use of services, and less than optimum patient care. Problems of patient management become magnified, because of the loss of continuity of physician services and the difficulty of followup by related service personnel. In the interest of more effective treatment and continuity of patient care, the various responsibilities for patient care must be identified and efforts made to coordinate the related activities into a comprehensive pattern of services more closely attuned to the patient's total needs. The area wide planning agency provides the logical mechanism through which this can be accomplished.

Low Licensure Requirements

In a number of States, failure to establish or to enforce adequate standards of construction and care has encouraged the development of nursing care facilities providing a low quality of service. Preemption by these institutions of the existing demand for services has, in some areas, inhibited the development of more adequate facilities. A favorable climate for improvement of care and services should be provided by raising requirements and by developing more effective procedures for their enforcement.

Primary responsibility for establishing and en forcing standards for patient safety and adequacy of basic services in these facilities rests with the State licensing authority, which in most instances is the State health department. This authority should be stimulated to review licensure requirements and the effectiveness of enforcement procedures. Where other agencies of State government are involved in the licensing process, recommended procedures for improvement should be developed on a cooperative basis. In this connection, special consideration should be given to the adequacy of structures that have been converted from other uses. minimum, the area wide planning agency should strongly recommend and work toward gradual elimination of all hospital and nursing facilities located in converted dwellings.

As a

In some States, power to impose additional licensing requirements is vested in agencies of

county and municipal government. The planning agency should enlist the active support and cooperation of these groups to assure a more effective inspection and enforcement program.

Inadequate Service Standards

In the interest of improved patient service, appropriate standards of performance and of program adequacy are needed. In many facilities and programs, inadequate consideration has been given to such factors as the availability and use of consultative and rehabilitative services, adequacy of staff training and education, maintenance of appropriate patient records, and periodic patient evaluation. Present standards of patient care which may be considered for adoption by the planning agency, in whole or in part, include the registration program of the Joint Commission on Accreditation of Hospitals; the standards of medical and nursing care approved by the American Medical Association, the American Nursing Home Association, and the American Hospital Association; the standards of the American Nurses Association; and those adopted by the National Social Welfare Assembly.3

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Lack of Continuity of
Patient Information

The changing needs of the long-term patient may occasionally require his transfer from one facility to another more appropriate to his changed status. At these times, the problems of proper diagnosis and development of suitable plans for care would be materially lessened if information developed in earlier phases of treatment were made available, under appropriate safeguards, to the receiving facility of service.

Ideally, this information should be furnished in advance of actual patient transfer. As a minimum, case summaries should be forwarded when the patient is transferred to another facility or service. The area wide planning agency could stimulate and assist in the development of a standard referral form to

expidite the transfer of essential information between facilities.

Zoning Problems

Zoning regulations in some areas may present barriers to proposed construction of needed facilities at locations which would be most advantageous in terms of proximity to anticipated patient sources or to related medical or other long-term facilities. In other instances, absence of adequate zoning restrictions may permit eventual deterioration of an area in which facility construction is being planned. Such factors as zoning laws, trends in land use, and land costs should be carefully considered by the areawide planning agency in terms of their present and future impact on planning objectives.

LACK OF WIDESPREAD public understanding of the magnitude and urgency of the need for long-term care facilities and services presents a major problem to the development of effective measures to meet this need. There is, moreover, little understanding of the necessary components of good programs of chronic care. Extensive programs of community education are required to stimulate public awareness of the growing problems of long-term care and to develop a sense of community responsibility for assuring adequate, properly staffed facilities and services for long-term patients.

The need for community education is especially evident in the field of care and support of the aged and infirm. The specialized nature of the services required by this group and the lack of appropriately organized programs of service are only beginning to be recognized. The area wide planning agency should evaluate public attitudes toward the problems of chronic illness and disability in order to successfully implement its long-term care program. If it fails to stimulate public interest in and recognition of the needs of long-term patients, its attempts to attract public support will be seriously hampered.

BECAUSE OF ADMINISTRATIVE and financing problems, hospital administrators and boards of trustees have, for the most part, shown little interest in establishing needed facilities and services for patients with long-term illness.

Organizations and individuals currently involved in providing long-term services are reluctant to accept proposed changes affecting the organization or administration of their programs. Physicians and persons in the other

health professions tend to consider care of longterm patients less interesting and less rewarding than work in other fields of health endeavor, and have been diverted to areas of professional interest considered more attractive.

Positive action by the planning agency to reorient these attitudes of professional groups

is essential if a coordinated plan for high quality services is to be achieved. Because of their key positions in the management of patients, physicians and hospital administrators, in particular, must be stimulated to assume major roles in planning and organizing long-term services into a comprehensive pattern of care.

THE ORGANIZATION for planning must be suitable to the planning function to be performed. It must have the authority and capability to achieve its objectives. Planning for long-term facilities should proceed hand in hand with planning for short-term acute illness facilities as part of the total area wide planning activity. Because such problems do not exist to the same degree in all communities and areas throughout the country, they must be examined and resolved by local initiative through the development of short- and long-range planning objectives geared to the needs of the area.

A major factor in assuring the development of coordinated planning objectives which will be supported by the community is adherence to sound principles in organizing and designating membership on the governing board of an area wide planning agency. Basic principles relating to the organization and function of such an agency are set forth in the joint report of the American Hospital Association and the Public Health Service, "Areawide Planning for Hospitals and Related Health Facilities." Foremost is the principle that the area wide planning agency should have a governing body comprising members drawn from the top echelon of lay and professional community leadership. The agency should be organized on a permanent basis, with sufficient staff and operating funds so that it can adequately discharge its responsibility to the community.

Since other planning groups in the fields of patient care, health, welfare, and physical

planning may already exist in the area, it is important to correlate the functions of an areawide planning agency for patient care facilities with the functions of these other groups and to recognize their spheres of interest and concern. Such correlation may take time, but upon its success will rest the future acceptance by people and groups already involved in serving the longterm patient. Through this correlation of effort, the area wide planning agency may gain access to pertinent information and to the services of staff members of these groups whose special skills will be invaluable to the planning process. Since the planning determinations will be sufficiently complex and widespread to create possible program and jurisdictional misunderstandings, the relationships that are worked out should be set forth in written agreements for formal adoption by governing boards of each collaborating agency. The understanding and endorsement of these planning determinations by professional organizations and societies concerned with the problem will help to achieve community acceptance.

Close cooperation should also be developed with State and local government agencies responsible for health, welfare and licensing. In particular, collaboration should be developed with the State Hill-Burton agency, which is charged by statute with the preparation of an annual State Plan for both long- and short-term patient care facilities. The area wide planning agency should be formally recognized by the State Hill-Burton agency.

mittee composed of representatives of collaborating planning agencies. The individuals selected should be qualified in procedures for data collection, tabulation, and analysis, and in facilitating access to required sources of information.

As the first step in collecting basic data, current studies and surveys of long-term patient