CURRENT PATTERNS of care and treatment of the long-term patient encompass a wide variety of resources. These include both institutional and out-of-institutional programs and services. While some basic services and facilities for longterm care are available in most communities, wide variations exist in the quality and quantity of the services provided. For the most part, the nature and availability of services depend upon community recognition of needs and the extent of financial support.

Changing concepts of treatment and care of the long-term patient emphasize the need, in

many areas, for a more effective arrangement of services and the development of new programs of prevention, treatment, and rehabilitation. Emerging patterns of treatment and care are, to a greater extent, community oriented and show an increased recognition of the expanding role of the general hospital in the treatment of the chronically ill and disabled. Although more and more medical centers are broadening the scope of their services, new concepts of organization and use of community resources are urgently needed.

INSTITUTIONAL CARE of long-term patients involves, to some degree, the entire complex of hospitals and related health facilities. More specifically, facilities for long-term care include chronic disease units of general hospitals, chronic disease hospitals, nursing homes, homes for the aged, mental and tuberculosis hospitals, and rehabilitation facilities. (See appendix D, Glossary of Terms, p. 80.) While precise knowledge of the extent to which long-term care is being provided nationally is lacking, data currently available by geographic areas indicate that there are wide variations in the quality and quantity of long-term care facilities.

General Hospitals

Most general hospitals do not provide specialized accommodations and services for the chronically ill. However, National Health Sur

vey data indicate that during 1958-60 more than one-fourth of the total hospital days for patients discharged from short-term general hospitals represented stays exceeding one month. (See table 7, appendix A.)

In the absence of an organized treatment program for long-term patients, their special needs are likely to go unmet in an institution with services geared primarily to care for the acutely ill. As a result of the rapid growth of this segment of the hospital population and of advances in medical techniques, an increasing number of general hospitals have established specialized units for the treatment of the chronically ill. Some have developed nursing home facilities for extended care as a component of the hospital's total service. These developments stem partly from recognition of the advantages to chronic patients of a planned program with ready access to organized medical

services and from an awareness of the economic advantages of specialized treatment units. Additional impetus has resulted from the greater availability of financial assistance from Federal and other sources for the construction of such units.

Chronic Disease Hospitals

Specialized hospitals for the treatment of chronic illness have long been accepted as a part of the pattern of long-term care. In addition to providing an organized medical staff and the definitive diagnostic and treatment procedures otherwise available only in the general hospital, these facilities offer continuing care and such additional services as physical and occupational therapy, social services, and recreational activities.

Many institutions designated as chronic disease hospitals have evolved, by addition of needed services over the years, from facilities originally intended for nursing and personal care. The resulting variation among facilities, in terms of the availability and nature of services, and differences in terminology give rise to problems in classification. However, data collected by the American Hospital Association indicate that, in 1961, there were 321 long-term general and special hospitals in this country providing approximately 71,000 beds. (See table 5, appendix A.) Increasing interest in developing services for long-term patients has resulted in efforts to define the unique functions of the specialized hospital and the nursing home, as well as the appropriate relationships which should be developed between general hospitals and other facilities for long-term care.

Nursing Homes and Homes for the Aged

During the past three decades, long-term facilities, called nursing homes, convalescent homes, homes for the aged, boarding care homes for aged persons, county homes, and the like,

have become a significant part of the complex of medical care resources available for the longterm patient. As a result of historical development and common usage, these terms frequently connote type of ownership rather than the nature of the services provided. Some of these facilities provide only room and board with a minimum of supportive services, while others offer comprehensive services, including medical and skilled nursing care, rehabilitation, dental care, and social casework and group-work services. All of these facilities, however, are characterized by the fact that they predominantly serve aged persons and, to a varying extent, meet the social as well as medical needs of the residents or patients. Currently, only a small proportion of these facilities are affiliated with general hospitals.

An inventory of nursing homes and related types of facilities, conducted in 1961 by the Public Health Service,' shows a national total of about 23,000 homes with 592,800 beds, of which 9,700 homes with 338,700 beds provide skilled nursing care. (See table 8, appendix A.) Although nearly 9 out of 10 (87 percent) of the homes offering skilled nursing care are owned by proprietary interests, these homes provide only about 7 out of 10 of the beds.

Mental and Tuberculosis Hospitals

Institutions for long-term care of patients with mental illness, mental retardation, or tuberculosis have, for the most part, developed as independent, geographically isolated facilities, primarily under State or local governmental auspices. Changing concepts of diagnosis, treatment, and care of mental patients, particularly of the older person with complicated medical conditions, have stimulated efforts to revaluate the responsibility of State and local government for providing needed facilities and

'U.S. Department of Health, Education, and Welfare, Public Health Service, 1961 Inventory of Nursing Homes and Related Facilities, Division of Hospital and Medical Facilities. (In process.)

care. As a corollary, present concepts of utilization of mental hospitals are being reexamined. Increasing emphasis is being placed upon return of selected mental patients to the community, where needed care may be provided in a more appropriate setting such as specialized nursing homes, halfway houses, day centers, night hospitals, or in a home environment.

The decline during the past decade in the number of tuberculosis hospital beds in this country may be ascribed principally to the advent of new chemotherapeutic techniques and the consequent reduction in need for extended institutional care. Resulting low occupancy rates have caused closure of a number of facilities, with complete or partial conversion of others to care for other types of patients. Many tuberculosis facilities have been converted to nursing homes and, in fewer instances, to use as chronic or mental hospitals or county infirmaries.

Rehabilitation Centers

The number of rehabilitation centers providing facilities and services for the restoration and retraining of the physically and mentally disabled has grown rapidly since World War II. These facilities are being used increasingly for the chronically ill, both for the restoration of function and the prevention and control of disability. Hill-Burton State plans show that some 200 rehabilitation centers provide comprehensive, coordinated services-medical, psychological, social, and vocational-for the longterm or permanently disabled. Of these, about 170 provide services for multiple disabilities while the remainder are organized to treat only a single disability. These centers usually serve a large geographic area, and a majority of those providing extensive rehabilitation programs are located in or adjacent to the larger cities. A significant number of these centers are integral parts of large general hospitals.

HOME HEALTH services should be an integral part of the area wide planning agency's program. Depending on the patient's needs, these services may range from the single service of nursing care under medical supervision to a complex network of coordinated services concerned with the total medical, nursing, restorative, and psychological needs of the patient. The potential value of these services is demonstrated by the following:

Recent studies of community need show that most of the chronically ill aged live in their own homes and receive either no health services or totally inadequate care.

Analyses of general hospital utilization show that from 20 to 30 percent of the extended-stay patients have been retained because of social rather than medical reasons.

Surveys of nursing homes show that many patients do not need the continuous nursing

services of the facility and could be adequately cared for in a home setting elsewhere if some type of nursing and related care were available.

Though care of the sick at home by the physician was the original basis of medical practice, a new dimension has been added in recent years. To utilize current knowledge in the treatment of long-term patients-whether in the home or in the hospital-the physician rarely serves as a self-sufficient entity. Today he frequently needs the help of such paramedical personnel as nurses, physical, occupational and speech therapists, nutritionists, and social workers. Adequate provision of these healthrelated services in the home requires that essential resources be developed within the community and that physicians become better oriented to working with these specialists in a home setting.

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Coordinated Home Care Programs

In some communities, plans to provide comprehensive care to patients in the home are evolving. These programs, directed at coordination of home care services, are characterized by central administration and coordination of planning, evaluation, and followup procedures to provide physician-directed medical, nursing, social, and related services to selected patients at home. Despite awareness of the need for such programs, their development has been relatively slow. In 1960, only 30 cities had 45 coordinated home care programs. For the most part, these are administered by hospitals. Public health departments and visiting nurse associations are the focal points of administration for a few.

Nursing Care of the Sick at Home

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The availability of nursing services for patients in their homes, regardless of age, cause of disability, or financial ability, depends to a great extent on the readiness of community agencies to offer this type of service. A 1961 Public Health Service study showed that 70 percent of all cities with a 1960 population of 25,000 and over (470 out of 676 cities) had at least one agency that provides "nursing care of the sick at home as one of its publicized objectives and offers service to all types of patients and on a continuing basis as needed." Most of these programs (80 percent) were provided by visiting nurse associations. Sponsors of the remainder were either official health agencies or a combination of agencies.

While available statistics do not indicate the extent to which these programs meet existing needs, the extent of coverage is limited by shortage of personnel and inadequate financial support. No data are currently available on the number of home nursing programs in communities of less than 25,000 population.

Homemaker Services and Foster Home Placement

There is general agreement that expansion of programs of homemaker services, home aid, and foster home placement would help to prevent or postpone institutionalization of many patients, or enable them to return to a home setting from hospitals, nursing homes or other institutions. Eligibility in most programs providing these services is limited primarily to low income families with children, and to aged, chronically ill, or disabled persons.

Despite widespread interest in the use of homemaker services for the chronically ill, there is a serious shortage of such services. According to a 1961 survey, more than 200 agencies were providing homemaker services in 40 States, the District of Columbia, and Puerto Rico. These agencies employed nearly 2,700 homemakers and cared for approximately 5,500 families during 1 month of 1961.

Foster home placement is being utilized by some institutions and community help and social agencies for those chronically ill persons who no longer require care in an institutional setting but do not have a suitable home. Most effective use of this type of arrangement requires close coordination of the services of the foster home placement agency, the hospitals, the physicians, and the employment, educational, and rehabilitation agencies. The number of programs currently in operation is not known, but there is general agreement that it is grossly inadequate to meet existing needs.

Supportive Services

The homebound chronically ill patient may require one or more of a broad range of supportive services. Some examples are social services, nutritional guidance or food service, physical therapy, occupational therapy, speech therapy, dental care, equipment and appliance loan service, pharmaceutical service, laboratory

and X-ray service, and vocational education.

In many communities, well-organized programs of social services provide major benefits to the chronically ill individual and his family. Social workers may provide guidance and aid in connection with financial problems, securing medical supplies and appliances, work adjustment difficulties, and living arrangements. In addition, they offer direct personal service and participate in evaluating personal relationships and physical and social environment in order to assist the patient and his family in adjusting to the implications of illness or disability.

Because of the importance of dietary treatment in chronic conditions, many patients are

under medical direction to continue on special diets after discharge from medical care facilities. Dietary consultation in the home is being increasingly utilized to provide vitally needed guidance to the patient and/or family members. Also, programs known as "Meals on Wheels" are being developed to provide hot meals regularly to the chronically ill and aged who are unable to leave their homes or to prepare adequate meals for themselves. Currently there are 26 known nonprofit Meals-on-Wheels programs, with the greatest concentration in the New York and Chicago areas. They serve a total of about 750 homebound persons per day, averaging about 25 to 30 persons per program.

EXISTING PATTERNS or facilities and services in most communities show serious imbalances in both availability and quality of care. Because of the absence of an adequate financial basis for operation, community hospitals and other voluntary agencies have, for the most part, been discouraged from developing needed facilities and programs for long-term patients. Those organizations and individuals who have assumed responsibility for service in this health care area have been forced to fit the services they could offer to the availability of financing.

Many institutions are organized to provide only limited programs of service. Admission of residents or patients is restricted to specific categories. The unavailability within the facility of resources capable of dealing with a variety of patient needs results either in the transfer of a patient with changed needs to another facility, or in the retention of the patient in a facility no longer appropriate to his needs.

Little attempt has been made to develop desirable functional relationships among the various facilities and agencies involved in programing, providing, and paying for services. This, in turn, has hindered the development of effective programs designed to make appro

priate services available in accordance with the patient's changing needs.

Because of the lack of adequate controls over programing and construction, certain types of facilities have been overbuilt, with resulting unnecessary duplication of services and uneconomic use of community resources. These developments, coupled with related problems of unsuitable location, lack of access to needed professional competencies and skills, and consequent gaps in service, have inhibited the development of a balanced, comprehensive program of services for the area.

In many States, low licensure standards and lax enforcement procedures have permitted the establishment or continued operation of institutions which do not meet the structural and staffing requirements for high quality service. Utilization by welfare agencies of such substandard facilities, and in some instances of unlicensed facilities, is both detrimental to the physical welfare of the patient and wasteful of the community's economic resources.

Quality of care in long-term facilities suffers from lack of adequately trained personnel. In many instances, inadequate patterns of financing preclude the employment of qualified