One of the most characteristic aspects of the frail period of life is that the person becomes quite tied to home and community. This is not a time when people travel far away on adventures, or even undertake travel for medical consultation. The range of moving around becomes smaller, and the services the person needs, such as home-delivered meals and personal care, are mostly tied to where he or she lives. Eventually, going out to see a doctor becomes a major production, requiring help from family and specially equipped transportation, so many frail elders come to see physicians only in the emergency room or in a hospital or nursing home. Senator Rockefeller once told the painful story of trying to get suitable help for his mother, living with dementia. His bottom line and ours is that even having money and influence cannot guarantee getting suitable support at home if the community has no trained workforce.
Remarkable efficiencies become possible in organizing care geographically, once many services need to happen where frail elders live. Now, we send a dozen aides from half a dozen companies into an apartment building where six people live who need a couple of hours of services in the morning and evening. Instead, a geographically organized service could send in half as many aides, pay them better, have them move around as different people need them in the building, give better care, and still come out costing much less. Similarly, if a dozen frail elders live down one road, sending a dozen different physicians or nurses out to see them entails a great deal of “windshield time,” which would be better spent if one or two went out and attended to all who need the service along that road. In addition, a team working in one area gets to know a lot about subtle elements that make the work more efficient or effective: they learn which pharmacy will deliver after hours, which church will provide food in a difficult situation, which roads will close in bad weather, and the thousand other things that make local endeavors work well. Various rules defending the appearance of competition now prevent implementing this commonsense approach.
Having a strong community will protect the interests of current and future frail elders. Stakeholders include frail elders and family members, service providers, and ordinary citizens, all of whom are prone to pay attention to the quality and supply of all of the needed services. All who are aware of the interests of their community can play a role in influencing societal arrangements, setting priorities, and allocating the authority and accountability for effective and efficient services. Having frail elder care become, in part, a responsibility of the community will also help build communities, just as taking responsibility for roads, schools, and business growth does.
The need for reform is urgent. Continuing the current course is impossible. Every analysis of the economic effects of the predictable aging of the American population shows that, without reductions in per capita costs and changes in financing strategies, the combination of Social Security, Medicare, and Medicaid expenditures will be inadequate to meet the need while also being an unprecedented threat to the economy. Hubert Humphrey’s famous quote in the entry hall of the Health and Human Services building in Washington, DC, holds that “the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.” Both for good moral reasons and for our own self-protection, we do not want our governments to fail in providing for the elderly, but we cannot simply keep doing what we have been doing: current practices are too costly and provide inadequately for what we most need when old and frail. So, we need a plan that assures needed services at an affordable cost. At this time, in this country, allowing some willing communities to step ahead and teach the rest of us how to succeed is a politically acceptable way forward.
 (National Research Council 2012)