People often end up in nursing homes when their health takes a sudden downturn, such as after an illness or injury that leads to hospitalization. After an acute illness older people are often profoundly weak and have lost the self confidence to return to their homes. Injuries such as fractures of the leg or hip may require that a person not bear weight, leaving them stuck in a wheelchair, needing help to get to meals or the bathroom. Many of these problems are temporary, but sometimes they are part of a cascade of events leading to no longer being able to function independently. When patients no longer require hospitalization, they may be transferred to a nursing home or "skilled nursing facility" (SNF or "sniff," for short.)
You can't always get what you want...
Like being in a sub-optimal summer camp as a child, people usually do adjust to living in a nursing home, but a large proportion of them, when they have returned home, tell me that they do not want to go back.
How about DIY?
As long as humans have existed, old people were taken care of by their extended families. This is shockingly inexpensive, since the very old don't eat much and already have all the clothes they need and rarely have expensive hobbies. Unfortunately not everyone has an extended family, and American lifestyles are not focused on having someone with time on their hands hanging out at home all the time. Even when family is available, things can go very wrong. About a year ago I saw a pair of sisters, one 96 and the other 102, who lived with their son in an apartment. They were hungry, thin and dirty and, according to the emergency medical crew, slept on a mattress together without sheets and just a grubby blanket. Their son wasn't cruel or abusive, just not much of a homemaker. There was shock and outrage among our hospital staff, but the sisters eventually went home with him because that was what they wanted.
Since staffing is the biggest cost associated with care of the very old or disabled, adult family homes have arisen so that the cost can be shared among several clients. These are large private homes that have 24 hour staff, some of whom live there, and care for several older adults. Some of these are great. Near my home, there is a family home care place run by a family from Kenya, and I've been told that they are wonderful. One of the great benefits of a place like this is that staff turnover can be quite low. If staff live in the home or are close friends of the owners, they really get to know the residents and they get good at what they do. Also there are a smaller number of clients to take care of than in nursing homes, which means that care is more personal. Some of these places have come into the spotlight for providing terrible care, which is made more possible by there being less regulatory oversight.
Adult foster care homes usually have one or very few clients, and caregivers need to have the basic knowledge necessary to care for their clients, but don't need to be nurses. If the chemistry is right, these can be great. I don't know of a clearinghouse for foster care providers, and in my experience these arrangements tend to happen when somebody knows somebody who is willing and able to do it.
For people who don't need 24 hour care, staying at home and having help come in is much more affordable. Medicaid will even pay for this, in some cases. Some people remodel to make room for a roommate and can trade rent for care duties. The patients of mine who have done this often have a long lasting solution that also can solve the problem of being isolated. They do, though, need to have contingency plans for vacations and illnesses and such.
What about out-sourcing? There are cultures that do personal care better than we do in the US, and at a much lower cost. Thailand, for instance. The last time I was in Thailand, there were professional massage places everywhere, and they cost maybe 5 or 10 dollars. Service in hotels was amazing and the staff actually seemed to enjoy doing their jobs well. The food was delicious. As it turns out, there are at least 2 nursing homes in Chiang Mai which are geared toward clients from Europe and the US. The very old in Thailand, and there are increasing numbers of them, are almost always cared for by their families, though there are a some facilities that cater to Thai seniors. One of the ex-pat focused nursing homes is called The Care Resort and is pretty high end, with multiple levels of care and big beautiful grounds and outings to see elephants, or so it appears on the website. I can't find anything about cost on the website, but an article about it in the UK Daily Mail says that a year's cost is about 21,000 British pounds, which is about $35,000. Another such nursing home, which appeared on the website actually to have some Thai clients, is at the McKean Rehabilitation Hospital, which was a home and hospital for lepers when I spent time there in the 1980's, after finishing my residency. It was a beautiful place then, a bit outside of the city, with shade trees and open wards and a wonderfully creative approach to all aspects of leprosy as a chronic disease, but not a death sentence. The staff was cheerful and caring and there was an affiliation with the Presbyterian Church. The website makes it look fine, but not opulent. No prices are mentioned. The extended grounds still house some aging patients with leprosy (a disease which, despite its reputation, is not very contagious) who have no other home, and there is a strong outreach program to serve and rehabilitate people with all sorts of disabilities.
Some people are wealthy enough and forward thinking enough to become part of continuing care retirement communities. For a chunk of money, which can range from $100,000 to over a million dollars, it is possible to have an independent house or duplex with the option to move into assisted living or a nursing home on the same grounds as the need arises. High end places of this type probably offer better staffing ratios and probably lower staff turnover than standard nursing homes, and it is certainly easier on couples who can live in close proximity even when one of the pair needs more help than the other.
Cooperatives and co-housing offer another alternative to the corporate approach to aging care. This requires immense planning by community members, but is a way to deliberately and intentionally create an extended family with whom we can age.
So what should we do about the fact that we will all, with any luck, grow old? In the year 2050 it is estimated that 1 in 10 people will be over the age of 80. Perhaps half of them will require care of various levels of intensity. I will be 89 years old, if I'm not dead. The majority of people reading this will be 80 or older, or, possibly, dead. I venture to say that none of us wants to be in a nursing home. Are we really doing the hard work of remaining healthy and alive only for the opportunity to spend a small fortune living in a small fusty room with a roommate who may or may not be a suitable companion, waiting for a nurse's aid to come help us? Some solutions may involve technology, unloading overworked personal care givers by having robotic solutions to bedpans and med passing. Perhaps technology will unload everyone's job, and personal care will be one of the only jobs that still requires the work of a human.
Staying strong and useful
Besides actually planning for our years of dependency, perhaps we not-quite-yet-old also need to think about policies that make us less dependent. Most people dream of retirement, but the reality of not being useful or needed does not usually make us happy. I came upon a link to Thailand's initiatives on the elderly while looking at the nursing home situation there. In 2003 they passed The Elderly Act which, in addition to guaranteeing healthcare and basic food and shelter needs to older citizens, also grants them vocational training and support to become involved in community networks. I don't think we are doing that in the US. It might be a really good idea.