When people begin to have trouble with cooking or getting around and their families cannot care for them, the knee-jerk reaction is to consider just a nursing home. But a nursing home may not be needed. Surveys show that some nursing-home residents do not need to be institutionalized; they could live in the community if they took advantage of the outpatient alternatives that exist. For instance, in one demonstration project, people otherwise bound for nursing homes called a special triage number. Through the use of community resources, the health-care team operating the project was able to keep 25 to 30 percent of these callers at home.

The decision to put a loved one in a nursing home frequently is made after a medical crisis. The patient is in a hospital and must be discharged soon. Handling life at home right now is impossible. There is a mad scramble to find a nursing-home bed. There is no time to explore other possibilities or even to select the best nursing home.

But in a hospital people are at their physical worst. After they recuperate they may not need institutional care. They may require only minor help with shopping or cooking or getting around. Placing this type of person in a nursing home is like using a sledgehammer to treat a problem that could be cured by a tap. And it is physically wasteful. Offering too much care produces excess disabilities, further eroding the quality of life.

A comparison of patients who entered nursing homes and two other groups with similar disabilities receiving different types of home care underlines this point. After three months the patients getting care in the community made greater improvements in their ability to care for themselves and get around, and they were happier than the group in the nursing homes.

Nursing-home care can also be financially wasteful. It is very expensive, costing on the average 20,000 to 25,000 dollars a year. Medicare covers 1 percent of the cost. The Medicare system covers only acute or curative care. Once care is labeled as custodial, chronic, or forever, Medicare will not pay.

Although nursing-home insurance has recently become available, it too is expensive – about 1,500 dollars a year for subscribers in their seventies, more costly beyond that age. A 1987 review of thirty-one policies showed that qualifying for this type of insurance can also be hard. Companies often impose numerous eligibility restrictions – for instance, weeding out anyone with obvious disabilities or even denying coverage if a person answers yes to any health-related question on the application. Policies can have numerous “exceptions” or provide very limited coverage for certain types of nursing-home care.

Most people begin by paying the astronomical nursing-home fees privately. In fact, while a mere 5 percent of people over sixty-five are residents of nursing homes; the lion’s share of the out-of-pocket health-care dollar spent each year by this age group goes not to hospitals or physicians, but to nursing homes. The steep expense bankrupts all but the wealthiest; resources are soon exhausted, and the nursing-home resident becomes eligible for Medicaid, the health-care insurance system for the poor, which does cover custodial care. This scenario fits an estimated half-million people every year.

If a relative is having problems functioning independently, you should explore every alternative to a nursing home. Visit your local office for the aging for information about what exists in your community. Get a full consultation from a social worker on the staff. Even when the answer must be a nursing home, the judicious use of these services may buy you time-to search out the best nursing home, to allow your relative to share the decision making and absorb the news, to make the transition to institutional living less wrenching.

The community services described below can also be costly. But unless full-time home care is required, they are likely to be much less expensive than paying privately for a nursing home. Just as Medicare covers only services defined as “rehabilitative or curative” in a nursing home, this condition also applies to its paying for non-institutional care. Unless a service is defined as medical and noncustodial and a doctor certifies that your relative needs it, Medicare is unlikely to pay.

While Medicaid, the health-insurance system for the poor, does cover non-institutional custodial care, specifically what it will pay for varies from state to state – the reason being that whereas Medicare is federally administered, the Medicaid program is under the jurisdiction of individual states. Here are the services to consider.

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GENERAL HEALTH