18. Planning for long-term care facilities and services should be based on patient needs rather than on the availability of funds.

The planning, organization, and development of facilities and services for long-term care should not be influenced by sources of funds or restrictions which may be attached to available methods of financing construction or operation. In the interest of optimum patient care and economic use of available resources, proposals for unnecessary or inappropriate types of facilities or services should be actively opposed. If restrictions applied by financing agencies, either public or private, have an adverse influence on planning for facilities or services, the planning agency should undertake action to modify or remove these restrictions, or it should develop new financing methods. Patient needs for service should be the prime determinant in the planning, organization, and development of facilities for long-term treatment and care.

19. Programs of research and evaluation should be established as a guide for continuing development of the planning process.

To assess the effectiveness of planning and implementation, the areawide planning agency

This problem is discussed in Areawide Planning for Hospitals and Related Health Facilities. (Item 16 in appendix C, Selected Bibliography.)

should promote the development of continuing programs of research and evaluation of selected factors affecting the provision of long-term services within the planning area. Examples of pertinent areas of study include: numbers and types of patients served, patterns of treatment, patient placement, patterns of referral, length of stay, effectiveness of staff utilization, methods of payment and use of funds, and the effectiveness of interservice relationships. The reliability of research results as bases for future planing action will depend upon the extent and quality of cooperation provided by the participating institutions, organizations, and agencies.

20. A greater proportion of funds raised through community fund-raising campaigns should be allocated to long-term care facilities and services.

In general, programs of long-term treatment and care receive less than their proportionate share of the funds provided for health facilities through fund-raising campaigns. The increasing demand for long-term services and the resulting need for capital and operational funds make it essential that financial assistance for these programs be sought from all available sources. Demonstration of the relative need for long-term care facilities and services, in comparision to other programs of health care, should provide a basis for requesting increased allocations from public fund-raising drives.

REALISTIC PLANNING for long-term care will depend upon the quality of leadership exercised and the accurate identification of the various factors that may affect the proposed program. Relevant legislation and regulations, current economic trends, and social attitudes toward long-term illness should be assessed to determine their influence upon planning recommendations and their projected development. In particular, factors that might impede the reali

zation of the planned program must be indentified and analyzed so that appropriate measures can be initiated to minimize or offset their influence.

The general areas requiring attention include: existing and proposed methods of financing construction and operation; availability of qualified staff; adequacy of organizational, administrative, and regulatory procedures; and the possible influence of prevailing social and cultural attitudes within the area.

THE ESTABLISHMENT and operation of an adequate system of facilities and services for the long-term patient is not inexpensive. Costs of treatment and care of the chronically ill and disabled vary widely, depending upon the nature and severity of the illness or disability and on the type of care being provided. Differences between the costs of caring for the acutely ill and for the long-term patient have been found frequently to reflect differences in quality of the services furnished. Per patient expenditure for long-term care may well exceed the comparable cost for the short-term patient, particularly if high quality care is provided. Efforts to expand or improve the services provided by facilities for long-term patients will be directly influenced by the extent to which new or improved patterns of financing can be developed, both for initial costs of needed construction and for continuing costs of operation.

Availability of Capital Financing

In programing additional construction, the planning group must consider the possible

sources of capital funds and the capability and willingness of prospective sponsors to provide the type and quality of service for which present and potential need has beeen determined.

Potential sources of funds for capital construction include tax revenues, funds received through contributions or bequests, and private investment. Identification of the source from which funds may be anticipated for specific construction projects will depend primarily upon the nature and sponsorship of the planned construction and on its proposed utilization. Certain types of facilities, for example, have traditionally been constructed and supported by public funds; proposed construction or expansion of these facilities must accordingly involve consideration of the availability of such funds. Similarly, the availability of funds for remodeling or expanding existing facilities will be influenced by the nature of the present sponsorship and the avenues of financial support which have already been established.

A number of States have developed programs of direct grant assistance to qualified sponsors for construction of needed long-term

facilities. The possibility of involving other levels of government in these programs as means of stimulating needed construction should not be overlooked. State, county, and local governments, through their programs of public assistance and aid to the aged and disabled, are already heavily involved in financing the care and treatment of the long-term patient.

The Hill-Burton program has, since its Inception in 1946, made grant funds available through State agencies for the construction of general, chronic disease, mental, and tuberculosis hospitals. Since 1954, similar funds have been provided for constructing facilities offering skilled nursing care. Integration of local planning into the statewide plan will ensure that Hill-Burton funds will be allocated to projects programed and approved by the local planning group.

Additional sources of capital financing include fundraising campaigns, charitable organizations, foundations, programs of organized philanthropy, and individual bequests. Heretofore, funds provided for health facility construction have been utilized principally by general hospitals. The increasing importance of long-term illness makes it essential that a larger proportion of the funds from these sources be allocated to facilities for the treatment and care of long-term patients.

Finally, funds available for private investment, if directed into facilities providing high quality of care, can materially assist in achieving areawide goals for long-term care. Federal assistance for constructing privately owned nursing homes is available through the Federal Housing Administration in the form of mortgage insurance and through the Small Business Administration as a direct or participating loan. The Federal Housing Administration also administers a mortgage insurance program for rental or cooperative housing and related facilities for the elderly. Related facilities may include infirmaries or other inpatient or outpatient health facilities.1

See Major Federal Aid Programs for Community Hospitals. (Item 4 in appendix C, Selected Bibliography.)

Cost of Maintenance and Operation

Although capital construction funds are important, adequate financial support for maintaining and operating facilities for longterm care is of equal or greater importance. No other single factor has as great an influence on the quality of institutional patient care.

Revenue for the maintaining and operating of long-term care facilities has heretofore been obtained primarily from direct patient payments and through allocation of tax funds. In recent years some Blue Cross plans have gained experience in covering services beyond those in general hospitals. Some plans are covering benefit days other than for inpatient care in lieu of a lesser number of unused hospital days, thereby encouraging appropriate use of facilities and programs. A growing number of plans are also offering benefits to those over age 65 in skilled nursing facilities, as well as in programs of visiting nurse services. Some commercial insurance companies provide insurance benefits beyond hospital care under major medical programs.

Despite progress in recent years, rates of payment by State and local welfare and public assistance programs in most instances do not cover the cost of adequate care for the indigent or medically indigent chronically ill patients who are their responsibility. In addition, failure to provide for long-term supportive services as well as short-term care has adversely affected the efficient utilization of existing facilities, and has deterred development of needed additional facilities. The planning agency, in cooperation with other groups, should urge State and local governments to appropriate sufficient funds to enable public agencies purchasing care and those operating longterm facilities, to make available the quality of care required. As a supplemental approach, the planning group should explore the feasibility of State, county, or local subsidies to exist

⚫Commission on Chronic Illness, Chronic Illness in the United States, Volume II, "Care of the Long-Term Patient," p. 432. (Item 1 in appendix C, Selected Bibliography.)

ing acceptable institutions as an incentive to expand their facilities and services.

Recent and proposed changes in Federal legislation which would provide assistance in financing medical care of the aged should be carefully considered by the local planning

group. Evaluation of the potential impact of these measures on the effective demand for services and on the need for long-term care facilities and programs within the area may influence planning objectives and the procedures proposed for their implementation.

THE SCARCITY of qualified personnel acts as a deterrent to the development of needed facilities and services. Although personnel shortages exist in virtually every field of health endeavor, they are particularly pronounced in the field of long-term care. The area wide planning agency should, therefore, be actively concerned with programs of recruitment, training, standards, utilization, and personnel policies within its area.

The role of the planning agency in personnel programs within its area will depend greatly on the local situation. In all cases, the agency should participate fully with other organizations and agencies, encouraging, stimulating, coordinating, or lending needed assistance. Where no programs exist, the agency should initiate them, in cooperation with other interested groups. In many instances, the agency may serve as a factfinding body. Some of the problems that arise in this area, and some approaches to their solution, are discussed in the following paragraphs.

Heretofore, professional specialization in treating and caring for the chronically ill and disabled has been considered less challenging and less rewarding than work with the acutely ill. Relatively larger proportions of qualified personnel have accordingly been attracted to other areas of health service. This lack of professional interest, compounded by use of available health competencies at less than peak effectiveness, presents a major obstacle to attempts to develop a comprehensive program of long-term services.

Improvement in personnel policies and working conditions will strengthen the competitive position of long-term care facilities, and

provide a firmer basis for an active recruitment program. Additional measures to alleviate shortages include: review and reassignment of functions within a facility to make more effective use of trained personnel; joint utilization of specialized personnel by two or more facilities or agencies; and the development of inservice training programs. The possibility of more extensive use of qualified part-time or semiretired personnel, volunteers, technicians, and aides to supplement the services of professional personnel, should not be overlooked. Moreover, the development of facility-based programs for training the family to care for the patient at home would assist in conserving skilled manpower. Selection of the particular measures to be used in a given local situation will depend upon the types of staff skills needed, the availability of qualified personnel within the planning area, and the probability of a productive response to recruitment efforts.

In addition to the shortage of skilled personnel, the related problem of standards for the various staff competencies should be reviewed. In the interest of improving patient care, those standards that are not commensurate with the desired quality of care should be recommended for revision, and proposals should be made for reassignment of present staff to functions more appropriate to their skills.

Finally, efforts should be made to increase the pool of available health manpower through programs of professional education and inservice training, and to induce a greater proportion of trained personnel to enter the field of longterm care. Current programs of medical, nursing, and social work education should be reoriented to place increased emphasis on the

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