The American population is aging rapidly. Health care experts say that means there will be a huge increase in the demand for long-term care in the next twenty to thirty years. Since the 1960s, much of that care has been provided in nursing homes. But today, more and more elderly Americans are choosing to remain home, getting help from a variety of health care providers in their community. The number of Americans getting government aid for home-based care has grown dramatically. One place to observe the the trend among the elderly to stay out of the nursing home is in the northeastern state of Vermont.

Helen Hill waves to a familiar face as she makes her way through a nursing home in Rutland, Vermont. She used to be an administrator here. These days she's a case manager with the Southwestern Vermont Council on the Aging. Ironically, a big part of her job now is to help people avoid nursing homes. She does that by helping them apply for benefits, fuel assistance, food money or prescription drug coverage. She also helps people design home-based health care plans, which are paid for by the state as part of its Medicaid waiver program. That's what she is setting up for Dorothy and George Walsh.

The couple just celebrated their fortieth wedding anniversary, but they can't be together. A bad case of pneumonia forced 77-year-old George Walsh into the hospital and then to a nursing home. Helen Hill has helped the couple apply for state-funded home care, which will allow Mr. Walsh to return home to his wife.

Ms. Hill says there's a growing trend in long-term care to help people remain home if they choose. State funds are now available to pay visiting nurses, relatives or other individuals who provide hands-on, home-based care. It saves Vermont money and provides more flexibility in the system. She says it also seems better for her clients. Dorothy Walsh, 73, says she hated the idea of her husband in a nursing home.

"It's kind of depressing, I hate to say that, but it's kind of depressing, so many old people congregated in the halls and all over," she said. "And just the sitting. I hated to leave him here in the evening, it's been hard."

The Walsh's are not alone in wanting to avoid nursing homes. In 1996, 400 people in Vermont received funds for home-based care. Today, the number has jumped to over 900. Patrick Flood, Commissioner of Vermont's Department of Aging and Disabilities, says the state doesn't need more nursing homes, it needs more money for the waiver program.

"It's the wave of the future and the wave is hitting the beach right now," he said. "The amount of change we've already seen is dramatic... And certainly by the time the baby boomers come along, we're simply not going to accept the old nursing home model of care. People want to stay in their own homes and it is in most cases cheaper to do that. It's less than half the cost to keep someone at home on the Medicaid waiver program than it is to have someone in a nursing home and I have no doubt that it is the future and the future's coming fast."

The future arrived years ago for Marilyn and Dick Del Bianco. The Rutland, Vermont, couple has taken care of Mrs. Del Bianco's 95-year-old mother, Holly Phillips, for 28 years.

"She has her own TV, she's got her sewing machine which she doesn't use much anymore, she does a little bit with her hands but not too much," said Mrs. Del Bianco.

She says her mother was fairly active until she broke her pelvis five years ago. Since then, the couple has had to provide much more care and supervision. "The hardest part is that we're tied down. And we have to find like a babysitter if we want to go anywhere and we kind of work together and he stays around the house or I stay around the house," she said. "If I go, he stays around the house so that someone is here. We do leave her for a couple of hours at a time, but not too often."

The couple takes one two-week vacation a year and finding people to care for Mrs. Phillips while they're away is difficult. Mrs. Del Bianco says she relies on relatives and girlfriends for some of the care, and has found additional help through the local council on aging. She says her mother feels bad about needing so much help and often tells her daughter that she'd rather die than be a burden. It's an ongoing issue, she says sadly. Dick Del Bianco says they modified their home to help his mother-in-law be more independent.

"We have a bathroom upstairs and a bathroom downstairs but nothing on the first floor," she said. "So we bit the bullet and took out a home equity loan and we created this bathroom, and what you see is a total of $8,000, plumbing, heating, carpenter work electrician and so forth."

Down the hall, they point to a new stair glider that allows Mrs. Phillips to get up and down the stairs by herself. "This stair glider... You're looking at $3,000-$3,300 right here."

$1,500 toward the cost of the stair glider came from the Vermont center for independent living, a private, non-profit organization that works to improve the quality of life for disabled Vermonters. The center also reimbursed the Del Biancos for the entire cost of the downstairs bathroom. The state Medicaid program pays part of the costs for fill-in care when the Del Biancos go on vacation and Medicaid recently began paying Mrs. Del Bianco for seven hours worth of care she provides a day. She says she's embarrassed to take the money but she and her husband admit it helps. State officials say the money is well spent. They say the Del Biancos and other home care providers are saving Vermont taxpayers millions of dollars a year in nursing home costs. But even more important is the quality of life for 95-year-old Holly Phillips.

"Here we can say what we want, do what we want and cook when we want and if we don't want to cook we can say the heck with it and find something else to eat...What more can you ask for?" she said.

Holly Phillips sits in a pool of sunshine in the kitchen and smiles. She says she'd go to a nursing home if necessary, but living with her daughter makes it easier for her to visit with her grandchildren and great grandchildren. That keeps her connected she says, and it keeps her young.