Written for a mixed professional and public audience concerned about current long-term care approaches, this book provides a detailed overview of a community-initiated alternative, “the Maine Approach”. The Maine Approach is designed to achieve a grassroots community network of coordinated volunteer and skilled provider support services to enable frail older people to age at home. Building beyond this local infrastructure, the author also introduces the reader to a national movement, “Full Circle America”, which acts as an umbrella and support infrastructure for other communities wishing to adopt the Maine Approach. Both the approach and the national infrastructure for promoting its uptake and application have been motivated by unsustainable escalating costs, growing needs for health and social services for an aging population, and the segregation, isolation, and marginalization of older people associated with current long-term care alternatives. The thesis underpinning this book is that the Maine Approach affords a cost-effective long-term care alternative comprised of the right amount of technology, organization, volunteer support, skilled care, and additionally, a “secret sauce” that ultimately enables frail older people to remain in their own homes, chart their own paths, and contribute meaningfully to their communities. The “secret sauce” missing from current models of long-term care is the approach’s emphasis on finding ways for older people to become involved in helping others enrolled in the program, thereby optimizing their sense of purpose, independence, and quality of life.
The book is clearly written. In a step-by-step fashion, the author explicates the problems of our current system: its disregard of both the human potential and the psychosocial needs of older people; its inadequacy for the growing demands of an aging population; its overly bureaucratized operation; its fostering of unhealthy dependencies, and its untenable cost to both public and private purses. This is followed by a full disclosure of the history of the Maine Approach, its three different service bundles, and in-depth real-life qualitative data that illustrate this strategy in action. The risks associated with optimizing the independence of frail older people are acknowledged and addressed. Illustrations of real-life incidents support the argument that there is dignity in accommodating the risk-taking that accompanies living alone at home, identified by frail older people with multiple chronic medical problems as essential to their quality of life.
With due respect for readers who might consider adopting the Maine Approach (in its fifth year at the time of this publication), the author then provides an analysis of the “slow response” to its adoption. The insights shared are premised upon his first-hand experiential knowledge as a family physician and as the leader of this movement, both of which have encompassed care for numerous older persons in Damariscotta Maine The challenges identified are associated with humanity’s natural inclination to deny physical and mental decline until the onset of a crisis that triggers action; to take a short-term, ad hoc, rather than a long-term, planned approach to deploying financial resources to address these crises; and to circumvent the real-life challenge of deciding and agreeing who, ultimately, is the decision maker about an older person’s life. The author concludes that such challenges mean that long-term care directions are driven more by concerns about finances and liability than quality of life. He also notes impediments to change, including current institutional norms, such as public sector resistance to innovation and risk-taking, existing government regulations, long-term care insurance policies, threats to the residential care industry, and the misfit of the democratic, liberal nature of the Maine Approach with the current political climate in the United States.
In subsequent chapters, these challenges are countered with several reasons why a community might adopt the Maine Approach: (a) the Eldercare Network costs up to 90 per cent less than current American alternatives to long-term care; (b) several of the features of the approach could be used by assisted-living facilities to reduce costs and enhance their appeal to older people; (c) adoption of the approach would decrease the need to build five to ten times as many residential care facilities to accommodate the expanding numbers of frail older people in the next two decades; (d) the approach affords the flexibility needed to accommodate ever-changing requirements for long-term care and increasingly higher and more loudly vocalized societal expectations for quality of life with aging; and (e) the approach would help to address the growing crisis of family caregiver burden.
The book concludes with an overview of thoughts about the challenges and opportunities of implementing the Maine Approach across the United States through the Full Circle America movement. The author recognizes that uptake of the approach requires that society in general be educated and encouraged to be proactive in confronting the likelihood of physical and mental decline in later life, and to be optimistic about their choices, options, potential to contribute, and value to impart. He recognizes as well that such attitudinal change requires leadership from health and social service professionals who can also embrace flexibility and choice as essential to the quality of life and health of older people. The Maine Approach, he argues, constitutes transformational change towards empowerment of the disenfranchised, warehoused, and abandoned frail older people through enabling them to retake control of their lives and begin again to contribute to the rich fabric of their communities. As well, the Maine Approach could arrest the mounting costs of a broken long-term care system, re-energize primary care medicine, be used to address the needs of other marginalized groups (such as the intellectually challenged), and afford opportunities for meaningful, gainful employment for people with physical disabilities. How to proceed with implementing the Maine Approach is also addressed, and an appendix detailing the Full Circle America movement is provided.
Alone and Invisible No More details an applied approach to long-term care. Though neither the scholarly theoretical evidence nor the research evidence underpinning the thesis of the Maine Approach is presented in this book, both are well documented in the interdisciplinary field of gerontology. The impact of involvement, sense of purpose, social support and interdependent relationships on the health, independence, and quality of life of older people has been repeatedly documented by gerontology researchers for decades and is experientially known by professionals of all disciplines working in the field, as well as by older people themselves. What has been missing until now is application of this knowledge in evidence-informed evolution of in-home care, with due consideration of its cost-effectiveness.
Perhaps more importantly, what also has impeded this direction in long-term care is the persistence of ageism in our society. We have needed a demonstration model of how long-term care informed by this knowledge might be achieved, but also we have needed someone to champion wide-scale change in attitudes towards independence/dependence versus interdependence, aging, and those who have aged. This book meets these needs with an in-depth, practical, and realistic overview of a long-term care model and attitudinal stance that could optimize the health, well-being, and quality of life of frail older people and the scarce fiscal and human resources needed for their care.
The fulfillment of long-term care requirements has reached a crisis level in Canada. Although frail aging Canadians, to varying degrees, have access to some in-home services, and “aging in place” policies and programs hold the promise of additional commitment, numerous studies and experiential knowledge confirm that the need, not just demand, for such services far exceeds supply. Research and experience also make clear that we continue to confront issues related to inadequate transportation, assistance with instrumental activities of daily living, oversight of daily care management, social support, and transition-care accommodation for frail older people residing in the community. Meeting all of these needs could be informed by strategies applied in the Maine Approach.
Our current long-term care approaches fail to address the health, financial, social and emotional well-being, and quality of life of older people. We need new partnership models for long-term care that encompass and build on the wisdom and potential of older people themselves. Although the elaboration of justifying details seems unnecessary, as they merely confirm plain common sense for those who may be already converted, this book will be of interest to all who are concerned about evolving cost-effective, not just cost-efficient, long-term care with the overarching goal of optimizing the health, well-being, and quality of life of frail older people. Academics, practitioners, policy makers and decision makers of all disciplines, and the general public at large may find courage, ideas, support, and impetus for change through reading and sharing with others this overview of grassroots community action towards a sound and sustainable option for long-term care.
