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FREQUENTLY heard criticism of

the voluntary hospital system is its lack of systemization. There are those who argue that the hospitals of the nation have developed at random and that we have no rational system but only a collection of uncoordinated principalities. These critics claim that whatever coordination has occurred is the result of individual hospitals watching each other out of the corner of their eyes rather than through overt, concerted group planning. The lack of formal mechanisms for community-wide planning on an organized basis has given great weight to these criticisms. Only in recent years has the movement for the formation of area-wide hospital planning bodies achieved any widespread momentum. The movement is still in its developmental stages, and more than half of our major cities have not as yet set up such bodies. There is every indication, however, that the strong emphasis and leadership provided by the American Hospital Association and the United States Public Health Service will result in a rapid increase in the number of hospital planning agencies in the next few years.

These emerging hospital planning bodies have made rapid prog

Because the expansion and coordination of high-quality services for the chronically ill and aged demand the combined efforts of many types of voluntary organizations and government agencies at all levels, the author states, ways must be found to coordinate these groups into a single objective under the voluntary system. He discusses the recommendations of a joint committee of the American Hospital Association and the U.S. Public Health Service in developing guides for planning long-term care facilities.

ress in the development of methodology and the establishment of planning principles applying to general hospitals and the care of the acutely ill patient. Considerable assistance was provided in this work by the national committee for Area-Wide Planning for Hospitals and Related Health Facilities, jointly sponsored by the AHA and USPHS and chaired by George Bugbee. Little progress has been made, however, in planning for the care of the long-term patient. This failure to extend the planning beyond the foot of the general hospital bed does not reflect a lack of concern for the longterm patient on the part of the hospital planning leaders. Most of them recognize that there can be no sensible planning that does not

take into account the total spectrum of patient care and the total range of facilities required. They see that anything less than comprehensive planning will result in costly and faulty use of acute facilities and will perpetuate gaps that exist in patient care.

The failure of the American hospital system to develop as a coordinated system of facilities comprehending all levels of patient care can be traced to a number of factors. It could be argued that this lack of coordination really made no difference until fairly recent years. The institutionalization of illness was not of much medical or cultural consequence even a few generations ago. It was not until rapid medical advances, and even more rapid social changes, occurred that institutional facilities for medical care assumed much significance. It didn't make much difference whether these facilities were coordinated as long as they didn't have much to coordinate; moreover, most types of illness could be treated as well at home as in a hospital. Advances in medical science called for expensive equipment and highly trained personnel, however, and these could be provided only in highly organized, central locations. The

same scientific revolution that was providing the medical advances simultaneously produced wholesale changes in family composition, living accommodations, work and recreational patterns, and attitudes toward medical care and hospitals. A rising standard of living and the growth of prepayment permitted the average family to exercise their new attitudes. All of these forces kept the general hospital in a mad run to provide the facilities required in order to implement the rapid succession of medical advances and the multiplying demand by the public for acute hospital care. It was this tremendous growth in facilities and use of the general hospital, and the consequent increase in

Growing realization of the serious deficiencies in facilities and services for the care of long-term patients and the need for sound planning for the coordinated development and use of such facilities prompted the formation in July 1961, of a joint committee of the American Hospital Association and the U.S. Public Health Service, assigned to develop guides for area-wide planning of facilities for long-term treatment and care. It was my privilege to serve as chairman of that committee, and the following is a brief account of some of its conclusions and recommendations.

Attempts to assess the inadequacy of existing programs and the reasons for these inadequacies

A SHIFT OF FOCUS

The preoccupation with the exploding demand for general hospital care drew attention away from the needs of the long-term patient. The hospital system and its prepayment plans became almost completely oriented to the needs of the acutely ill. But the same forces that were increasing the utilization and the cost of the acute facilities began to focus attention on the needs of the long-term patient. It became increasingly apparent that effective hospital planning was impossible without appropriate planning for the longterm patient. As a result of the failure to take chronic illness into account, long-term patients were occupying acute facilities and were subject to serious gaps in care as they migrated from one level of intensity of care to another. Both the economies and the equity of the hospital situation dictate that the needs of the longterm patient be recognized in the planning process.

by RAY E. BROWN

inevitably result in a realization that much remains to be learned about the best methods for providing long-term care. During the past few years there have been many experiments and demonstrations directed toward new patterns of providing health care services to the chronically ill and disabled. These include chronic disease units in general hospitals, day hospitals, night hospitals, coordinated home care programs, and the like. Some of these emerging patterns are as yet too new to permit thorough evaluation of their effectiveness. Nonetheless, to delay longer in establishing general principles to guide future planning can only lead to further failure to provide adequately for the care of these patients or the construction of facilities inadequate for the functions that should be performed on behalf of long-term patients.

The committee, recognizing the lack of definitive knowledge as to the methods that would be most desirable in all situations, nevertheless reached its conclusions and recommendations in the light of the best knowledge available.

In a recent statement approved

*These recommendations will be published by the USPHS in a booklet entitled, Area-wide Planning of Facilities for LongTerm Treatment and Care, publication number 930-B-1.

by the Board of Trustees of the American Hospital Association entitled, "Guide to Development of Effective Regional Planning for Hospital Facilities and Services," regional planning is defined as a process through which pertinent information is gathered and analyzed as the basis for intelligent decisions by informed citizens, and through which information gathered and decisions reached are made known to institutions and people concerned with meeting community needs. This definition aptly describes the content in which the committee attempted to work.

The fundamental goal of planning for long-term patient care is the development of a comprehensive and coordinated pattern of service to meet the many and varied needs of chronically ill and disabled individuals. In terms of facility planning, achievement of this role involves (1) providing for a sufficient number of highquality facilities with a full range of needed services; (2) promoting flexibility of design to facilitate maximum utilization of resources; (3) integrating these facilities into a comprehensive pattern of service, and (4) developing cooperative arrangements to promote high-quality care and optimum efficiency and economy in use of all community resources.

WHO ARE THE PATIENTS?

In attempting to identify the kinds of patients whose needs for health services on a long-term basis were being considered by the committee, we found it difficult to keep a constant focus because we, like many others found ourselves unconsciously identifying longterm patients with aged patients. Although the needs of older people for long-term care exceed those for any other single age group, there is nevertheless a substantial number of persons with chronic disabilities in all age groups. Planning must take into account this variety of needs and must avoid concentrating solely on the aged.

The committee defined the longterm patient as an individual who because of physical or mental illness, deterioration or disability, requires medical, nursing, or supportive health care for a prolonged