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Reinventing Care

Assisted Living in New York City

David Barton Smith

Publication Year: 2003

The recent growth of "assisted living" facilities and programs has shaken the foundations of the system of long-term care for the elderly in the United States. Fueled by consumer frustrations with the available options, notably nursing homes, the assisted living model emerged during the 1990s to promise shelter, health care, control of one's own life, less government involvement, and a "real home." But how well have the advocates and developers of assisted living delivered on such promises? And what are the model's implications for public policy and the future of caregiving? In Reinventing Care, David Barton Smith offers brilliant insights into those questions by examining the realities of assisted living in New York City. Encompassing the largest, most concentrated population of elderly in the United States, New York spends more per person caring for its seniors than any other urban center. Yet, while the size of the city's care system boggles the mind, it nevertheless contains the same elements that exist in other metropolitan areas and thus provides valuable lessons for the nation as a whole. Smith's study draws on twenty-five years of research, including hundreds of interviews and visits to representative facilities. He provides a succinct overview of how care is presently organized for New York's aging population and traces the history of the system up to the present. Among the key issues he addresses are the role of market forces and government regulation, the impact of class differences on access to quality care, and the ways in which perceptions of community affect the creation and management of assisted living programs. At the heart of the book are ten fascinating case studies, half of them focused on private-pay facilities and the other half on public-pay institutions. While finding that the actualities of assisted living rarely match the rhetoric of its proponents, Smith sees much to admire in its goals. He suggests tactics and strategies--such as promoting family- and community-based models of assisted living and adopting a standard of licensure for certain facilities--that could point the way to a better future. 

Published by: Vanderbilt University Press

Table of Contents

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pp. vii

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pp. ix-xv

The long-term care system frustrates the frail elderly who want to control their lives. It also frustrates those who struggle to finance, regulate, and provide their care. This book attempts to make sense of the dramatic changes in such care. It raises troubling questions about where we are headed. The book focuses on the evolving system of care in urban America...

I. Inventing Care

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pp. 1

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1. Growing Old in a City

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pp. 3-27

How does one grow old in a city? Many New Yorkers, and residents of other major metropolitan areas, might say that you don’t. Instead, they might say that in such a place you live a full life, like that which Shaw describes in Man and Superman, full of the energy of a center of such lives. For the out-of-towner, growing old or, in the language of gerontology, ...

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2. A Brief History of Care

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pp. 28-57

This chapter presents the history and the alternative paths that have been chosen in the past in caring for the frail elderly in New York City. This sector of the population needs assistance with the same activities of daily living (e.g., ambulation, feeding, dressing, bathing, etc.) now as they always have. Understanding how this care has been provided in the past...

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3. Emergence of the Killer Application

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pp. 58-79

The seeds for the killer application had been sown in the 1970s with the nursing home scandals and subsequent regulatory pressures. Some nursing home developers chose to switch from the traditional nursing home business to the seemingly greater freedom, simplicity, and profitability of private senior housing and boarding homes. They entered a diverse, ...

II. The Struggle for Control over Markets and Lives

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pp. 81

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4. Markets, Margin, and Mission

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pp. 83-97

The great American dream of serving humanity while making large profits flourished as a driving force behind the development of assisted living in the 1990s. Yet even missionaries unconcerned about profits need a margin of income greater than expenses. “No margin, no mission,” as they say in the nonprofit sector. This chapter describes how developers...

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5. Market-Driven Private-Pay Assisted Living

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pp. 98-133

The organization of health and social services in the United States changed in the twentieth century. In 1900, hospitals, county homes, and other institutions cared almost exclusively for the indigent. Nursing students, as a part of their training, provided much of the direct care. Most nurses left these institutions after graduation to serve as private-duty nurses in the homes of families that needed and could afford their services. Most...

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6. Publicly Supported Assisted Living

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pp. 134-162

“Over the Hill to the Poorhouse,” familiar lines to all at the beginning of the twentieth century, captures the fear and shame of institutionalization in old age, still present at the beginning of the twenty-first century. What do we owe to the elderly? Is poverty in old age a crime that should be punished by imprisonment? Do individuals in a community have value beyond what they can...

III. Reinventing Care

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pp. 163

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7. A Future for Care

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pp. 165-186

Neither the old nor the new models of care fit well with the day-to-day realities described in the preceding section. The elderly and their families wanted less institutional settings for care and more control of their lives. Developers, seeing a growing, profitable market, constructed facilities. The Medicaid program, seeing it as a way to reduce the cost of...

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pp. 187-190

Now sixty-one, I face with my twin brother and sister the problem of how to care for our parents. Most of our experiences are not much different from those of other adult children our age. Yet because it has influenced this book in so many subtle ways, it seems important to at least acknowledge the influence of our experience. Parents give us our first...


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pp. 191-198


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pp. 199-208

E-ISBN-13: 9780826591708
Print-ISBN-13: 9780826514288
Print-ISBN-10: 0826514286

Page Count: 224
Publication Year: 2003