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Community-Based Elder Care is Not Enough

If Americans want a better aging care system, relying exclusively on community-based approaches such as the GUIDE Model will not do.

Credit: Andrew Angelov

The Biden administration, in partnership with the Department of Health and Human Services (HHS) and the Centers for Medicaid and Medicare Innovation (CMMI), recently announced a new model program to address elder care. The program, called GUIDE, funds aging-in-place and community-based programs for the elderly. While this approach is fashionable among activists, it fails to address the needs of many aging Americans.

The GUIDE Model overview is long on slogans and short on details. It states that the program will “streamline dementia care, improve efficiency and affordability, and advance health equity,” and claims its implementation will save the government $21 billion over 10 years in related dementia and healthcare costs. It never says where those savings will come from, though, or how many people will lose services as a result.


The administration is responding to a real problem in elder care. The estimated health and long-term care costs associated with Alzheimer’s disease, for example, is $345 billion, not including unpaid caregiver costs. The Biden administration’s solution is pushing more people to stay at home and out of facilities. GUIDE, which stands for “Guiding an Improved Dementia Experience,” proposes the creation of more community-based dementia care teams to provide in-home services for patients.

The administration plans to saddle these teams with onerous regulations, requiring both a GUIDE-trained care coordinator and a clinician with a background in dementia to be part of the care teams. Behavioral health managers and pharmacists can also be part of the teams, but are not required under current protocol.

It is not clear how HHS and CMMI will actually staff these care teams; fewer than 1 percent of physicians have a gerontological certification, and of the 2.5 million nurses in the U.S., fewer than 15,000 are certified in geriatric care. Fewer than 4 percent of social workers have a formal certification in geriatric social work.

Beyond the practical concerns of staffing these teams, moving more services to the community would further destabilize an already foundering aging-care system. America is on the precipice of an aging crisis, as hospitals, nursing homes, and community-based programs are ill-equipped to handle the coming surge of aging adults. Many can hardly manage their current caseloads.

Those facilities and providers will need an estimated 1.2 million workers to address the growing needs of Alzheimer's patients within the healthcare system. Alzheimer’s accounts for 60 to 80 percent of the nearly 7 million dementia cases, and for those patients, aging-in-place policies like those proposed by the GUIDE program can lead to fragmented and disjointed care. Often, community-services workers hop from house to house, trying to provide care and oversight, ending up overwhelmed.


That problem would not be solved with more staffing and funding for community-based aging programs. The nature of Alzheimer’s is such that it often cannot be managed safely in community-based settings. The physical and mental disorders that can accompany the onset of Alzheimer’s often require both physiological and psychological therapies that can only be provided in the safe and controlled environment of an institution. As the Biden administration has done in its disability and mental-health policy, it seems to be pushing for community-based aging services alone, rather than a combination of community and facility-based care.

The benefits of institutionalized care for Alzheimer's patients cannot be overstated. These facilities, often memory care units, provide a safe environment and structured routine for those in the later stages of Alzheimer’s. The need for memory care units has doubled over the past decade, and grants overextended and overwhelmed caregivers peace of mind by providing a safe space for their loved one outside of the home. These facilities supplement all aspects of the patients day with activities, consistent meals, and structured routines. These are vital aspects to the care of a severe Alzheimer's patient, and decrease the risk of falling, boredom, and wandering.

Facilities already face an uphill battle, as Medicaid and Medicare typically do not cover long-term care services in nursing facilities. More than half of Medicaid dollars go towards home- and community-based services, funneling money away from long-term care.

As the community-based aging system expands, more elderly Americans will fall through the cracks. Just as an excessive focus on community-based services failed in the mental-health, disability, foster-care, and substance-abuse arenas, focusing solely on community at the expense of facility-based services in elder care will overwhelm Adult Protective services and other elder care providers. Efforts across our social safety net to rid the landscape of institutions have continuously failed clients and overwhelmed social workers, doctors, nurses, and other care workers.

Assisted living and long-term facilities address the failings of community-based services by offering residents a comprehensive system of care and providing a community of peers. These institutions can work closely with other community-based services and programs, and provide housing, consistent medical care, activities, and meals for elderly patients who may not have reliable family support. Community-based approaches often ignore the needs of those who live at home alone with no family or financial support.

If Americans want a better aging care system, relying exclusively on community-based approaches such as the GUIDE Model will not do. We need to improve, not abolish, long-term-care institutions, and offer the most vulnerable among us a combined approach that blends the best of community and facility-based services.


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