efforts currently underway that put considerable
control of both dollars and services into the hands of
consumers and their families.
The shift toward evaluating outcomes rather than structure and process is also moving rapidly in long-term care
with the development of data systems such as OASIS —
Outcome and Assessment Information Set for Home
Health Care — (Shaughnessy et al., 1994a) and the MDSRAI — Minimum Data Set for Nursing Home Resident
Assessment — (Morris et al., 1990) which provide personlevel empirical indicators for use in data-driven evaluations
of patient outcomes. Establishing measurable outcomes in
long-term care has proven elusive because, as Evashwick
observes, the goal of such care is often "maximizing inde276
pendence" or delaying decline, as opposed to seeking
recovery. Development of data systems in long-term care
such as the OASIS and MDS, however, represent major
steps in improving the capacity to identify, measure, and
monitor patient outcomes. Although several of the volumes reviewed here include chapters on information systems, these are discussed only in a management context
(e.g., the greater efficiencies obtained through information systems that integrate financial, clinical, and utilization data).
Finally, knowledge about the impact of managed care on
people with long-term care needs is in its infancy. At
present few states require disabled Medicaid recipients to
obtain services through managed care organizations and
enrollment of elderly people in managed care is disproportionately by healthier people (Brown, Clement, Hill, Retchin, & Bergeron, 1993). Nonetheless, there are warning
signs. A new study suggests that adults with chronic illness, including hypertension, diabetes and congestive
heart failure, fared less well in HMOs than fee-for-service
(Ware, Bayliss, Rogers, Kosinski, &Tarlov, 1996). An earlier
article by Shaugnessy (1994b) found poorer outcomes for
Medicare beneficiaries in need of home health services
who were enrolled in HMOs compared to those who relied
on fee-for-service.
Managed care presents the same concerns and opportunities for those with long-term care needs as for others,
but significantly intensified by the greater and more complex care needs resulting from chronic disease or disability. Continued development of data systems that allow
outcomes assessment of people with long-term care needs
as well as mechanisms for patient evaluation of issues of
concern to this population (e.g., access to specialty providers) are being urged by consumer advocates and professionals in long-term care. It seems inevitable that the
legitimacy of these concerns will become increasingly apparent to the health care community at large.
Long-term care is a complex, rapidly changing, and
growing component of the health care system. This is clear
to those with responsibility for administering and providing these services, to researchers in long-term care, and to
many consumers. Educating a wider audience about the
integral place of long-term care within health care generally will be an ongoing process. As Evashwick and Branch
point out, "every person is a potential user . . . because
any one of us is at risk of developing the chronic or
continuous care needs" (p. 21) which bring into play the
extensive and complex types of support and assistance that
make up "long-term care."
Judith D. Kasper, PhD
Associate Professor
Dept. of Health Policy and Management
The Johns Hopkins University School of Hygiene
and Public Health
Baltimore, MD 21205
References
Brown, R. S., Clement, D. C , Hill, J. W., Retchin, S. M. & Bergeron, J. W.
(1993). Do health maintenance organizations work for Medicare? Health
Care Financing Review, 75(1), 7-23.
Doty, P., Liu, K. & Wiener,). (1985). An overview of long-term care. Health
Care Financing Review, 6(3), 69-78.
Kane, R. A. & Kane R. L. (1987). Long-term care: Principles, programs, and
policies. New York: Springer.
Morris J. N., Hawes, C , Fries, B. E., Phillips, C , Mor, V., Katz, S., Murphy,
J., Drugovich, M. L , & Friedlob, A. S. (1990). Designing the national
resident assessment instrument for nursing homes. The Cerontologist,
22, 293-307.
The Gerontologist
Ware, J., Bayliss, M. S., Rogers, W. H., Kosinski, M., & Tarlov, A. (1996).
Differences in 4-year health outcomes for elderly and poor, chronically
ill patients treated in HMO and fee-for-service systems: Results from
the Medical Outcomes Study. Journal of the American Medical Association, 276(13), 1039-1047.
Shaughnessy, P. W., Crisler, K. S., Schlenker, R. E., Arnold, A. C , Kramer,
A. M., Powell, M. C , & Hittle, D. F. (1994a). Measuring and assuring the
quality of home health care. Health Care Financing Review, 76(1), 35-69.
Shaughnessy, P. W., Schlenker, R. E., & Hittle, D. F. (1994b). Home health
care outcomes under capitated and fee-for-service payment. Health
Care Financing Review, 76(1), 187-222.
THE PERVASIVE NATURE OF NUTRITIONAL ISSUES:
THE NEED FOR INCREASED AWARENESS1
health issues. To the contrary, there is a growing consensus that nutrition figures prominently, and pervasively, as a
major determinant of quality of life for the elderly.
Take, for instance, the ramifications of protein-calorie
malnutrition, and the closely allied condition of diminished muscle mass. It is well accepted that protein-calorie
malnutrition is a common condition among institutionalized elderly. Recent estimates suggest that it is present in
30-50% of all nursing home residents (Abbasi & Rudman,
1994). Even among community-dwelling elderly, where the
problem often goes undetected (Manson & Shea, 1991;
Morley, 1991), the prevalence is thought to be 5-10%
(Fiatorone, 1990). Muscle mass in the extremities, in turn,
is a major determinant of mobility, the ability to carry on an
independent existence, and the ability to prevent disabling
falls (Bendall, Bassey, & Pearson, 1989; Fiatorone & Evans,
1990; Vellas et al., 1992). Most important of all is the fact
that diligent attention and appropriate intervention lead to
remarkably improved outcomes with this problem.
In the hospital setting, aggressive nutritional support of
malnourished elderly surgery patients has resulted in a
15% to 30% reduction in rehabilitation time and a 40%
reduction in the duration of hospitalization as well as a
significant reduction in morbidity and mortality (Bastow,
Rawlings, & Allison, 1983; Delmi, Rapin, & Bengoa, 1990).
In a nursing home setting, a modest exercise program, in
conjunction with adequate nutrient intake, can significantly improve muscle strength and mobility among frail
elders (Fiatorone et al., 1994).
In a similar fashion, our understanding of micronutrient
needs in the elderly is undergoing a virtual revolution:
requirements for elders are clearly different from those in
younger adults (Russell & Suter, 1993; Wood, Suter, &
Russell, 1995) and supplementation with levels greater
than the present Recommended Daily Allowances (RDA)
for selected nutrients convey some real health benefits.
Take, for example, the issue of subtle B12 deficiency related to chronic atrophic gastritis. Plasma B12 levels diminish with age, and more so in the large minority of elders
with chronic atrophic gastritis (Krasinski et al., 1986). Neurologic degeneration can manifest itself even before
plasma B12 levels drop to abnormally low levels, an observation which has prompted the increasing use of more
sensitive indicators of B12 status, such as serum methylmalonic acid (Lindenbaum, Savage, Stabler, & Allen, 1990).
Similarly, a dietary folate intake at the present U.S. RDA is
apparently inadequate for up to one third of ambulatory
elders since such intake results in significant rises in serum
homocysteine, an independent risk factor for cardiovascular disease, which appears to be as strong a determinant of
disease as an elevated cholesterol (Boushey, Beresford,
Omenn, & Motulsky, 1995).
Annual Review of Gerontology and Geriatrics, Volume 15:
Focus on Nutrition, edited by John E. Morley and
Douglas K. Miller. Springer Publishing Company, New
York, 1995, 265 pp., $54.00 (cloth).
Geriatric Nutrition: A Comprehensive Review, second edition, edited by John E. Morley, Zvi Click, and Laurence
Z. Rubenstein. Raven Press, New York, 1995, 415 pp.,
$98.00 (cloth).
The Mini Nutritional Assessment (MNA): Nutrition in the
Elderly, edited by B. J. Vellas, Y. Guigoz, P. J. Garry, and
J. L. Albarede. Serdi Publishing Company, Paris, 1994,
148 pp., $29.00 (paper).
Nutritional Assessment of Elderly Populations: Measure
and Functions, edited by Irwin H. Rosenberg. Raven
Press, New York, 1995, 314 pp. no price listed (cloth).
Clinical and investigative gerontologists have become
accustomed to the fact that health problems attendant to
geriatric populations are usually a consequence of a complex interplay of medical and psychosocial factors. For
instance, gram negative bacteremia and cystitis in an elderly man may initially appear to merely reflect inadequate
treatment of his benign prostatic hypertrophy. Upon
closer examination, however, one might recall that the
patient's chronic lymphocytic leukemia compromises his
resistance to infection and that reluctance on the part of
that patient to take the appropriate medicines is related to
intolerable drug-drug interactions. Further examination
might reveal that severe osteoarthritis is sufficiently debilitating to discourage trips to the medicine cabinet, or that
his cataracts have interfered with his ability to read prescriptions correctly. A proficient gerontologist, therefore,
must stubbornly and meticulously dissect a problem if all
of the important determinants are to be identified regardless of whether it be for research or clinical purposes. Such
is the nature of gerontology: the multiplicity of chronic
diseases, their treatments, and the complex social and
physiologic issues which accompany the aging process
conspire to weave an intricate web that is difficult to
unravel.
In the past, gerontologists have readily recognized that
nutritional issues play a role in some of the common
geriatric problems such as osteoporosis and hypertension.
Nevertheless, the past decade has witnessed a remarkable
expansion of knowledge in the field of nutrition and aging
— knowledge which increasingly indicates that nutritional
issues do not merely serve as minor contributors to a few
1
This work has been supported in part by a grant from the U.S. Department of Agriculture, Agricultural Research Service Contract 53-3K06-01. The
contents of this publication do not necessarily reflect the view or policies of
the U.S. Department of Agriculture, nor does mention of trade names,
commercial products, or organization imply endorsement by the U.S.
Government.
Vol. 37, No. 2,1997
Heretofore, this discussion has outlined compelling reasons why there needs to be wider dispersion of our recently acquired insights into nutrition and aging. It is
therefore timely that several books have been published
over the past 18 months whose themes are germane to this
277