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Foster Home Care for the Frail Elderly as an Alternative to Nursing Home Care: An Experimental Evaluation JULIANNE S. OKTAY, MSW, PHD,

AND

PATRICIA J. VOLLAND, MSW, MBA

Abstract: This paper describes a program (Community Care Program) in which some elderly hospital patients who were candidates for nursing home placement were placed in foster homes. Caregivers were carefully trained and supervised. A total of 112 elderly inpatients were randomly assigned to placement in a nursing home or a foster care home. Patients and caregivers were interviewed at 3, 6, 9, and 12 months after placement. Community Care Program patients were more likely to maintain

or improve ADL (activities of daily living) and mental status scores. They also had better nursing outcomes and were more likely to get out of the house than were nursing home patients. Nursing home patients had higher life satisfaction, and participated in more social and recreational activities. The Community Care Program was 17 per cent less costly than nursing home care. The results suggest that foster care may be a viable altermative for a segment of the nursing home population. (Am J Public Health 1987; 77:1505-1510.)

Introduction While the institutional bias of public policy for the frail elderly is commonly deplored,",2 the search for alternatives has been frustrating. Quasi-experiments with coordinated service packages (case management),3 homemaker and day care4 have shown that these programs often serve populations that are healthier than nursing home patients, or those who will never be placed in nursing homes.5 When patients equally dysfunctional to those in nursing homes are served, community-based programs are very costly.67 Some argue that cost should not be an overriding factor,8 but when we consider the dramatic increases in the elderly population expected in the coming decades,9 along with the increasingly limited funds available for health care, cost cannot be overlooked. This paper describes an experimental evaluation of a different type of alternative to nursing home care: community-based foster home care. Whereas frail elderly have lived with non-relatives for centuries, these arrangements have traditionally not involved any outside supervision. In fact, problems in these "boarding-home" arrangements contributed to the development of the modern nursing home. Recently, however, foster home programs have been developed by psychiatric hospitals and mental health departments, social service departments, and the Veterans Administration.'>14 These programs provide varying degrees of supervision and care for elderly with mild to moderate levels of disability. Only within the last few years has this idea been tried with a severely disabled elderly population. Acute care hospitals in Boston, Honolulu,'5 Poughkeepsie,'6 and Baltimore'7 have started small foster care programs for patients in need of intermediate or skilled care. Such programs offer promise of providing a non-institutional alternative that simulates family living at a reasonable cost. In this paper, one such program is compared with nursing home care on the basis of quality of care and cost. Program Description The Community Care Program was started in March of 1979 by the Johns Hopkins Department of Social Work. It

was staffed by a social worker (licensed MSW), a nurse practitioner (geriatric nurse practitioner at the master's degree level), and a part-time secretary. The staff took

Address reprint requests to Julianne S. Oktay, MWS, PhD, School of Social Work and Community Planning, University of Maryland at Baltimore, 525 W. Redwood Street, Baltimore, MD 21201. Ms. Voiland is with the Department of Patient Services, Johns Hopkins Hospital, Baltimore. This paper, submitted to the Journal April 18, 1986, was revised and accepted for publication June 3, 1987 Editor's Note: See also related editorial p 1499 this issue.

responsibility for the recruitment and training of suitable caregivers, the selection of appropriate patients (from inpatients at Johns Hopkins Hospital who were ready for discharge), the placement process, and ongoing monitoring and service to both patient and caregiver. Medical back-up was provided by the Johns Hopkins Internal Medicine Associates-a faculty and housestaff group practice located in the hospital. Caregivers were paid $350-$500 a month, depending on the care needs of the patient. (Funds from the Robert Wood Johnson Foundation were used to make up the difference between what the program determined the caregiver should be paid and the amount the patient could afford. RWJ funds also paid for salaries of the staff, for equipment and supplies not covered by 3rd party payers, and for transportation.) Caregivers provided the patient with a private room in their home, meals, laundry, assistance with personal and instrumental activities of daily living, 24-hour supervision and nursing tasks (as needed) such as monitoring medications, keeping daily records on patient status, injections, and behavioral modification. Most caregivers took in only one patient, but a few with unusual experience or ability cared for two patients at a time. Figure 1 illustrates the placement process. Following placement, the Community Care Program staff monitored the patient's care through daily recording forms, weekly phone calls, and monthly home visits at a Patient

Caregiver

Patient enters hospital

Caregiver responds to newpaper advertisement.

Floor ocial worker refers patient to

C'ommunit! Care.

Caregiver attends meeting at hospital where program is explained. Filts in application form.

Communit% Care staff determine that patient is suitable for Communit% Care.

Community Care staff social worker competes homne evaluation (including fire inspection).

Communit% Care staff present program to patient. Patient/fnmil% agree to randomized ptacement in nursing home or Community Care.

Caregiver attends and passes training prograni.

Csfmmunit% Carestafl match patient with caregiser. Patient meets and accepts caregiver.

Community Care staff match caregiscr oith

patient. Caregiver meets and accepts patioict.

PLACEMENT

C 1987 American Journal of Public Health 0090-0036/87$1.50

AJPH December 1987, Vol. 77, No. 12

FIGURE 1-Community Care Placement Process

1 505

OKTAY AND VOLLAND

minimum. The nurse was responsible for direct in-home nursing services, health education of the caregiver and patient, ongoing assessment, consultation with the physician, and supervision of the caregiver. The social worker dealt with patient and caregiver adjustment, family problems, financial problems, and helped link the patients and caregivers to needed community services, such as senior recreation or day care programs. Caregivers were reevaluated every six months. The typical caregiver was a middle-aged Black woman who was married and lived with her husband and children. She had a high school education and previous experience caring for frail elderly patients-either with family members and/or through paid work as a nurse's aide. The caregivers as a group were very religious people who professed to be motivated by a combination of humanitarian goals and a desire for additional income. They did not need to be licensed because, in Maryland, licensing only applies if there are four or more patients in the home. The homes of all caregivers had to pass a fire inspection.

Methods Patients at the Johns Hopkins Hospital who were 65 years and older and who were thought to have no alternative to nursing home placement were screened by the Community Care staff. Excluded were those patients whose needs could not be met in a community foster home (e.g., needed 24 hours care, multiple skilled nursing needs, extremely obese, aggressive). Eligible patients (and families when available) were told about the Community Care Program. There were 112 patients (representing about 20% of the eligible patients) who agreed to random placement into either community foster care or nursing home care. The patient population that found foster care acceptable was more likely to be poor, single, and living alone at admission. Also, Blacks were more likely than Whites to accept foster home placement. Finally, those accepted into foster care were somewhat higher in functional ability than the majority of frail elderly being discharged from the hospital. The program was often rejected by family members, who seemed to feel less threatened by the institutional setting of a nursing home. Random assignments were initially 60 per cent to Community Care and 40 per cent to nursing home to ensure adequate numbers in the experimental group. This ratio was later changed to 50-50. The individual randomization assignments were placed in sealed envelopes by the research staff before the experiment began. A hospital staff member unknown to the program staff was called when a patient was ready. After recording the patient's name, this person opened the next envelope and revealed the random assignment. Between March 1979 and September 1981, 59 patients were assigned to the Community Care Program and 53 to area nursing homes. Of the initial 112 patients, we were able to interview 53 (47 per cent) at 12 months after hospital discharge. Of the remainder, 34 (30 per cent) had died, and 25 (22 per cent) were lost to follow-up. Of those assigned to the Community Care Program, 42 (71 per cent) actually were placed there; of those assigned to nursing homes, 36 (68 per cent) actually went. The large majority of patients who were not placed as assigned returned to their homes or went to live with friends or relatives. Patients were interviewed prior to hospital discharge, and both patients and caregivers were interviewed at 3, 6, 9 and 12 months post-discharge. The patient interview included 1 506

the following instruments: a mental-status scale,'8 a lifesatisfaction scale,'9 an item on perceived health, and four questions on social interaction: frequency of telephone calls, frequency of visitors, participation in social or recreational activity, and frequency of getting outside of residence. The caregiver interview measured activities of daily living,20 instrumental activities of daily living,21 patient mental status, and life satisfaction (see Appendix A for a description of these indices). Background information on demographics and health status was obtained from the medical record. Specific nursing goals were set for each patient before the random assignment took place, to avoid bias. Three months later, the nurse returned to visit the patient and ascertain to what extent each goal had been met. Each goal was rated in four categories: "exceeded," "met," "partially met," and "not met." For each goal, the extent to which deterioration had been avoided was rated in three categories: "avoided," "partially avoided," and "not avoided." All three instruments were tested for interrater reliability. Two different interviewers interviewed patient/caregiver pairs on consecutive days. For the nursing goal attainment scale, the program nurse and an outside nurse rated 10 patients with respect to the discharge goals. Correlation (r) between the two sets of ratings were as follows: MSQ (.75) LSI-Z (.52) ADL (.86) IADL (.81) Nursing Goal Attainment

(.69).

The data from individual and caregiver interviews were analyzed by comparing the scores 12 months after discharge with the same scores at the time of discharge. To evaluate changes in functioning or attitude on the various measures, each patient was classified into one of two categories for each measure: 1) patient deteriorated; and 2) patient did not deteriorate or improved. A more complex measure was also calculated to take into consideration the magnitude of the change in each case. For this purpose, each patient's initial score was subtracted from their score at 12 months, again on each indicator. To compensate for different amounts of possible change based on the initial score, the "difference" score was then divided by the total change possible. The result is a proportional change score, which can be interpreted as the improvement or deterioration achieved as a proportion of the total improvement or deterioration possible. Finally, the average proportional change was calculated for each group-Community Care, and Nursing Home. In addition to comparing the quality of care in the two settings, we made some cost comparisons. The data for the cost comparisons were based only on those patients who were actually placed in the assigned settings. To calculate the cost of an average day in the Community Care Program, cost data from years 2 and 3 of the program were used. Years 1 and 4 were eliminated because of the impact of a "start up" condition (year 1) and incomplete data (year 4). To begin, the basic cost of providing community care (payment to caregiver plus staffing costs) was compared with the average daily nursing home rate. Second, indirect costs (transportation, space, physician services, and respite) were added. Finally, we considered costs that went beyond direct costs to the programs. For example, utilization of out-of-program health services, such as physician visits, ambulance, hospital days, emergency rooms, etc., could differ in the two settings. This difference would add a cost to the larger system rather than the program itself. To estimate this cost, a sample of 10 patients was selected randomly from each of the two programs. Medicaid and Medicare payment history records were reviewed for the 20 sampled patients. Costs by type by year AJPH December 1987, Vol. 77, No. 12

FOSTER HOME CARE FOR THE FRAIL ELDERLY TABLE 1-Demographic Characteristics by Random Assignment Group Demographic Characteristics X Age (years) Race White (%) Black (%) Sex Male (%) Female (%)

Marital Status Married (%) Single (%) Separated/Divorced (%) Widowed (%) Living Arrangement at Admission Alone (%) Spouse (%) Children (%) Sibling (%) Other Relative (%) Non-Relative (%) Institution (%) Median Yearly Income Prognosis Good (%) Guarded (%) Poor (%)

NH (N = 53)

CCP (N = 59)

P 1.0O-

\

---

"

-

----

-

-____

-------------------------------------

0 09-, R

---_--------_____-

-------

-----------

------------------------

T 0.7-

70.2

69.8

0 0.6

18.6 81.4

41.5 58.5

U 0.21

--------------------------

"

0.5

pp

d

r

m

R

'-

V 0.3 --_ -----------

I

35.8 64.2

35.6 64.6

v o0.2

I

.

-

5.7 11.3 17.0 60.4

57.6 6.8 8.5 8.5 10.2 6.8 6.8

54.7 5.7 13.2 1.9 6.8 13.2 7.5

$2,000-2,999

$2,000-2,999

47 27 25

42 30 28

0

30

-----------------

95 % confidence intervals

----

G O .0

10.3 27.6 8.6 50.0

-pts. placed as randomized pts. not placed randomized

_..................... 60

90

120

150

180

210

240

270

300

330

360

390

DAYS )

TIME

FIGURE 2-Survival Curves with 95% Confidence Intervals of Patients Placed as Randomly Assigned to Community Care Program or Nursing Home (N = 78) and Patients Not So Placed (N = 34)

Outcome: Discharge to Community Living

Eight patients were discharged from the Community Care Program to various community living arrangements. Some moved into other types of boarding homes, others moved in with family members, but most returned to independent living. Five patients were discharged from nursing homes to community living. This represents a difference of 5 per cent (95% CI -7%, + 16%). Outcome: Functional Status and Attitude

were summarized to obtain an average incremental cost per day due to Medicaid and Medicare reimbursemenLs.* This average per patient cost was then applied to all patients in the two programs.

Results Initial Comparison of Experimental and Control Groups

Randomization is designed to ensure that the experimental and control groups do not differ at the onset. With experimental design, observed differences after the "treatment" has been applied can be attributed to the differences between the programs, in this case, between the Community Care Program (CCP) and nursing home care. Table 1 shows the initial characteristics of patients assigned to the CCP and nursing home care. Demographically, the two groups are comparable for age, sex, living arrangement at time of admission, and income. Similar proportions of both groups are without a spouse, although the reason why varies somewhat. More Black patients were assigned to the CCP than to nursing home placement. Outcome: Mortality At the end of 12 months following hospital discharge, 17 (32.0%) of the 53 cases assigned to nursing home placement had died, and 17 (28.8%) of the 59 cases assigned to Community Care Program died during the same time period. The difference is 3.2 per cent (95% CI - 14%, +20%). If we consider only the cases who were placed as randomly assigned, the figures are 25.0 and 16.6 per cent, respectively, giving a difference of 8.4 per cent (95% CI - 14%, + 30%). Figure 2 compares the survival curves (based on the product-limit method developed by Kaplan and Meier) of those placed as assigned and those not so placed.22 The cases who were not placed in either a nursing home or a community foster home clearly had a higher mortality rate. *The analysis of the Medicaid and Medicare costs was conducted by the Leventhal and Horwath Accounting Firm.


Data on activities of daily living (ADL), instrumental activities of daily living (IADL), mental status, perceived health, and life satisfaction for all patients who were interviewed at 12 months are presented in Table 2. Data are also presented for the subgroup of patients who were placed as randomly assigned. Table 2 shows the per cent of patients in each group (Nursing Home and Community Care) who either improved or maintained their scores between the initial interview (done in the hospital) and the one done one year later. The table shows that more patients assigned to the Community Care Program improved or maintained ADL functioning (.78) than did those in nursing homes (.60). The difference between the treatment settings is somewhat larger among patients placed as randomly assigned. When we examine the categories that make up the ADL scale, we find that the difference is TABLE 2-Proportion Cases Maintaining or Improving in 12 Months by Treatment Group for all Cases Randomized and for Only Those Placed as Randomly Assigned*

Outcome Indices

Functioning Activities of Daily Living Instrumental Activities of Daily Living Mental Status

Attitudes Perceived Health Life Satisfaction

Community Care Program

Nursing Home

N

N (N

=

28

(N = 24)

=

25

=

21)

Difference

95% Confidence Interval

(a-b)

.78 (.86)

.60 (.63)

+.18 (+.23)

-.07 (-.02)

+.43 (+.48)

.74

(.77) .64

.68 (.61) .58

+.06 (+.16) +.06

-.17 (-. 11) -.21

+.31 (+.43) +.33

(.65)

(.50)

(+.15)

(-.14)

(+.44)

.68 (.61) .45

.83 (.78)

.73

-.15 (-.17) -.28

(.56)

(.67)

(-.11)

-.39 (-.44) -.55 (-.39)

+.09 (+.10) +.01 (+.17)

*Data for those cases placed as randomly assigned are in parentheses.

1 507

OKTAY AND VOLLAND TABLE 3-Average Change In Functioning and Attitude as a Proportion of Total Possible Change by Treatment Group for all Cases Randomized and for Only Those Cases Placed as Randomly Asslgned*

Treatment Group

Outcome Indices

Functioning Activities of Daily Living Instrumental Activities of Daily Living Mental Status Aftitude Perceived Health Life Satisfaction

Community Care Program

Nursing Home

Difference

N = 28

(N = 24)

N = 25 (N = 21)

(a-b)

+.29 (+.35)

+11 (+.21)

+.18 (+.14)

-.10

+.46

(-.14)

(+.42)

-.37 (-.25)

-.15

-.12

-.03

(-.12)

(-.26)

(+.14)


+.17

+.10

(+.18)

+.07

-.21

(-.02)

(+.20)

+.31 (+.53) +.35

(-.08)

(+.48)

+.10 -.02

+.23 (+.23) +.21

-.13 (-.11 ) -.23

-.52 (-.55) -.51

(+.07)

(+.22)

+.26 (+.33) +.05

(-.45)

(+.23)

(+.12)

*Data for cases placed as randomly assigned are shown in parentheses.

explained by improvement in bathing, dressing and, to a lesser extent, transferring. In the areas of toileting and continence, nursing home patients did as well or better. This finding is consistent with program experience, where caregivers found it very hard to manage problems of bowel or bladder incontinence. Techniques used in nursing homes, such as toilet training and manipulation of diet, were often objectionable to community caregivers. In the areas of instrumental activities of daily living and mental status, there was a small difference in favor of the Community Care Program. However, the confidence intervals show that the difference has a substantial likelihood of being negative. Thus we cannot be sure that these differences are meaningful. Again, the differences are more substantial among those placed as randomly assigned. In the "attitude" measures, the trend is reversed. That is, the patients assigned to nursing home placement did better over the one-year period than those in the Community Care Program. On the "perceived health" question, .68 of those assigned to community care improved, compared to .83 of those assigned to nursing homes. On "life satisfaction," the figures are .45 and .73, respectively. The confidence intervals for life satisfaction range from -.55 to -.01, suggesting that we can be reasonably sure that the direction of the relationship is negative. However, the difference among those placed as randomly assigned is weaker, in this case. The use of mood elevating drugs was examined as a possible confounding factor. We found that nursing home patients were more likely to receive these substances (44 per cent as compared to 17 per cent of CCP patients). However, controlling for this factor did not alter the magnitude of the relationship. Table 3 shows the same data as Table 2 except that the size of the differences and the amount of possible change (given the initial score) are taken into account. This analysis does not substantially change the interpretation of the results. Assessment of Confounding by Race Because there was a difference in the proportion of Blacks and Whites randomly assigned to the two treatment settings, it is important to evaluate and remove any confounding due to race. Table 4 shows the crude difference in 1 508

proportion improving or maintaining initial scores after 12 months and the pooled difference in proportion controlling for race, and the confidence intervals for the two difference scores.24 The pooled difference was determined as a weighted sum of the race specific differences. Comparison of the crude and pooled difference scores (controlling for race) shows that confounding was present only in the case of the mental status index. Here, the pooled score shows a considerably better outcome in the Community Care Program (difference = + .14, 95% CI -.12, + .40) than does the crude difference score (difference = +.06, 95% CI -.21, +.33). Examination of the data show that overall, more Whites improved or maintained their initial mental status (87%) than did Blacks (50%). Both Blacks and Whites placed in the Community Care Program did better than those in nursing homes. However, because Blacks were more likely to be placed in the Community Care Program than were Whites, this difference was confounded. In this case, the pooled difference score (+.14) is the more accurate estimate.

TABLE 4-Crude Difference in Proportion Improving or Maintaining InItIal Score at 12 Months and Pooled Difference In Proportion Scores Controlling on Race Difference in

Activities of Daily Living Crude Pooled Instrumental Activities of Daily Living Crude Pooled Mental Status Crude Pooled Perceived Health Crude Pooled Life Satisfaction Crude Pooled

Proportion


+.18 +.19

-.07, +.43 -.07, +.45

+.06 +.08

-.17, +.31 -.19, +.35

+.06 +.14

-.21, +.33 -.12, +.40

-.15 -.13

-.39, +.09 -.37, +.11

-.28 -.29

-.55, -.01 -.58, +.004


FOSTER HOME CARE FOR THE FRAIL ELDERLY Outcome: Nursing Goal Attainment

Community care patients did somewhat better than nursing home patients on nursing goal attainment, with 46 per cent of CCP patients meeting all three goals within three months, compared to 31 per cent of nursing home patients. This represents a 15 per cent difference in favor of the Community Care Program (95% CI - 10o, +40%o). Our findings also show that 88 per cent of CCP patients avoided deterioration in all three goals, compared to 69 per cent of nursing home patients-a 19 per cent difference in favor of the Community Care Program (95% CI -.01, +.39). Outcome: Social Activities

One of the initial assumptions underlying the development of the Community Care Program was that living in a community-based foster home would facilitate interaction with family, friends, and neighbors. There was a tendency for community care patients to receive more telephone calls than nursing home patients in the first six months of the program, but by nine months into the program, phone calls to CCP patients had dropped to the level of nursing home patients (about one-third receiving calls once a week). On the other hand, nursing home patients had more frequent visitors at all time periods, although the visits dropped off for both groups during the year. Nursing home patients were also more likely to participate in social and recreational activities than were community care patients. This difference is especially marked in the first three months. By the time patients had been in the CCP for six months, rates of social participation increased, although they never attained the level of nursing home patients. Finally, community care patients were more likely than nursing home patients to get out of their place of residence; this difference holds for all four time periods. Cost of Community Care Program At the time of the Community Care Program, the average charge by nursing homes in Maryland was $36 per day, 31.5 per cent more expensive than the basic cost of providing community care (Table 5). However, this calculation may be misleading because indirect costs, such as transportation, physician, space, and respite care are not included. When these costs are included, the difference is reduced to 26 per cent. In addition, the average out-of-program health care TABLE 5-Estimated Cost of Community Care and Nursing Home Care (costs per patient per day)

Community Care Nursing Program Home Difference % Savings (a)

(b) $36.06

Basic Daily Cost

Caregiver Payment:

Patient Contribution Program Contribution Staff Salaries, Benefits Total Basic Costs Other Costs* Total Program Costs (Basic + Other) Health Care Costs** Total Costs (Basic + Other + Health

Care)

(b-a)

$6.54

$6.55 $11.61

-

WM

$11.36

31.5%

$3.40

$36.06 $2.16

$28.10 $3.76

$38.22 $0.23

$10.12

26%

$31.86

$38.45

$6.59

17%

*Includes transportation, equipment, medication, respite, physician back-up, and indirect costs. "Includes all charges to Medicaid/Medicare for medication, doctor visits, hospital use,

transportation, etc.


costs were higher for the community care patients: $3.76 per day compared to only $0.23 per day for nursing home patients. Even when these additional costs are taken into consideration, however, the Community Care Program was

17 per cent less costly than nursing home care. While a difference of $6.59 per day may not seem very important, this amount represents a saving of $2,405.35 per patient per year. Thus a small foster care program with only 30 patients represents a potential savings of over $70,000 a year. A more sophisticated analysis might take into account the use of community services such as day care centers, senior centers, buses, etc. Also, thought might be given to the cost/benefit to the larger community through consideration of the effect of the program on the caregivers and their families. It is possible that the CCP creates savings in social service programs such as general assistance, food stamps, energy assistance, etc., by stabilizing the income of the caregiver families.

Discussion It was possible to provide foster home care, with no clear deleterious effect, to frail elderly patients who would otherwise have gone to nursing homes. Patients assigned to the Community Care Program had greater likelihood of improving or maintaining ADL and mental status scores (at 12 months), and were more likely to attain nursing goals (at three months). On the other hand, patients in nursing homes were more likely to maintain or improve life satisfaction scores (at 12 months). The social patterns in the two settings also differed: CCP patients were more likely to be getting out of the house, while nursing home residents were more likely to participate in social and recreational activities. The results with respect to life satisfaction will be of concern to those wishing to advocate for foster care for the frail elderly. We considered several possible explanations for this finding. The fact that the reliability (in this study, the life satisfaction index showed an interrater reliability of only .52) and validity of the short version of the life satisfaction index in this context are questionable may be a factor.** Recent research on this index shows that Black and White elderly may differ on factors predicting life satisfaction,24'25 making the interpretation of life satisfaction more complex in studies with multi-racial populations. If life satisfaction is lower in the Community Care Program population, an explanation may be found in reference group theory,26 i.e., patients in the nursing home may have been comparing themselves with other nursing home patients. As this Nursing Home Group is limited to the severely impaired, they may have come to perceive their health as better than others their age. In contrast, patients in community-based foster homes (where they are usually the only frail elderly person in the home) may have compared themselves with the caregivers or with other age peers living in the neighborhood. Thus they may have come to feel themselves to be relatively worse off. Also of concern are the results on social participation. Research on foster care for geriatric 2 and mentally retarded27 populations has found social isolation to be a problem. Foster care programs in communities that do not have adequate resources for social activities (e.g., transportation, social **The LSI-Z was originally tested on a healthy population of rural elderly. The reliability was considered by the authors acceptable only for males.19 1 509

OKTAY AND VOLLAND

programs for the frail elderly) may have to limit themselves to patients who are not interested in this type of activity. The findings with respect to cost show that the direct cost of foster care is about 25 per cent lower than nursing home care, and these savings remain substantial even when additional health care utilization and costs of community social programs are taken into account. Recent concern about the low rate of nursing home utilization in the Black population may spark interest in foster care programs. The CCP proved to be especially attractive to Blacks, both as patients and caregivers. (Foster home programs in other cities (e.g., New York,'6 Honolulu'5) suggest that foster care is also acceptable to Whites and Asian groups.) An interesting-and unanticipated-finding was that the mortality rate for patients who rejected either treatment alternative (CCP or Nursing Home) was very high. This finding suggests that the frail elderly who return to the community against the recommendation of the hospital staff constitute a very high-risk group. The Community Care Program provided an alternative to nursing home care at a somewhat lower cost. Unlike many community-based programs considered to be alternatives, it provided what those most likely to enter nursing homes need-24-hour supervision and daily personal care.28 Because this alternative appealed to those with minimal family resources who were in need of extensive care, the development of foster care programs is unlikely to create an extensive demand for service, as is often feared for communitybased alternatives. The quality of care appears comparable to nursing home care, suggesting that a closely supervised caregiver can provide skilled care as well as personal care and supervision. As Callahan states, "One fact that seems clear is that the majority, but not all, of disabled elderly prefer to remain out of a nursing home if at all possible. We should strive to make this a reality."8 ACKNOWLEDGMENTS The research reported in this paper was supported by a grant from the Robert Wood Johnson Foundation. An earlier version of this paper was presented at the 110th Annual Meeting of the American Public Health Association in Montreal, Canada, 1982. The authors thank John R. Hebel, Rosalie Kane, Donald M. Steinwachs and Ellen J. MacKenzie for their very helpful comments on an earlier version of this paper.

REFERENCES 1. Vladeck BC: Unloving Care: The Nursing Home Tragedy. New York: Basic Books, 1980. 2. Palley HA, Oktay JS: The Chronically Limited Elderly. New York:

Haworth Press, 1981. 3. Hicks B, Raisz H, Segal J, Doherty N: The triage experiment in the coordinated care for the elderly. Am J Public Health 1981; 71:991-1003.

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