Component plan. Long term care : swing-beds

COMPONENT PLAN: LONG TERM CARE: SWING-BEDS
Georgia State Health Policy Council and the
Georgia State Health Planning Agency 4 Executive Park Drive, N.E. Suite 2100 Atlanta, Georgia 30329
July 1989

Joe Frank Harris
GOVERNOR

STATE OF GEORGIA
OFFICE OF THE GOVERNOR ATLANTA 30334

August 22, 1989

W. Douglas Skelton, M.D. Chairman State Health Policy Council Suite 2100 4 Executive Park East, N.E. Atlanta, Georgia 30329
Dear Doug:
In accordance with your request and with the authority granted me in Code Section 31-6-20 of the Official Code of Georgia Annotated, I have reviewed the Component Plan for Long Term Care: Swing Beds and do hereby approve it. I would like to commend the council and the State Health Planning Agency on the time and effort which have gone into the development of this plan.
I am particularly pleased with the open, public participatory process which has been initiated by the council and the agency in the development of both the component plan and the certificate of need rules. If I can be of further assistance on this or any other matter of concern to you, please contact me.
With kindest regards, I remain
~FrsainnkciHarr,is
JFH:mbe

4 Executive Park Drive, N.E. Suite 2100
Atlanta, Georgia 30329 (404) 894-4899
August 3, 1989

STATE OF GEORGIA
HEALTH POLICY COUNCIL

The Honorable Joe Frank Harris, Governor The State of Georgia The State Capitol Atlanta, Georgia 30334 Honorable Sir: It is with great pleasure that the State Health Policy Council transmits to you for your approval this Component Plan:
Long-Term Care: Swing Beds. The Plan is a product of the Council and the State Health Planning Agency, which operate within the authority of Georgia Law 552, Code Title 31, Chapter 6 amended. This Component Plan identifies and addresses issues related to Swing Beds and recommends goals, objectives and system changes to insure a statewide system of cost-effective and efficient care. The Plan is designed to achieve official state health policies relating to access to quality care and cost containment. Th is Pl an has been produced through an open, pub1ic part i ci patory process initiated and monitored by the Policy Council. The Policy Council and the State Agency commend this Plan to you and urge your approval of it. It is believed that the Plan provides a rational basis for the development of needed Swing Beds. Sincerely,
~S~
W. Douglas Skelton, M.D. Chairperson WDS:kr Encl osure

TABLE OF CONTENTS

I. Long-term Care: Swing-beds

1

II. Background

1

III. Application of the SWing-Bed Provision

2

IV. Use Patterns for SWing-Beds

4

V. Conditions for Participation

4

VI. Swing-Beds in Georgia

6

VII. Goals, Objectives and Recommended Actions

8

VIII. Recommended Guidelines for SWing-Bed Facilities

8

IX. Appendices:

15

Appendix A - Swing-bed utilization: 1986 Appendix B - Swing-Beds Approved
July 1983 - December 1988

X. References

18

Note: Numbers in parentheses in the text indicate references.

ii

PREFACE This Component Plan is a product of the Georgia State Health Policy Council and the Georgia State Health Planning Agency which are funded through and operated within the authority of Georgia Law Act 552 and formerly Federal Public Law 93641 and amendments. The purpose of this Plan is to identify and address health issues, and recommend goals, objectives and system changes to achieve official State Health Policies. This Plan has been produced through an open, public participatory process developed and monitored by the 25-member Governor-appointed State Health Policy Council. The Plan, once approved by the Governor, supersedes all related sections of the 1981, 1983 and 1987 editions of the State Health Plan, and any eXisting related Component Plan and is designed to be consistent with the overall State Health Policies. For purposes of the administration and implementation of the Georgia Certificate of Need (CON) Program, criteria and standards for review (as stated in the Rules, Chapter 272-1, 272-2 and 272-3) are derived from this Component Plan. The Rules, which are published separately from the Plan and which undergo a separate public review process, are an official interpretation of any official Component Plans which the review function has the legal authority to implement. The Rules are reviewed by the State Health Policy Council (prior to their adoption) for their consistency with the Plan. The Rules, as a legal document, represent the final authority for all review decisions. Any questions or comments on this Component Plan should be directed to the Planning and Implementation Division of the State Health Planning Agency, 4 Executive Park Drive, N.L, Suite 2100, Atlanta, Georgia 30329; telephone: (404) 320-4829.
iii

I. Long-Term Care: Swing-Beds
The term 'swing-bed' refers to an acute care hospital bed which can be used to provide care to patients who require either acute or long-term care.(I) This use of beds based on documented care needs of the patient allows for continuity of care and less physical and geographic dislocation for the patient. The hospital designates the skill level of nursing care in the swing- bed when the physician determines that the patient is no longer in need of acute care services.
II. Background
In 1973, responding to the decrease in Medicare-certified skilled nursing beds and under-utilization of rural hospital beds, the Health Care Financing Administration (HCFA) funded the Utah Cost Improvement Project (UCIP) as a threeyear demonstration project to test the Viability of providing long-term care in acute care hospital beds. During that period the term 'swing-bed' arose from the use of a hospital bed for both acute and long-term care.(2)
Additional sWing-bed demonstration projects were funded by HCFA in Texas, South Dakota and Iowa for a total of 107 participating hospitals. The HCFA evaluation of the four demonstration projects found the approach to be costeffective. (3) The Omnibus Reconciliation Act of 1980 (PL 96-499) amended Titles XVIII and XIX of the Social Security Act to provide reimbursement for swing-beds in rural hospitals with fewer than 50 beds. On July 20, 1982 rules and regul at ions were issued by the Department of Health and Human Servi ces and amended September 1, 1983.(4)
The provision allowed certain small rural hospitals to use their inpatient facilities to furnish skilled nursing facility services (SNF) to Medicare and Medicaid beneficiaries, and intermediate care facility (ICF) services to Medicaid beneficiaries. The regulations governing Medicare reimbursement for swing-bed hospital services were based on reasonable cost reimbursement principles. The amendment, in response to the prospective payment system, determined that the
1

swing-bed payment for SNF-type services would be reimbursed as an ancillary service on a cost basis, but that the carve-out method would no longer apply, since under prospective payments, reimbursement for inpatient hospital services is no longer based on cost.(5)
Additionally in 1981, the Robert Wood Johnson Foundation funded the Rural Hospital Program of Extended Care Services to foster the growth of sWing-bed care in selected rural areas. Five states, involving 26 hospitals, were selected and funded to administer the model programs.(6)
The 1987 Omnibus Budget Reconciliation Act (OBRA) amended Section 1883 of the Social Security Act to expand hospital participation to rural hospitals of 51-99 beds (i.e., fewer than 100 beds) effective April, 1988.(21) At the same time, the 1987 OBRA requires that hospitals with 50-99 beds must enter into transfer agreements with each skilled nursing facil ity (SNF) within their geographic area and must transfer any swing-bed patient to an available SNF within 5 weekdays. A complete discussion on these requirements is included in Section V: "Conditions for Participation".
III. Application of the Swing-Bed Provision
The provisions for SWing-beds of small rural hospitals were designed to allow maximum flexibility to provide a needed service. The evaluation studies acknowledge that a continuum of care is necessary to meet patient needs. In rural areas the transition from acute care to long-term care services is sometimes more difficult to accomplish because of the need for geographic transfer of some distance. Swing-beds are one method of meeting individual patient needs as well as community needs for long-term care, while providing flexible utilization of hospital beds in small hospitals where establishing distinct part nursing home services is not feasible.
Because of the relatively small number of beds involved in swing-bed programs, it is unlikely that the usage of swing-beds to provide long-term care services will significantly impact the overall use of nursing homes or home
2

delivered s~~vices. The HCFA evaluation study reports that greater integration and coordination of long-term care services is likely to occur.(7)
The stated intent of the law is to treat 'swing-bed' hospitals similarly to skilled nurstng facilities to assure quality of care for long-term patients. Specifically the Skilled Nursing Facility Requirements which apply are:
a. Patient Rights - establishment and implementation of patient rights policies which address the residential status of the longer-stay patient. b. Rehabilitative services - required to meet SNF standards for specialized rehabilitation services, including physical therapy, occupational therapy, speech pathology and audiology. Services must be under the direction of qualified personnel to bring patients to their highest level of activity, retard deterioration and teach patients to function effectively within any limitations. Services may be offered by in-house personnel or negotiated arrangements if patients are admitted who require rehabilitative care. A specific service is not required unless the hospital admits patients who are assessed by a physician as being in need of such care. c. Dental Services - must be provided by arrangement which includes staff development on oral hygiene policies and practices for the care of patients. d. Social Services - adequate arrangements for identifying and meeting the social and emotional needs of the patient must be available. In-house social services must be delivered by a qualified social worker or a person supervised by a qualified social worker. Referral arrangements must be documented. e. Patient Activities - must be provided by a qualified activity coordinator to create opportunities for long-term patients to continue 1ife tasks and exercise abilities to minimize pathology and prevent disability. f. Discharge Planning - must prOVide an organized discharge planning program to assure continuing care to meet the post discharge needs of the . patient. (8)
3

IV. Use Patterns for Swing-Beds
In the past decade, the practice of swinging beds between various levels of acute and extended care has been evolving. Since the initial demonstration projects involving 107 hospitals in four states, a total of 471 hospitals in 33 states had been approved for participation by the end of 1984. This represents approximately 27% of the hospitals that met the eligibility parameters at that time.(9)
As changes in the entire continuum of long-term care services take place to meet the increasingly elderly population, the feasibility of swing-beds for a given hospital or rural area becomes more difficult to ascertain. Feasibility considerations are based on financial indicators, hospital mission and goals, staff and especially professional support and perceived and actual community need, as well as the physical ability of the hospital to meet the requirements for swing-beds.
V. Conditions for Participation
The Omnibus Budget Reconciliation Act of 1987 amended Section 1883 of the Social Security Act to expand hospital participation in the swing-bed program. Previously, one criterion for participation was that the hospital had to have fewer than 50 beds, exclusive of newborn, ICU, and CCU beds. The statute now allows that, effective April 1988, hospitals can participate in the program if they have fewer than 100 beds. The statute change also prescribed additional conditions for participating hospitals of 50-99 beds. Guidelines for implementation of these changes were issued by Transmittal Numbers 36 and 215 of the Health Care Financing Administration (HCFA). (21) The conditions for participation require that the hospital:
1. Must have a Medicare prOVider agreement; 2. Must have fewer than 100 beds (excluding newborn, intensive and
coronary care unit beds); 3. Must be located in a rural (non-urbanized) region;
4

4. Must obtain a Certificate of Need fo~ the provision of extended care services if required by the State in which it is located;
5. May not have in effect a 24-hour nursing waiver; 6. Must not have had a swing-bed approval that was terminated within the
last two years; and 7. Must meet the SNF Conditions of Participation on patients' rights,
specialized rehabilitation services, dental services, social services, patient activities, and discharge planning.
In addition, hospitals that have 50 - 99 beds and meet the above criteria must also have a policy that when there is an available SNF bed in the geographic region of the hospital, a swing-bed patient must be transferred within 5 weekdays (excluding weekends and holidays) of the availability date unless the patient's physician certifies that the transfer is not medically appropriate. Hospitals must have "availability" agreements with all the SNFs in the geographic region. Geographi c regi on for HCFA swi ng-bed hospital purposes means an area that includes the SNFs with which a hospital has traditionally arranged transfers and all other SNFs within the same proximity (i.e. within a 50 miles radius) to the hospital. In the case of a hospital without existing transfer practices, the geographic region includes all the SNFs within 50 miles of the hospital.(21)
In 1988 the State Health Policy Council (SHPC) appointed a task force to examine the various problems facing Georgia's rural hospitals and to recommend practical solutions. Among the numerous recommendations which were adopted by the SHPC was to increase the maximum size of hospitals eligible to participate in the swing-bed program from under 50 beds to under 100 beds. In addition, the maximum number of swing-beds each hospital may offer was increased from 10 beds to 10 beds or 15% of the facility's total eligible beds, whichever is higher.(22)
Licensing Rules and Regulations for Hospital Nursing Homes must also be met. (Chapter 290-5-6-.21). As of January 1985, full CON review of sWin~-beds was required in 15 states. Expedited review was required in five states, and
5

approval without review in 16 states. Seven states were reviewing their approval procedures and the program is not applicable in seven states.(ll) Medicare approval of a claim for skilled care in swing-beds is subject to the same reimbursement approvals as for any other form of long-term care.

VI. Swing-Beds in Georgia

In 1983, Certificate of Need rules were adopted by the State Health Planning Agency consistent with Department of Health and Human Services regulations. Table 1 shows hospital approvals for swing beds since 1983.

TABLE 1 Hospitals Approved For Swing-Beds in Georgia

Hospital Report Year

Number of Approved Hospitals

1983

4

1984

11

1985

20

1986

28

1988 (Nov.)

37

As shown, as of November 1988, a total of 37 hospitals had been approved

for swing-beds(12). The 37 hospitals approved for swing-beds represent 68.5

percent of the hospitals that were eligible for swing-bed participation prior

to the change allowing participation by hospitals of 50 to 99 beds. Further, of

the 28 hospitals approved for swing-beds by December 1986, nursing home

utilization of swing-beds ranged from 0 to 121%. Specifically, 10 hospitals

reported 0 utilization during that period. Additionally, 10 hospitals reported

utilization of up to 25%, 3 reported 26-50%, 2 reported 51-75%, and 1 reported

utilization of 121%. (See Appendix A).

As a result of the change in

eligibility, it is estimated that approximately 50 additional hospitals might

now be eligible for participation.

6

Appendix B is a map which shows the location of approved sWing-bed hospitals in-Georgia. The hospital reporting the most extensive use credits the success of the swing-bed program to community support, good working relationships between the utilization review staff and the physicians, who have viewed swingbeds as a service to their patients.(13) Often patients occupying swing-beds are awaiting nursing home placement or require short-term convalescent care before returning home. In these situations any charges incurred by the patient and/or Medicare/Medicaid are considerably less than hospital daily acute care charges. Reimbursement approval by the Medicare fiscal intermediary is subject to the same review as other long-term care, and disapproval may make it necessary for the patients to assume the costs. The relatively short length of stay is compatible with the intent of the law.
The success of a swi ng-bed program can be measured on many axes: community service, patient satisfaction, family satisfaction and physician acceptance of involvement in continuing care and rehabilitation. Financial success is relative to the reimbursement rate of Medicare and Medicaid and the financial viability of the facility.(14) Medicaid does not currently reimburse for swing-beds in Georgia. However, the 1989 Georgia legislature approved Medicaid reimbursement for swing-beds. Reimbursement is expected to start in January, 1990.
limited data on swing-bed usage in Georgia made it difficult to assess the impact, potential or actual, on long-term care services. At best it can be perceived as a relatively limited adjunct to overall services that can improve continuity of care and facilitate the transition between acute care services and rehabilitative or long-term care.
7

VII. Goals, Objectives and Recommended Actions
Goal: The population of rural areas should have convenient accessibility to Medicare skilled care facilities to provide continuity of care.
Objective: the sWing-bed option should be available to small, rural hospitals that meet eligibility standards for participation in the program, in a number consistent with long-term care needs of the area.
Recommended Actions By 1993, the State Health Planning Agency should evaluate the use of the sWing-bed options by analyzing data on: a. number of patients b. number of patient days c. level of care provided d. cost and payor e. discharge provisions for continuity of care f. impact of the change allowing participation of hospitals of 50 99 beds, and increasing maximum number of beds per hospital from 10 beds to 10 beds or 15% of total beds, whichever is higher.
VIII. Recommended Guidelines for SWing-Bed Facilities
A. Definitions. 1. "Swing-bed option" allows an eXisting or proposed rural hospital
with less than 100 eligible beds and located in a rural area to use a specified number of beds interchangeably as either hospital, skilled nursing or intermediate care beds, with reimbursements based on the specific type of care provided.
2. "Swing-bed facility" means a hospital with less than 100 eligible beds and located in a rural area that participates in Medicare, that has an approval from the Health Care Financing Administration to provide extended care services as defined in Title
8

42.C.F.R. Part 405.125, and meets the requirements specified in Title 42 C.F.R. Part 405.1041 and all other pertinent federal rules and regulations.
3. "Eligible beds," for purposes of these Standards, means a licensed or an evaluated capacity of less than 100 acute care hospital beds exclusive of special care beds designated as intensive care and newborn beds.
4. "Rural area," for purposes of these Standards, wi 11 be determi ned by using the most current U.S. Department of Commerce, Bureau of the Census information, which defines and specifies the urbanized areas. All other areas will be considered rural.
5. "Service Area," for a sWing-bed hospital that has less than 50 eligible beds means the county in which the hospital is located. Service area for a sWing-bed hospital that has 50-99 eligible beds means the land area within a circle whose radius extends 50 miles from the applicant hospital.
B. Availability and Continuity Standard 1 To be designated as a swing-bed facility, an existing or 'proposed hospital shall be located in a rural area and shall either be licensed consistently for the most recent 12 months for fewer than 100 beds or shall have an evaluated capacity of fewer than 100 beds. Because of their special nature, beds designated as intensive care beds and newborn beds will be excluded from the calculation for swing-bed eligibility purposes.
Rationale for Standard The 1980 Omnibus Budget Reconciliation Act 904 P.L.96-499 provides for
fleXibility in the use of hospital beds in small, rural hospitals which may have difficulty establishing a physically identifiable nursing home unit because of the limitations of the physical plant and accounting capability. Rural area hospitals frequently also have an excess of hospitals beds.
9

The clear intent of the law is to provide continuity of care for patients in rural areas where nursing home services are not readily available and in a setting that offers the least dislocation and most potential for rehabilitation of the patient. It is designed to provide a cost-effective means of providing nursing home care. The relatively sparse utilization in Georgia makes evaluation of cost-effectiveness and the impact of swing-beds on long-term care services difficult to assess. The calculation of eligible beds assures that only those general routine beds capable of providing nursing home services will be considered. (20)
Traditionally the SHPA has used evaluated capacity in determining bed need for the various programs and services. The use of licensed beds or evaluated capacity beds in this case affords more flexibility for purposes of determining need and eligibility for swing-beds.
c. Accessibility and Need
Standard 1 - A maximum of 10 beds or 15 percent of total eligible hospital beds, whichever is greater, per hospital may be designated as swing-beds.
Standard 2 - The need for swing-beds will be determined based on the expected utilization of swing-beds and on the admission of Medicare patients to existing nursing homes in the service area where the applicant hospital is located. Special consideration will be given to applicants who:
(i) intend to serve a county or adjoining county or counties which do not have a general nursing home with skilled care capability; and/or
(ii) have a certified hospice service.
10

The Joi nt Nurs i ng Home and Intermediate Care Home Quest i onna ire submitted for the most recent year and/or the cost reports for institutions will be used to evaluate the availability ~f care to Medicare beneficiaries. No hospital may operate more than the allowable maximum beds as allowed in Accessibility and Need. Standard 1.
Rationale for Standards Standard 1 - The swing-bed option is intended for small institutions and a limit on the number of beds included under the reimbursement option is in keeping with the intent of the law, and reasonable need for long-term care.(18) To address the rural hospitals' financial viability, the 1988 Rural Hospital Task Force, appointed by the State Health Policy Council at the Governor's request, examined the various problems facing Georgia's rural hospitals. In its deliberations, the Task Force recommended that the maximum number of eligible beds for swingbeds be increased from 10 to 10 or 15 percent of total eligible hospital beds, whichever is greater. (22)
Standard 2 - The studies done to evaluate the swing-bed concept pointed out that the concept was developed to meet the unmet demand for Medicare-certified skilled nursing home care, while making cost-efficient use of underutilized hospital beds.(23) The evaluation of need is provided for under Section 1883(b)(2) of the Act requiring the facility to obtain a Certificate of Need, consistent with the demonstrated need for long-term skilled care services in the service area. The exceptions are stated to provide for continuity of care in the situations stated.
As additional swing beds are established in Georgia, assessment should be made of the impact on swing bed need and utilization by factors such as the Medicare Catastrophic Coverage Act of 1988, needs of "heavy care" patients, and changes in HCFA medicare criteria for skilled care.
11

As outlinedjn Section V: "Conditions for Participation", the 1987 OBRA Act (21) requires that hospitals with 50-99 (eligible) beds have a policy that when there is an available SNF bed in the geographic region of the hospital, a swing-bed patient must be transferred within 5 weekdays (excluding weekends and holidays) of the availability date unless the patient's physician certifies that the transfer is not medically appropriate. At the time of the Certificate of Need appl ication, the appl icant must show proof that the appl icant has transfer agreements (that are contingent on being approved by HCFA for Medicare participation) with all the SNFs in the geographic region.
D. Quality Standard 1 - Applicants for a Certificate of Need for sWing-beds shall submit a statement signed by the hospital's chief executive officer providing a commitment that the hospital intends to become a Medicare certified swing-bed facility meeting all requirements of the Health Care Financing Administration (HCFA) as defined in Title 42, CFR part 405.125 and Title 42 CFR Part 405.1041 and all other pertinent federal rules and regulations. Implementation of the Certificate of Need will be considered accomplished when swing-beds are operational and when the hospital furnishes proof to the State Health Planning Agency that it has entered into a Medicare swingbed agreement with HCFA. Thereafter, the hospital is expected to maintain Medicare certification for swing-beds.
Rationale for Standard There is a clear intent to treat 'swing-bed' hospitals similarly to SNF's
in order to assure adequate quality of care for long-term care patients in sWingbed hospitals. The specific areas address patient rights, specialized rehabilitative services, dental service, social services, patient activities and discharge planning program.(19)
12

This provlslon is also intended to encourage the most efficient and effective use of inpatient hospital beds for the delivery of either hospital or nursing home services. Hospitals certified and approved as swing-bed providers will be reimbursed at rates appropriate for those services and which are lower than hospital rates.(17) For a hospital to participate in the swing-bed program, the hospital must continue to meet the eligibility requirements of being a rural hospital, have less than 100 eligible acute care hospital beds, and participate in the Medicare program. The hospital must continue to meet all the eligibility requirements discussed in Section V: "Conditions for Participation".
E. Expans ions Standard 1 - When expansion of a sWing-bed program is reviewable by virtue of adding beds to the overall hospital evaluated bed capacity and/or the capital expenditure exceeding the Certificate of Need threshold, the proposed project must meet all applicable criteria in these Standards and all app1icab1e cri teri a in any other Standards pertaining to the additional beds and the capital expenditure.
Rationale for Standard It is recognized that a hospital can increase its number of sWing-beds up
to the applicable maximum allowed in C. Accessibility and Need - Standard 1, without the necessity for applying for a Certificate of Need (CON). The hospital is required to meet and remain in compliance with all applicable Standards of this Plan at all times, including during periods of the expansion of swing-beds not requiring a Certificate of Need review. When an applicant intends to add beds to the overall hospital evaluated capacity and/or has a capital expenditure exceeding the Certificate of Need threshold, the project must meet all the applicable criteria.
13

F. . Data Collection Standard 1 - Applicants requesting a Certificate of Need for swingbeds must agree to provide data to the State Health Planning Agency necessary to record and evaluate the use of sWing-beds. These data will include at least the number of patient days identified by the level of care and payor and the total number of patients served.
Rationale for Standard For effective health planning it is critical that health care facilities
provide accurate and current data to the State Health Planning Agency. The data required from swing-bed facilities will be essential in evaluating the effectiveness of the swing-bed program in Georgia and in the overall planning for long-term care delivery.
14

APPENDICES
15

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~rce: Sl-PA, 19ffi Joint Hospital Questionaire, 1988. (unpoltPo)

(l).CON Wi thdrawn

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APPENDIX 8
SW lNG-BEDS APPROVED
JULY 1983- NeVEMBfR- 1988
STATE OF
GEORGIA'

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Total: 37 f-bspitals

360 eeds

17

S:u'ce: 9'fA, NOV 1988

REFERENCES
1. An Eva-iuation of Swing-Bed Experiments to Provide Long-Term Care in Rural
Hospitals, Vol. II Final Technical Report, Department of Health &Human
Services, March 1981.
2. Shaughnessy, P., "Overview of Swing-Bed Care", Chapter 1 in A SWing-Bed Planning Guide for Rural Hospitals, American Hospital Publishing, Inc., Chicago, 1984.
3. Shaughnessy, ibid., pp. 4-5.
4. Federal Register, "Swing-Bed Provisions", Vol. 47, #139, July 20, 1982 and Vol. 49, #1, January 3, 1984.
5. Federal Register, "Reasonable Cost of Extended Care Services Furnished by a Swing-Bed Hospital", Vol. 49, #1, January 3, 1984, pp. 298-299.
6. Shaughnessy, op. cit., p. 5.
7. Shaughnessy, p. 6.
8. Federal Register, "SWing-Bed Provisions", Vol. 47, #139, July 20, 1982, pp. 31520-21.
9. Burda, D., "Alabama Swing-Bed Program in Limbo", Hospitals, July 1, 1985, p. 21.
10. Grim, S. and Guptill, P., "Meeting Federal, State and Local Swing-Bed Requirements", Chapter 4 in ASwing-Bed Planning Guide for Rural Hospitals, American Hospital Publishing, Inc., Chicago, 1984.
11. Shannon, K., "Swing-Bed Programs Success Spurs Proposals to Expand Eligibility", Hospitals, March 1, 1985, p. 78.
12. State Health Planning Agency, 1988.
13. Conversation with Frances Norton, Towns County Hospital.
14. "Iowa Swing-Beds", Hospitals, March 20, 1986, p. 105.
15. "Swing-Bed Hospitals - Calculation of Bed Size", HCFA Program Issuance, State Letter #31-85, September 10, 1985.
16. Memo from Margaret Van Amringe, Acting Director, HCFA/Office of Survey &
Certification, March, 1983.
17. Federal Register, July 20, 1982, p. 31518. 18. Federal Register, July 20, 1982, p. 31524. 19. Federal Register, July 20, 1982, pp. 31520-21.
18

20. Federa-l Register, July 20, 1982, p. 31519 and HCFA Program Issuance, September 10, 1985.
21. Regional Office Manual - Standards and Certification and State Operations Manual - Provider Certification, HCFA, (Advance Copy) Transmittals #36 and 215, November 1988.
22. Final Report of the Rural Hospital Task Force, State Health Policy Council/State Health Planning Agency, June 1988.
23. Shaughnessy, P.W. - 'Hospital swing-bed care in the United States'. Health Services Research, October 1986, pp. 477-498
19