As the discussion of hospices suggested, most individuals who experience chronic or acute health problems—whether children, working-age adults, or elderly and whether their problems are physical or mental—receive most of their care at home. This is even truer now than in the recent past because of technical, demographic, and policy changes. Because of technological advances, babies born prematurely or with birth defects and persons who have experienced severe trauma are increas- ingly likely to survive, although often with severe disabilities that require lifelong assistance. Much of this care is now given by family members in the home. In addition, technological advances also have made it possible for families to provide treatments at home that previously were available only in hospitals such as chemo- therapy and kidney dialysis.

At the same time, the rise in the numbers of frail elderly, many of whom have both multiple physical problems and cognitive impairments, has increased the number receiving care at home. In addition, the movement begun in the 1960s to deinstitutionalize people with disabilities and mental illnesses, combined with the lack of community supports for such individuals after deinstitutionalization, have shifted much of the burden of care from state institutions to the home. Finally, as described previously, policy changes have encouraged hospitals to discharge patients to their homes “sicker and quicker,” in essence replacing paid hospital workers with unpaid family caregivers.

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Because of limited public or private insurance coverage for home care, most who need long-term supportive care receive services only from family members and, less often, friends. Research suggests that home care has little impact on the overall costs of care or the mental or physical health of those receiving care but can produce small improvements in individuals’ satisfaction with life.

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