Healthcare Administration

Instructions: This assignment must be done in APA format. A minimum word count of 1600 for the overall

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assignment (without references included) is required. A minimum of four (4) scholarly references along with in-text citations is also required for this assignment. However, each question ask for different things so please pay attention. Also, although this assignment is in APA format; please keep the question and answer line up (see example below) For Example: Question: XYZ Answer: XYZ Reference: XYZ Note: Please FOLLOW instructions and keep the above format. Each question is separate. DO NOT COMBINE. 1. Knowledge: What are the key things to “know” about each of the 3 systems discussed? Why are they “key” issues? 2. Comprehension: What is your understanding of why there are three different / separate models? 3. Application: Give an example of one of the three systems as to how it works in real life. A personal story of yours / someone you know or a case study from the research or an example from your work. 4. Analysis: From the example you gave what are the pros and cons of the experience? What casued the events you describe to happen? 5. Synthesis: Offer a new and unique idea of yours or from the research as to how the example you gave could have been handled better. What could have been improved? Your own new idea or a known best practice. 6. Evaluation: Why would your idea be better / same / worse than what happened in your example? Has your idea been tried / practiced before? How did it work out? Or why hasn’t it been tried? Obstacles? Instructors Note: Each of these needn’t be long or expansive. Brevity is the soul of wit (Shakespeare). Practice efficiency and directness in your answers. Get to the point quickly. Avoid unnecessary “backfill”. Every word needs to make a contribution to the end points that you intend to make. Part Two Write a 150 word response to each discussion post. A minimum of two references per post is required. In-text citations must be included and cited properly. Note: Write the response as if you are talking to a person in person. Post One Knowledge Hospitals: Hospitals are a very complex organization that can offer a large array of services and provide minor care and all the way up to severe trauma cases that require life support (Williams & Torrens, 2008). Long term care facilities/programs: Long-term care is any type of care that requires a degree of time to either heal from any type of injury, surgery or illness and can also be a form of assisted living for the elderly and disabled. Mental Health efforts: Mental health is based on a population-based public health model that is characterized by the concern for the health of a population and the physical and psychosocial environment (Williams & Torrens, 2008). Mental health is a very vague diagnosis because there are many types of mental illnesses that can range from a mild form of ADHD all the way to severe psychosis. Comprehension Hospitals- Hospitals are more focused on acute care and treating the condition that the patient is currently presenting with, whether it be an emergency room visit, surgery or outpatient testing. Some hospitals also offer hospice care, which is typically care for terminally ill or elderly patients who are nearing the end of their lives within a few days to a few months. Long term care facilities/programs- Long-term facilities differ from hospitals in the fact that they focus on a longer-term type of care, which typically last months, years or until the person passes away. There are many levels of care involved with long term care facilities that are all dynamic in their own ways. Two examples of different types of care would be assisted living that is self -pay that is accredited by JCAHO and requires only personal care staff while hospice is primarily paid by Medicare and accredited by JCAHO and CHAP and requires multiple professional staff led by an MD (Williams & Torrens, 2008). Mental Health efforts- Because any type of mental illness is classified as such, it does not differentiate levels of intensity or minor disorders that could be very mild versus more dangerous or high risk. This can be an issue when addressing mental illness because there are some mental illnesses that are highly managed while others prohibit the individual from being a productive member of society and carries a high risk of harm to themselves or other. Being able to address and properly label mental health is important for future development and treatment for these individuals. Application Hospitals: Hospitals started off as an institution for the poor and ill, however with new advancements in technology and the focus on clinical medicine we are able to provide patients with a vast array of services and care (Williams & Torrens, 2008). American hospitals were started by religious, ethnic and community groups to serve healthcare needs and this was created by the immigration into eastern cities that required the creation of education and service facilities to serve these populations (Levin, 2011). Catholic sisters were all over the country establishing schools and hospitals to provide medical care for the sick as well as spread their religious beliefs and this all occurred between 1850 up until the 1950’s. Shortly after the 1950’s, hospitals started losing its religious affiliations due to woman playing more of a leadership role in other aspects in society (Levin, 2011). However, Catholic-affiliated churches made a comeback from 2001 to 2011 by increasing by 16% while non-profit hospitals declined in numbers (Melling, 2015). Non-profit hospitals are down in numbers primarily due to lower reimbursements and are no longer profitable. Long term care facilities/programs: Long-term care facilities and nursing homes are an integral part of the final years of elderly, terminally ill or disabled. Since the population age is increasing, the need for long term care increases and although the majority of long-term care is provided by family and friends, there are different levels of care that is needed (Williams & Torrens, 2008). These services have increased over the years and is being closely monitored by governing agencies such as the Joint Commission. These are being closely monitored because these long term care facilities are primarily paid for by Medicare & Medicaid Services and they have set standards that need to be in place for effective nursing home compliance in order to receive reimbursement and be compliant for the Patient Protection and Affordable Care Act (Herrmann, 2018). Mental Health efforts: Mental health care and efforts have grown significantly from decades ago with both how the patient is treated and diagnosing these patients. We have developed our technological aspect of healthcare that is able to better understand, diagnose and treat mental health disorders. MRI now offers a model that can diagnose ADHD and Autism, both of which cannot be easily tested or diagnosed like many mental health illnesses (Sen, Borle, Greiner & Brown, 2018). Advances like these allow us to look at mental illness better than ever and to be able to properly care for these patients. Analysis Hospitals: The biggest issue with hospitals are the government tax cuts, with $3.6 billion dollars cut in 2018 and even more expected for 2019 (Phillips & Hoban, 2018). These cuts are detrimental to healthcare facilities and decreases services and offerings to the communities. With so many advancements in healthcare, we have access to many services and life-saving treatments that may be harder to receive if the government keeps cutting funding to hospitals forcing more and more hospitals to close in the near future. Long term care facilities/programs: Long term facilities, although they offer a range of different levels of care, serve primarily as a bridge between being hospitalized and returning to as normal of a life as possible with the assistance of trained professionals (Bowman, 2015). A big problem of these facilities is that many patients are back and forth from these facilities and hospitals because they are either discharged too quickly or the facilities do not have the proper resources to handle some critically ill patients. Being able to close the gap and have a better system in place would most likely prevent these readmission rates that are up to 25% in a 30-day period for those who were admitted originally for heart failure. Mental Health efforts: Society has started to change their perspective on mental health from a time where we used to reject people who had mental illnesses and diseases into an asylum to now being able to get a better understanding and classification of mental illnesses. Mental health efforts have increased with insurance coverage being increased for those between 19 and 35 years old ever since the Affordable Care Act was passed to better care for mental health that was once ignored (Olfson, 2018). This unfortunately decreased the coverage for older patients. Synthesis Hospitals AND Long-term care facilities: Because hospitals and long-term care facilities can be closely related, having high-risk individuals that are terminally ill or need 24/7 assistance would be best if hospitals adopted long term care as part of their services. This would be implemented in an attached building or a certain floor within the hospital that acts as a small home for the patients whether it be for a few days or few years. These patients would essentially be living in a hospice/assisted living type of room and would have access to hospital services such as x-rays, lab work, rehab and other services that may be needed. It would be for terminally ill or high-risk patients that cannot be cared for at a nursing home. Mental Health Efforts: An idea for mental illness would be labeling it green, yellow or red to differentiate risk, dangers, etc. of each patient to protect staff and patient from harm. This would assign those with no or low-risk and mild mental illnesses to be labeled as green and those with red labels would be those that have suicidal or homicidal ideations or have psychotic breaks. At my facility, we are the first hospital in North Carolina to be “dementia friendly” by labeling patients that have dementia with a picture of a seahorse outside the room, this allows staff such as radiology know that this patient may have a breakdown and may not comprehend procedures and this would be the same as labeling the outside of these patients with mental health issues that could save staff or the patient from harm. Evaluation Hospitals AND long-term care facilities: Having a hospital and long-term care facility integrated into one space can be a challenge due to limited space, resources and money that many hospitals face. It would be challenging to evaluate what patients qualify for this living, someone who is constantly in and out of the hospital with illnesses and falls versus someone who has terminal cancer and has no family to take care of them may be hard to decide and evaluate who would be the best candidate for that type of living. However, those who are able to stay there would benefit most from the services and the continuous care that may not be offered at at-home care, nursing homes and other assisted living facilities. Mental Health efforts: Labeling a patient’s room as green, yellow and red may raise some flags for patients and visitors and may even agitate patients more that they are being labeled as high risk if they find out why they are labeled the way they are. However, this would help communication with staff that may not know the patient’s history and can avoid harm to all that may be involved in the patient’s care. Post Two Knowledge: • Hospitals are entities that provide services that are related to an acute illness or injury. These services range from emergency care, inpatient care, and surgical services. These services are only provided to the patients for a short period of time. Once the illness or • • injury is treated the patient will be discharged home or possible to another type of institution for long-term care. Long-term care is a type that will need to be provided for an extended period of time and can a wide variety of things. This focus of this care is to assist with a person’s daily living needs. These services include physical and mental disabilities and are not just limited to medical care. These services include rehab facilities, nursing homes, home health and assisted living. This is only a small list of examples. Mental health services are services provided to those who need mental, behavioral, and emotional support. These services can be provided on an inpatient and outpatient bases. These services are provided to those with an actual mental disorder such as bipolar disorder and also to those who don’t such as an addiction. These services also include emotional support for those who may have recently lost a loved one or any other type of change that can be difficult to deal with. Comprehension: Healthcare in the United States has been called a “broken system” for many years. These three types of healthcare are “fragmented” pieces that provide a comprehensive healthcare system. The way this comprehensive care system works is that the pieces work together to provide care. The patient goes to the hospital for their acute illness or injury. After the treatment, the patient could be discharged to home with home health and or physical therapy or to a rehab facility or long-term care facility or even a mental health facility. The healthcare professionals at each of these facilities work together to provide comprehensive care to each patient. This care has a greater comprehension when the facilities are affiliated with each other or if there are associated physician groups. The viability of each group is reliant on their comprehensive work. This is largely due to the advancement of ambulatory care, technology, and money. When two of the pieces are not comprehensive then the system is broken. Application: Vertical integration is beneficial in comprehensive healthcare. Vertical integration is when many different health care delivery systems are integrated together (Williams & Torrens, 2008). I currently work for a healthcare system that has recently increased their vertical integration and will further that in the future with the possibility of creating a specialty hospital within the system. The system has increased their vertical integration due to the location of the system and to provide a greater comprehensive care to those in the communities it serves. The system that I work for is made up of six hospitals, a free-standing ER, two rehab facilities, EMS, a cancer care center, a free-standing imaging center, surgical center separate from the surgery within some of the facilities, home health, hospice, mental health facility, walk-in clinics, numerous PT sites, and numerous family care physicians. By having this much integration the system is able to provide comprehensive care and keep patients within the system for a majority of their care. This integration is key because of things of rural hospitals closing and because of the previously stated; ambulatory care and technology advancement and money. The integration and healthcare are all about the money. Analysis: These three pieces are all different and each of them has their own responsibility to the overall healthcare system. Due to the advancements in ambulatory care and technology and money (which is largely reimbursements and payments) these three pieces are being affected in different ways yet each of effects on one-piece bleeds over to the others. That being said these three pieces have to find ways to help each other to decrease the effects and stay viable. This is especially important for smaller and rural communities. This comprehension is not only good for the patients because it should provide a higher quality of care, but it is also good for communities via jobs and revenue. Since money is the root of the problem if there is no cohesiveness and comprehension then it is going to impact one of the pieces by cause closures and loss of jobs. Synthesis: Comprehensive health in the United States is a complicated issue. To help combat this the three pieces (Hospitals, LTC, and Mental Health) have to work together to ensure the patients do not fall through the cracks and receive all of the necessary medical and non-medical care. The new idea that I have is for each patient in a hospital, either during their stay or near discharge, have a patient care meeting revolved around the future of their care. These meetings would consist of their primary hospital physician (or someone from that group), LTC specialist/mental health specialist (some representative from the type of care that will be received after the hospital), a case manager, and a social worker. More than one patient can be discussed at each meeting, but each patient will have a future plan of care once the meeting is over with. Each patient or patient representative can be involved directly in the meeting and decision-making process. This idea is especially important when the system vertically integrated. During my research, I found a study from Norway where the team concept was used in a rehabilitation setting. The study reported that this team concept had better patient-reported continuity of care and higher ADLbenefit scores (Hustoft, Biringer, Gjesdal, Aβmus, & Hetlevik, 2018). Evaluation: This idea will allow each patient to be involved in their care process which should be beneficial to the patient’s outcome. It will also allow each patient to receive the comprehensive care each one deserves. This meeting will not allow the patient to fall through the cracks or miss any type of necessary service. The negative part of this idea is that it requires a number of people to be at this meeting which can be time-consuming. I believe that these meetings should occur every day or almost every day, which is also time-consuming and possibly costly. An unexpected consequence is that the patient does not agree to the care or does not want the care. There is also the possibility that the patient will back out of the planned care. There is also the possibility that the patient may not be accepted to any facility which leaves the hospital to care for the patient or there could be an issue with the patient’s insurance. Post Three Knowledge Hospitals provide “specialized” care to the patients that need these services (Patterson, 2017). These services include “intensive and critical care units, acute and chronic care” (Patterson, 2017; Winpenny, Corbett, Miani, King, Pitchforth, Ling, . . . Nolte, 2016). In addition, some hospitals offer emergency and trauma services, and perform surgeries. Different hospitals have different missions (e.g. “profit, non profit, specialty, horizontal/vertical integration, community”) [Williams & Torrens, 2008; Winpenny et al., 2016). Hospitals are finding ways to increase their income by making processes to care for outpatients also (Vogenberg & Santilli, 2018). Rural hospitals are the beacons of hope to bridge the gap in the lack of healthcare services for the people living in those communities. One of the ways for hospitals to survive is the capacity of their leadership to “recruit and retain surgeons” (Yoshinor, Yuichi, Sayaka, Hiroto, Hiroshi, & Tomohiro, 2018). This will give the hospital a competitive advantage. The viability of the hospital seems great due to the “specialized” services that they offer of emergency, “critical care”, and trauma (Patterson, 2017; Winpenny et al., 2016). Some services may be provided on an “ambulatory basis” but not all services (Williams & Torrens, 2008). The use and role of long term care is to provide assistance to people that need help with “functional disabilities” (Williams & Torrens, 2008). The patients need some assistance with their conditions. “Residents centered care” is the model in the long term care industry to teach clients to have autonomy as much as possible (Azios, Damico, & Roussel, 2018). The main reason for these long term care setting is to help people get better. The challenges is to change the attitude of the staff and the culture of the place to be dedicated to helping the patient get better (Azios et al., 2018). Not all long term care places have this problem, but the environment is a challenging place to work. “Dementia” is one of the problems that results in disability that requires assistance to the patient (Chenoweth, Jessup, Harrison, Cations, Cook, & Brodaty, 2018). Sometimes “antipsychotic drugs” are recommended as treatment, but they have side effects (Chenoweth et al., 2018). Adequate inservice training is beneficial to staff to prepare to work in this setting. The expected “increase in the elderly” group of people will increase the need for long term care (Kokonya, 2018). This will provide the opportunity to build more “long term care facilities” (Kokonya, 2018). Behavioral services help clients to resolve internal crisis and non crisis with mental health concerns [e. g. “Depression, suicide, anxiety, substance abuse, mild intellectual disability, eating disorders”] (Cleverly, Gore, Nasir, Ashley, Rich, Brown, Hanssman, Holmes- Haronitis, Villafana, Kish, & Leavy, 2018). When hospitalization is needed for mental health, care providers can help them to transition back into life with less interventional services. Comprehension Hospital administrators can obtain feedback from patients through “Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys” and in other ways (Patterson, 2017). This will give some insight into what processes and procedures are working and which ones are not working. This will enhance the determination of the viability of the hospital. The scores and comments will allow the administrator to focus on adjustments that need to be made to improve in those areas that have deficiencies. According to the American Hospital Association, (n.d.), “71% of hospitals or health systems” plan to join together with “providers and payers” to enhance health care delivery in the immediate future. Application The Hospital Corporation of America has several hospitals across the country as an example of horizontal integration (HCA, n.d.). I worked in a long term care facility, Mur-Ci Homes, Inc as a supervisor several years ago. The facility served the needs of clients with developmental disabilities. Some of the staff falsified documentation and I had to take disciplinary action for their error. I was not popular or liked, but I had to be an advocate for the clients. It is challenging to work in that setting and it was challenging to obtain adequate staffing for the facility. Vanderbilt University Medical Center’s Psychiatric hospital offers behavior, health for “inpatients and outpatient services” (Vanderbilt Health, n.d.). CHAPTER 8 Hospitals and Health Systems Stephen J. Williams and Paul R. Torrens CHAPTER TOPICS History of the Hospital H I G G S , LEARNING OBJECTIVES Upon completing this chapter, the reader should be able to The Scope of the Industry 1. Understand the role of the hospital in today’s health care system. S H A N I C Q U A Structure of Hospitals and Health Systems Hospital Organization The Hospital and Medical Staff Key Issues Facing the Hospital Industry 2. Appreciate the historical trends that have shaped the hospital industry. 3. Understand the types of hospitals, ownership patterns, and differentiating characteristics of various hospitals. 4. Comprehend the development of health systems and the role of hospitals in such systems. 5. Follow the impact of competitive pressures and other developments on the structure and operation of hospitals and health systems. 6. Understand the internal organizational structure of hospitals. 1 1 0 5 T S 182 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems The hospital’s role in the nation’s health care system has changed dramatically over the years. The hospital originated as an institution for the poor, offering little in the way of therapy, and then evolved into the center of the system and the primary technology focus of health care. Now the hospital is a provider of highly specialized services and the hub of an assortment of other activities. The traditional independence of each hospital has been dramatically altered by horizontal and vertical integration within the health care system such that today few H technolhospitals are truly freestanding entities. The ogy to manage hospitals has likewise changed with I an information systems focus and the application of G complex parameters of performance measurement. Gand payExpectations of consumers, providers, ers have also changed dramatically over the years S with the anticipation of more effective interventions at more efficient and competitive pricing., Finally, as has always been the case in the past, the hospital industry continues to face immense challenges, opS portunities, and expectations for the future. The hospital has also changed fromHan island of care to an institutional octopus, with tentacles A affiliatspringing out throughout the community, ing with other institutions and providers, N and providing outreach services for consumers. On the inpatient side, hospitals are increasinglyI providing the most complex of care to the most critically ill C patients. On the outpatient side, most hospitals are Q broadening the array of services that they offer to better compete. U Hospitals face the challenges of sick and dying A patients, demanding payers, government officials seeking accountability, physicians demanding the availability of the latest equipment and 1 support, and many other crosscurrents. Some hospitals are 1 for-profit entities, while others are not-for-profit. Some hospitals are highly specialized while 0 others offer a broad range of services. Hospitals are often major employers in their communities 5and many provide the bulk of indigent care for low-income T and disenfranchised citizens. Through it all, the S backbone of hospital management has increasingly adopted the managerial principles of commercial 183 industry, seeking to provide services in an efficient, but cost-effective manner, and to offer competitive pricing to third-party and governmental payers. The challenges of this industry are immense and unlikely to recede in the decades that follow. HISTORY OF THE HOSPITAL Although the hospital today is in the forefront of technology and clinical medicine, the history of the nation’s hospitals actually began as facilities for housing the poor and the ill. These institutional warehouses for human suffering were the almshouses, the pest houses, the poor houses, and the workhouses that sheltered the homeless, the poor, the mentally ill, those with serious degenerative diseases, and others for whom there was little to offer in the era before modern medicine. Isolation of individuals during epidemics of cholera and typhoid, among other diseases, also led to the utilization of these institutions. Little medical knowledge was available and few individuals received any significant treatment. The middle class avoided these institutions and received their care at home. Not until the 1700s and 1800s did hospitals emerge with a mission of providing some form of clinical medical care. Many of these early hospitals were supported by philanthropic efforts and religious organizations. Also during this period, many public hospitals were established in various cities to provide for the social needs of local populations, laying the groundwork for our modern acceptance of local government as the provider of last resort. Finally, by the early 1900s, with the introduction of scientific method in medical practice and the recognition that hospitals and clinical medicine must adhere to a stricter formulation of practice focused on scientific discovery, was the era of the truly modern hospital established. Throughout the twentieth century, the escalating advance of knowledge accelerated the focus of the Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 184 hospital as a center for medical technology. After World War II, the hospital’s role as a center of technology and innovation became firmly established. At this point, the practice of medicine itself was increasingly dependent on scientifically valid knowledge and training. Finally, over the past 30 years the degree of rigor of clinical practice and the scope of scientific knowledge has escalated greatly, and the hospital has become a center of high standards, scientific applications, and advanced technological capability. At the same time, the increasing shift of servicesH to an ambulatory care arena facilitated by technological I advancement itself has left the hospital with an everG more complex base of patient care, higher acuity, G and higher costs. In addition, pressure from payers, as noted previously, has escalated greatly as has the S expectation of providers and consumers alike. Indus, try consolidation, vertical and horizontal integration, public policy concerns, and quality assessment and assurance have placed the operation of the naS tion’s hospitals under tremendous scrutiny. Yet, through it all, the nation’s hospitals have risen to the H challenge of providing superlative care overall in a A high-intensity, stressful atmosphere that has significantly contributed to our improved health status and N well-being. This is a remarkable achievement in light I of countervailing financial and political pressures that have always buffeted the hospital industry. We C owe a great debt of gratitude to the nation’s hospitals Q and to those dedicated individuals who work within these institutional walls for achieving so much in U an environment that started as a warehouse for the poor A and sick, left to die without care and concern. 1 1 THE SCOPE OF THE 0 INDUSTRY 5 Although the hospital industry has seen its share T of the nation’s health care dollar decline someS what, hospital systems are still immense segments of the industry and of our nation’s economy. (See Table 8.1.) PART THREE Providers of Health Services Table 8.1. Hospital Expenditures by Source of Funds: United States, Selected Years Source of Funds Hospital care expenditures All sources of funds Out-of-pocket payments Private health insurance Other private funds Government Medicaid Medicare 1960 1990 2003 Amount in billions $9.2 $253.9 $515.9 Percent Distribution 100.0 100.0 100.0 20.8 4.4 3.2 35.8 38.3 34.4 1.2 4.1 4.1 42.2 53.2 58.3 — 10.9 16.9 — 26.7 30.3 In 2003, the hospital industry alone accounted for more than $500 billion of expenditures. In 1960, the industry counted for only $9.2 billion of economic activity annually. The growth of private health insurance and government entitlement programs, particularly Medicare, has shifted the burden of paying for hospital care to third parties. In 1960, more than 20 percent of the hospital bill was paid by people out of their own pockets; by 2003, this percentage had dropped to 3.2 percent. Private health insurance now accounts for a little more than one-third of all hospital expenditures while government programs account for nearly 60 percent. Medicare alone counts for nearly a third of all hospital expenditures; in many facilities the Medicare program pays about half the bill overall. Certainly, for the nation’s seniors, Medicare is a critical source of support for paying for the enormous costs of hospitalization. The number of hospitals in the United States has decreased dramatically. Table 8.2 illustrates this decline with the total number of hospital in 1975 at 7,156 dropping by 2003 to 5,764. A small number of the nation’s hospitals are owned and operated by the federal government. These include the Veteran’s Administration Hospitals and military facilities. The vast majority of hospitals are nonfederal and are nonprofit, for-profit, or owned by state and local governments. The information in this table Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems 185 Table 8.2. Hospital and Beds by Ownership and Hospital Size: United States, Selected Years Type of Ownership and Size of Hospital Hospitals All hospitals Federal Nonfederal Community Nonprofit For profit State-local government Bed size 6–24 beds 25–49 beds 50–99 beds 100–199 beds 200–299 beds 300–399 beds 400–499 beds 500 beds or more H I G G S , S H Abe noted reflects hospital ownership, and it should that some hospitals, while owned by one N type of entity, may be operated under contract by another entity, such as a hospital managementI company. The largest grouping of hospitals in C the nation are nonprofit community hospitals. Although their Q numbers have declined overall, they remain the primary source of hospital care for most Americans. U These hospitals are owned by nonprofit entities, A although they are sometimes operated under contract by for-profit or other nonprofit corporations that specialize in managing hospitals and 1 health systems. 1 function Nonprofit entities, including hospitals, under special provisions of corporation law 0 in each state, and under federal and state tax provisions that 5 The narecognize their community service function. tion has approximately 1 million nonprofit T entities of various sorts and hospitals have long been a traditional service provider in the nonprofitSsector. Nonprofit entities serve a community service and have special recognition under the law due to 1975 1995 2003 7,156 382 6,774 5,875 3,339 775 1,761 Number 6,291 299 5,992 5,194 3,092 752 1,350 5,764 239 5,525 4,895 2,984 790 1,121 299 1,155 1,481 1,363 678 378 230 291 278 922 1,139 1,324 718 354 195 264 327 965 1,031 1,168 624 349 172 256 their role in our society. Nonprofit entities do not have owners and are governed by a communitybased board that has ultimate authority for operation of the entity. Nonprofit entities are generally exempt from most taxes at the federal, state, and local levels including income and property taxes. Many nonprofit entities have tax exempt status under Section 501C(3) of the federal tax code, allowing individuals to make potentially tax deductible donations to these organizations. Nonprofit entities are able to raise funds through donations, retained earnings, and debt obligations, often on favorable terms. Nonprofit entities may be “sponsored” by various types of organizations. Many hospitals have traditions of religious sponsorship. However, they are not owned by such sponsors. Nonprofit entities may also affiliate with each other through various organizational arrangements. Most nonprofit hospitals operate in a manner similar to other types of hospitals by employing modern management techniques, sophisticated information systems, and other Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 186 principles of twenty-first-century management. Nonprofit entities are generally expected to provide some indigent care and serve the community in a variety of ways as well. A much smaller percentage of the nation’s hospitals are operated as for-profit businesses. Forprofit entities have owners and issue stock to those owners to reflect their equity position. For-profit entities, including hospitals, may be publicly or privately held. Publicly held for-profit entities have stock that is available for purchase by anyone, typiH cally through the nation’s various stock exchanges. A variety of accountability and registration rules I and regulations affect publicly owned for-profit G entities, generally administered by the Securities G and Exchange Commission at the federal level and similar entities at the state level. Privately held S for-profit entities also issue stock, but that stock is , not available to the general public for purchase. Accountability and other regulatory oversight are much less for privately held entities. S For-profit hospitals may be independent and historically in this country and throughout the world H today many for-profit hospitals have been owned A by the physicians who practiced in them. Today, however, due to the tremendous capital costs N of building, maintaining, and operating a hospital, I most hospitals in the United States that are for profit are part of large multihospital chains, mostC of which are publicly traded. For-profit hospitals are Q not just accountable to the community but must also provide a return on investment to the shareU holders; therefore they expect to generate a profit A to pay a return to the equity investors for their capital. For-profit hospital companies may also manage not-for-profit and governmental hospitals as1a separate line of business. The third category of ownership in Table 8.21is state and local government hospitals. These are 0 hospitals that are owned by state or local govern5 ments, but again, may be managed under contract by other entities, either for-profit or not-for-profit T management companies. Many local government S hospitals are owned by counties or other local government units. They are often the providers of last PART THREE Providers of Health Services resort, bearing the burden of indigent care in their communities. In the western United States, hospital districts were created much like water districts to provide infrastructure for communities as populations moved West. These local taxing districts were responsible for the construction and operation of hospitals for their communities. In recent years the taxing authority of these districts has accounted for a very small percentage of total hospital operational costs. As reflected in Table 8.2, the majority of the nation’s hospitals are relatively modest in size as measured by licensed hospital beds. The very large institutions are typically teaching hospitals, often associated with medical schools, and have a range of residency programs for postgraduate medical education. The small hospitals are typically in rural areas, raising particularly complex issues regarding financial viability. Broadly speaking, large hospitals are more prevalent in the East as the trend over time has been to build smaller rather than larger facilities. Significant numbers of smaller hospitals, particularly in urban areas, have closed over the past 25 years due to financial and competitive pressures, and to the difficulty of efficiently operating a small number of hospital beds. Specifying the optimal side of a hospital is particularly difficult given the complexity of services now offered on an inpatient basis. Most likely, the very small and very large hospitals are the least efficient. As reflected in Table 8.3, the total number of hospital beds has dropped from just under 1.5 million to just less than 1 million since 1975. This trend reflects a combination of closures and reductions in operating licensed beds among those hospitals still in operation. Large hospitals, because of their size, account for a disproportionate share of the total number of hospital beds. About 70 percent of the nation’s hospital beds are in nonprofit facilities. As reflected in Table 8.4, there are approximately 36 million admissions to the nation’s hospitals every year, of which 25 million are to nonprofit hospitals. The number of admissions has been remarkably Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems 187 Table 8.3. Hospital Beds by Ownership and Hospital Size: United States, Selected Years Type of Ownership and Size of Hospital Beds by Ownership All hospitals Federal Nonfederal Community Nonprofit For profit State-local government Bed size 6–24 beds 25–49 beds 50–99 beds 100–199 beds 200–299 beds 300–399 beds 400–499 beds 500 beds or more H I G G S , 1975 1995 2003 1,465,828 131,946 1,333,882 941,844 658,195 73,495 210,154 Number 1,080,601 77,079 1,003,522 872,736 609,729 105,737 157,270 965,256 47,456 917,800 813,307 574,587 109,671 129,049 5,615 41,783 106,776 192,438 164,405 127,728 101,278 201,821 5,085 34,352 82,024 187,381 175,240 121,136 86,459 181,059 5,635 33,613 74,025 167,451 152,487 119,903 76,333 183,860 S H Table 8.4. Hospital Admissions by A Ownership and Hospital Size: United States, Selected Years N Type of Ownership and Size of Hospital 1975 1995 I Beds by Ownership Number in thousands C 36,157 33,282 All hospitals Q Federal 1,913 1,559 Nonfederal 34,243 31,723 U Community 33,435 30,945 A Nonprofit 23,722 22,557 For profit State-local government By hospital bed size 6–24 beds 25–49 beds 50–99 beds 100–199 beds 200–299 beds 300–399 beds 400–499 beds 500 beds or more 1 1 0 5 T S 2003 2,646 7,067 3,428 4,961 36,611 973 35,637 34,783 25,668 4,481 4,634 174 1,431 3,675 7,017 6,174 4,739 3,689 6,537 124 944 2,299 6,288 6,495 4,693 3,413 6,690 162 1,098 2,464 6,817 6,887 5,590 3,591 8,174 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 188 stable over the years, but the total number of hospital days has declined dramatically due to sharp reductions in the average length of stay. A relatively small proportion of admissions to hospitals are accounted for by the smaller hospitals. Examining hospital utilization based on population data illustrates a significant decline in discharges per thousand U.S. population as reflected in Table 8.5. Overall explanation of this trend lies in changes in the number of Americans, which Table 8.5. Discharges and Days of Care, Nonfederal Short-Stay Hospitals: United States, Selected Years Characteristic Total Age Under 18 years 18–44 years 45–54 years 55–64 years 65 years and over Sex Male Female Geographic Region Northeast Midwest South West Total Age Under 18 years 18–44 years 45–54 years 55–64 years 65 years and over Sex Male Female Geographic Region Northeast Midwest South West H I G G S , 1980 S H A N I C Q U A 1 1 0 5 T S 2003 Discharges per 1,000 population 173.4 119.5 75.6 155.3 174.8 215.4 383.7 43.6 91.3 99.5 145.7 367.9 153.2 195.0 104.4 135.1 162.0 192.1 179.7 150.5 127.6 117.1 125.8 103.9 Days of care per 1,000 population 1,297.0 574.6 341.4 818.6 1,314.9 1,889.4 4,098.3 195.5 339.7 477.2 735.9 2,088.3 1,239.7 1,365.2 546.7 605.2 1,400.6 1,484.8 1,262.3 956.9 694.4 507.9 609.8 476.4 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems 189 has led to a larger denominator. Declines in discharges are much more moderate for higher-age individuals. Overall, changes in technological innovation combined with financial pressures from payers has led to an increasing proportion of medical care being provided on an ambulatory basis, and to much shorter lengths of stay for equivalent diagnoses for those patients who are admitted to the hospital. The impact of these trends is to yield a much higher intensity or complexity of care for H hospitalized patients. Table 8.6 presents hospital occupancy rates I since 1975 for the nation’s hospitals. Even with G shorter lengths of stay, the closure of many hospiG of hostals, and an overall reduction in the number pital beds, occupancy rates remain on the decline. S On average, today, only about two-thirds of the , nation’s hospital beds are filled with patients each night. This trend is evident in virtually every category of hospital ownership. In the days since September 11, 2001, and more recently since various epidemics and natural disasters, the issue of ideal targets for hospital occupancy rates has become much more complex. How much capacity should be maintained for potential utilization in emergency situations is a complex policy issue. Maintaining unused capacity costs money. As a result, the industry has some reluctance to do so. On the other hand, operating at a more efficient level of occupancy, say 85 or 90 percent, not only restrains the ability to respond to normal fluctuations in utilization but also significantly impacts the ability of hospitals to respond to a critical community emergency situation. Alternatives for providing reserve back-up capacity for community-based emergencies have become an important priority as communities prepare for S H Table 8.6. Hospital Occupancy Rates by Ownership and Hospital Size: United States, Selected Years A Type of Ownership and Size of Hospital N 1975 1995 I Occupancy Rates by Ownership Percent All hospitals 76.7 65.7 C Federal 80.7 72.6 Q Nonfederal 76.3 65.1 Community 75.0 62.8 U Nonprofit 77.5 64.5 A For profit 65.9 51.8 State-local government By hospital size 6–24 beds 25–49 beds 50–99 beds 100–199 beds 200–299 beds 300–399 beds 400–499 beds 500 beds or more 1 1 0 5 T S 2003 70.4 63.7 68.1 64.8 68.3 66.2 67.7 59.6 65.3 48.0 56.7 64.7 71.2 77.1 79.7 81.1 80.9 36.9 42.6 54.1 58.8 63.1 64.8 68.1 71.4 31.9 44.6 57.2 62.6 67.0 68.5 70.7 74.2 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 190 unforeseen events without significantly impacting hospital cost structures. STRUCTURE OF HOSPITAL AND HEALTH SYSTEMS Although technological advancement and reimbursement policy are among the key factors affectH ing the development of the hospital industry over the past half century, other dramatic changes in the I corporate environment of health care and particuG larly of the hospital sector have served a prominent G role in affecting hospital management. Horizontal and vertical integration and the affiliation of hospiS tals with each other and with other sectors of the , health care system have been extremely important developments in the organizational structure in governance and in the operational management of S the hospital industry. These changes in the legal and organizational environment have profoundly H affected how the hospital industry is structured and lines of accountability. The introduction of an A increasingly typical corporate environment for the N hospital industry has, to an extent, changed the I roles for the key players, affected the organizational design, and facilitated other related changes within C the industry such as closures and consolidations. Horizontal and Vertical Integration Q U A The development of organizational and financial efficiency in the hospital industry has been most ac1 celerated by both vertical and horizontal integra1 tion. Because both of these forms of integration have been occurring, it is certainly fair to say that 0 this is an industry in transition still seeking a level 5 of equilibrium that can respond to changes in the health care marketplace and pricing as well as proT viding an adequate response to the invested comS munity. Along with horizontal and vertical integration, the industry has experienced a tremendous phase of closures and consolidations, particularly affecting smaller institutions. The dramatic changes in the number of operating hospital beds and hospitals in the United States are a result of this process as the industry seeks to provide more competitive products and pricing, an increasingly market-driven health care economy dictated by such payers as the government programs and various forms of managed care. Both horizontal and vertical integration have experienced ebbs and flows over the past decades. The objectives of integration of resources have also varied depending on the participants involved and local market conditions. National integration of various types, particularly for horizontal integration, has also been driven in part by the behavior of for-profit entities. To this day, the success of both vertical and horizontal integration varies tremendously across the country, and changing economic and market conditions suggest that such integration is a dynamic rather than static process with players possibly assessing their assets and adding and subtracting from their portfolios. In horizontal integration, similar units of production affiliate with each other. For example, for-profit and not-for-profit chains of hospitals under common ownership operating in different geographic locations all providing similar hospital-based services would be a horizontally integrated system. Horizontal integration occurs in the for-profit and not-for-profit sectors and can involve various levels of organizational affiliation from direct ownership to looser affiliation arrangements. Horizontal integration, designed to provide an enhanced level of efficiency of scale across multiple institutions and in related geographic areas, may serve to reduce duplication of services and marketplace competition. In a form of horizontal integration associated with regionalization of health services, smaller hospitals may feed into larger tertiary care facilities. Horizontal integration may also facilitate operational efficiency such as purchasing, information systems, quality assurance, and management capacity. Horizontally integrated multihospital networks may establish contractual arrangements with other types of Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems health care providers and participate in larger health care delivery systems. Vertical integration implies the establishment of integrated health care delivery systems that incorporate all or most aspects of the health care process. In this form of integration, inpatient hospital services, ambulatory care services, mental health, long-term care services, and other related health care products are incorporated into a comprehensive delivery system. Vertical integration, in many respects, is more complicated than horizontal inteH diverse gration because it involves a range of highly and not always easily integrated services.Vertical inI tegration was prompted by the objective of negotiG ating with insurers and managed-care providers G be prosuch that the full range of services could vided in a contractual arrangement. In addition, S vertical integration provides for feeding patient flows into hospital inpatient services and, other critical delivery components to ensure the financial viability of these institutions. Vertical integration alS intelows for greater capture of patients within grated systems and a more established H institutionally based relationship with physicians. Vertically A typiintegrated systems in managed-care settings cally contract for a broad range of services N rather than just for inpatient or other discrete care. VertiI chain for cally integrated services provide a delivery a range of health services rather than specializing in C only one product.Vertically integrated systems have Q greater capture of premium dollars but at the same time, assume a greater degree of financial Urisk. This increased risk has represented a significant chalA lenge in recent years. Some vertically integrated systems have also established their own health plans independently or in conjunction with insurance en1 tities. However, this trend has faced significant 1 challenges from financial and legal perspectives and they increase the risk to the institutional 0 provider. 5 Both horizontally and vertically integrated systems of care need to align physician interests with T institutional objectives. This has always been a challenge in health care and continues to beSso, particularly with today’s more competitive markets and 191 pricing pressures. Vertically integrated systems may have a greater likelihood of success in this regard because they can control a broader range of delivery systems and capture more of the health care dollar. Physician ownership initiatives such as for ambulatory, surgery centers, or even specialty hospitals are an additional threat to hospital delivery systems. HOSPITAL ORGANIZATION The traditional organization of hospitals is centered around three sources of power. These are the governing entity, the medical staff, and the administration. Traditional hospital governance was predicated on independent institutions each with its own corporate-style board. Legally and structurally, the governing body has ultimate authority for all activities and decision making within the organization, delegating certain tasks among administration and the medical staff. Among nonprofit entities, these boards were historically composed of well-to-do individuals who could provide a platform for fundraising. Over time demands for accountability resulted in substantially ramped-up professional representation on these governing bodies. Physicians, accountants, attorneys, and others with a knowledge base relevant to institutional governance were elected to membership. Although frequently a volunteer activity with minimal, at least by corporate standards, pay and fringe benefits, public service was the key motivation. For-profit entities have typically been components of larger corporations with advisory rather than legally binding governing boards. Hospital governing entities have delegated dayto-day management of the institution to hospital administration and the clinical medical affairs to the medical staff, which itself is typically formally organized with by-laws, elected officials, and specific duties and responsibilities. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 192 In recent years, considerable effort has been directed toward educating members of governing entities and hospitals to better understand the principals and legal responsibilities of hospital management and to more critically assess decision-making activities, particularly pertaining to large capital investments, organizational mission, the role and management of medical staff, and contractual arrangements with other entities. With both horizontal and vertical integration, the ultimate governance responsibility is typically H shifted to the highest level of organizational structure. Depending on corporation status of compoI nents within the larger organization separate G boards may exist with statutory authority or may G serve primarily in an advisory capacity. In the forprofit sector, a parent organization governing S board serves a corporate role analogous to that of , any public or privately held for-profit corporation. In the publicly held environment, the corporate board has an additional legal responsibility atS tributable to securities; regulation and corporate governance are defined by state and federal laws. H For all governing entities, specific duties and responsibilities are specified in the legal charter A or other documents creating the organization and N defining the duties, responsibilities, and memberI ship of the board. With increased accountability for individual and collective acts of governance, board C members must assume that they do have personal Q and professional liability to perform their corporate duties in an appropriate fiduciary manner. U Hospital administration has also changed appreA ciably over the years moving toward a more traditional corporate operational approach. In addition, hospital management increasingly incorporates the 1 delegation of responsibility to an array of other 1 managers including, on the front lines, departmental administrators. Specific technical expertise 0 is typically incorporated into the management structure in such areas as information systems,5finance, legal environment, quality assurance, marT keting, and contracting. Traditional roles such as S patient care, including the hotel function, physical plant, admissions, discharge, other operational PART THREE Providers of Health Services responsibilities, and various other key functions, are also represented. Today’s hospital administrators are often defined by traditional corporate titles and attractive pay packages. In the not-for-profit sector, seniorlevel hospital managers typically earn from the $100,000s to more than $500,000 per year. In the for-profit sector, these managers may also receive stock and stock options and other equity-related benefits. In both nonprofit and for-profit sectors, managers typically receive valuable benefit packages and in some instances, pay for performance and other types of bonuses. Hospital administrators usually have a management-related background or have clinical training and have worked their way into a management position or some combination of both. Hospital managers, like their employees, work in a relatively high-stress and demanding environment, answering not only to their formal bosses, but also to the public, consumers, physicians, and other constituencies. THE HOSPITAL AND MEDICAL STAFF With authority delegated from the governing entity, the hospital medical staff has specific responsibilities related to the clinical care provided in the facility and regulation of those individuals who practice clinically. Hospital and medical staffs are typically organized with elected officials, various committees, and with a leadership role represented by the president of the medical staff. State medical practice laws generally prohibit direct employment of physicians by hospitals. As a consequence, and due to historical independence of physician practices, physicians and other health care professionals have affiliated with institutions such as hospitals in a variety of other ways. Historically, these affiliations have primarily been through membership in hospital medical staffs. More recently, hospitals and physicians have affiliated Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems through joint ventures such as physician/hospital organizations, indirect employment of practitioners in other contractual arrangements, hospital purchases of group practices, and a variety of other models. Hospital medical staff membership has generally followed a model whereby physicians apply for hospital privileges in their area of specialty and are vetted by a committee of the hospital medical staff supported by administration. If found to be of good character and having a reputable clinical repHwhich is, utation, physicians are granted privileges, in essence, the ability to admit and discharge paI tients, provide care within the hospital facilities, G and serve as a participating member of the medical G staff. Although the governing entity is ultimately responsible for granting privileges, this responsibility S is usually delegated to the medical staff in recogni, and abiltion of their knowledge of clinical practice ity to assess professional skills. The evaluation of individuals for the granting of privileges is one of S medical the key and most important roles of the staff. Physicians, for example, are evaluated on H their medical and specialty residency training, their track record of clinical care as reflected A in medical malpractice and other quality assurance N indicators, and their reputation in other respects. I he or she When a physician is granted privileges, remains subject to surveillance by the medical C staff to ensure continued maintenance of a minimum Q level of quality of care. This surveillance typically consists of monitoring cases to assess any Uinstances for patterns of poor quality of care as well as other A indicators of difficulty such as being associated with a physician impaired with alcohol or drug or other abuse. Hospitals and their medical1staffs also serve a regulatory role in reporting violations of clinical practice standards by physicians1and other practitioners to state licensing agencies0and other entities. Physicians, as members of the medical5staff, may participate in various committee assignments and T historically were expected to provide some level of S many inindigent care although this requirement in stances has largely dissipated. In most hospitals 193 physicians are also expected to utilize their clinical privileges only in those areas in which they have proper training and credentialing. Physicians and other professionals who are less frequently utilizing a specific hospital may be granted a separate category of privileges for occasional use with less expected participation and fewer responsibilities. Physicians who are interested in clinical leadership positions may assume responsibility for medical staff committees or seek to be a leader in the medical staff hierarchy. Increasingly, physicians who are interested in managerial roles may also be employed for that purpose by the hospital on the administration side, typically a position such as vice president for medical affairs. In addition to credentialing physicians for hospital privileges, the medical staff is typically responsible for ensuring the quality of care provided in the hospital under delegated authority from the governing entity. Various committees may be formed for this purpose, including a quality assurance committee or other peer review committee. The medical staff will seek to provide feedback to physicians and other clinicians who are not meeting expected standards of the quality of care in their clinical practices within the institution. This feedback can take many forms, including quantitative data assessment comparing each individual to the norms of other practitioners in their specialties, or even informal feedback from the medical staff president or a clinical department chief. Ultimately, hospital privileges may be revoked in extreme situations where clinical standards are clearly not met. In this instance, appropriate due process must be followed utilizing specified procedures as outlined in the medical staff bylaws. The increasing utilization of computerized information systems and a more interested younger generation of clinicians have greatly accelerated the attention to data-based assessments of quality of care. National voluntary organizations have worked hard to promote these efforts so as to elevate the overall quality of care provided in the nation’s hospitals. Voluntary accrediting agencies, in particular, have also increasingly pressured institutional Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 194 providers to incorporate quality assurance mechanisms in their ongoing production methods. Many types of approaches have been developed in this regard, including a range of processes designed to encourage the use of clinical approaches that are validated from scientific and evidence-based research. Many clinical quality assurance and quality improvement techniques have been adapted from the corporate environment, particularly industrial settings as well. Payers are also demanding enhanced quality surveillance and improvement. H In contrast to a typical corporate environment, hospitals do not directly employ most physicians, I who are key decision makers and decide resource G allocation and utilization. Thus, the medical staff G serves an important role in aligning physician behavior and objectives with institutional needs. S Medical leadership is particularly important in , today’s complex environment to facilitate this relationship. Ultimately, the traditional hospital structure, particularly with regard to the medical staff, is S inconsistent with managing an organization that faces numerous competitive and pricing pressures. H Some medical staff organizations, such as those A in group practice, model HMOs that directly own all resources in their systems, and certain governN mental entities such as the military and veteran’s I administration hospitals, have more direct control over the medical staff. C KEY ISSUES FACING THE HOSPITAL INDUSTRY Q U A 1 The hospital industry almost continuously faces key 1 critical issues that challenge its structure, viability, and roles in health care. This section discusses 0 many of these issues. 5 T Specialty Hospitals S In recent years, the development of highly specialized hospitals has gained considerable traction. Although not a new concept by any means, the more rapid recent development of these specialty hospitals poses a threat to community general hospitals to a much greater extent than in past years. The new specialty hospitals include those focused on cancer and heart disease and other highly discrete areas of practice in lucrative fields such as orthopedic surgery. To further complicate the controversy over specialty hospitals, these institutions are increasingly partially owned by the physicians who practice within them. Ironically, in the early days of the modern development of hospitals, physician ownership was not unusual. However, the popularity of physician-owned proprietary hospitals today has been challenged by two ramifications. The first is that these hospitals draw profitable patients from community hospitals, and the second potential conflict of interest is represented by physicians admitting patients to hospitals in which they have an ownership interest. Of course, our quality of care data suggest that high volumes of discrete services can enhance quality. From some perspectives, highly specialized institutions may in fact provide the best care. On the other hand, many of these specialty hospitals may siphon off insured and relatively healthier patients, leaving the less profitable and more complicated cases to community general hospitals. Physician ownership of specialty hospitals raises concerns that financial incentives will affect the treatment decisions, such as the use of specialty and diagnostic services. In addition to providing care to the less complex and more profitable cases, these hospitals may also leave the uninsured and underinsured to community and public hospitals for treatment. The combination of adverse selection and less private insurance and public coverage for community general hospitals and government facilities does raise significant policy concerns. Federal policy development has been slow to respond to this trend. Medicare has complex rules regarding physician ownership of health care resources and potential conflicts of interest. And both the Medicare and Medicaid programs have a valid Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems concern with respect to the distribution of health care costs across all facilities and patient groups. The impact of specialty hospitals on community general hospitals and governmental hospitals has yet to be fully assessed, but this development is potentially significant clinically and financially. Changes in Technology The hospital industry is all about technology. Although the hotel function of a hospital is in a way H of techprimary to its purpose, it is the provision nology that is its true mission. Technology has I shaped the physical and operational structures of G hospitals, has affected the lives of patients and families, and has provided a delivery vehicleGfor physicians in clinical practice. S From its earliest days as a modern institution, the , defined availability of technological resources has the services provided in hospitals. The discovery of anesthesia and of antisepsis clearly established the early stages of the provision of surgicalScare. The vast array of imaging technologies has had H tremendous impact on effective intervention for patients A seeking care in the hospital setting. Laboratory, diagnostic, and other technological innovations have N also greatly facilitated clinical medicine. Successful I of inintervention is dependent on the technology novative therapies including pharmacological C interventions and surgical techniques. Q More recently, the huge range of technological advancements that have vaulted to the forefront of U the tertiary care role of inpatient services within A hospitals have included organ transplantation, a vast array of minimally invasive surgical technologies, advanced cardiac treatments, primarily 1 through a variety of surgical interventions, an impressive 1 range of successes in advanced emergency and trauma care, and vast improvements in the underly0 ing technologies related to information systems, 5 medical records, and other aspects of hospital and health care operations to facilitate the T delivery of services to patients. Technological advances have affected obstetric patients, pediatric care S needs, patients with terminal illnesses, and a range of other 195 problems that present to the inpatient side of hospital operations. Technological advancement has led to the development of increased specialization and clinical practice, expansion of specialized services, new medical and surgical specialties, and treatments for many diseases for which little curative or other care could be provided in the past. Advanced technologies including the many applications of lasers, the use of ultrasonic technology for treatment, and more recently, the development of automated surgical assistant or robot technologies have all been revolutionary. Hospitals operate in competitive markets and the pressure to provide a full range of technology, and to keep that technology current, yields significant cost pressures and even potential conflicts with medical staff members. Insurers and employers as well as government entities seek to pay for the latest technologies, but at efficient pricing. The continuing advancement of technology is a double-edged sword providing us with tremendous new capabilities, but at the same time, many challenges. The hospital, perhaps more than any other sector of the health care system, faces these opportunities and challenges in the most dramatic ways. And, ultimately, it is their customers, their patients, and their physicians who utilize these hospitals and health care systems, who have the highest expectations and often the least sensitivity about costs. Clinical Practice Patterns Hospital design and operations are significantly affected by accepted clinical patterns of practice. The increasing attention to best practices and practice norms of various types, particularly under quality assurance programs, requires institutional adherence to various protocols and guidelines. Information systems and other operational requirements must also be compliant with the need to provide evaluative information to assess and report on physician clinical patterns of practice. Medicare and many managed-care contracts require such Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 196 reporting. Accreditation by the Joint Commission for Accreditation of Health Care Organizations and other specialty accreditation bodies also requires the availability and interpretation of data. In addition to the availability of appropriate information to monitor and evaluate clinical protocols and practice guidelines, institutions are increasingly expected to offer a governance structure that assigns responsibility for these activities. Typically, in most community hospitals, that responsibility is delegated from the governing body to the H medical staff. The governing board and institutional administration, however, retain responsibility for I successful compliance with these requirements. G Individual practitioners are likewise increasingly G being held accountable for their practice patterns and behavior through a variety of monitoring and S feedback mechanisms. , The complexity of integrating all the requirements pertaining to clinical practice is of itself a significant burden on institutional operations. Legal S and ethical expectations, combined with reporting requirements contained in various contractual H arrangements, further enhance the depth and comA plexity of this obligation. Physician independence has been significantly weakened by the introducN tion of various external regulatory requirements. I Reimbursement Mechanisms C Q Hospitals and hospital systems are heavily constrained by the reimbursement mechanisms that U pay their bills. The most significant source of A funds for most hospitals is the federal Medicare program. As discussed elsewhere in detail in this book, financial mechanisms for reimbursement 1 under the Medicare program have become increasingly complex. Medicare has moved 1to reward efficiency and specialization while increas0 ingly squeezing institutional cash flow. Medicare, 5 being a federal program, also has significant regulatory and force of law powers unknown to thirdT party insurers in the private sector. Medicare has S imposed an array of requirements to reduce fraud and abuse, but these efforts have had secondary PART THREE Providers of Health Services effects in complicating organizational administration and financial arrangements. Nongovernmental sources of payment, primarily from managed-care organizations, have themselves become fraught with complexity and cost pressures. Most payers now seek a competitive market advantage in pricing in an attempt to drive down the cost of health care, while at the same time shifting an increased burden of cost to the consumer. The negotiated per diem rates are heavily discounted and many insurers exclude a range of reimbursements for various specific services. Many third parties also require reporting from institutional providers on utilization patterns, use of resources and services, and other parameters of the care process. Hospitals are generally expected by payers to provide extensive oversight of practitioners through aggressive credentialing efforts and other responsibilities. All these developments have resulted in pressure to improve efficiency, reduce waste and duplication, and provide care as quickly as possible and at the lowest possible cost. While payers are increasingly squeezing payments to all providers, hospitals in particular are susceptible to financial pressures. Hospitals provide services that require a high degree of capital investment, have limited control over the cost of many of their products due to such considerations as shortages of nursing and other specialized personnel and the high cost of innovative products, and finally, the expectations on the part of both consumers and individual practitioners for reasonable ambience and excellent outcomes. Academic Medical Centers Academic medical centers typically consist of medical schools and their primary teaching hospitals. Academic medical centers provide tertiary, secondary, and primary care but have a principal focus on biomedical research, teaching of medical residents and medical students, and often an array of other professional training, research, and service activities. These organizations are highly complex Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems with a multitude of power structures, funding sources, and sometimes conflicting missions. Hospitals that are part of academic medical centers are operationally constrained by the demands of the teaching mission, particularly with regard to medical students and postgraduate medical education, and a mandate to conduct both basic biomedical and applied clinical research. Financial efficiency and consumer satisfaction are not typically the top priorities. Physicians and researchers place considerable demands on these organizations to H and to provide the latest technology and staffing allow for teaching and clinical investigation. I The success of academic medical centers in G achieving their missions should be a national priG of our ority. The long-term strengths and successes health care system depend on this. Although not S necessarily widely acknowledged, financial effi, priority ciency in fact should probably not be a top from a national health policy perspective. Unfortunately reimbursement policies by Medicare and S other government and private payers typically do not overtly allow enough latitude for academic medH ical centers. In addition, academic medical centers are frequently the providers of last resort,Afurther restraining cash flows and viability. Local government N and, to an extent, private insurers through cost I shifting, pick up part of the tab. A lot of attention has been directed C toward academic medical centers in recent years. The chalQ lenge is to reconcile the needs for medical education and research with the fiscal realities of U available resources in a manner that will meet our nation’s A educational and clinical needs. This remains a huge challenge for the nation’s health care system. 1 1 SUMMARY 0 The hospital industry has faced numerous challenges over the years and will continue 5 to do so in the future. Markets have changed, pricing T pressures have increased, and consumer and payer expectations have evolved. Yet, throughSit all, our nation’s hospitals have continued to provide the best hospital-based care in the world, delivering a 197 technology that is second to none with top-notch staff dedicated to patient care. REVIEW QUESTIONS 1. Describe the historical development of hospitals in the United States. 2. Describe the differences between nonprofit and for-profit hospitals. 3. List the major trends that have occurred within the hospital sector. 4. What is horizontal integration, and why is it used? 5. What is vertical integration, and why is it used? 6. Describe the internal organization of community hospitals. 7. Describe the key issues facing the hospital industry. REFERENCES & ADDITIONAL READINGS Birkmeyer, J. D., Siewers, A. E., Finlayson, E. V. A., Stukel, T. A., Lucas, F. L., Batista, I., Welch, H. G., & Wennberg, D. E. (2002). Hospital volume and surgical mortality in the United States. New England Journal of Medicine, 346, 1137–1144. Davis, M., & Heineke, J. (2003). Managing services: Using technology to create value. Boston: McGrawHill/Irwin. Gapenski, L. (2004). Healthcare finance: An introduction to accounting and financial management (3rd ed.). Chicago: AUPHA Press/Health Administration Press. Halm, E. A., Lee, C., & Chassin, M. R. (2000). How is volume related to quality in health care? A systematic review of the research literature. Prepared for National Academy of Sciences, Interpreting the volume-outcome relationship in the context of health care quality workshop. Washington, DC. Kelly, D. L. (2003). Applying quality management in healthcare: A process for Improvement. Chicago: AUPHA/Health Administration Press. Martin, L. L., & Sage, R. (Eds.). (1993). Total quality management in human service organizations. New York: Sage Publications. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care Connie J. Evashwick CHAPTER TOPICS Definition of Long-Term Care H I G G S , LEARNING OBJECTIVES Upon completing this chapter, the reader should be able to Clients of Long-Term Care How Long-Term Care Is Organized Service Categories Integrating Mechanisms Long-Term Care Policy S H A N I C Q U A 1. Describe who uses long-term care and under what circumstances. 2. Explain the role and scope of services included in long-term care. 3. Articulate how long-term care services are organized, operated, financed, and integrated. 4. Evaluate model delivery system approaches to long-term care for the future. 5. Articulate national policy issues pertinent to long-term care. 1 1 0 5 T S 198 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care WHAT IS LONG-TERM CARE? ■ A child with cerebral palsy attends a special needs classroom in a public school, with therapy available on-site, and her parents care for her when she is at home. ■ An 85-year old recovering from a broken hip receives meals on wheels during theHweek and relies on her daughter for meals over the I weekend. G in shelA young man with schizophrenia lives tered housing, with financial assistance Gprovided through a public housing voucher program and medication or counseling assistanceSavailable from an on-site staff when needed. , An elderly couple, one of whom is blind from advanced glaucoma and one of whom is crippled with severe arthritis, uses Sa moneymanagement service from a local community H agency to pay their bills, since neither can write A a check. N sclerosis A middle-aged woman with multiple has a live-in attendant to assist her with the I activities of daily living. ■ ■ ■ C All these are examples of long-term care provided by formal or informal sources. Q Long-term care is defined as health, mental health, U residential or social support provided to a person with A functional disabilities on an informal or formal basis over an extended period of time with the goal of maximizing the person’s independence. 1 Services change over time as the person’s and 1 caregivers’ needs change. The goal of long-term care is to help 0 people achieve functional independence, in contrast to the 5 of all goal of acute care, which is to cure. People ages and a wide range of clinical diagnoses T need long-term care. The vast majority of long-term care Sand fam(80 to 90 percent) is provided by friends ily. However, formal services are essential to enable 199 the informal system to be sustained. The formal services that provide long-term care are described in this chapter using a conceptual framework referred to as “the continuum of long-term care.” The ideal is an integrated set of services that provides continuity of care over time and across settings. In reality, services are highly fragmented due to financial drivers, local community variation, and a lack of uniform federal and state policies. This chapter provides an overview of the ideal continuum of care juxtaposed with the reality of existing services, structure, and policies. WHO NEEDS LONG-TERM CARE? The clients of long-term care are growing rapidly. They represent a mosaic of population segments of those with functional disabilities. Three intersecting concepts warrant explanation to understand the users of long-term care. The fundamental reason that a person needs long-term care is because they suffer from one or more functional disabilities. Functional ability is a person’s ability to perform the basic activities of daily living (ADLs) or instrumental activities of daily living (IADLs). ADLs include the ability to bathe, dress, perform personal care and grooming, walk, transfer from bed to chair, maintain bowel and bladder continence, and eat. ADLs were initially defined by Katz and colleagues through research (Katz et al., 1963), and years of study have produced commonly accepted measures and scales of functioning. ADLs tend to involve large motor skills, and they are lost in a predictable order. IADLs are more loosely defined (Lawton & Brody, 1969) but typically involve cognitive reasoning and finer motor skills. IADLs include telephoning, managing money, taking medications, grocery shopping, housekeeping, doing chores, and using transportation. The conditions that underlie the need for longterm care may be physical health, mental health, Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 200 57.6% 80⫹ 73.6% 38% 57.7% 28.3% 70 –74 46.6% 30.7% 44.9% 24.2% 55– 64 35.7% 13.9% 22.6% 8.1% 25– 44 13.4% 5.3% 10.7% 3.8% 7.8% Under 15 0 20 H I G G S , Severe Disability Any Disability 40 60 80 Figure 9.1. D i s a b i l i t y P re v a l e n c e b y A g e , 1 9 9 7 S SOURCE: From Health, United States, 2005 (Special Excerpt), Trend Tables on 65 and Older Population (DHHS Pub. H Health Statistics. No. 2006-0152) (Table 58, p. 243), National Center for A or a combination, as well as family situation and N environmental context. Of the 288 million people I in the United States in 2005, more than 12 percent, or more than 35 million people suffered from some C type of disability that limited their ability to perQ form basic activities of daily living (National Center for Health Statistics, 2005). Limitations in funcU tional ability affect people of all ages but increase A with age and the concomitant chronic conditions that accumulate with aging. Figure 9.1 shows the estimated number of people with disabilities. How 1 a person manages a functional disability depends 1 on several factors, including other health conditions, age, family and social support, economic sta0 tus, housing, and personal preference. 5 Chronic is defined by the National Health Interview Survey as any condition that lasts 3 months T (or 90 days) or more (National Center for Health S Statistics, 2007). Chronic conditions may derive from physical or mental conditions. Over the progression of a disease, both may occur. Chronic conditions may be as life-threatening as coronary artery disease or as harmless as mild arthritis. In 2005, an estimated 133 million people had some type of chronic condition (Hoffman, Rice, & Sung, 1996). Chronic conditions often (although not always) result in functional disabilities. An impairment as used by the National Health Interview Survey is defined as “a chronic or permanent defect, usually static in nature, that results from disease, injury, or congenital malformation. It often represents a decrease in or loss of ability to perform various functions.” Permanent impairments, such as limb amputation or blindness, may require an initial adjustment and are then more or less stable. People may attain a level of independence by learning special skills to overcome the disability or by using adaptive devices. For example, a person with myopia can have their vision corrected by wearing glasses or contact lenses and thus suffer Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care no disability as a result of their impairment. Nonetheless, impairments are closely associated with functional disability. Impairment, chronic condition, and functional ability are intertwined. For example, a person who is blind, who lives with a supportive family, learns Braille, and masters the immediate environment, may achieve a fair degree of independence on a daily basis. However, if that person ages and becomes cognitively diminished, he or she may no longer be able to remember the environment, and H (or just without the ability to use the visual clues simple notes or lists) that a person withI sight can use to help overcome cognitive weaknesses, is less G able to function independently. If that person then G impairslips and breaks a hip, suffers a permanent ment, and has to use a walker, they will lose more S functional ability than a sighted person or a person , to unwithout cognitive impairment who is able derstand rehabilitation routines. In addition to a person’s health and mental S health, social situation, finances, housing, and community context all affect the extent H to which a person can perform ADLs and IADLs independently and the type of assistance they A may need. Contrast a male veteran in a wheelchairNwho lives with a spouse, can afford a personal caregiver, resides in a one-story home, and lives Iin a large urban community served by a community-based C agency coordinating services for the disabled and Q a Veterans Affairs hospital that provides a full range of health care for people with U disabilities with an elderly widow who breaks her hip, has no A family nearby, has no income except Social Security, resides in a two-story walk-up in a small rural town, and must travel 30 miles to reach1a hospital with an orthopedic service. The man will main1 a multitain his independence by working with faceted support system; the older woman will 0 most likely end up moving to a relative’s home or an assisted living facility for those 5with low income and be forced to move awayTfrom her friendship network. The United States makes no single,Sconstant, routine count of people needing long-term care 201 that factors in all the variables that determine if, what type, and how much care a person needs to perform ADLs and IADLs. Rather, subsets are counted, and each subset of the total population has a segment that may require long-term care at some point from formal or informal sources. Population segments at high risk of needing longterm care are growing steadily. They include the aged (especially those age 75 and older), those with certain chronic conditions (such as stroke, mental illness, degenerative neurological conditions, Alzheimer’s disease), people positive for HIV/AIDS, and children with special health care needs, to mention just a few. For each group, and each individual, the care needed will vary and will be some combination of informal care provided by family and friends and formal care provided by external organizations. The rationale for structuring the long-term care system for specific segments of the population rather than a single encompassing system is based on the differing needs of each segment and the multiple factors that shape service delivery, particularly financing. Users of long-term care services are called by differing terms, depending on the service. Table 9.1 shows the terms used by various services. Table 9.1. Te r m i n o l o g y f o r U s e r s o f S e l e c t S e rv i c e s S e rv i c e Te rm f o r C l i e n t s Nursing homes Hospitals Adult day services Home care Hospice Outreach Wellness programs Disease management programs Durable medical equipment Assisted living Residents Patients Participants Clients Patients Consumers Clients Enrollees Customers Residents Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 202 ■ HOW IS LONG-TERM CARE ORGANIZED? One of the greatest challenges of long-term care is that there is no single organized formal delivery system. As noted earlier, the vast majority of long-term care is provided by friends and family. Care is orchestrated around the unique needs of each indiH vidual and family, as well as the resources of the particular community. A person may require multiple I services, provided in a range of settings, and by proG fessionals representing a broad spectrum of disciplines. Moreover, services can be expected to change G over time as the client’s and family’s needs change or S as new technologies arise.Thus patterns of care vary, for population segments as well as individuals. , To analyze long-term care service delivery, the conceptual framework of an ideal continuum of long-term care is used. The continuum of careSis defined as H A client-oriented system composed of both services and integrating mechanisms that guides and tracks clients over time through a comprehensive array of health, mental health, and social services spanning all levels of intensity of care. (Evashwick, 1987) A N I C Q The ideal continuum of care is the formal care system that complements the informal services proU vided by friends and family. The ideal continuum of A care is a comprehensive, coordinated system of care designed to meet the multifaceted needs of persons with complex and/or ongoing problems efficiently 1 and effectively. A continuum is more than a collection of fragmented services. It includes mechanisms 1 for organizing those services and operating them as 0 an integrated system. The purpose is to facilitate the client’s access5to the appropriate services at the appropriate time, T quickly and efficiently. Ideally, a continuum of care S does the following: ■ Matches resources to the client’s health and family circumstance. ■ ■ ■ ■ ■ Monitors the client’s condition and changes services as needs change. Coordinates the care of many professionals and disciplines. Integrates care provided in a range of settings. Enhances efficiency, reduces duplication, and streamlines client flow. Pools or otherwise arranges financing so that services are based on need rather than narrow eligibility criteria. Maintains a comprehensive record incorporating clinical, financial, and utilization data. A true continuum should serve three major goals: (1) Provide the health and related support services that foster independence, for the client as well as the family, (2) achieve cost-effectiveness by maximizing the use of resources, and (3) enhance quality through appropriateness and continuity of care. Some clients may use only select components of the system and may remain involved with the organized system of care for a relatively short period of time; others may use only a limited and stable set of services over a prolonged period of time. Continuum Overview More than 60 distinct services can be identified in the complete continuum of care. For simplicity, the services are grouped into seven categories, as shown in the schematic and in Table 9.2. The seven categories represent the basic types of health care and related services that a person could need over time, through periods of both wellness and illness. Table 9.2 lists select services within each category but should not be interpreted as the complete list of all health and mental health services. The table does not include social support services, which also comprise a lengthy list. By definition, the continuum of care is more than a collection of fragmented services; it is an integrated system of care. The United States health care delivery system has evolved historically as highly fragmented. Integration of services does not happen automatically. For providers, payers, and clients to gain the system benefits of efficiencies of Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care 203 Table 9.2. C a t e g o r i e s a n d S e rv i c e s o f t h e C o n t i n u u m o f C a re* Extended Skilled nursing facility Step-down unit Swing bed Nursing home follow-up Intermediate care facility for the mentally retarded Long-term care hospital Psychiatric hospital (residential model) Acute Medical/surgical inpatient services Psychiatric acute inpatient services Rehabilitation short-term inpatient services Interdisciplinary assessment team Consultation service Ambulatory Physician’s office Outpatient clinics ■ Primary care ■ Specialty medical care ■ Rehabilitation ■ Mental health ■ Surgery Psychological counseling Day hospital Adult day services Home Care Home health—Medicare Home health—Private Hospice High-technology home therapy Durable medical equipment Home visitors Homemaker and personal care In-home caregiver H I G G S , S H A N I C Q U A Outreach and Linkage Screening Information and referral Telephone contact Emergency response system Transportation Senior services program Meals on Wheels Mail order pharmacy Wellness and Health Promotion Educational programs Exercise programs Recreational and social groups Senior volunteers Congregate meals Support groups Disease management Housing Continuing care retirement community Independent senior housing Assisted living Congregate care facility Adult family home Group home Board and care facility Alcohol and substance abused facility 1 1 *Lists of services within each category are not 0exhaustive. From “Definition of the Continuum of Care,” by C. Evashwick, 2005, in The Continuum of Long-Term Care, 5 C. Evashwick (Ed.), Albany, NY: Delmar. T S Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 204 INTER-ENTITY STRUCTURE AND MANAGEMENT INTEGRATED INFORMATION SYSTEMS CARE COORDINATION INTEGRATED FINANCING EXTENDED ACUTE AMBULATORY HOME H I G G S , OUTREACH WELLNESS HOUSING Figure 9.2. S e r v i c e s a n d I n t e g r a t i n g M e c h a n i s m s o f t h e C o n t i n u u m o f C a r e SOURCE: From “Definition of the Continuum of Care.” by C. Evashwick, 1987, in Managing the Continuum of Care, by C. Evashwick and L. Weiss (Eds.), Gaithersburg, MD: S Aspen Publishers. H operation, smooth client flow, and quality of service, formal structural integrating mechanisms are A essential. Four integrating management systems are N required: inter-entity structure and management, care coordination, integrated information systems, I and integrated financing (Figure 9.2). SERVICE CATEGORIES C Q U A This section briefly describes each of the seven service categories and presents data, when available, 1 on major or select services within each category. 1 Not every client will use every service. However, the ideal is that the services are available and accessible 0 if a person should need them. There is no set order 5 for the services, since each client will use ones appropriate for his or her individual and unique T needs. S A significant aspect of the services is that each has its own operating characteristics, even within the same category. Services vary according to intensity of care offered, professional and support staffing, predominant financing, licensing, certification, accreditation, equipment, space, and significant other management dimensions. This variation poses a challenge to managers trying to coordinate services, as well as to payers and clients who are trying to achieve continuity of care. Extended Inpatient Care Extended inpatient care is for people who are so sick or functionally disabled that they require ongoing nursing and support services provided in a formal health care institution, but who are not so acutely ill that they require the technological and professional intensity of a hospital. The majority of extended inpatient care facilities are referred to “nursing facilities” or “nursing homes,” although this is a broad term that includes many levels and types of programs. Specialty facilities range from subacute units in hospitals to intermediate care facilities for the mentally retarded or developmentally Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care disabled to psychiatric hospitals caring for the severely mentally ill on an indefinite basis. Nursing facilities in the nation number about 16,100, with about 1.4 million residents at any given time (American Association of…
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