period of 10 years of operation, chronic disease hospitals as a group exceed the age of the other facilities, which are predominantly of more recent origin. The average proprietary nursing home in the 5 States had been in existence for 4 years; the average nonproprietary nursing home, 7 years; and the average domiciliary care home, 5 years. None of the hospitals included in the survey had been in operation less than 2 years. But about one-eighth of the nonproprietary nursing homes and as many as three-tenths of the proprietary nursing homes and domiciliary care homes were established within the 2 years preceding the study. Rate of Occupancy. The overall rate of occupancy of the various facilities studied does not vary substantially. At the time of the survey, 86 percent of the beds in the chronic disease hospitals and proprietary nursing homes were occupied. The other types of homes had a slightly higher percentage of beds occupied, 90 percent in the nonproprietary nursing homes and 88 percent in the domiciliary care homes. In the individual study States, occupancy of chronic disease hospitals varied from about three-fourths of the beds to nearly full occupancy: Rhode Island Maryland V. Nursing Homes in Perspective The nursing home is not a homogeneous type of institution. Nursing homes cannot be described entirely fairly with precise statistical statements. Such statements are made in this report to represent average situations or ranges of differences, but their object is not precision as such; it is rather to distill out of the arrays of data a fair general sense of what nursing homes are about. This much of a general sense has served the Commission on Chronic Illness and the Public Health Service in their appointed tasks, and it is hoped that it will serve others as well. This study was undertaken to help develop a broad understanding of the role of establishments known as nursing homes. It focused on (a) what patients in nursing homes are like, and (b) what type of care they are receiving. Thirteen States in various parts of the country joined the Commission on Chronic Illness and the Public Health Service in surveying existing nursing homes to gain a better understanding of the function of these homes. Interest was centered on proprietary nursing homes, which have increased so rapidly in numbers in the last two decades. In order to perceive in better perspective the role of this relatively new Average percent occupancy 77 83 87 91 96 and now quite numerous type of facility, the survey to a partial extent also encompassed some similar types of long-term care facilities. These included voluntary and public nursing homes, domiciliary care homes, and chronic disease hospitals. On the basis of the survey findings, the several types of institutions can be made out to be either quite similar or quite different from each other, depending upon the emphasis one desires to give. There are, in fact, both similarities and differences among the types of institutions; differences sometimes of small degree and sometimes large enough to suggest basic contrasts. Thus one can say altogether validly that all of these types of facilities-proprietary and nonproprietary nursing homes, domiciliary care homes, and chronic disease hospitals have an important characteristic in common: they all serve older people predominantly. Nevertheless, significant implications are suggested by the differences contained within this sameness. Figure 12 tells the story by comparing the findings of five States which surveyed all four types of facilities. A large majority of the people in each type of institution are past 65 years of age. But, whereas in proprietary nursing homes, only 1 patient in 10 is less than 65 Figure 12. Age of patients in nursing homes and similar long-term care facilities, 5 States. years old, in the chronic disease hospitals 1 patient in 3 is below 65 years of age. In chronic disease hospitals, in fact, 1 patient in 10 is less than 45 years old. In the other institutions, a negligible number (between 1 and 3 percent) are that young. The makeup of the domiciliary care homes and the proprietary nursing homes is virtually identical with respect to age of their residents. Patients in non proprietary nursing homes are midway between the extremely aged group in domiciliary care homes and proprietary nursing homes on the one hand and the rather younger population in chronic disease hospitals, on the other. About two-thirds of the patients in proprietary nursing homes are women. Domiciliary care homes show the same predominance of women. The nonproprietary nursing homes, however, average about an equal number of men and women. The pattern reverses completely in the chronic disease hospitals, where men outnumber women. As their age would suggest, large proportions of the patients in each type of facility are widowed. In the proprietary nursing homes, almost 2 out of every 3 patients have lost their spouses. Even in the chronic disease hospitals, where the least aged group is found, as many as 2 out of 5 are widowed. The number of nonwhite patients in all types of homes is negligible, even in relation to their proportion in the general population. Only in the chronic disease hospitals -at least within 4 of the 5 States reporting for hospitals-do nonwhites more nearly approach or even exceed, their proportion of the general population. Proprietary nursing homes have not only a very aged group of patients, but an ex tensively disabled one as well. While all 13 study States surveyed proprietary nursing homes, the 5 States which covered the other three types of facilities as well serve to point up similarities and contrasts among the types of patients served, this time with regard to disability (fig. 13). Proprietary nursing homes and chronic disease hospitals serve the groups who are most disabled; voluntary and public nursing homes, those who are, in general, less disabled; and domiciliary care homes, the least disabled group. In all categories, however, if one wishes to emphasize similarity, there is, as figure 13 shows, an imposing extent of disability. A wide variety of chronic diseases characterize the patients in all the facilities. Cardiovascular conditions are the most common, with heart disease and hemiplegia large elements among these. Found among the patients in each of the types of institutions are such chronic diseases as arthritis, neuromuscular disturbances, diabetes, neoplasms, and mental disorders; and even fractures take on a chronic character as old age and the severity of hip fractures join to incapacitate so many of the patients with fractures for prolonged periods. The selected diagnostic information given in figure 14 suggests some distinctions among the several kinds of facilities. The proportion of hemiplegics in each type of institution forms a declining array starting with chronic disease hospitals and followed by proprietary nursing homes. Patients in chronic disease hospitals also show the largest proportions with a primary diagnosis of heart disease and of neoplasms. Persons with hip fractures, however, make up a distinctly larger proportion of proprietary nursing home patients than of any of the other institutional groups. The extent to which intensive medical supervision and active nursing service are demanded by the nature and stage of the patient's condition certainly must play a large part in the choice of type of facility for care of patients with Figure 14. Primary diagnoses of patients in nursing homes and similar long-term care facilities, 5 States. conditions within a given diagnostic category as well as among different categories of diseases. A telling fact about diagnostic reporting is brought out by the "senility" figures, as figure 14 demonstrates. The larger number of patients with a reported primary diagnosis of senility in the various types of homes than in the chronic disease hospitals may of course be partly attributed to the somewhat older age of the patients found in the homes. However, the range of variation also undoubtedly reflects differences among the facilities in access to true medical diagnoses of patients. Proprietary nursing homes seem to a startling extent to lack definitive medical information on their patients. Substantiating the comparative disability pattern, a relatively high proportion of the patients in proprietary nursing homes and chronic disease hospitals were judged by the persons caring for them actually to require a type of care which could not ordinarily be given in the patient's own home. In domiciliary care homes, as we would expect, about one-half of the patients were adjudged to need mainly boarding care. The nonproprietary nursing home patients, however, are once again found between the two extremes -two-fifths were reported as absolutely needing the institutional setting for their care and one-fourth required only a boarding home type of care. These judgments as to the needs of the individual patients are reflected in the types and extent of services received in the several categories of facilities. Relative to the other facilities, a higher proportion of the patients in proprietary nursing homes and chronic disease hospitals receive various nursing and personal services. Nonproprietary nursing home patients rank next in extent of services received, and the residents of domiciliary care homes receive the least amount of care. This gradient holds regardless of whether the particular service is of a nursing or personal service nature. A distinguishing characteristic of chronic disease hospitals emerges when we consider the attendance by physicians. All but a small proportion of the patients in chronic disease hospitals had been seen by a physi cian within 30 days preceding the survey. This is far from true in nursing homes, where somewhat more than half of the patients had been seen that recently. A not inconsiderable number of nursing home patients are medically unattended for very long periods of time; approximately 15 percent had not been seen by a physician for 6 months or more. Although no attempt was made to obtain data on the total length of time spent in the facilities surveyed, information was secured on the length of stay up to the date of the survey. The average patient in a proprietary nursing home had spent about a year in the present home-the shortest length of stay observed among the four types of establishments. Patients in chronic disease hospitals and nonproprietary nursing homes had been in these institutions for somewhat longer periods, and residents of domiciliary care homes had an average stay of more than 2 years. These long periods of care naturally impose a severe financial drain on many patients and their families. It is, therefore, quite natural to find that public welfare funds are supporting roughly one-half of the patients in proprietary nursing homes. Similarly large proportions are receiving such assistance in the other types of homes. Public assistance does not play quite as large a role among patients in the chronic disease hospitals surveyed. However, other resources voluntary agencies, including those operating the hospital, and public auspices other than public assistance funds-which are little involved in the homes, finance the care of almost half of the patients in chronic disease hospitals. Average charges vary according to the different levels of services provided. The average (median) monthly charge of about $150 in proprietary nursing homes is therefore exceeded only by the $185 average monthly charge in the chronic disease hospitals studied. Charges in the other types of homes are in the neighborhood of $70$105 per month. The average amounts paid by self-financing patients are higher in all categories of homes than amounts paid from public welfare funds. |