Industrialized countries face the challenge of increasing home care services to the growing number of functionally dependent elderly. The disability model suggests that social and health policy should be directed at supporting the caretakers and providing the social and physical environment to allow elderly maximum opportunities to be physically and socially active. The natural trajectory of ageing is punctuated by critical events which can place the patient on a steeper, lower trajectory of decline. Efforts could be made to identify these at the earliest point and to educate the patient, the caretakers, and the primary care physician. Functional disability is multideterminant and once established cannot be easily sorted out or treated. Sensitive techniques for detecting the earliest problem might allow more effective intervention. Research areas and goals for improved medical education are suggested.

In conclusion, health care has become increasingly important and at the same time more difficult and more costly. An understanding of functionality provides a model on which to plan for effective home care. The majority of home care is provided by significant others, and although their numbers are declining, an organized approach should do everything possible to support the caregivers (13). These include providing “travel-agent” functions to help the uninitiated take advantage of community resources, backup home rehabilitation, no-fault admissions to minimal care units or other. Assistive devices are notoriously poorly prescribed, maintained and followed through. Many devices and assistive aids are never used. Better prescription and an organized recycling of such materials would be useful. Finally, we should not miss treating reversible functional decline. To do so one must bring the concept of functionality out of the medical model to the community and create a culture in which function rather than death or life is the most important. Health education is needed at the earliest point possible to allow people to understand what normal function is expected. Research should be directed at identifying those critical incidents in which function can be readily reversible if identified early enough. Finally, medical education needs to supplement its traditional emphasis on the medical model of disease with a biosocial model that emphasizes function to prepare the physicians in this regard.