WASHINGTON -- For 60 years, Bobbie Jones, 88, had lived in the same District of Columbia row house where she raised four children -- including one born in an upstairs bedroom -- and became a grandmother to 10 and a great-grandmother to nine. But last year, a stroke and a fall landed her in the hospital and then in a nursing home.
In the past, a nursing home might have wound up being where she lived out the rest of her days. But through a new program that helps Washington residents receive care in their homes and communities, Jones was able to go home. She is among 58 people who have been relocated since the D.C. Office on Aging launched its Nursing Home Transition Program in April.
Those who qualify for Medicaid can receive Medicaid-funded services at home; for those who don't, the Office on Aging helps find other funding for in-home care. The office also offers nonmedical help such as transportation, meals and homemaker services to all District of Columbia residents 60 and older, regardless of income, in accordance with the federal Older Americans Act.
The program reflects a national trend toward providing older and disabled people with in-home care rather than keeping them in nursing homes. To encourage this shift, the 2010 Affordable Care Act makes Medicaid benefits more broadly available to people living at home and increases federal funding to states that make more home-care services available to those who would otherwise be in nursing homes. So far, 17 states, including Maryland, have been approved for additional funding.
Surveys have long shown that older people prefer to stay in their homes as long as possible. In recent years, grass-roots movements such as senior villages, in which older people pay a fee in exchange for help from community volunteers, have gained in popularity across the country. But federal and local government policies have also reflected a change in philosophy and a recognition of elder care as a looming economic problem.
One impetus for change was a 1999 Supreme Court ruling that public entities must provide community-based services to people with disabilities whenever possible.
Another reason for the change in thinking is the high cost of institutional care. As the population of older Americans grows, advocates say, it won't be economically sustainable to have so many people live in nursing homes. The average annual cost per person for nursing home care is about $75,000 nationwide. In the District of Columbia, it is $110,000. Providing in-home services costs an estimated $30,000 to $60,000 a year, according to the city's Office on Aging.
Demand for home care has also increased as a more vocal generation ages, said Alayna Waldrum, executive director of LeadingAge DC, an advocacy group for aging services.
"Consumer preferences haven't changed, but generational personalities have," she said. "The people currently in nursing homes, the Silent Generation, they are the ones who don't complain. They aren't really rabble-rousers for change. What's happened is that as the young disabled and baby boomers are looking at their options, what people want has become more of a driver in how our long-term care system is going to look."
Advocates of in-home care acknowledge that there is a place for nursing homes, for those who need a level of care that cannot be provided in a private home. But about one-third of the people in nursing homes are capable of receiving services at home, Thompson said.
The numbers are part of a movement away from institutionalization. In the past 20 years, the percentage of people 65 and older who live in nursing homes has steadily decreased, from 5.1 percent in 1990 to 3.1 in 2010, according to the Census Bureau.
During that time, there has been an estimated 125 percent increase in the investment to keep people in their homes and communities, said Elaine Ryan, AARP's vice president for state advocacy and strategy.
Her organization, along with two other advocacy groups, the Commonwealth Fund and the Scan Foundation, released a score card in 2011 that ranks states on how well they provide long-term services and support, including alternatives to nursing home care. The District of Columbia ranked 10th, Virginia was 12th and Maryland was 24th.
Since returning home, Jones receives such services as help from an aide who comes to the house every morning and evening and a physical therapist who comes twice a week, as well as transportation five days a week to a day facility, all at a lower cost to taxpayers than the nursing home.
This approach is a stark change from the past, when institutionalization was the preferred solution for those who needed help with day-to-day living. "If they qualified for nursing-home level of care, they would just put them in a nursing home," said John Thompson, executive director of the D.C. Office on Aging.
The District of Columbia program serves people who are ineligible for a federal Medicaid program called Money Follows the Person, which also helps older people and those with disabilities return to their communities from nursing homes but has requirements such as that a person must have been in a nursing home or hospital for at least 90 days and must have received Medicaid in the last month of services there.
Some states, along with the District of Columbia, offer waivers for older or disabled people to receive Medicaid-funded long-term care in their homes.
Such programs represent the "next big thing" in elder care, said Mary Ann Parker, a staff attorney with the Legal Counsel for the Elderly's D.C. Long-Term Care Ombudsman Program, which advocates for older D.C. residents.
"It's really kind of a new way to try to fund long-term nursing," Parker said, adding that studies have shown that older people do better if they can stay in their homes and communities.
In the District of Columbia, the budget for services for older residents has increased from $26.4 million to $40 million in the past two years. About a quarter of this is federal funding, but the increase came from the city's budget, to catch up with the growing population of older residents, according to the Office on Aging.
Along with that commitment has come a rising awareness of what is possible, said Margaret Woods, the transition program's coordinator. "Before, family members really didn't know what their options were," she said. "Now, people are more aware that it is possible to bring Mom or Dad home."
Jon Pynoos, a gerontology professor at the University of Southern California and director of the National Resource Center on Supportive Housing and Home Modification, praised the District of Columbia's program, saying it is "on the forward cusp of what we should be doing."
In areas, such as the District of Columbia, where real estate values have soared, returning to the community is not always easy, particularly if a person does not have a home to move back into. To address this, some advocates are pushing for new housing developments to include affordable housing specifically for older people.
RemainHome Solutions, based in Baltimore, works with private and public health systems nationwide to adapt homes to meet the needs of older residents as well as to set up systems, such as wearable glucose or heart rate monitors, to digitally transmit information about their health.
For Jones, life in the nursing home was colorless. "You got up, and you ate," she said, adding that she was told what to eat and when to eat and had to ask permission to go to the bathroom. "It was just so depressing."
Now, sitting in her dining room, Jones grinned as she pulled a yellow therapy band taut and a physical therapist counted her repetitions. Behind her sat a cabinet full of ceramic figurines she had made over the years; in front of her sat her two daughters, as well as a son who moved back into the house to help care for her.
The possibility of returning home was what kept Jones from losing hope at the nursing home, said her younger daughter, Laura Jones Jackson.
"Once she found out that she may be eligible for the program, she got really motivated," Jackson said. "She said, 'Anything they tell me to do, I'll do.'"