The U.S. long-term care field: a dialectic analysis of institution dynamics

This paper presents an institutional analysis of organizational change and inertia in the US. field of long-term care. We employ a dialectic approach to concentrate on the contest between interests aligned with two templates of organization (archetypes) that draw from distinctive sets of beliefs and values (interpretive schemes) to specify appropriate structural forms, roles, and resource distributions. It is shown that the long-term care field was historically characterized by a nursing home archetype which legitimates the provision of care in residential facilities under the control of medical professionals. After a century of reformers' efforts to build legitimacy and resource support for alternative home and community-based services that maintain consumers' independence, the field now accommodates both the nursing home archetype and a home and community-based services archetype. While this new institutional framework reflects aspects of change, especially the establishment of the home and com-munity-based services archetype, it also displays inertia including the continued dominance of the nursing home archetype. Roles played in these contested dynamics are traced along a key process of change in each archetype: (1) the growth of large multi-facility (chain) nursing home corporations, and (2) political advocacy for home and community-based services.