Seven reasons why it is so difficult to make community-based long-term care cost-effective.

A decade of research on home- and community-based long-term care shows that few of the assumptions behind expectations of tis potential cost-effectiveness were warranted. Few who use home- and community-based long-term care would otherwise have been long-stayers in nursing homes. Long-stayers tend to be older, sicker, more dependent, and poorer in social resources than those who use community care. Fewer still who use community care actually have their institutional stay averted or shortened by its use, even if they are at risk. But more effective targeting on those most likely to be institutionalized may lead to high screening costs and small, inefficient programs, because few patients in the community fit the profile for high risk of institutionalization. Conversely, the very sickest and most dependent patients may be cheaper to serve in a nursing home than in the community. Patient outcome benefits have also been limited: except for the higher contentment levels found in some studies, community care appears to produce no special outcome benefits in longevity, physical or mental functioning, or social activity levels. Nonetheless, community care serves a sick, dependent, and--most people would agree--deserving population of patients and their caretakers. A refocusing of public policy to target specifically on the functionally dependent rather than the aged per se may be the best hope for public support for community care.