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| Illustration: Walter Vasconcelos |
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Long-Term Care in Puerto Rico: Improving
the System and the Quality of Life
Fall 2004 Five children, three housekeepers, and multiple in-home doctor visits have created an around-the-clock support network for José F. Maldonado Moll’s father, José Fernando. Fernando, 89, has lived in an apartment adjoining his son’s since his wife passed away three years ago. After a series of strokes left him wheelchair-bound and with speech problems, Fernando’s children knew the award-winning scientist and professor needed to maintain as much independence as possible. Many in Puerto Rico are facing an impending long-term care dilemma, but the San Juan family has been able to successfully manage their father’s care. This at a time when many families, government agencies, and professionals are grappling with how to provide sufficient long-term care services to a rapidly aging population. Nearly 27 percent of Puerto Rico’s population is 65 and older, with nearly 3 percent 80 and older, according to the 2000 U.S. Census. Those 80 and older are the fastest-growing segment. This group also shows a high occurrence of chronic diseases and will place a greater demand on long-term care facilities.
Studies in Puerto Rico indicate that the family remains the primary caregiver for older adults, says Melba Sánchez-Ayéndez, Ph.D., a professor of gerontology at the University of Puerto Rico and a member of the Advisory Panel on Aging and Health to the World Health Organization. “Ninety-eight percent of the elderly live in the community; if home care services are provided properly, it is definitely a preferable model to institutionalization,” she adds. About 2 percent of adults 65 and older live in long-term care facilities. Moll, Ph.D., a University of Puerto Rico professor, acknowledges the difficulties of caring for an aging parent. But he says, “taking care of our father has given us something in common. It has brought us closer as a family.” The 64-year-old knows his family is fortunate to be able to provide for his father, whose savings and pension, along with Social Security and Medicare, help pay for the caregiving that averages $4,000 a month. The type of care one receives is strongly linked with socioeconomic status. Sánchez-Ayéndez explains that wealthy families need not depend on the government, but they account for less than 2 percent of the population. Government support is available for those who are eligible, but services are often limited. The middle class, she says, is feeling the devastating effects of not earning enough to care for loved ones, but making too much to qualify for government aid. Government agencies and private companies provide services ranging from housekeeping and meal delivery to in-home doctor visits and door-to-door transportation. Businesses such as Caregivers Inc. know the demand for specialized services is high, and several cater to older adults with specific dietary needs, such as vegetarians, diabetics, and those with high cholesterol. “In Puerto Rico we have most of these services, but in a limited way. For example, Amas de Llave [a housekeeping service] is limited in the number of hours and personnel it offers. Many older adults could be more independent and stay in their homes if they had access to efficient housekeeping services,” says AARP Puerto Rico Associate State Director Luis de la Cruz. Leticia Rivera-Perez, an administrator of services for older adults with the Department of Family, agrees. “As a philosophy, we [Department of Family] believe that one’s own home is the most convenient place for an individual to age. We need to create a structure where the older adult population can age in place.” To begin addressing these complex issues, AARP Puerto Rico sponsored a long-term care conference in November 2003 in San Juan, bringing together 200 health care professionals, academics, government-agency representatives, and service providers. Sánchez-Ayéndez presented a long-term care study detailing several significant findings, including that:
She adds that despite the government’s efforts to coordinate services, for most people those services are not well integrated. She cites the lack of equipment for mammograms at some facilities, which makes it difficult for those without transportation to have a mammogram. While the Autoridad Metropolitana de Autobuses (the government’s bus service) offers free rides to older adults, its reach is limited. Moll considers himself lucky not to rely on government resources for his father’s care, saying that many agencies “are very inefficient and spend excessively on activities of little social value.” Rivera-Perez acknowledges the lack of coordination, but says strong efforts are under way to make services more uniform, accessible, and specific to the aging population’s diverse and complex needs. She says regular meetings with government officials and the community are part of an effort to “begin to speak the same language, as we are all trying to serve the same aging population.” “It is the type of population that needs us to bring the services to them. We can’t wait for them to come to us,” she says. While no perfect model for the future of long-term care exists, many believe the first step would be an effective public policy. More than 50 laws deal with the well-being of older adults. “We need to revise the current public policy to ensure it is both broad and realistic, while taking into consideration the problems of the present and anticipating the future needs and realities of the older adult population,” de la Cruz says. Rivera-Perez thinks a good first step is to get everyone involved. “We need to create a structure that involves community intervention and, more specifically, the family,” she says. “The government alone cannot deal with the demand for services.” She cites the Amas de Llave service as one of the most popular, but also most expensive, services. Puerto Rico is, in many ways, on the right path, long-term care professionals say. In 1986, the commonwealth was one of the first governments to create a Bill of Rights for the Older Person. This measure establishes the rights of older people to live in a peaceful environment where they are treated with respect and dignity and where their physical, emotional, mental, social, and spiritual needs are addressed. The rights of individuals in long-term care establishments and hospitals are outlined. Law 190 requires long-term care providers to take a course on the latest developments in gerontology, with an emphasis on the basic needs and care of older adults. The Department of Family and other agencies are working to ensure the law is implemented effectively. Sánchez-Ayéndez adds that in the past four years, services and information have become more accessible. De la Cruz is hopeful. “We must recognize that in both the public and nonpublic sectors there has been a wealth of goodness and dedication offered by thousands of people.... To them we owe virtually all the positive changes, and with their example we can build a new future." |
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