Copyright 7997 by The Cerontological Society of America The Cerontologist Vol. 31, No. 3, 337-346

A holistic approach to the provision of social care of the elderly can best meet their future needs for assistance. In this paper, the concept of social care is delineated, and a systemwide model presented. This model emphasizes the interrelatedness of the component parts — informal, mediating, and formal — and the need for well-articulated linkages among them. Trends affecting future demand for care, and the ability of family and community to respond, are discussed. Although the family will retain an important role, some of its functions may shift to formal care in the decades ahead. Within the proposed framework, a research and policy agenda is suggested. Key Words: Social care system, Social supports, Hierarchical compensatory theory

Family and Community: Changing Roles in an Aging Society1

During the past 50 years, the role of the family in the nurturance of children has been well documented. More recently, as people have lived longer, gerontological research has turned to a careful analysis of the familial role in sustaining the elderly. The literature on family life and the elderly reveals two main streams of investigation: studies of normal interactions between family members, friends, and neighbors in the provision of social support to the elderly, and investigations involving care of the elderly suffering from functional disability or cognitive impairment. Although research involving normative intergenerational exchanges focuses on concepts such as family solidarity, consensual and affective bonding, and reciprocity, the literature on caregiving emphasizes issues of emotional strain and burden, and the impact on the health and well-being of those providing care to disabled elderly. My own work, starting with a study of the elderly in the inner city of New York (Cantor, 1975a), as well as more recent studies involving mentally and functionally frail elderly, and the "new" elderly in suburbia, spans both approaches. In addition, I have stressed a third systemwide approach to the care of the elderly, including both informal and formal care within a broader ecological context. This perspective grows out of concern with the delivery of services in the broadest sense, and stresses the interrelationship

1 Donald P. Kent Award Lecture, presented at the 43rd Annual Scientific Meeting of The Cerontological Society of America, Boston, MA, November 1990. I acknowledge a deep debt to my many colleagues, both at the New York City Department for the Aging and at Fordham University and its Third Age Center. Thanks also to the Brookdale Foundation, which has so generously supported my work during the past years. I am grateful to Eileen Chichin, Mary Mayer, and Jack Cornman for their comments on earlier drafts of this lecture, and to Alice Silverman for the preparation of the manuscript. 2 University Professor and Brookdale Distinguished Scholar, Fordham University, New York, NY 10023-7479.

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between the various components of what I call the "social care system" of older people. This paper first defines social care as used in my work, then describes the model of social care employed, and, finally, comments on the current and future outlook with regard to several components of the social care system: the elderly and their needs, the family, and the community, as illustrated in the provision of home care. This approach sheds light on changing roles of family and community in an aging society.

Social Care and the Social Care Model

Although the term social care is sometimes used synonymously with formal social services, the concept is broader, encompassing both informal and formal support activities, which, in fact, exist side by side. The conditions of elders requiring support are usually ongoing. Although purely medical and health-related services may be involved, most usually the assistance needed is of a social nature (Brody & Brody, 1981). Thus, social care addresses three main kinds of needs: first, opportunities for socialization, self-affirmation, and self-actualization; second, assistance with everyday tasks of daily living; and, third, help with personal care needs arising out of severe disability. Basic to the concept of social care is that such assistance augments individual competency and mastery of the environment rather than increasing dependency. Perhaps the best way to fully grasp the intricacies involved in providing social care to older persons is through the use of a system model. This model, while recognizing the separate support components (i.e., family, community, social agencies, government), emphasizes the ever-changing interactive nature of the social care system, both from individual and ecological perspectives. Furthermore, because 337

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Marjorie H. Cantor, MA2

Figure 1. A model of the social care system of the elderly. Source: Cantor (1979).

people receive help from family or tertiary organizations, for example, but elderly people often provide as much help to other generations in the kinship system, or to friends and neighbors, as they receive in return. And, increasingly, older people are a significant factor in the political scene, influencing legislation as well as receiving the benefits from the political process. Thus, the interaction and interdependence of generations throughout the life course is crucial to the operation of the system model as a whole and to its several parts. The holistic nature of the social care system is further illustrated by the fact that similar services may be offered by more than one sector, whereas other services are more likely to be the province of one subsystem. Only formal organizations, by definition, provide institutional care, but increasingly families are being involved in institutional settings, not only as visitors but as participants in care. Furthermore, many of the same type of services are provided in nursing homes and by families who maintain equally impaired elderly persons in the community. And, as we will see later, home care workers and family members frequently perform the same tasks, and together share many of the functions of family. In this model, caregiving is conceptualized as a subset of social care performed by either informal or formal providers. Distinguished from the garden variety of intergenerational assistance, it involves ongoing help to a disabled person with measurable limitations in the performance of activities of daily living. In summary, the model has three attributes that make it an effective framework for developing a social care system for the future: 1) With its notion of concentric circles, the model emphasizes the inter338

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social care involves both formal and informal components, any attempt to understand the operation of the system requires an examination of individual and societal forces and their interactive effects (Cantor, 1975b, 1976,1979,1980,1989; Cantor & Little, 1985). As can be seen in Figure 1, this model envisions an older person at the center of a series of concentric circles, each containing a different kind of support, ranging from informal at the center to formal at the periphery. Older people interact with each of these circles and subsystems at varying times and for varying types of assistance, and at times these separate networks interact with each other, and even overlap. In the outermost circle, furthest in social distance from the older person, are the political entities such as the U.S. Congress or state and local legislatures, which determine the basic social policy and entitlements of older people. Somewhat closer, though still far from playing a central role in daily life, are the governmental and voluntary social agencies that carry out the economic and social policies and services mandated by law, or determined by community need. All organizations in these two outer rings are clearly the formal part of the support system. Still closer to the older person, and standing somewhere between formal organizations and informal networks, are the nonservice formal organizations and the quasi-formal service organizations (or their representatives). Often referred to as mediating structures, these include religious organizations; racial/ cultural, social, neighborhood, and block groups; as well as individuals such as letter carriers, shopkeepers, bartenders, and building superintendents. Frequently serving as a link between the individual and society, as well as sometimes themselves providing assistance of an informal nature, this network has been labeled tertiary because it resembles the informal network, but springs from, and is related to, formal social structures. Finally, closest to and most involved in the daily life of an older person are the individuals who constitute the two innermost circles: the informal support system of kin, friends, and neighbors. It is this informal system that older people turn to first and most frequently, and who provide the broad base of social care throughout the world (Brody, 1981,1985; Cantor, 1975a; Cantor & Little, 1985; Horowitz, 1985; Shanas, 1979; Shanas et al., 1968). Only when members of the informal system are unavailable or can no longer absorb the burden of providing assistance do older people and their families tend to turn to formal organizations for help. In my work, I have categorized this manner of selecting assistance as the "hierarchical compensatory theory of social supports" with kin, particularly spouse and children, preferred as the cornerstone of the support system in most situations, followed next by friends, neighbors, and eventually formal organizations in a well-ordered hierarchical selection process (Cantor, 1979). Although in the model each support element is separate and distinct, the amount of interaction between the subsystems is considerable, illustrating the dynamic nature of the system. Not only do older

relatedness of the informal and formal components, which must both be part of a responsive system; 2) the model underscores the fluidity and overlap of the circles — or components of social care — making clear that boundaries, and what happens to boundaries, are affected by a host of population, aging, health, economic, and social trends; and 3) perhaps most important, by placing the older person at the center, and informal care as the closest of the circles, the model makes clear that changes in the status of the elderly, and the availability of informal care, are crucial to what happens with respect to the other elements of the model.

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Societal Trends and Their Effect on Social Care

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The Elderly

The central starting point of the social care model is the elderly and their need for assistance. Projections regarding the increasing number of elderly expected in the future, the increasing proportions of the oldest old (in whom disability is most concentrated), and increases in life expectancy particularly at the oldest ages, are by now commonplace (Soldo & Agree, 1988). A basic tenet of our research in New York City has always been that older people are highly diverse with regard to race and ethnicity, gender, age, and social class, and that these are crucial dimensions in both the demand for social care and the patterns of response by family and community. Never has this been a more important overriding principle guiding research than at the present time. Particularly pertinent to issues of social care for the U.S. at large are the following factors involving older people. • The number of elderly persons has almost doubled since 1960, from nearly 17 million to a projected 51.1 million by 2020and 66.6 million by 2040, when older people will compose 23% of the total U.S. population (Day, 1985; Siegel & Taeuber, 1986; Taeuber, 1989). • The most rapid growth will occur among the 85 + population, which will triple by 2020 and nearly double again by around 2040-2060, when the baby boom generation will join the ranks of the oldest old (Soldo & Manton, 1985b). • Minority elderly will increase significantly both in absolute numbers and as a proportion of the total elderly population. Elderly blacks are projected to rise from 8% of the total older population in 1990 to 14% by 2050, and Hispanics from less than 4% to nearly 12% in the same period (Siegel & Taeuber, 1986; Taeuber, 1989). • Differences in life expectancy between men and Vol. 31, No. 3,1991

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With respect to disability and the demand for care, all signs point to exponentially increasing care needs. Based on the size of the aged population and greater life expectancy at advanced ages, it is projected that by the year 2000 the number of chronically disabled community-based elderly will grow by 31% to 7.16 million persons, as contrasted with only a 19.7% increase among the nondisabled. By 2060, when all members of the baby boom generation will be 85 and over, there will be a 17.9% growth, as compared with a growth of 12.6% among nondisabled older persons (Manton, 1988,1989; Manton & Liu, 1984). We need also to be cognizant of the

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Trends and factors in our changing society affect the elderly and their demand for care, the ability of the informal family system to respond, and the role of formal care in the future. The following sections highlight some of the emerging trends affecting various components of the social care model.

women are narrowing, but are unlikely to converge, and gender-related marital and social care patterns are likely to continue in the future. (Currently, white women reaching 65 can expect to live another 19 years, black women 17 years, white men 15 years, and black men 14 years. Similar data is unavailable for Hispanics) (Siegel & Taeuber, 1986; Taeuber, 1989). Older men are far more likely than women to be married and have an available spouse as a potential source of social care. This is a result of a combination of factors, including greater longevity of women, the tendency of men to marry younger women, and the sevenfold greater likelihood that widowed men will remarry than will widowed women (Longino, Soldo, & Manton, 1990; Soldo & Manton, 1985a; Taeuber, 1989; Watkins, Menken, & Bongaarts, 1987). The probability of widowhood increases with age. Therefore, not only are women more likely to face widowhood because of greater longevity, but their average duration of widowhood is twice that of men. Black women are even more apt to be widowed, and widowhood occurs earlier than among white women (Siegel & Taeuber, 1986). Women are more likely to be found living alone, or in the case of severe functional disability, with children or other relatives. Therefore women, more than men, depend on children, other relatives, or formal service providers for social care (Click, 1979; Soldo, Sharma, & Campbell, 1984). Although most older people may suffer from one or more chronic illnesses, and functional limitations tend to increase with age, the prevalence of severe functional impairment requiring extensive social support is not common until the later part of the age continuum: late 70s and the 80s (Siegel & Taeuber, 1986). Men are more likely to develop the lethal diseases that kill, whereas women are more at risk from chronic disabling diseases. This fact, combined with the greater number of women in the aged population, tends to make chronic functional disability disproportionately, though not exclusively, a women's problem (Manton, 1988,1989). The risk of poor health and functional disability falls disproportionately on minority elderly and those of lower socioeconomic status (Cantor & Little, 1985).

Spouses

growing incidence and prevalence of disability among some younger age groups as well, which influence resources available for providing care.

The Informal System

Family Structure Just as dynamic changes are occurring in the size, composition, and health status of the aging population, the American family is also undergoing transformations that will affect their ability to provide care for their elder members. In this paper the term family is used in its broadest sense to include the many varieties of family structure in which related and nonrelated individuals live together and function as family to each other, both instrumentally and emotionally. Only such a broad definition accurately captures how the care of older people occurs in a "family sense." Furthermore, in considering the capacity of families to provide care for disabled elders, we are concerned not only with individual units, but also with kin networks spanning several generations. The following trends in family structure may affect the continued ability of families to provide caregiving for impaired members (Bengtson, 1986; Bengtson, Rosenthal, & Burton, 1990; Day, 1985; Hagestad, 1986,1988). • Multigenerational families are becoming the norm. By the year 2020, the typical family will consist of at least four generations. • Families today are becoming increasingly verticalized, leading to the so-called bean-pole family, with a greater number of relationships that cross generational lines and fewer siblings and other age peers within a single generation (Bengtson & Dannefer, 1987; Hagestad, 1986). • Kin networks are becoming increasingly top heavy, with more older family members than younger. For the first time in history, the average married couple has more parents than children (Preston, 1984). • Due to lengthening life expectancy and lower birth rates, shifts are occurring in the time spent in various family roles. For example, middle-generation women in the future will probably spend, on average, more years with parents over 65 than with children under 18 (Watkins, Menken, & Bongaarts, 1987). • As the period of childbearing becomes increasingly more concentrated, and age differences between first and last child narrow, the lines of demarcation between generations are sharper. Only rarely do we now hear of aunts or uncles the same age or younger than their nieces and nephews, a not uncommon phenomenon at the turn of the century (Pullam, 1982). • Alterations in the timing of childbearing, the increasing incidence of divorce and reconstructed or stepfamilies, and single-parent families are affecting and complicating family structures {Riley, 1983). 340

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In much of the gerontological literature on caregiving, and certainly in the popular press, one gets the impression that informal caregivers are synonymous with children, mainly daughters. This has proved to be a gross oversimplification of caregiving patterns. Actually, all research indicates that in most cases, the caregiver will be the spouse if one is available and capable; otherwise children will assume the caregiving role. Our own research with caregivers in New York City suggests that "spouse" is a singularly important group who often carry a substantial portion of the support function, probably suffer more from strain, and about whom we know relatively little (Cantor, 1983). The findings from two national samples of disabled elderly people and their caregivers illustrate the emerging role of the spouse (Stephens & Christianson, 1986; Stone & Kemper, 1989). In both cases, spouses were major actors. Of the 4.2 million active caregivers in the 1984 National Long Term Care Survey, 1.6 million were spouses, whereas in the case of the National Long Term Care Channeling Demonstration, almost one-quarter of the caregiver sample were spouses. Furthermore, based on the level of involvement, the Long Term Care Survey found that spouses were far more likely to be the primary caregivers, with children predominately as secondary caregivers. Also, caregiving spouses are not only women: the growing importance of husbands caring for wives has been overlooked. Soldo and her associates (1990) note that in the 1982 National Long Term Care Survey, nearly all disabled married women lived with spouses, and 85% of these women depended on their husbands for personal care. What of the future of spouse caregivers? Although future cohorts of elderly people will probably include more "never married," as well as larger numbers of unrelated persons living as family, there is no evidence to suggest that the principle of hierarchical compensatory selection of primary caregiver will be altered. Thus, where a spouse exists, we can expect such a wife or husband to serve as principal caregiver. With more men expected to live to older ages in the decades ahead, it is likely that spouses as caregiver will be even more important in the future, and that elderly couples will play a more significant role in family life (whether such couples are composed of original partners or result from men remarrying in later life). However, a word of caution about the caregiving capacities of old-old couples is in order. As a concomitant of increased age and greater prevalence of morbidity, many of the older spouses may themselves be impaired and unable to provide extensive assistance with activities of daily living without help from either children or the formal sector. Thus, although there may be more couples, the pool of active spouse caregivers may not increase proportionately, and children may increasingly find themselves responsible for two frail or disabled parents, attempting to care for each other.

Children Adult children are the principal caregivers of older widowed women, older unmarried men, and are secondary caregivers in situations where spouses are still alive. According to an analysis by Stone and Kemper (1989) of the 1984 National Long Term Care Survey, a minimum of 7% of all adults in the U.S. are either spouses or children of disabled elders, and therefore potentially involved in caregiving decisions. The vast majority of these potential caregivers are children between the ages of 45 and 64. At present, the single age cohort most affected by caregiving responsibilities are the 45-54 year olds, with 17% of this age group having a disabled elder. Looking only at those actively involved in caregiving, we find that about 2.7 million adult children provide hands-on care of disabled elders. However, the 1984 Long Term Care Survey also discovered that adult children were more likely to be secondary rather than primary caregivers. This may come as a surprise, given the extensiveness of gerontological literature concerning the primacy of the role of adult children, but it reflects the previously mentioned fact that where spouses are available, they are generally the major source of care (Cantor, 1980; Shanas, 1979). But even as secondary caregivers, adult children are vital sources of back-up and respite services to parents, as well as providing crucial socialization and emotional sustenance. In addition, research suggests that children frequently serve as family financial managers and intermediaries to formal services (Cantor, 1979, 1980; Cantor, Brook, & Mellor, 1986; Chappell, 1985; Horowitz, 1985). The importance of adult children is further illustrated by the National Long Term Channeling Demonstration. In that sample of only primary caregivers, about half were children or children-in-law, as compared with one-quarter spouses, and the rest were relatives, friends/neighbors, and paid help (Stephens & Christianson, 1986). Thus, although children are not always the major caregiver, they are usually part of the caregiving network, and it is children more than any other group who are the caregivers of elderly widowed women, the largest single component of the disabled elderly population. Competing Responsibilities Two competing responsibilities — child care and employment — are usually cited with respect to family caregivers, particularly adult children. The 1984 Long Term Care Survey elucidates these potential sources of conflict, and the popular press has made much of the dual responsibilities faced by women of the "sandwich" generation. Actually, however, child care and elder care duties affect far fewer women than might be expected. The 1984 National Long Term Care Survey found that only about 7% of all women in the U.S. with children under 15 were potentially faced with elder care responsibilities in addition to care of children (Stone & Kemper, 1989). Furthermore, many less — 436,000 women, or only 2% of U.S. mothers with young Vol. 31, No. 3,1991

Adult Children as Caregivers in the Future In considering the role of adult children as caregivers in the future, several important trends need to be considered. First, and in some ways most crucial, is the later age at which most adult children will become involved in caregiving. With delay in the onset of morbidity, the young old rather than 45-59 year olds will increasingly be called upon to care for 341

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children — were actively involved in providing elder care, and a much smaller group (only 164,000) served as primary caregivers. Other research also reports a similar picture regarding child and elder care responsibilities (Boyd & Treas, 1989; Scharlach & Boyd, 1989; Stone, Cafferta, & Sangl, 1987). Although conflicts between care of children and adult parents can pose serious problems for the individuals involved, such conflicts are far less pervasive than might be thought. Almost two-thirds of the daughters in the Long Term Care Survey sample were either middle aged or elderly themselves, and were more likely to be grandmothers than mothers of young children. This trend toward caregiving at an older age is expected to continue, further minimizing the likelihood of overlapping child care and elder care responsibilities. However, in some inner-city urban communities, particularly among black and other minority groups, grandparents with both elder and child care responsibilities are on the increase. The impact of employment on caregiving is, however, more pervasive and potentially more serious. The 1984 Long Term Care Survey suggests that half of the spouses and children of disabled elderly — over 7.4 million persons — are working full time. They represent about 9% of the full-time employed population of the U.S. The importance of women in the work force can al ready be seen by the fact that 43% of the daughters and wives of the disabled population work full-time, as do 69% of the sons and husbands (Stone & Kemper, 1989). Furthermore, among employed caregivers, 1.5 million (or 2% of the total fulltime work force in the U.S.) are actively involved in providing assistance with activities of daily living, and close to 40% of the active caregivers carry the primary care responsibility. In line with many findings regarding the preeminent role of women in elder caregiving, women working full time are four times as likely to be primary caregivers as are men (Stone & Kemper, 1989). The National Long Term Care Demonstration Project reported an even higher proportion of employed persons among primary caregivers: 34% were working. Of these, close to 70% were employed full time (Stephens & Christianson, 1986). Whatever the exact magnitude of employees with caregiving responsibilities, it is clear that a sizable segment of working adult children and some spouses must juggle work and elder care as part of their everyday lives. The potential for emotional, physical, and financial stress within such families is clearly present, to say nothing of the effect on productivity of such dually burdened workers.

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was the second salary to help pay for the education of children, and a rising standard of living. Today there are increasing numbers of women who are the sole support of families, as well as career-oriented women, for whom work provides opportunities for self-fulfillment, as well as financial rewards. As a result, the work trajectory of women, many of whom enter the growth period of their careers later, may differ from men. And, older women in the future may be even less willing or able to follow men out of the labor market than at present. Thus, working until the early or mid 70s may be far more common in the future, for both men and women, a phenomenon that could restrict the availability of adult children as primary providers of hands-on care. Other complicating trends bound to affect the availability of adult children as parental caregivers include the decline in the average number of children per family and the increase in nonmarried persons and childless couples. Finally, future attitudes are a still unknown factor that may radically influence the role of family members as providers of direct care. A key finding of the study of the elderly in the inner city of New York (Cantor, 1975a), replicated in other studies as well, was the reluctance of older people to utilize formal care. For most respondents, such care was considered as a last resort when the informal system was nonexistent or unable to continue to provide the necessary assistance due to lack of requisite skills or competing responsibilities. In the 1970s nursing homes were the primary alternative and home care was in its infancy, and only for the rich. But many things have changed since then, not the least being attitudes regarding appropriate sources of assistance. Those coming into the aged cohorts are better educated, many have greater resources to purchase assistance, and there are intimations that they may feel differently regarding the use of services such as in-home care and adult day care. Evidence of this shift was discernable in our recent study Growing Old in Suburbia (Cantor, Brook, & Mellor, 1986), in which a representative sample of the "new" elderly were interviewed using the same instrument as employed in the earlier study of the inner city elderly of New York. The "new" elderly evidenced much greater willingness to consider turning to community formal agencies for assistance in the home, even though they were as well endowed with family and friend/neighbor networks as their inner city peers studied 15 years previously.

The Formal System

The last element in the social care model is the formal system. Although no evidence suggests that families will abandon their elderly (assistance to older people is based on deep psychological needs and well-established social norms), the nature of the family role will, in all likelihood, undergo changes, and the community of tomorrow will be called upon to play a more expanded role in the provision of social care than at present. Such an enlarged role is already The Gerontologist

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parents, as well as for older spouses. Most experts agree older people in the future will spend a longer time with chronic illnesses, but that, due to medical advances, earlier disease detection, and changes in life-style, this longer time will often be accompanied by a slowing down in the process of the disease, its severity, and disabling effects (Verbrugge, 1984). Thus, the period of severe disability is projected to move further up the life cycle, being most concentrated in what English social historian Peter Laslett (1989) refers to as the Fourth Age, where the brunt of dependency needs will be felt. As a result, the majority of those over 85 will have need for assistance, whereas a smaller proportion of the middle old, and even fewer of the young old, will find themselves in a state of social care dependency. With such a scenario, although there will be larger numbers of older people, the social care "curve" will probably shift upwards, and the age at which adult children will confront parent care will similarly rise. Adult child caregiving occurring later in the family life cycle could, of course, virtually eliminate competing child care responsibilities, and at least mitigate the conflict between employment and elder care. However, several labor force trends exist that could potentially minimize the availabiliity of postretirement-age adult children as caregivers. First is a projected rise in the official retirement age for Social Security. At present, it is scheduled to start rising after the turn of the century, but there may be pressure to increase the age to 67 sooner. Currently, many workers leave the labor force before the existing official retirement age of 65 due to poor health, company retrenchment policies, or worker personal preference. However, it is expected that the population and the work force will grow more slowly in the next 15 years than at any time since the 1930s, and the pool of younger workers, particularly those with requisite skills, will shrink (Johnston & Packer, 1987). This may provide a more conducive atmosphere for older workers to remain in the labor force longer as the need for skilled employees increases. As a result, in line with improved health status and higher living standard expectations, many younger elders may choose to remain in the work force longer. Retirement preferences, however, are influenced by social class and nature of employment. Therefore, the willingness to continue to work longer will more likely affect business and professional occupations rather than factory and service industry jobs. Furthermore, because women play so predominant a role in caregiving, their work patterns will greatly affect the availability of family caregivers. Over the next decade, it is expected that women will continue to enter the labor force in substantial numbers. By the year 2000, 48% of the work force will be women, and 61% of working age women will be employed (Johnston & Packer, 1987). Although women continue to be concentrated in traditionally female occupations, increasingly they are entering the business and professional worlds. In the past, a primary motivation for women working

evident in many other developed countries. Current long-term care debates frequently concern financial and structural issues. But often overlooked are two equally important questions: Where will we get the work force required to provide the formal services in the home, and how will the two systems (formal and informal) be helped to function in harmony?

helped out, and 50% actually had a family member or friend living in the household. A natural division of labor seemed to emerge between worker and family based on the composition of the household, the amount of home care services provided, the time of day when assistance was needed, and the extent of employment responsibilities carried by family members. The study raised both micro and macro issues, which are often inseparable. Interventions aimed at maximizing job satisfaction, and therefore attracting workers, are constrained by such systemwide issues as the financing of long-term care and the extent of economic growth in the decades ahead. Similarly, national restrictions on immigration interact with local labor market conditions in affecting the ability to recruit and retain necessary workers. But in each area, certain things stand out.

Home Care as Illustrative of Formal Care

Interventions to Strengthen Community-Based Systems of Home Care In studying home care from the perspective of the workers, certain qualities of the job seem particularly attractive to the workers. For many women, home care represents an entry-level job with duties comparable with previous life experiences. The tasks build on skills in their repertoire, and transfer of skills to the work place is easy. In addition, home care can offer more flexibility in work schedules than factory jobs, including part-time work attractive to women still involved with family responsibilities. But, most compelling for recruitment of workers is that home care is a people-oriented helping occupation in which relationships play a primary role. Over and over workers talked of feeling needed and useful, and of the sense of accomplishment in making a critical difference in the lives of the old and sick. From the standpoint of the competitive labor market projected for the future, these special aspects of home care can enhance the ability of the industry to attract workers. Such positive factors can be quickly negated, however, if not accompanied by adequate wages, fringe benefits, and working conditions. This means not only a sufficiently high minimum wage for the entry level job, but commensurate pay differentials for more skilled and specialized care, as well as extra compensation for overtime, night, and weekend work. We cannot expect women at the lowest rungs of the economic ladder to continue to subsidize the home care of the elderly, a lesson we are only beginning to learn with regard to hospital and nursing home workers. The adequacy and portability of health and pension benefits must also be scrutinized. The final economic issue raised by our findings is probably most difficult and long-range: how to bring employment stability to the industry. At present, if a client is hospitalized or dies, down time between jobs is not unusual. For marginal-income workers supporting families, any cessation of income and health benefits can be devastating. Some movement toward year-round employment for at least a core of

The New York City Experience Currently, New York State and City have the most extensive Medicaid-financed home care program in the country, serving in New York City alone an average of 48,000 persons daily. The findings from our recent study (Cantor & Chichin, 1990) of a randomly selected sample of 500 home care workers employed by the 22 agencies that are part of that program suggest some of the factors essential to ensure a home care force of the size and calibre required to meet social care needs in the future. Home care in New York City at present is provided by a classic low-income, low-skilled work force, composed almost exclusively of middle-aged to older, black and Hispanic women, mainly recent immigrants, and most with limited potential for upward job mobility. Income from home care during the preceding year of the study was abysmally low: 80% of the group indicated home care earnings of $10,000 or less. Even when incomes from spouse and others in the household were taken into account, the pooled household incomes were not much higher — only rising to a mean of $12,171 (median $10,999). In addition, in the case of the New York City home care workers, we have issues of race and social class divisions, with minority workers caring for a predominantly white clientele. This may change somewhat in the future, with the increase in minority elderly, but differences in race and ethnicity between workers and clients is likely to remain an issue. The clients cared for represented the quintessential disabled elderly, with limitations in both instrumental and personal care activities of daily life. About one-quarter to one-third of the clients, according to the workers, also exhibited behaviors suggesting varying degrees of cognitive or psychological impairment. Furthermore, these were not deserted elderly: The vast majority had family members who visited and Vol. 31, No. 3,1991

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In discussing formal care, home care rather than institutional care has purposely been chosen as the focus. Currently, there seems to be no evidence that either the national government or local communities have an interest in building large numbers of new nursing homes. This picture could change in the future given the pressure of long waiting lists and overcrowded institutions. But in response to the desiresof the elderly and their families, as well as the ever-present interest in hospital and institutional cost containment, it seems likely that the emphasis will be on keeping older people in the community. Thus, most widely discussed at present is the need for an expanded and viable system of home care.

Macro-Level Recommendations If the projected demand for home care materializes, and all indications are for increased needs for in-home services, the most serious issues will concern the financing of the system and its overall structure. Such issues involve national and state policies and regulations. Among the questions for the future is the nature of our immigration policy. At present, immigrant labor is a major factor in New York and other areas as well. Yet our current immigration policies are restrictive and limit the pool of semiskilled workers such as those currently attracted to home care, nursing home, and hospital jobs. With increased demand for in-home services, pressures will escalate on how best to fund such care. There appears to be increasing interest in a national health insurance program covering longterm care. Such a program would not only help the elderly and their families procure the in-home care needed, but would also ensure that workers have adequate health coverage, a serious omission at the present time. As the home care industry increases in scope and complexity, quality assurance will assume even greater importance. Today, the primary responsibilities for standards in home care rests with states and localities. In the future, this will likely become a national concern, and minimum national standards may be in order. And finally, we must consider the issue of resource allocation. Home care is currently structured to provide individual workers to meet the needs of individ344

ual clients. However, in the future we will need to consider the possibility of grouping clients and sharing workers if more clients are to be served with the resources at hand. Also, the current system tends to operate separately from other providers of care to chronically frail populations. Thus, there will be a need for coordination of services within a catchment area, including senior centers, adult day care, home care, and various forms of congregate housing with shared services. No one advocates turning home care into an assembly-line operation, and the relationship time between workers and clients is an essential part of the caring process. But just as we need to restructure the job to bring it more in line with task demands, we need to view home care as an integrated part of a long-term care system rather than an isolated industry as such.

Future Research and Policy Agenda

Based on the model of social care presented at the outset and the emerging trends involving both the nature of the elderly population and the care system that will support it in the future, several research and policy questions seem to require particular attention. 1) What do we mean by caregiving — its salient characteristics, parameters, and the target population to be served? Presently, the term is used indiscriminately to include a wide variety of populations, degrees of disability, and types of assistance. As a result, comparisons among samples are almost impossible, limiting both theory building and social policy deliberations. 2) What is the effect of race, ethnicity, culture, and class on patterns of use of informal and formal services? To what extent do social care needs differ among varying ethnic and racial groups? What can we learn regarding the provision of social care from the diversity of the elderly population and family structures? 3) What is our purpose in providing expanded formal services, particularly in the home? To enhance the ability of families as providers of direct care? To provide alternatives to enable women and other workers to remain as productive members of the work force? To enhance quality of life for the elderly and their families? These are not necessarily mutually exclusive goals, but depending on the relative importance attached to each, different program interventions and financing mechanisms may be appropriate. 4) If the formal system is to assume greater importance in the provision of social care, what is the appropriate division of responsibility between family members and formal sector caregivers? What factors need consideration in devising service plans that are equitable, both from family and societal perspectives? 5) Why do older people and their families often fail to utilize existing community services? Are there psychological factors, as well as service-delivery issues, inhibiting formal service utilization? Perhaps The Gerontologist

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workers, or some form of a guaranteed minimum annual wage, would help stabilize the industry and provide better continuity both for workers and those for whom they care. Closely related to economic issues is the need to rationalize job tasks and training and provide an orderly path for advancement, both within the industry and between home care and other allied health and social welfare occupations. Another area of great concern that emerged in the study is the crucial nature of relationships in the home, not only between worker and client but also between worker and family. This is clearly related to the question of building positive relationships between informal and formal service providers. Although relationships were generally positive, according to the workers several points of potential conflict emerged. Most important is the need for a clear delineation of the scope of the workers' job, including the specific areas of work for which they are not responsible. Furthermore, more adequate training and supervision is needed, as well as an avenue for complaints for both clients and workers. The final, often overlooked area of potential conflict concerns differences in race, ethnicity, and class often occurring between workers and clients. Given the current tension in the country between racial and ethnic groups, some method must be found to ensure that prejudice and discrimination do not face the home care worker on the job.

To encompass the broader vision of social care required for the future, a systemwide model is needed. Contrary to the current tendency to consider informal and formal care as separate and often polarized systems, this model stresses the holistic nature of social care and the interrelatedness of the several parts. Such a conceptualization, it is argued, can best meet the desires of older people for independence and self-mastery, and at the same time ensure the level of concrete assistance they will require in the decades ahead. Thus, the structure of future social care interventions, whether on an individual or macro level, must involve consideration of the several partners in the care system and the maximization of the appropriate contribution of each. Which component provides which type of intervention at any given time will then be a function of several factors, including the needs and levels of specialized skills required by the older person, the preferences of the elderly and their significant others regarding appropriate care, the impact on the total family system, and the availability of assistance in the immediate environment from one or more support sources. Such an approach stresses the need for careful articulation of linkages among formal, informal, and mediating structures. The family, in its broadest sense, will continue to play an important role, but many of its current direct-care functions may shift to shared care with the community. Only by adapting a systemwide approach can we achieve a working partnership between the various components of social care. Unless the informal and formal systems are mutually supportive, working cooperatively, and in tandem, it will be impossible to provide social care throughout the life cycle, at the level required in the future.

References

Bengtson, V. (1986). Sociological perspectives in aging, families and the future. In M. Bergener (Ed.), Perspective on aging: The 1986 Sandoz lectures in gerontology. New York: Academic Press. Bengtson, V., & Dannefer, D. (1987). Families, work, and aging: Implications of disordered cohort flow for the 21st century. In R. Ward & S. S. Tobin (Eds.), Health in aging: Sociological issues and policy directions. New York: Springer. Bengtson, V., Rosenthal, C , & Burton, L. (1990). Families and aging: Diversity and heterogeneity. In R. H. Binstock & L. K. George (Eds.), Handbook of aging and the social sciences (3rd ed.). New York: Academic Press. Boyd, S. L, & Treas, J. (1989). Family care of the frail elderly: A new look at "women in the middle." Women's Studies Quarterly, 17, 66-74. Brody, E. M. (1981). Women in the middle and family help to older people. The Gerontologist, 21, 471-480. Brody, E. M. (1985). Parent care as a normative family stress. The Gerontologist, 25, 19-29. Brody, E. M., & Brody, S. ). (1981). New directions in health and social supports for the aging. In M. A. Lewis (Ed.), The aging: Medical and social supports in the decade of the 80's. New York: Fordham University Center on Gerontology. Cantor, M. H. (1975a). Life space and the social support system of the inner city elderly of New York. The Gerontologist, 15, 23-27. Cantor, M. H. (1975b). The formal and informal social support system of older New Yorkers. Paper presented at the 10th International Congress of Gerontology, Jerusalem, Israel. Cantor, M. H. (1976, November). The configuration and intensity of the informal support system in a New York City elderly population. Paper presented at the 29th Annual Meeting of the Gerontological Society of America. New York. Cantor, M. H. (1979). Neighbors and friends: An overlooked resource in the

Conclusion In the preceding sections I have elaborated a model of social care, discussed trends affecting the various component elements or subsystems, and suggested a series of research and policy questions requiring attention in the years ahead. Some of the demographic trends are relatively clear; others, particularly with regard to morbidity and disability, are still emerging. As such, the picture can be likened to a child's kaleidoscope, splintered and ever changing. However, central to any scenario of an aging America is the interdependence of generations and the notion of one generation caring for another. Thus, the role of family defined broadly will, I believe, continue to be central to gerontological research and policy deliberations for decades to come. But the environment in which families function is changing. Most significant is the emerging role of the formal care system in providing services in the home, analogous to, and in some cases replacing, the care presently being provided by family members. Vol. 31, No. 3,1991

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the time has come to place less emphasis on issues of caregiving strain and network analysis, and shift attention to the structural, attitudinal, and systemic barriers to providing care. 6) How can we most effectively finance an expanded home care system? As part of a national health care system for all ages? As expanded Medicare coverage, through private insurance or some combination of approaches? What will the costs be, depending on disability criteria and levels of care provided? 7) If an expanded home care system were to become a reality, what must we do to recruit and retain the necessary work force? What role does national immigration policy play? What sorts of training, supervision, and on-the-job supports are required? How do we minimize tensions between caregivers of one race and economic class and clients from another? 8) What is the role of the private sector in the provision of social care? What kinds of interventions in the work place would be most helpful to future cohorts of caregivers? What effect will changing economic conditions have on the attitudes of employers regarding the use of older workers and the provision of elder care services? 9) How can we build the continuum of care that has been a goal for so long? The current tendency is to dichotomize between community and institutional care, with home care being viewed as care in the individual home. Are there kinds of congregate living situations, or ways of providing shared home care, that we should consider in order to enhance resource allocation? 10) And finally, is a working partnership between the various components of social care a realistic objective? What are some of the current barriers to such a partnership? What changes in attitudes and organization of services are required?

twenty-first century. Indianapolis, IN: Hudson Institute. Laslett, P. (1989). A fresh map of life: The emergence of the third age. London: Weidenfeld and Nicolson. Longino, C , Soldo, B. J., & Manton, K. G. (1990). Demography of aging in the United States. In K. Ferraro (Ed.), Gerontology: Issues and perspectives. New York: Springer. Manton, K. G. (1988). Planning long-term care for heterogeneous older populations. Annual Review of Gerontology and Geriatrics, 8. Manton, K. G. (1989). Disability policy: Restoring socioeconomic independence. The Milbank Quarterly, 67(2). Manton, K. G., & Liu, K. (1984, March). The future growth of the long-term care population: Projections based on the 1977 National Nursing Home

346

Survey and the 1982 Long-Term Care Survey. Paper presented at The Third National Leadership Conference on Long-Term Care Issues, Washington, DC. Preston, S. (1984). Children and the elderly: Divergent paths for American dependents. Demography, 21, 435-457. Pullam, T. W. (1982). The eventual frequencies of kin in a stable population. Demography, 19, 549-565. Riley, M. W. (1983). The family in an aging society: A matrix of latent relationships. Journal of Family Issues, 4, 439-454. Scharlach, A. E., & Boyd, S. L. (1989). Caregiving and employment: Results of an employee survey. The Gerontologist, 29, 382-387. Shanas, E. (1979). Social myth as hypothesis: The case of the family relations of old people. The Gerontologist, 79, 3-9. Shanas, E., Townsend, P., Wedderburn, D., Friis, H., Milhoj, P., & Stehouwer, J. (1968). Old people in three industrial societies. New York: Atherton Press. Siegel, J., & Taeuber, C. M. (1986). Demographic dimensions of an aging population. In A. Pifer & D. L. Bronte (Eds.), Our aging society: Paradox and promise. New York: W. W. Norton. Soldo, B.J.,& Agree, E. M. (1988). America's elderly. Population bulletin no. 43. Washington, DC: Population Reference Bureau. Soldo, B. J., & Manton, K. G. (1985a). Demographic challenges for socioeconomic planning. Socio-Economic Planning Science, 19, 227-247. Soldo, B. J., & Manton, K. G. (1985b). Health status and service needs of the oldest old: Current patterns and future trends. The Milbank Quarterly, 63, 286-319. Soldo, B. J., Sharma, M., & Campbell, R. T. (1984). Determinants of the community living arrangements of older unmarried women. Journal of Gerontology, 39, 492-498. Soldo, B. J., Wolf, D., & Agree, E. M. (1990). Family, households, and care arrangements of frail older women: A structural analysis. Journal of Gerontology, 45, 238-249. Stephens, S., & Christianson, J. (1986). Informal care of the elderly. Lexington, MA: D. C. Heath. Stone, R. I., Cafferta, G. L., & Sangl, J. (1987). Caregivers of the frail elderly: A national profile. The Gerontologist, 27, 616-626. Stone, R. I., & Kemper, P. (1989). Spouses and children of disabled elders: How large a constituency for long-term reform? The Milbank Quarterly, 67, 485-506. Taeuber, C. M. (1989). Diversity: The dramatic reality in the issues facing the White House Conference in aging and beyond. Oakland, NJ: Scott, Foresman. Verbrugge, L. M. (1984). Longer life but worsening health? Trends in health and mortality of middle-aged and older persons. The Milbank Quarterly, 62, 475-519. Watkins, S. C , Menken, J. A., & Bongaarts, J. (1987). Demographic foundations of family change. American Sociological Review, 52, 346-358.

The Gerontologist

Downloaded from http://gerontologist.oxfordjournals.org/ at Sheffield University on June 12, 2014

informal support system. Research on Aging, 1, 434-463. Cantor, M. H. (1980). The informal support system: Its relevance in Ihe lives of the elderly. In E. Borgatta & N. McClusky (Eds.), Aging and society. Beverly Hills, CA: Sage. Cantor, M. H. (1983). Strain among caregivers: A study of experience in the United States. The Cerontologist, 23, 597-604. Cantor, M. H. (1989). Social care: Family and community support systems. Annals of the American Academy of Political and Social Sciences, 503, 99-112. Cantor, M. H., Brook, K. H., &Mellor, M. J. (1986). Growing old in suburbia. New York: Fordham University, Brookdale Research Institute, Third Age Center. Cantor, M. H., & Chichin, E. R. (1990). Stress and strain among homecare workers of the frail elderly: Final report. New York: Fordham University, Brookdale Research Institute, Third Age Center. Cantor, M. H., & Little, V. (1985). Aging and social care. In R. H. Binstock & E. Shanas (Eds.), Handbook of aging and the social sciences (2nd ed.). New York: Van Nostrand Reinhold. Chappell, N. L. (1985). Social support and the receipt of home care services. The Cerontologist, 25, 47-54. Chappell, N. L. (1990). Aging and social care. In R. H. Binstock & L. K. George (Eds.), Handbook of aging and the social sciences (3rd ed.). New York: Academic Press. Day, A. T. (1985). Who cares? Demographic trends challenge family care for the elderly. Population trends and public policy no. 9. Washington, DC: Population Reference Bureau. Click, P. C. (1979). The future marital status and living arrangements of the elderly. The Gerontologist, 19, 301-309. Hagestad, G. O. (1986). The aging society as a context for family life. Daedalus, 115, 119-139. Hagestad, G. O. (1988). Demographic change and the life course: Some emerging trends in family realm. Family Relations, 37, 405-410. Horowitz, A. (1985). Family caregiving to the frail elderly. Annual Review of Gerontology and Geriatrics, 5, 194-246. Johnston, W., & Packer, A. (1987). Workforce 2000: Work and workers forthe