Among industrialized countries, Canada and Sweden have well-developed (although imperfect) systems of long-term care. The USA is unique in that its long-term health care system does not protect the el¬derly against either chronic disability or impoverishment. The phenom¬enon of spending down to become eligible for government-paid long-term care is found only in the USA.
TABLE 106-3 lists the long-term care options available in various de¬veloped countries. Very few formal arrangements for long-term care exist in less developed countries. TABLE 106^ depicts variations among the rates of long-term institutionalization in several countries. The percentage of elderly needing institutional care varies from < 2% in Hungary to almost 11% in the Netherlands.
Use of nonmedical facilities (eg, a home for the aged or sheltered housing) also varies significantly. In European countries, commitment to provide nonmedical residential care and coordinated community ser¬vices contrasts greatly to what is available in much of the USA. Despite cultural and other similarities between the USA and Canada, the two

Long-term care institutions have increasingly come under legal scru¬tiny, spurred primarily by exposes of neglectful and abusive care of vul¬nerable, often demented, elderly institutionalized patients. The nature and degree of abuse offended legal, moral, and civic sensibilities. This offense resulted in a framework of federal and state regulations that prescribe staffing patterns, record-keeping procedures, and many as¬pects of institutional practice. Increasingly, long-term care facilities are being challenged about policies that automatically provide life-sustaining treatment to unknowing patients with no provision for stop¬ping such treatment. Yet, many of these facilities are afraid to adopt policies allowing a resident to die because they may be accused of ne¬glect and abuse. Practitioners should be aware of developments as states struggle to define and regulate these decisions. The legal climate is crucial in discussions with patients and families about possible future care. Many long-term care facilities are adding information about future preference for care and resuscitation status to their postadmission dis¬cussions in response to the Patient Self-Determination Act and because of concern for legally supportable decisions.

Federal and state laws and regulations also govern long-term care financing (see also Chs. 110 and 114). Most long-term care is funded by Medicaid, the needs-based cooperative federal and state health reim¬bursement program. Very little long-term care is funded by Medicare, the age-based federal medical program for the elderly and for some per¬sons with disabilities. Most elderly patients, couples, and families do not understand the complex rules that require spending their income and assets to a level of poverty before Medicaid will assume the cost of long-term care. In most states, legal advocates can protect a spouse living in the community from impoverishment by appealing to state reg¬ulations that permit segregation of funds. If such an arrangement is not possible, an attorney may file a suit for support in the Family Court or other appropriate state forum. Every state has a long-term care ombudsman whose office is funded by Medicare. These offices can provide information about some of the rights and protections available to residents of long-term care facilities.

Among industrialized countries, Canada and Sweden have well-developed (although imperfect) systems of long-term care. The USA is unique in that its long-term health care system does not protect the elderly against either chronic disability or impoverishment. The phenomenon of spending down to become eligible for government-paid long-term care is found only in the USA.
TABLE 106-3 lists the long-term care options available in various developed countries. Very few formal arrangements for long-term care exist in less developed countries. TABLE 106^ depicts variations among the rates of long-term institutionalization in several countries. The percentage of elderly needing institutional care varies from < 2% in Hungary to almost 11% in the Netherlands.
Use of nonmedical facilities (eg, a home for the aged or sheltered housing) also varies significantly. In European countries, commitment to provide nonmedical residential care and coordinated community services contrasts greatly to what is available in much of the USA. Despite cultural and other similarities between the USA and Canada, the two * Approximate date.
11981 census data indicate that 3% of the elderly were “usually resident” in communal establishments (mainly homes for the elderly but also hospitals, hostels, and hotels); another 1% was present in such places (usually hospitals), though not usually resident.
$ Excludes elderly in general hospitals.
N/A = not available.
Notes; For reasons of definition, coverage, and temporal reference, rates of institutional use may not be well suited to comparison across nations. Hence, differences between figures in this table should be taken as roughly indicative of different national propensities toward institutional use. Generally, a national use rate reflects the percentage of all elderly persons resident in institutional settings at a particular point in time.
From Suzman R, Kinsella KG, Myers GC: “Demography of older populations in developed countries,” in Oxford Textbook of Geriatric Medicine, edited by JG Evans and TF Williams. Oxford, Oxford University Press, 1992, p 10; used by permission of Oxford University Press.
countries differ greatly in how they care for the elderly. With respect to payment for long-term care, the average Canadian is far better off than his American counterpart because all Canadians are eligible for such care regardless of income.
Many governments are being pressured to provide more institutional care for the frail elderly. Projections of increases in this population and in the costs of institutionalized care have precipitated an intense debate over the ideal number of beds for such care.

Long-term care institutions have increasingly come under legal scrutiny, spurred primarily by exposes of neglectful and abusive care of vulnerable, often demented, elderly institutionalized patients. The nature and degree of abuse offended legal, moral, and civic sensibilities. This offense resulted in a framework of federal and state regulations that prescribe staffing patterns, record-keeping procedures, and many aspects of institutional practice. Increasingly, long-term care facilities are being challenged about policies that automatically provide life-sustaining treatment to unknowing patients with no provision for stopping such treatment. Yet, many of these facilities are afraid to adopt policies allowing a resident to die because they may be accused of neglect and abuse. Practitioners should be aware of developments as states struggle to define and regulate these decisions. The legal climate is crucial in discussions with patients and families about possible future care. Many long-term care facilities are adding information about future preference for care and resuscitation status to their postadmission discussions in response to the Patient Self-Determination Act and because of concern for legally supportable decisions.

Federal and state laws and regulations also govern long-term care financing (see also Chs. 110 and 114). Most long-term care is funded by Medicaid, the needs-based cooperative federal and state health reimbursement program. Very little long-term care is funded by Medicare, the age-based federal medical program for the elderly and for some persons with disabilities. Most elderly patients, couples, and families do not understand the complex rules that require spending their income and assets to a level of poverty before Medicaid will assume the cost of long-term care. In most states, legal advocates can protect a spouse living in the community from impoverishment by appealing to state regulations that permit segregation of funds. If such an arrangement is not possible, an attorney may file a suit for support in the Family Court or other appropriate state forum. Every state has a long-term care ombudsman whose office is funded by Medicare. These offices can provide information about some of the rights and protections available to residents of long-term care facilities.