作为一名在医疗康复护理机构工作的职业治疗师，凯特琳·西诺维克（Caitlin Synovec）经常见到一些五六十岁的人，他们的人生在某一刻发生了永久性的改变。也许是一次中风或其他严重的医疗事件将他们送进了医院。但太常见的情况是，在漫长的治疗过程中，他们失去了工作，随后又失去了住所。在沦为无家可归者后，他们或许能设法在为居无定所且需要康复场所的人群设计的康复护理项目中争取到一个名额。但紧接着，一个问题便笼罩在他们的未来之上：接下来他们该去哪里？
As an occupational therapist working in medical respite care, Caitlin Synovec saw people in their 50s or 60s at a moment when their lives had forever shifted. Perhaps a stroke or other serious medical event sent them to the hospital. But too often, during their extended treatment, they lost their jobs and then their housing. Newly homeless, they might manage to snag a spot in a respite care program designed for people without stable housing who need a place to continue their recovery. But then, a question would loom over their future: Where would they go next?
许多处于这种情况的患者最终只能流落街头或住进收容所，尽管人们一直在努力为他们寻找永久性住房。然而，令人惊讶的是，有相当一部分老年人最终住进了疗养院——即使他们并不需要或不想要那种程度的护理。
Many patients in that situation wind up living on the streets or in shelters, despite efforts to find them permanent housing. A surprising number of older adults, however, find themselves in a nursing home—even if they don’t need or want that level of care.
根据联合健康基金会（United Health Foundation）的研究，疗养院中每11个人里就有一位属于“低护理需求”人群，这意味着他们在床上移动、转移、如厕或进食方面并不需要身体上的协助。各州的比例各不相同，从夏威夷的2.5%到俄克拉荷马州的近23%不等。
According to research from the United Health Foundation, one in 11 people in nursing homes have “low-care needs,” meaning they do not require physical assistance for bed mobility, transferring, using the toilet, or eating. The ratios vary by state, from a low of 2.5% in Hawaii to nearly 23% in Oklahoma.
这是一种昂贵的住房解决方案：在疗养院住一年的平均费用为119,340美元，而包含部分服务的补贴性永久支持性住房，每人每年的费用约为16,000美元。
It’s an expensive housing solution: One year in a nursing home costs $119,340 on average, compared to around $16,000 per person per year for subsidized permanent supportive housing that includes some services.
西诺维克回忆起她的一位50多岁的客户，该客户在因中风住院治疗期间失去了住所。尽管有家庭成员愿意收留她，但她无法进入他们位于二楼的公寓。中风导致她的一只手臂无法活动，并伴有轻微的认知问题，但她仍然能够处理大部分日常活动，包括乘公交车去探望家人、朋友和去教堂。她确实需要一些帮助——例如穿衣——但她非常珍视自己的独立生活。
Synovec recalls one client in her 50s who lost her housing while she was in the hospital getting treatment for a stroke. Although a family member was willing to take her in, she couldn’t navigate their second-floor apartment. The stroke left her without the use of one arm and with mild cognitive problems, but she still was able to manage most daily activities, including taking the bus to visit family, friends, and her church. She needed some help—for example, with getting dressed—but she valued her independence.
“她不想被送进机构，”Synovec说，他现在是国家无家可归者医疗保健委员会医疗喘息服务的助理主任。“她想留在社区里。”这位女士去了无家可归者收容所，但随后跌倒了，最终进了急诊室。医院将她出院转至养老院。许多紧急收容所不适合老年人入住，尽管老年人是无家可归人口中增长最快的群体。
“She didn’t want to be institutionalized,” says Synovec, who is now assistant director of medical respite at the National Health Care for the Homeless Council. “She wanted to be in the community.” The woman went to a homeless shelter, but then she fell and ended up in the emergency room. The hospital discharged her to a nursing home. Many emergency shelters aren’t equipped for the elderly, even though older adults are the fastest-growing segment of the homeless population.
收容所通常安排人们住在上下铺。它们的浴室通常不是为残疾人设计的。而且收容所居民每天清晨必须离开，自谋生路，直到晚上收容所重新开放。
Shelters often house people in bunk beds. Their bathrooms typically aren’t designed for people with disabilities. And shelter residents must leave early each morning and fend for themselves until the shelter reopens in the evening.
更好的选择——永久性支持性住房——平均等待名单超过两年，而且即使是这种住房，也可能缺乏适合行动不便老年人的无障碍设施。在特朗普政府从永久性支持性住房转向限时过渡性住房的政策下，等待名单预计将增加，一些曾经无家可归的老年人可能会被迫搬离。
The better option—permanent supportive housing—has an average wait list of over two years, and even that housing may lack accessibility for elderly people with mobility issues. Under the Trump Administration’s shift away from permanent supportive housing toward time-limited transitional housing, wait lists are expected to grow, and some formerly homeless older adults could be displaced.
“他们实际上到了一个地步，社区里没有地方可去，”Synovec说。“唯一的选择是长期护理——养老院护理——或者死在街头。”宾夕法尼亚大学专注于住房政策和无家可归问题的社会科学研究员Dennis P. Culhane表示，随着婴儿潮一代老龄化，社会安全网的漏洞正在扩大。2025年，每五个住在紧急收容所或街头的人中，就有一个年龄在55岁或以上。“我们在各个方面都在失败，未能提供庇护——让人们面临更大的伤害、健康风险和残疾，”Culhane说。
“They get to a point essentially where there’s not a place in the community for them to go,” says Synovec. “The option is long-term care—nursing home care—or they die on the street.” Gaps in the social safety net are widening as Baby Boomers age, says Dennis P. Culhane, a University of Pennsylvania social science researcher with a focus on housing policy and homelessness. In 2025, one out of every five people living in emergency shelters or on the streets was 55 or older. “We’re failing in every direction in terms of not providing shelter—exposing people to greater harm and health risk and disability,” Culhane says.
作为一名社会工作者和研究者，伊恩·约翰逊（Ian Johnson）在西雅图采访了数十名社会工作者、护士及其他专业人士，他们正协助无家可归的老年人应对严重的健康状况。许多老年人担心，如果入住养老院，自己将被置于一个限制更多的环境中。护士和社会工作者们讲述了这样的案例：一些患者宁愿从医院或康复病房回到街头，也不愿接受长期的养老院护理。
As a social worker and researcher, Ian Johnson interviewed dozens of social workers, nurses, and other professionals in Seattle who were helping unhoused older adults cope with serious medical conditions. Many of the older adults feared being in a more restrictive environment if they went to a nursing home, and nurses and social workers told of patients who chose to return to the streets from a hospital or rehab unit rather than enter long-term nursing home care.
这是一种普遍的情绪。根据为美国老年人权益发声的组织AARP的调查显示，四分之三的老年人希望在自己目前的住所和社区中安度晚年。“过早机构化”往往使人们与家人、朋友和邻里分离。约翰逊目前任职于波士顿大学社会工作学院，他表示：“对于居住在支持性住房中的人，或者有时住在树林里的帐篷或无家可归者收容所的人来说，情况并无不同。人们希望在生命的最后阶段，依然能保有自我意识和自主感。”与此同时，也有大量关于养老院将脆弱的老年人遣送至无家可归者收容所——甚至没有任何安置目的地的报道。触发这一情况的原因可能是违反了规定，例如吸烟或使用毒品，或者是保险额度耗尽。
That’s a common sentiment. Three out of four older adults want to age in their current home and community, according to surveys by AARP, an advocacy organization for older Americans. “Early institutionalization” often separates people from their family, friends, and neighborhood. “That is not different for people living in supportive housing or sometimes living in a tent in the woods or at a homeless shelter,” says Johnson, who is now at Boston University School of Social Work. “People want to spend their end of life still having a sense of self and a sense of autonomy.” At the same time, stories also abound of nursing homes discharging vulnerable older adults to homeless shelters—or to no destination at all. The triggering event could be a violation of rules, such as smoking or substance use, or depletion of insurance.
这些相互矛盾的趋势似乎并不合理，除非将其置于成本压力和选择匮乏的背景下理解。当短期康复护理结束时，患者被要求自费支付或离开。医疗补助计划（Medicaid）覆盖长期养老院护理，但各州的资格认定规则各不相同。一些仅需部分时间协助个人护理和服药的人，可能会因医疗补助的覆盖而滞留在养老院。而在另一些情况下，尽管联邦法规对安全出院有明确规定，养老院仍将居民直接送往收容所。
Those opposing trends don’t make much sense, except in the context of cost pressures and sparse options. When short-term rehabilitation care ends, patients are expected to pay on their own or leave. Medicaid covers long-term nursing home care, but state eligibility rules vary. Some people who just need parttime help with personal care and medication may end up lingering in a nursing home, covered by Medicaid. In other cases, despite federal rules about safe discharges, nursing homes have dropped off residents at shelters.
解决这一困境的方法之一是建造补贴性住房，既能满足低收入老年人的行动和护理需求，又能保持他们的独立感。换句话说，适老化低收入住房将为那些正在变老且无家可归的人提供“4M”框架，旨在解决行动能力（Mobility）、药物管理（Medication）、精神状态（Mentation）以及老年人最关心的事项（What matters most）。
One answer to this predicament is to build subsidized housing that meets the mobility and care needs of older adults with very low incomes but preserves their sense of independence. In other words, age-friendly, low-income housing would give people who are aging and homeless the “4 Ms” framework that seeks to address mobility, medication, mentation, and what matters most to older adults.
为面临无家可归的老年人寻找合适的护理方案，可以作为重新思考长期护理工作的一部分。纽约市“新犹太之家”（The New Jewish Home）总裁兼首席执行官、老年病学家杰弗里·法伯（Jeffrey Farber）博士曾写道：“疗养院服务于三类截然不同的老年人群体，但其中只有一类真正属于我们传统认知中的疗养院。”医院往往在患者病情稳定后就立即安排出院，因此疗养院（也称为专业护理机构）成了短期康复服务的提供者。当患者结束康复离开时，大多数人只能依靠家庭照护者或付费护理人员来获取持续的帮助。
Finding the right care for older adults facing homelessness could be part of a broader rethinking of long-term care. Dr. Jeffrey Farber, a geriatrician who is president and CEO of The New Jewish Home in New York City, has written that “nursing homes serve three distinct populations of older adults—and only one of those actually belongs in what we think of as a nursing home.” Hospitals tend to discharge patients as soon as they’re medically stable, so nursing homes, also known as skilled nursing facilities, became providers of short-term rehabilitation. When they leave rehab, most patients rely on family caregivers or paid aides for any ongoing help.
法伯对我表示：“当医疗系统失灵，且患者找不到安全且负担得起的去处时，他们中的一些人最终只能留在疗养院里。他们确实从我们提供的某些服务中受益，但他们完全可以在护理强度较低或成本较低的环境中得到照顾。”法伯设想了一种重构方案：由医院提供亚急性护理，仅在患者准备好回家时才安排出院。那些无家可归、正在变老且医疗状况可控的人，将能够获得补贴性住房以及为其需求量身定制的特殊项目。
“Some of those patients, when the system breaks down and there’s no place for them to go that’s safe and affordable, they just end up staying” in the nursing home, Farber told me. “They’re benefiting from some services that we provide, but they certainly could be cared for in a lower-acuity setting or a lower-cost setting.” Farber envisions a remake: Hospitals would provide the sub-acute care and only discharge patients when they are ready to go home. People who are homeless and aging with manageable medical conditions would have access to subsidized housing and special programs tailored to their needs.
其余的人则将在转型后的疗养院中接受长期监测和针对复杂医疗需求的护理。他将这些机构重新命名为“慈爱护理院”（Compassionate Care Homes），并强调它们必须“始终是非营利性的，且以使命为导向”。他补充说，这些护理院必须获得充足的资金支持，并加大对员工培训的投入。
The rest would receive long-term monitoring and care for their complex medical needs at a transformed version of nursing homes that he would rebrand as Compassionate Care Homes, “always non-profit, mission-driven.” He added that these homes must be funded adequately, with investment in workforce training.
最早的一批婴儿潮一代将在2026年年满80岁。到2030年，所有婴儿潮一代都将达到65岁或以上。正如他们曾对社会诸多方面产生深远影响一样，他们也将使养老住房、长期护理和紧急避难所的承载能力不堪重负。
The oldest Baby Boomers turn 80 in 2026. By 2030, every Baby Boomer will be 65 or older. Just as they have impacted so many aspects of society, they will overwhelm the capacity for senior housing, long-term care, and emergency shelter.
将护理需求较低的人群安置在疗养院的做法本就缺乏合理性，而这波浪潮将使这种做法变得难以为继。法伯希望引发一场关于变革长期护理及其资助方式的讨论。
It never made sense to house people with low-care needs in nursing homes, but this wave will make doing so unsustainable. Farber wants to spark a conversation about transforming long-term care and the way it’s funded.
“这个系统从根本上已经崩溃了，”他说，“我们无法通过修修补补来解决问题。”
“The system is fundamentally broken,” he says, “and we’re not going to fix it with band-aids.”