Component plan. Long-term care : nursing homes

COMPONENT PLAN LONG-TERM CARE: NURSING HOMES
GEORGIA HEALTH STRATEGIES COUNCIL AND THE
GEORGIA STATE HEALTH PLANNING AGENCY 4 EXECUTIVE PARK DRIVE NE SUITE 2100 ATLANTA GEORGIA 30329
NOVEMBER 1992

Zell Miller
GOVERNOR

STATE OF GEORGIA
OFFICE OF THE GOVERNOR ATLANTA 30334-0900

March 18, 1993

Dr. Francis J. Tedesco, Chairman Health Strategies Council 4 Executive Park Drive, N.E. Suite 2100 Atlanta, Georgia 30329
Dear Fran:
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 amendments to the Component Plan for Long-Term Care and have approved the amendments.
I appreciate the public participatory process which has been initiated by the Council and the State Health Planning 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 personal regards, I remain
Sincerely,

ZM/lld

~~~ ~ WAR 22 1993 . ,
HDl1~t:t:T;'}."~:"i:;.in(l1G::~:lG!RGA1GAENCY
Pl..ANN1NG SECTION

4 Executive Park Drive. N.E. Suite 2100
Atlanta. Georgia 30329

.~. 'i'n' STATE OF GEORGIA
HEALTH STRATEGIES COUNCIL
December 18, 1992

The Honorable Zell Miller Governor of Georgia The State Capitol Atlanta, Georgia 30334
Honorable Sir:
It is with great pleasure that the State Health Strategies Council hereby submits, for your approval, amendments to the following Component Plan:
Long-Term Care: Nursing Homes.
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 long-term care in nursing homes and recommends goals, objectives and system changes to insure a statewide system of cost-effective, efficient care. The Plan is designed to achieve state health policies relating to access to quality care and cost containment.
This Plan has been produced through an open, public participatory process initiated and monitored by the Strategies Council. The Strategies Council and the State Health Planning Agency commend this Plan to you and respectfully urge your approval of it. It is believed that the Plan as amended provides a rational basis for continued development of skilled nursing and intermediate care facilities for Georgians.
Sincerely,

Francis J. Tedesco, M.D. Chair
FJT:kr Enclosure

PREFACE
This Component Plan is a product of the Georgia Health Strategies Council and the Georgia State Health Planning Agency which are funded through and operated within the authority of Georgia Law Act 552.
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 Health Strategies Council. The Plan, once approved by the Governor, supersedes all related sections of previous 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 Health Strategies 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, NE., Suite 2100, Atlanta, Georgia 30329; telephone: 404/679-4829.

TABLE OF CONTENTS

PAGE

I. LONG-TERM CARE PLANNING

A. Background

B. Nursing Home Services in Georgia

2

C. Alternative Services in Georgia

3

II. THE POPULATION OVER AGE 65

A. Demographic Changes

6

B. Long-Term Care - Use Patterns

6

C. Health Status

7

D. Summary

8

III. ISSUES AND TRENDS IN LONG-TERM CARE

A. Informal Long-term Care

10

B. Factors Affecting the Use of Nursing Home Services

11

C. DRG's and Affect on Nursing Home Admissions

13

D. Reimbursement Issues

14

E. Quality Issues

15

F. Alternative Services - Options for Care

16

G. Retirement Communities and Nursing Home Services

17

IV. RECOMMENDATIONS - LONG-TERM CARE

21

V. GOALS, O~JECTIVES AND RECOMMENDED ACTIONS

23

VI. RECOMMENDED GUIDELINES FOR DEVELOPMENT OF

NURSING HOME SERVICES

28

VII. APPENDICES:

Appendix A - Counties with Nursing Homes

Counties without Nursing Homes

46

Appendix B - CON Approvals - Nursing Homes

47

Appendix C - A Classification of Services

for Older Persons. Focus of

Service Delivery

48

Appendix 0 - Urban Areas - Counties with

62,000 or above population

49

Appendix E - Inventory of State Nursing

Facilities, Georgia, 1990

50

VIII. REFERENCES CITED

52

IX. ADDITIONAL REFERENCES

55

NOTE: NUMBERS IN PARENTHESES IN THE TEXT INDICATE REFERENCES.

t. LONG-TERM CARE PLANNING
A. Background Long-term care continues to be a major health care priority in the 1980's. The section on Long-term Care in the 1983 State Health Plan addressed the development of a range of services and facilities in order to provide a level of care that was responsive to the needs of the consumer. It was recognized that long-term care services might be needed by various age groups, but it was acknowledged that the aged were the group most likely to utilize such services. The planning efforts were specifically addressed to the long-term care needs of those persons over age 65.
Long-term care is defined as 'the personal or professional services that are required on a recurrent or continuous basis by an individual because of chronic or permanent physical or mental impairment. The services may be provided in a variety of settings, including the client's own home' .(l) The purpose of long-term care services is to relieve the effects of illness, and to maintain or enhance functional capacities that maximize personal independence.(2)
The Long-term Care section of the 1983 State Health Plan pruvided related standards for the development of nursing home services as a component of long-term care services. Nursing home beds were projected on a bed-to-aged population ratio of 47 beds/1000 population 65 years of age and over. Geographic access was planned with a 40 mile radius. With implementation of that Plan and Certificate of Need rules, the overall statewide access to nursing home services was improved. At present, only 23 of the 159 counties do not have a nursing home, and geographic access within 40 miles has been established throughout the state.(Appendix A)
The rate of increase in excess beds in nursing hom~s was reversed and occupane,y rates remain high. Long-term nursing home care has been traditionally viewed as a primary resource and focal point for long-term care planning. The assessment of service needs and de-
1

mands points to a need for a broad range of services to be sensitive -fo the needs and preferences of the consumer.

This Component Plan will specifically address nursing home services and the issues surrounding the use, need and provision of facilitybased services. The use and development of home health and other alternative services wi'l be addressed in separate Component Plans.

B. Nursing Home Services in Georgia

Georgia's measured growth in nursing home services since 1980 is

reflected in the table below:

HSA 1 HSA 2 HSA 3 HSA 4

COMPARATIVE HICHLICHTS GEORGIA: GENERAL NUISING HOMES
Nuaber of beds (capacity)

He.lth Service Are Northwe.c Ceorlia (Ca. part)

illQ 373

llli
493

.!.2.!!
416

l2ll
516

Appalachiaa Georlia

3.466

3,831

3,900

3,900

No. Ceaeral Ceorli.

9,663

9,916 10,396 10,556

E. Ceneral aeorlia

3,181

3,599

3,719

3.847

.!.ill
516 4,094 10,908 3,847

1980l984 Chan!1 + l43 + 628 + 1.245 + 666

HSA 5 HSA 6 HSA 7

Cencul aeorli. Souchwe.e Georli. Souchec aeorlia
STATE

6,391 l.814 4,110 lO,998

6,388 3,919 4.205 32,351

6,389 3,914 4,:'47 33.181

6,3.56 4.114 4,441 33.730

6,411 4,114 4,441 34,331

+ !O + 300 + 331 + 3. 3J3

SOURCE: State aealtn Planning Agency, February 1986.

The availability of nursing home services is also apparent 1n the

nursing home bed-to-population ratio by HSA (population over age

65)

BED-!O-POPULATION RATIO

~
HSA 1 N.W. Georgia

GENERAL CAR.! 41.8

HSA Z AppalaeniaD Georgia 55.8

eSA 3 K. Central Georgia 50.3

HSA 4 E. Central Georgia 62.5

HSA 5 Central Georgia

72.3

HSA 6 s.w. Georgia

59.6

HSA 7 S.E. Georgia

63.6

SrA!!'

58.0

STAT! & paIVA!! MIl
0
1.3 2.4 13.1 8.6 9.4
0 4.8

~ :'1.8
37.2 52.7 75.6 80.9 69.1 63.6 62.8

SOURCE: State Health Planning Agency, April 1985.

2

_.}he state currently has a total of 34,331 general nursing home beds. When this total is compared to the aged population for 1988, a rate of ~3.8 beds/1000 aged population is produced.

The rate of 53.8/1000 aged population is higher proportionately than Tennessee, Alabama, Mississippi, North Carolina, South Carolina and Flor-ida. (3) Planned growth in nursing home services is further illustrated by the map noting nursing home CON approvals for the per-od July 1979 to September 1985. (Appendix B)

In line with demographic changes increasing the segment of the population over 75, the average occupancy rate of nursing homes increased slightly in 1984. The occupancy rates are noted as follows:

Health Se~'ic. Areas Northwest Georgia

- - 1979 .!1.Q llli. 1982.

99.0

99.5

96.6

86.2

Appalachian Georgia

97.1

97.8

97.2

96.2

North Cent:,a1 Georgia

94.5

94.5

94.6

93.7

East Cantril Georgia

97.3

97.5

96.~

91.8

Central GeJrgia

96.8

96.6

94.2

94.7

Southwest ;eorgia

96.9 96.9 97.0 96.6

Southeast Georgia

95.1

95.9

94.2

92.8

STAT!

96.0

96.1

95.3

94.1

SOUlC!: State Health Planning Agency, February 1986.

-1983
90.5 98.2 93.2 92.5 94.1 95.8 91.9 94.0

llli
97.8 97.9 93.7 95.4 95.0 96.9 94.7 95.2

C. Alternative services in Georgia The Long-tenn care section of the 1983 State Health Plan addressed the provision of alternative services to those persons who need assistance in personal, medical or social services, and could receive those services outside of a facility-based setting. The Community Care and Services to the Elderly Act was passed by the Gener.ll Assembly in its 1982 session. with the expressed purpose. Ito assist functionally impaired elderly persons in Hving dignified.
an.i reasonably.independent aves in their own homes or in the. homes'
of relatives or caregivers, through the development, expansion, re-
organization and coordination of various community-based services to prevent unnecessary or premature placement of individuals in longtenm care facilities .(4)
3

-The program was implemented in all 18 Area Planning and Development areas as of July 1985. Assessment s~rvices are offered to persons eligible for Medicaid and those that could beco~e Medicaid eligible within 180 days of nursing home placement.

Currently, there are HCFA restrictions on the total number of persons who may actually receive services, as well as restrictions on the total amount of funds which can be spent for the services offered.

HCFA LIMITS for THREE FEDERAL FISCAL ~~EAlS

FFY' 85 FFY'86 FFY'87

5,100 persons to be servecl 6,425 persons to be served 8,100 persons to be serVed

SOURCE: Status Report of Implem.ntation of :ommunity Care and Services for the Elderly Act, DHll J04,June 1985.

These restrictions may result in greater numbers of assessments of individuals than actual services of~ered.(5)

A survey concilcted in February 1986 under an H(.FA contract, covering October 1, 1984 to September 30, 1~J5 pointed cut several areas that impact upon the use of nursing home services. The Community Care Services program served largely a f~ale (73S) and single (90S) poplation:
21% of persons served were ages 65-74 25% of persons served were ages 75-84 29% of persona served were age 85+
SOURCE: HCFA, LaJolla Management Co., SecllUd Annual Survey.
Ninety-two percent of the cases surveyed addre,s the needs of persons with functional impairment in activities Jf daily living of level 3 or 4, which indicates needing assistance with dressing, bathing, toileting and eating.~ In ,the sample, 431 of the clients surveye~ ~ventually entered a nurs4 ng home.(6) It has beert r-ecom~ mended in the' Performance Audit 'of June i986 that the' Department of Human Resources expand Community Care services to include the functionally impaired el derly who ,:an partially or totally pay for
4

the cost of the services.(7) Increased use of Community Care services, both in persons served as well as scope of services, could result in even fewer younger persons being admitted to nursing homes. The demand for nursing home services will continue to be high for those older and frail citizens who require skilled care for multiple chronic illnesses. The continued development of home delivered services increases the alternatives available and accessible to older Georgians.
5

II. The population over Age 65

A. Demographic Changes

Long-term care requirements are determined largely by the relative size

and composition of the elderly population. In Georgia, the population

over 65 years of age is projected to increase at a rate 1.7 times higher

than the general population. This demographic change is noted in the

table below:

~
O-~4
?5~

?OPUL\TtON

l2!2
317.304

.illQ
3.049.J93

: tnc:r .7.3

315.156

?70.103

30.l

SOURCE: OPI Po~ulatioQ Proj.ction.

Further, the 01 der age cohorts are growing at a greater rate t.han the

younger age cohorts within this population group.

~
?5-74 75-84 35~
TOTAL

l'OPUUttOM

l2!2

1990

: (acr

329.961 145.917
39.~78

40~.837
Z06.826
,1.140

Zl.i 41.i 58.9

315.156

670.l03

SOURCE: OPI Po~u!atioQ PrOj.c:t3ioQ.

B. Long-term Care Use Patterns

The population changes become significant in that the elderly over 75,

and especially those over 85, are most likely to utilize long-term care services to meet their needs.(8) This use pattern is demonst-ated 1nth~

ages of the occupants of nursing homes in Georgia as shown below:

6

The National Center for Health Statistics estimated that a total of 5% of persons over age 65 are in nursing homes. These data are consistent with those 1n Georgia. Nationally, in the age group 85 years and over, almost 22% were residing in nursing homes. Moreover, 32% of nursing home residents were admitted from general or short-stay hospitals.(9) The greater use of facility-based care for the age cohorts over age 75 is apparent in Georgia. Since 1982, the percent of nursing home patients in the age group 75-84 and 85+ increased, and the percentage of patients in age groups 65-74 and 15-64 years declined.

Percent Distribution of General Nursing Home Patients by Age Group - 1980, 1982 & 1984

Patient Age

-YEAR

1980

1982

1984

Under 15 years

0.1

0.1

0.1

15 - 64 years

13.4

12.3

11.8

6S years & above

86.5

87.6

88.1

6S - 74

21.2

21.5

20.9

75 - 84

37.8

38.1

38.2

85 years & above

27.5

28.0

29.0

SOURCE: Joint Nursing Home and Intermediate Care Home Questionnaires, 1980, 1982, 1984.

C. Health Status

Clearly both statewide and nationwide, the nursing home population repre-

sents only a small segment of the elderly population that might need

health care for a long duration. The health status of the elderly popu-

lation and resulting need for specific health care services 1s difficult

to assess in absolute terms. The trend 1s toward an increased life

expectancy. As medical science becomes more successful in overcoming the effects of chronic illness, l1fe expectancy will move closer to equaling

11fe span.

This trend is described as a 'rectangulation of society and reflects

.

"

more pec;ple 1hi ng a "full term life -ended by a natural death. It does

not mean that the larger proportion of the elderly will be' necessarily

infirm, bl.ft it does illustrate a trend of poplation shifts that has

implications for long-term care.(lO)

7.

~
I
.-1
,
.

-- - --..., ........ \ \ I

~

--

-

18
--

-

---


...

........


~-

..

,.

.

cb'" 'tD ~ or un a:nc:.urcr

.. cbe .IIHa Qf cDmuc ~. an M .....'"

MdiC&l. letcca

This rectangularization of life expectancy includes the phenomenon of 'wellness' that is likely to increase as fitness !nd preventative health care trends affect the aging populaticn. This ph!nomenon has been desdescribed as 'youth creep', and descr.ibes the pattern of the elderly living longer, healthier and more active and independent lives.(ll) Health problems increase with age, bu~ severe levels of disability are the exception rather than the rule.

o. Summary
Planning for long-tenn care and long-term care services demands that the characteristics of the population and issues related to health status be given primary consideration. If nursfng home services can be perceived as providing a greater level of perso~al assistarlce, then such services exist at one end of a much larger continuum of services.

The development of an array of life-enhancing, preventative and enabling
services that can be community-based lengthens t,e continuum and provides
opportunities for intervention and early treatme,t, if not prevention. 'In loriq-term' care, t~e process (how ~ n fndfvidua 1 comes' to use se~;'ces) -is as important as the product (what services are used). Perhaps the
outcome (health status and quality of life) is the most important factor.

8

The followin~ section will address issues and trends that relate to the use of nursing home services as one fonn of long-term care.
9

III. ISSUES and TRENDS in LONG-TE~ CARE Long-term care arrangements for the elderly are determined by a complex set of interacting personal. environmental. physical and fiscal factors. Elderly persons generally utilize a variety of formal and informal care systems until a crisis occurs in the helping system. the health status of the individual. in housing or in financial arrangements.
The use of nursing homes to provide long-term care services is often preceded by exhaustion of other resources. The factors that impact the use of long-term care services are discussed below.
A. Informal Long-term Care As was noted. only 5% of persons over age 65 are in nursing homes. Despite myths to the contrary. the family remains the major provider of health care to the aged. There is considerable research literature that documents the existence of this large informal support system.
The U.S. Department of Health and Human Services (DHHS) reports that the family provides 80% of the medically related services received by the aged and even a larger proportion of household maintenance and other in_strumental services. The family often provides care for long periods of time. even care for the bedfast and housebound in their own households.
There is increasing evidence that families continue to be willing to proprovide long-term care. Changing family structures may alter the actual capacity to provide all of the services needed by the elderly. Women in the age group 45-65 are likely to be the primary care givers. and are now more likely to be working outside the home. The offspring of those frail elderly persons over 85 years are often elderly themselves.
The research evidence has given gerontologists a firm foundation to call for family-oriented ~olicies I a vast increase 1s neede~ 1n concrete instrumental, and personal care servic~s that " helP. faml1ies deal wi th long-'tenn care services on a day-to-day basis l (13) To be consistent with this trend. established formal services should recogize and augment the informal services prowlded by families and friends. and focus on ser-
10

viGes' to the segment of the population most likely to need formal services.
B. Factors Affecting the Use of Nursing Home Services The changing demographics of the aged population and the mortality decline has led to a growing increase in the percentage of persons 75 and over in the aged population. Persons age 75 and older are three times more 11 kely to need personal assi stance than those between the ages of 65 and 74. Nursing home utilization increases with age. Actual disability or functional limitation is a necessary, but not sufficient, condition of risk for long-term care. Not all persons in even the high-risk categories (the very old and disabled) are dependent upon others for care. Even those who are dependent have needs that vary in intensity, duration and scope. The needs of an individual for specific long-term care services or nursing home services are related to the person's desire for services. perceived need for services. advice by others of the need for services and the availability of such services, rather than the absolute needs of the indfvidual.(14)
Several studies have addressed the risk factors of persons actually ad- admitted to a nursing home. One such study conducted in Framingham.
Massachusetts identified five key variables related to the use of nursing home services:
1. advanced age 2. need for aids in ambulation 3. mental disorientation 4. livi ng alone 5. the need for human assistance in performance
of independent activities of daily living.(15)
In another study, it was reported that only one-half of those with even the most severe dependencies were institutionalized. Dependency is a critical variable. However, individuals who needed no human assistance 1n activities of daily living or mob~1ity had less than a 11 chance of being institutionalized. while indiv.iduals who need.d 'h'elp with bathing and dressing. or toiteting and eating had a 37.81 and 621 chance respectivelYt.of being institutionalized at some point. This study identified the presence of mental disorder as the single most important factor
11

leadi-ng-to institutionalization via nursing home admission, and functionally, mental disorder is the most important dependency factor.(16)
This factor is illustrated further by the Study Committee Report on Alzheimer's Disease and Related Disorders issued in December 1985. The Report cites an estimated prevalence rate of Alzheimer's Disease at 5-10% of the population over 65, which increases to a rate of 20% of the population over 80. The long-term and short-term effects of this group of disorders on both formal and informal caregivers is significant. While facility-based care is often not sought until significant functional disability is present, it is estimated by the survey report that 30% of residents in Georgia's nursing homes have organic mental impairment of the Alzheimer's type.
Nursing home services were among the services recommended by the Study Commrittee and the public comments as being a service that is necessary to serve the needs of this group.(17}
Poverty was the neKt most important identified determinant. While overall older age increases the risk of institutionalization, the actual probability remained low unless aging was accompanied by high dependency, a high-risk medical diagnosis, poverty and/or the loss of a spouse.(lS) Poverty may have previously impacted the health status of the individual and may influence both the choice and availability of long-tenn care options.
Nursing home bed supply and availability has also been identified as a factor in predicting use regardless of disability. Institutionalization rates for aged persons, age 75 or above, with high dependency who are unmarried were double in states with high bed rates as compared with states with low bed rates.(19)
.. Clearlt, nultiple factors come to bear on a decision to use nursing home care. Duration of physical problems and recent hospitalfzation are also important. determi nants. A study of needs for care before nursing home admission reported that nursing hOme residents were admitted directly
12

from__.ahospital in 66~ of the cases. More than 80% of admissions had been recently hospitalized with an average of five health problems each, and 88~ had probl ems of longer than a year's duration. Ski 11 ed care admissions were usually preceded by acute exacerbation of problems and required a high level of nursing care. Admissions to intermediate care facilities were most likely to be preceded by gradually worsening problems and difficulty in providing care.(20)

Such high variability of factors pointed toward use of nursing homes only when high-risk factors combine to make nursing home care a desired option. Planning for such services needs to focus on population characteristics as well as availability of other types of long-term care services that may enhance development and use of alternatives to facilitybased care over time. When such formal inpatient services are needed, their accessibility and availability encourages the continuity of care that meets the human needs for social connection as well as physical care.

C. DRGs and Affect on Nursing Home Admissions

The trend toward nursing home admissions by persons with multiple-risk

factors is amplified by the Diagnosis Related Group (DRG) method of

prospective payment by Medicare for acute hospital care. This type of

rei.mursement system is based on a fixed length of stay for specific

diagnostic entities. There is. therefore. an incentive for earlier

discharge of patients from acute care hospitals. Patients with multiple

problems do not 'fit' this system as the Dfagnostfc Group standard

applies to the prima~ diagnosis. In a recent survey done of all State

Administration on Aging onmudsmen and reported to the Senate Select

Committee on Aging, 75~ of the respondents reported that patients are

'dfscharged sicker or much sicker' than before the institution of pro-

spective p~ents. This has led to a greater demand for post-hospital

support services, and 71~ reported that many more people need skilled

nursing

c. are sin. ce t~e

initiation

of

prospective

payment. '

Further, of
.

those responding, over 50S stated that existing skilled nursing care was

not adequate to meet the needs of discharged patients in rural areas,

and 33S of the care was inadequate 1n urban areas.(21)

13

The--need for such intermittent skilled care is in contrast to a view of nursing home care as prolonged in all cases. Home health care as an alternative is often not ava ilable in suffi cient quantity to meet the skilled care needs of the most recently discharged patients. The reimbursement system influences the use of long-term care services, and at this point, seems to favor the use of facility-based services.
D. Reimbursement Issues Reimbursement profoundly affects accessibility to long-term care serservices, and affects, over time, the type of services that are developed. In discussions with nursing home administrators and hospital discharge planners, there was general agreement on the difficulty of locating and providi ng care for patients with mul tiple medical probl ems or severe dementias such as Alzheimer's Disease. The care requirements of these patients are more expensive to provide, and reimbursement does not cover costs in all cases.(22)
Currently, Medicare pays for less than 1~ of nursing home care. In Georgia, only 92 of 356 licensed nursing homes are Medicare certified. (23) Variations in claim acceptance by various fiscal intermediaries for the Medicare progr~ has resulted in some confusion over covered services, and eventually determines what services are available.
For example, a patient who is a member of the Medicare program may require skilled services after a stay in an acute care hospital. If the services cannot be provided in the patient's home, a skilled care fac11ity placement is sought in a Medicare certified facility. If subsequently the cla1. for coverage of such services is not allowed by the Medicare fiscal_intermed1a~, then the nursing home must absorb the costs for the initial services given and arrange for the patient to pay charges until Medicaid eligibility is met.(24)
Consequent~y; facilty-based services and eventual Medica~dsubsidy'become the only viable alternatives for care. Thts fiscal fact can become the over-rid1ng variable in choice of care. It can also result in theimpoverishment of a remaining spouse, and narrows their continuing care op-
14

tions~ A study of 75 year 01 d persons in Massachusetts found that if one member of a couple entered a nursing home, the spouse at home would be impoverished within 13 weeks for 11% of the couple, within six months for 25%, and within one year for 41% of the couples.(25)
Partly as a result of these reimbursement issues and the lack of 10ngterm care insurance, Medicaid continues to pay for the majority of nursing home expenses. (26) This affects the state funds available for health care services of all kinds within the state. The Senate Long-term Care Insurance Study Committee is investigating long-term care insurance activities, and a full report is anticipated by the end of 1986.
The reimbursement picture is further complicated by the provisions of the 'Medigap' insurance policies which are purchased by the elderly to supplement Medicare coverage. These policies often do not cover even shortterm skilled care services if Medicare does not approve the claim. This fact is often not discovered until such care is needed and found not to be covered.
Other reimbursement issues relate to the rate of reimbursement. Low reimbursement rates, while containing overall costs, result in reduced accessibility of services to those with more complex needs. Specifically persons with Alzheimer's Disease or related disorders, and person~ who require highly skilled care involving the need for oxygen, catheter care, hyperalimentat10n, respiratory therapy, IV's or other time consuming care, find it difficult to have access to such care. Medicaid does not cover oxygen costs for example. This general issue, in effect, limits accessibility and provides no incentive to providers to develop or provide such services. The Department of Medical Assistance has begun to address this issue by increasing payment for increased skilled nursing hours for persons requiring such a level of care.
E. Quali ty I.ssues The quality of services provided in nursing .homes is important to nursing home re~idents, as well as to the families, communities and providers of care. Basic qual1 ty standards are provided for under the Rules and
15

Regul~tions for Nursing Homes (Chapter 290-5-8), Intermediate Care Homes (Chapter 290-5-9) and Hospitals (Chapter 290-5-6), and administered under the Office of Regulatory Services.

Further, the Long-term Care Ombudsman program is organized to protect the rights of individuals in lqng-term care facilities by receiving and investigating problems involving residents, as well as providing information and referrals about long-term care and related services. During FFY'85, a total of 2,224 complaints were received, of which 80% were verified by investigation. In addition, 2,014 individuals contacted the program for information and assistance.(2l)

These programs, together, are valuable linkages between nursing home residents and the community at large, and uphold the 'Bill of Rights for Residents of Long-term Care Facilities' (GA Law 1981, p.14951).

F. Alternative Services - Options for Care Alternatives to long-term institutional care can be defined as 'the whole range of health, nutritional, housing and social services designed to assist the aged and disabled in meeting a range of service needs and to continue to fUnction in the home and community environment.(28)

The developnent of a coordinated array of services can be instrumental in providing long-tenn care to meet specific needs without the need for premature nursing home care. Alternative services may include housing and residential services. interMittent or long-term home health care. homemaker chore services. transportation services. respite care. adult day care and other coordinating and support services.(29) Such services enhance the infbrmal services available, and can substitute in some cases for nursing home services.

Other congregate living centers. meals and recreation services can pro-

v.ide soci a1 support. and reduce the .need for professionally delivered

.

.

health services. The coordination of serv.ices model is the tiasis for the

Community Care and services for the Elderly Act, and the development of

the Assessment System. The limitations on the program are fiscal at

16

present, but the program continues development of the continuum model framework of services. Health and long-term care include many dimensions of physical, social and psychological well-being. and the locus of the service may be less important than the perceived long-term care needs they address. Home health care will be addressed as part of a continuum of service in a separate Component Plan.
G. Retirement Communities and Nursing Home Services Retirement communities represent another option for long-term care services. The basic services arrangements of most retirement communities would be categorized as falling on the more formal end of the long-term care continuum of services.
Definition The term 'retirement community' has many different meanings and represents a variety o~ housing and service options, as well as fee structure variations. For the purpose of this Plan, retirement community will be defined as a planned, age-restricted, congregate living development which offers housing, recreation, security, dietary and health care services, and offers shared living space areas accessible to residents.
Service Options Some retirement centers offer housing and some services, but health care is not a part of all communities, or part of the basic fee structure in all cases. In this Component Plan, the health care services provided in retirement communities are of interest because of the impact on overall long-term health care resources. Many types of housing resources for the elderly can provide opportunities for social support and informal caregiving as well as assist in such services as transportation and meals. Any of these service features can potentially decrease the need for other forms of long-term care. This phenomenon has been termed 'independence through interdependence'.(30) Such a concept reinforces t~e notion of housing and social support resources as important variables th~t ultimately affect utilization of long-term care resources.
17

Retirement Community Population Characteristics The proliferation of retirement communities is beginning to constitute a large and competitive market for the housing share of the elderly care market. The elderly most likely to choose a retirement community are sometimes referred to as 'second generation retirees'. Some other type of retirement is chosen initially and later, a living arrangement that offers more security is sought to maintain independence.(31) The average age of residents at entrance to a retirement community is 70-76 and remains constant for entrance age despite the aging of the entire community.
The retirement community resident is likely to be relatively affluent and able to afford the entry fees and monthly fees required. There are considerable variations in cost. Retirement communities developed initially were generally 'life care' communities, with a large initial investment and a fixed monthly fee which included health care. Florida and Pennsylvania have legislation governing the financial makeup of life care communities.
Until recently, retirement communities have been developed by non-profit organizations, with churches and fraterrtal organizations being the major developers. A 1984 directory of continuing care retirement facilities lists 333 such communities nationwide.(32) It is expected that this type of community as well as other types of retirement communities will increase dramatically in the next decade. Expansion in the for-profit retirement community is also expected. The options for services, providers and facilities are becoming numerous.
Health Care in Retirement Communities Retirement communities offering health care services as part of the pack.age of services vary considerably in the actual level of services offered, as well as fees charged. Heal~h care services mayrange"from extensive guaranteed services including skilled nursing care at no additional
18

" cost. to minimal health care such as a 24-hour emergency call system. rn the mid-range, assisted living might be augmented by contracted services in other facilities or home health care.(33)
In one report on life care centers, a type of retirement community with larger entry fees, a median revenue loss of $2,209 per apartment unit for permanent transfers to the nursing unit, and $473 per apartment transfer was reported. In this si tuation, residents pay only apartment rate charges while occupying a higher priced nursing bed on a permanent basis. (34) Retirement communities constructed in the last five years generally charge additional fees for skilled nusing care. Health care is viewed as the 'security factor' when nursing home services are available on the premises.
The actual provision of health care services is based on the perceived demand for services. In most cases, preventative care, routine physicals, assessments or follow-up visits for chronic conditions are not provided. Home health care is not always available. Nursing home beds may, therefore, become the focus for long-term health care within a retirement community.
Actual use patterns for nursing hemes within a retirement cOllllllnity are difficult to predict. As a community matures,. more residents may be likely to need nursing home services; the need to make additional charges for such services makes it difficult to insure that the residents will have adequate financial reserves to cover such costs.
In the early phase of a retirement community, fewer residents may need nursing home care, but as the population ages, more residents may require at least temporary nursing home care. Initially, extra beds can be made available to the larger cOllllllnity at a per diem charge that can offset some of the financial loss described earlier.
Retirement Community Market The for-~rofit development of retirement communities is relatively recent
19

and.expected to grow rapidly. It has been estimated that approximately 2.000 projects will be built nationwide before 1995.(35) There will certainly be changes in the entire spectrum of housing and health care options.
Laventhol &Horwath in their fifth annual study of 102 retirement commun-
ities noted that 90% were located in urban or suburban areas. and 90% had a nursing center on the premises. The average ratio of nursing home beds to residential units was 1:4.24. In the newer communities studied. the ratio was 1:5.4. Also noteworthy was the reported 80~ indicating that the market area was less than a 25..mile radius.(36)
While these findings cannot be generalized to all communities. they may be applicable to trends that might be expected in development in Georgia. In a recent article. there were nine companies planning or constructing retirement communities in the Atlanta metro area. The numbers actually desiring nursing home services is not known. Some are interested only in providing housing and amenities; others are interested in developing retirement communities around existing health care or nursing home facilities.(31) Such diversity is further illustrated by the entrance of such ~ompanies as Sears, Marriott Corporation and Holiday Inn Corporation. Sears has begun to develop active life centers in the midwest and plans to contract with hospitals, group health care plans, nursing homes and social HMOs.(38) The diversity and interest in development is indicative of a growing indust~.
Quality Issues - Retirement Communities The provision of health care services in a manner consistent with the assessed health care needs of the residents is of major concern. Skilled nursing facilities are licensed by the State of Georgia (Chapter 290-5-8) and there are established standards governing. the physical plant as well as nursi ng staffi ng ratios and the provision of auxillary services such as physical therapy. pharmacy. etc. If a retfrement .community chooses to set up an i nfi rmary or health center, they are not presently covered under licensure standards. This may be a factor for future consideration.
20

Recommendations - Retirement Communities A task force was convened to address the issues involved in nursing home beds as part of a retirement community. It was recommended that retirement nursing home beds be subject to the bed need formula, and that they be considered a defined part of the state's long-term care nursing home resources. It was also recommended that retirement community nursing home beds be made available to the community at large, and that they be Medicaid certified.
Because the actual nursing home bed need in a retirement community is limited, a retirement home may apply for nursing home beds in a ratio of one nursing home bed for every four residential beds. Retirement communities will be considered as a special service for favorable consideration under Certificate of Need Standard l.v.
Further analysis of the impact of retirement cOfl'llllnities on long-term care resources is necessary. Patient origin studies and payor mix analysis of all long-term care services, as well as a profile of retirement community residents in Georgia will need to be analyzed to assist in future planning efforts.
IV. RECOMMENDATIONS - LONG-TERM CARE Planning for long-term care services in Georgia represents a present challenge with implications for both the near and distant future of health care. If health planning is viewed as being concerned with improving health then the health status of the elderly 1s of primary concern. The present and eventual health status of the senior population will determine the need for long-term care services of all types.
The process of health planning sets goals for levels of health in the future. and recommends selections among alternative actions. This process includes making choices that are considered most likely to affect the health system, the health status of the elderly population, and direct improvements in the performance of the }lea1th systeJ1t.
Nursing home services are the major focus Of this Component Plan. However a continuum of services is necessary to address the improvement of the health status of the present and future elderly and enhance the quality of
21

life.ofthis population. Nursing homes, therefore, represent services at the more restrictive and institutional end of the health service continuum.
Plans for nursing home services and retirement community nursing home services must consider the factors that determine the demand for such services. These determinants, as discussed, include the increase in the relative size of the aged population cohorts, the health status and consequent health care needs of the elderly, the use and desirability of formal and informal long-term care services, the availability and accessibility of alternative and auxillary services, as well as the perceived need for such services. Reimbursement and fiscal viability issues also significantly impact upon the use of nursing home services.
Americans may indicate more concern with facilities than services. The total health care budget and ultimately, the funds available for many health care services will be affected by decisions involving the provi~ ion of long-term care. The quality of life and the availability of costeffective services to meet identified needs of a gra.nng elderly population is at issue.
The goals, objectives and recommended actions that follow are directed toward service objectives to meet long-term care needs, and to address the continued development of an array of long-tenn care services that support a continuum model of care. The recommended guidelines will address nursing home services specifically. A trichotomized classification schema for services for older persons is presented in Appendix C.
22

V. GOALS, OBJECTIVES and RECOMMENDED ACTIONS
A. GOAL: The health status of older Georgians improved through activities directed toward prevention of chronic health probleMs, or the reduction of disability resulting from health probleMs.
OBJECTIVES: 1. Health services available and accessible to Georgians which offer wellness and preventative/risk management services as part of health care services.
2. Curriculum development in schools of medicine, nursing and allied health and gerontology which offer specific content concerning geriatric health and wellness.
RECOMMENDED ACTIONS By 1990, further development of assessment tools directed toward the identification of functional disability as well as functional ability and possible service needs as part of the Community Care and Services for the Elderly assessment effort, through the Office of Aging and the Division of Public Health.
By 1990, the State Health Planning Agency will participate in the identification of long-term care services and areas of need to share with persons in schools preparing geriatric service providers, administrators and others involved in geriatric services.
By 1990, the Department of Education, in coordination with the Office of Aging and the State Health Planning Agency will survey available educational programs with specific focus on gerontology programs and health care for 01 der Georghns.
During 1986 and: 1987, the State Health Planning Agency will participate as a member of the Advisory Committee on Healthy Older Persons and.assist in implementation of a national educational and health promotion program to promote prevention actions for older Georgians.
23

__The State Health Planning Agency will support the Oepartment of Human Resources' initiative 'Independence for nlder Georgians', and survey the availability of formal services for older Georgians which encourage adaptive life choices to i~prove health status, and support the network of services which i~pact on the need for facility-based long-term care services.

B. GOAL:

A full continuum of services available to ~eet the long-term care needs of older Georgians to include assessment services, alternative services and auxiliary services, financially and geographically accessible.

OBJECTIVES: 1. Assessment services to determine individual health status and assessment of need for services, available statewide.

2. Expansion of the availability of services offered under thp. Community Care and Services for the Elderly Act, by inclusion of all persons needing such services without regard to Medicaid eligibility.

3. Increased information concerning the range of long-tenn care services available.

RECOMMENDED ACTIONS By 1990, assessment services to detennine individual health status and need for services should be available to older Georgians by expansion of existing assessment services through the DHRlDivision of Public Health, in cooperation with established health care services.

By 1990, the Department of Human Resources will expand the Community Care program to include the functionally impaired elderly who can partially Qr totally pay for the cost of the services.

By 1990, a directory of geriatric and long-term care services should be developea and distributed by the Office of Aging through the Area Agencies on Aging.
24

The availability of community-based long-term care services to meet the neeos of geriatric patients, and improved knowledge of these services increases the likelihood of the use of services and decreases reliance on facility-based services. Improved financial accessibility effectively increases the population who are able to use the available services. Use of community services decreases reliance on nursing home services and medical assistance only (MAO) institutional financial support.
c. GOAL: Nursing home services available and geographically accessible to the
population who require skilled and medically supervised care.
OBJECTIVES: 1. Nursing home services based on guidelines presented in this Plan.
2. Services provided on a skilled care level to those who require extended care post-hospitalization and more intensive skilled care.
3. Services developed to meet the needs of special populations such as persons with Alzheimer's disease and related disorders, as part of overall service programs.
4. Services developed of high quality that meet all licensing standards and physical plant standards.
5. Nursing home services developed as part of or including other services which provide aid to meet the needs of older Georgians while expanding options in the continuum of care offered.
RECOMMENDED ACTIONS By 1986, nursing home services will be developed based on a population based .methodology that provides for geographic ~ccessibility within a county servi~e area~
25

___By 1988, nursing home services will include provisions for skilled care when expansion, renovation, replacement or new construction is authorized (beginning in 1986), as defined by Certificate of ~:eed review.
By 1988, services in nursing homes to ~eet the needs of persons with Alzheimer's disease or related disorders will be planned as part of general services with provisions to meet special needs.
By 1990, a survey of use patterns of major services to older Georgians will be conducted by the State Health Planning Agency.
By 1991, all nursing homes will meet or exceed physical plant licensing standards as verified by licensing inspections and services.
Nursing home services developed by a population-based methodology remain quantitatively responsive to the population of an identified county service area. Services are to be available within a county of origin where continuity of care and social support patterns can be maintained. Nursing home services represent the most institutional services, and should include provisions for skilled care within its programs and services to complete the continuum of long-tenn services. Retirement communities may apply for nursing home beds at a ratio of one bed for each four residential units, and should be encouraged to make provisions for the availability of a range of services which maximize independence.
D. GOAL: Financial incentives and considerations that support the provision of long-tenn care services by informal caretakers, and reimbursement levels consistent with the level of patient need for skilled care.
OBJECTIVES: 1. Continued" le.gislative study on the -provision of options for long-term care insurance.
2. Legislation authorizing tax credits for those who provide
26

---substantial care to disabled older Georgians who require such care as verified by assessment.
3. Development of a strategy that offers reimbursement based on the patient's acuity of need for levels of care, rather than the provider chosen.
4. Modification of medical assistance regulations to prevent impoverishment of the spouse.
RECOMMENDED ACTIONS The State Health Planning Agency will monitor the testimony and recommendations of the Senate Insurance Committee Long-term Care Insurance Task Group.
By 1990, legislation will be developed allowing for reasonable tax credit for long-term care providers as verified by assessment.
By 1987, the Departm.nt of Medical Assistance provision for increased nursing hours for skilled care patients will be approved.
By 1988, a proposal will be developed to modify existing reimbursement mechanisms for provision of skilled care and modification of Medicaid eligibility requirements to prevent impoverishment of the spouse.
Current fiscal policies encourage the use of institutional services as Medicaid assistance is the only avenue open to meet long-term care needs. Fiscal policies that enhance the availability of formal and informal long-term care systems to meet specific needs in a cost-efficient manner ultimately determine which services will be provided and available.
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I. ~ECOMMENOED-GUIDELINES FOR DEVELOPMENT OF NURSING HOME SERVICES
A. Definitions 1. 'A nursing home' is a long-term care facility which admits patients by medical referral and provides for continuous medical supervision via 24-hour a day nursing care and related services in addition to food, shelter and personal care. A nursing home may be licensed as a skilled nursing facility, an intermediate care facility or an intermingled facility.
2. 'A skilled nursing facility' (SNF) as defined in Certificate of
Need Chapter 272-2-.01(22).
3. 'An intermediate care facility' (IeF) as defined in Certificate
of Need Chapter 272-2-.01(15).
4. 'An intermingled facility' is a facility licensed to care for patients under skilled and intermediate levels of care. Th~ facility is required to operate under the requirements of a skilled nursing facility.
5. 'A freestanding nursing home' is a facility operating as a selfcontained health care facility to provide nursing home services and related support services.
6. 'A non-freestanding nursing home' is a nursing home facility which operates as a lesser part of a hospital or retirement community. Such a nursing home is located in sufficient proximity to enable the sharing of medical personnel and managerial or admini strative resources, central ized dietary and/or supply and maintenance services with the hospital or retirement community.
7. 'A retirement community' is a planned, age-restricted, congregate living development which offers housing, recreational, security, dietary services and health care services and shared livjng space areas accessible to residents.
28

--s. 'Official State Health Component Plan' means the documents
related to the above-named services developed by the State Health Planning Agency, established by the Georgia State Health Policy Council and signed by the Governor of Georgia.
9. 'Rural area' means any county in Georgia with less than 62,000 population.
10. 'Urban area' means any county in Georgia with 62,000 population or more.
11. 'Health service area' (HSA) means the official service areas in Georgia established under P.l.93-641 as amended.
12. 'Service area' for all nursing facilities with the exception of State Nursing Facilities means each county in Georgia. 'Service area for a State Nursing Facility' means the State of Georgia.
13. 'Intergovernmental contract' is a legally binding contract, between two county governments for the purpose of allocating nursing home bed need by a county without either a nursing home or general hospital physically located within its geographic boundaries to an adjoining county, that is binding for at least 25 years; such a contract may not include providers or others as parties to the contract.
14. 'Adjoining county' means any county which adjoins the county without a nursing home or general hospital at one or more points along its geographic boundary.
15. 'A State Nursing Facility' is a facility which meets the definition of a Nursing Home as defined in this Plan, and is owned ,and operated by a branch or branches of government of the State of Georgia.
29

B. AVAILABILITY
Criterion I - Need for Service Standard 1 1. A new nursing home shall be approved in a service area only if the following conditions are met:
(i) need for beds in each service area shall be based on a ratio of 47 beds/IOOO projected CNI (civilian non-institutional) population age 65 and over; and
(ii) new freestanding facilities must meet the need standard. The desired minimum bed size for a new freestanding nursing home is 60 beds in a rural area and 100 beds in an urban area. The Agency may allow variance from the need standard to allow development of a new nursing home of the desired minimum size in a rural county where the net bed need is between 55 and 59 beds, where the growth of the elderly population shows an upward trend, and where the county has no hospital and no nursing home.
(i i i ) permanent convers ion of exi sti ng underut i1ized acute care hospital beds to skilled or intermingled beds will receive more favorable consideration to meet identified need when proposed capital and operating costs are demonstrated to be cost-effective and financially feasible; and
(iv) new, non-freestanding facilities must meet the need standard and demonstrate that the size of the proposed operation is financially feasible and cost-effective. Applications from retirement communities for a new, non-freestanding nursing home will be accepted at no more than a ratio of one nursing home bed for each four residential units. Requests for expansion of a retirement community nursing home above the initial ratio may be considered when justified by the experience of occupancy by the nursing home, b~ need in the service area and when the proposal is in compliance
30

with all other applicable standards and by demonstration that placement of the additional beds is a superior alternative to placement elsewhere; and
(v) in competing applications, favorable consideration will be given for the inclusion of specialty services, such as Alzheimer's and related disorders, retirement community nursing home beds and/or the inclusion of cost-effective alternative services within the facil ity plan, such as adult day care, respite care, intergenerational day care, etc;. The proponent must demonstrate that the area to be served has a need for such servi ces, and must also document a11 associated costs and other requirements to make the special service operational.
Rationale for Standard (additions/modifications) (i) Since 1983, the Long-Term Care Component of the State Health Plan has had a bed-to-elderly population method for determining bed need for nursing home services. The present 47 beds/1000 aged population has resulted in planned growth based on population projections for the age group over 65. It is acknowledged that persons under 65 may have use of long-term care facilities, but the overwhelming use is by those over 65 (99%).(40) The bed need per 1000 older population is a target number to assure availability to those most likely to need the services of a nursing home.
The target number of 47 beds/IOOO population over age 65 ranks Georgia higher than the actual number of beds-to-population in South Carolina, Florida, Tennessee and Mississippi in the Southeastern region.(41) The actual number of beds in a given service area is likely to be higher than the target ratio when 'approved for construction' beds are considered. Presently, the bed-to-population ratio in Georgia is 53.8 beds/IOOO aged population for 1988. These beds do not include state-operated beds or private MR beds.(42)
31

(ii) &-- (lv) New construction costs are based on an economy of scale, related to the costs of land, materials, construction, labor, etc., in the area where new development is planned. The primary purpose of the desired minimum bed number cited reflects the variations in such cost and economies of scale in rural and urban areas. The actual configuration of the project should demonstrate economy in the use of space, planning of patient care areas to support optimal access to each patient from each nursing station, and the most efficient use of staff.(43) This rural/urban designation also allows for the differences in the demand for nursing home services and the availability of staff to provide long-term care services.(44)
The purpose of a variance from the need standard to allow development of a new nursing home of the desired minimum size in a rural county where the net bed need is between 55 and 59 beds where the county has no hospital and no nursing home is to address access issues in underserved areas. As noted on page 35 of this Plan, the county is chosen as the service area to provide maximum geographic accessibility and foster a sense of community relationship that will continue within a facility. The nursing home also can serve as the pivot for encouraging development of a continuum of 10ngterm care services in the community. In addition, patient origin data show that the majority of nursing home patients are residents where the nursing home is located, thereby enhancing the patient's ties to family, friends and community.
(iii) The effects of reimbursement policies and changing hospital use patterns have resulted in underutil ization of some hospital beds. The conversion of such beds to long-term care nursing home beds is feasible if the project is financially feasible and the post-hospital needs of patients are served in a manner consistent with quality care which may contribute to substantially reducing health care expenses by allowing for appropriate continuing care. Vertical integration of long-term care provides, in some cases, a continuum of care by providing optimal patient care, efficient use of resources, and post-hospital arrangements when such interim s~rvices are needed.(45)
32

Financial feasibility will include construction costs, comparative costs with other facilities in the area, occupancy and referral sources, payment source expectat ions and fi nanci al mechani sms. Retirement communities desiring nursing home services will be reviewed as a non-freestanding facility. The ratio of one nursing home bed to four residential units is consistent with the ratios in general use (1:4 - 1:5) cited by Laventhol
&Horwath. (46).
(v) The inclusion of prOV1Slons for services to special populations for long-term care services will be considered. These provisions for services may include, but are not limited to, services for Alzheimer's and related disorders, and consideration for development of alternative services such as adult day care, respite care and intergenerational day care. The provision of care for Alzheimer's Disease and related disorders must be specific to the needs of the individual patient. There is no consensus that services must be provided on a separate unit, but services for AD/RD patients demand that a facility demonstrate attention to design considerations, such as but not limited to provision for large, safe and protected areas for exercise and wandering, enclosed outdoor areas for walking and the use of wall and floor coverings to reduce over or under sensory stimulation.(47)
Applications that propose to serve patients with Alzheimer's Disease and related disorders must demonstrate the appropriately high staff-to-patient ratios, training of staff for the safe and effective behavioral management of patients and activities that promote independence within the limitation of the mental disability present. Facilities which propose such services should promote support for the family and family support of the patient to maximize the patient's use of his/her existing abilities.(47)
Provision of alternative or continuing long-term care services, such as respite care, adult day care or intergenerational day care may enhance the financial feasibility of the project, as well as meet the long-term care needs of the service area population. Retirement home nursing home beds will be considered at a ratio of 1:4 to expand the total range of services
33

offered-to elderly residents, which may include skilled nursing care, as well as other health and social services.
C. Accessibility Criterion I - Geographic Accessibility Standard 1. The service areas will be defined as each county in Georgia.
Criterion II - Financial Accessibility Standard 1. An appl icant for a new or expanded facil ity must provide evidence of meeting the following requirements:
(i) the applicant shall provide written assurance of intent to participate in the Medicaid program; and
(ii) favorable consideration will be given to proposals which provide written assurance of intent to participate in the Medicare program; and
(iii) the applicant shall demonstrate a case mix of Medicaid, and when appropriate, Medicare and private pay patients and document policies and practices of non-discrimination by past performance of the applicant and all facilities owned or operated by the parent company; and
(iv) the applicant in a county without skilled care beds must include provisions to be licensed as a skilled or intermingled care facility so that skilled care services are available; and
(v) the applicant for skilled and intermingled facilities shall document provisions such as the necessary staffing levels and related costs essential for operation as a skilled care facility.
34

Rationale .for Standards Accessibility refers to the ability of a population to obtain appropriate, available services. This ability is determined by economic, locational, architectural, cultural, organizational and informational factors.(Sl)
The county is chosen as the service area to provide maximum geographic accessibil ity and foster a sense of community relationship that will continue within a facility. It also encourages development of a continuum of services in each community. Patient origin data show that the majority of nursing home patients are residents of the county where the nursing home is located.
Access, further, includes financial accessibility which includes the concept of non-discrimination based on source of payment. Ideally, a long-term care system provides the most cost-effective care of the right level, at the right time, in the right setting and at the maximum quality achievable.(S2)
The availability of skilled care and participation in financial programs such as Medicare and Medicaid provides the consumer with reasonable access to appropriate needed care.
D. QUALITY Criterion I - Services to Residents Standard 1: An applicant for a new or expanded nursing home must provide evidence of the intent to meet all appropriate requirements regarding quality of care.
(i) the appl icant shall submit evidence of intent and abil ity to meet the requ i rements for 1i censure by the Department of Human Resources, Office of Regulatory Services; and
(ii) the applicant shall provide evidence that there are no uncorrected operational standards in any existing Georgia nursing homes owned and/or operated by the appl icant or by the parent
35

~_9mpany . Pl ans to correct phys ical plant defi ci enc i es in the applying facility must be included in the application.
Rationale for Standard Quality is a measure of the degree to which delivered health services meet established standards and judgements of value to the consumer. (53) The provisions of licensure Rules and Regulations for Nursing Homes (Chapter 290-5-8) and Intermediate Care Homes (Chapter 290-5-9) are to assure the minimal standards for services delivered. Quality is a function of many variables, including but not limited to:
- education, experience and understanding of the health care providers;
the process of service delivery, including the provision of appropriate level of care to meet specific patient care needs;
- institutional capacity to deliver services in an efficient and costeffective manner, via physical plant arrangement and safety considerations;
- licensure and certification (Medicare - S.S. Act Amendment, 1965) to survey compliance with established standards;
- the ability of the facility to satisfy the expectations of the community to deliver care of quality acceptable to established and community standards.
E. CONTINUITY Criterion I - Provision of policy regarding referral agreements, rehabilitation plans and services and discharge planning procedures. Standard 1: An applicant for a new or expanded facility must document provisions of continuity of care by meeting each of the following:
36

ii) the applicant shall document the existence of proposed and/or existing referral agreements with a nearby hospital to provide emergency services and acute care services to the residents of the proposed or existing facility; and
(ii) the applicant shall document assurances of the prOV1Slon of adequate rehabilitation plans and services to facility residents; and
(iii) the applicant shall provide assurances that adequate discharge planning activities and coordination of services exist for each facility resident.
Rationale for Standard Continuity relates to 'the extent of effective coordination of services prov ided to i nd i vi dua1s and the commun i ty over time with in and among health care settings' .(54)
In long-term care, this relates to the continuum of services and the provision of 'bridge' services to coordinate service needs effectively. The ability to coordinate services enhances the ability of a facility to meet the needs of each individual patient, while providing access to the least restrictive service to meet the patient's need. The provision of rehabilitation and discharge planning services may influence the outcome for the patient, the use of subsequent services and enhance the efficient use of available services.
37

F. DEVELOPMEnT OF SERVICES
Criterion I - Provision For Intergovernmental Contracts Standard 1: Intergovernmental contracts for the allocation of nursing home bed need will be recognized when the following criteria are met:
(i) the governing body of a county in which there is an unmet need for less than 60 nursing home beds in a rural area or less than 100 beds in an urban area and in which there is neither an existing nor approved nursing home nor general hospital physically located within its geographic boundaries may enter into an intergovernmental contract with an adjoining county(ies) to allocate all or a portion of its net need that exists at the time of the contract to such adjoining county(ies) for the following purposes:
A. to permit the construction of a new nursing home; or
B. to permit the addition of beds to one or more existing nursing homes in the adjoining county(ies); or
C. to permit an underutilized acute care general hospital to convert up to 50 percent of its evaluated capacity to a nursing home under the provisions in Standard 1 (ix); and
(ii) such contracts must contain provision for assurance that the citizens of the county without a nursing home will receive preference for the beds established in response to their county's need; and
(iii) to insure that the county without a nursing home is being served, the contract must contain a requirement that the county in which the allocated beds are to be established will require that the nursing home or nursing homes comply with all data reporting requirements of the State Health Planning Agency; and
38

(iv) the terms of the contract must be in effect for a minimum of 25 years, except for the provision covered in Standard 1 (ix); and
(v) the county without a nursing home or general hospital may contract with more than one adjoining county within the same year (April 1 to March 31) to allocate specified portions of its bed need when justified for the purposes of geographic accessibility; and
(vi) the nursing home beds which are allocated via the contract with the adjoining county or counties and for which a Certificate of Need may be subsequently granted must be operational within three years of the final decision of any appeal of the Certificate of Need decision; if the beds are not operational in the time specified, the contract must contain provisions for the contract to become null and void; and
(vii) the intergovernmental contract must be between the county governments only and may not include any other parties to the agreement and may not include any prejudgment of a potential provider, except for that covered in Standard 1 (ix); and
(viii) the planning agency may recognize at only one later point-in-time an additional intergovernmental contract or contracts following the same cri teri a and executed by the county wi th no nurs i ng home or general hospital; and
(ix) an additional option shall be available for an underutilized, acutecare, general hospital to convert beds to a nursing home allowing the terms of the contract to be in effect for a minimum of five years; the intergovernmental contract under this option shall include the following provisions in addition to meeting all other requirements in Standard 1 (i) through Standard 1 (viii):
A. no more than 50 percent of the hospital's evaluated capacity may be converted to a nursing home; and
39

B. at-the end of the contractual period, the affected acute-care, general hospital shall close the nursing home beds related to the donor county when the home county of that hospital is notified by the donor county that the donor county no longer will contract beds to that county and there is an ability to develop those beds into a nursing home within the donor county; and
C. as soon as a nurs i ng home is operat i ona1 in the donor county, the affected acute-care, general hospital shall make provisions for an orderly transfer of all nursing home patients to an appropriate nursing home within a period of time not to exceed six months; and
D. the affected acute care, general hospital shall close the nursing home beds resulting from the contract(s) permanently unless another Certificate of Need is obtained under another rule; and
E. the affected acute-care, general hospital shall not admit new nursing home patients from the time the new facil ity is opened in the donor county.
Rationale for Standards The development of nursing home services in a geographic area presumes sufficient population to support the services, with sufficient numbers of residents who need such services as well as financial considerations, staffing, referral services, etc. Acounty without a nursing home and with insufficient population to support the development of even a 60-bed nursing home may have some residents which require such services.
The provisions for intergovernmental contracts provide for counties without a nursing home or hospital to enter into a contract with an adjoining county to provide the services for the residents of that county as an alternate way to develop such services without waiting for the population to increase sufficiently to support the development of services within the county. As noted in the rationale for Standard l(iii), pertaining to the conversion of unused hospital beds to nursing home beds under Criterion I -- Need for Service, certain events
40

such as reimbursement policies and changing hospital use patterns, have resulted in underuti1ization of some hospital beds. The conversion of such beds to 10ngterm care nursing home beds may be feasible under certain circumstances and may enhance access to care in some geographic areas. This provision for intergovernmental contracts provides another means for appropriate conversion of unused hospital capacity. However, this provision is not intended to allow an acute-care general hospital to convert totally to a freestanding nursing home. Not more than 50 percent of the hospital's total evaluated capacity beds should be converted to nursing home beds under this provision since a hospital must continue to meet the acute-care needs of the residents of the area. The need for nursing home placement of patients experienced by the hospital is a strong reason for allowing this conversion. Fewer hospital beds would mean a diminished need for such placement.
Other factors which may support conversion of underuti1ized hospital beds to nursing home beds include the following:
(1) Unused capacity in acute-care general hospitals in Georgia is increasing, as indicated by declining occupancy rates, a trend which is contributing significantly to system-wide costs; and
(2) While hospitals are responding to the acute-care needs of community residents, some hospitals indicate that they are experiencing increasing difficulty in placing patients who need longer term care. Alternatives to expensive acute-care services should be available to provide other appropriate settings for the patients who need long-term care; and
(3) Some existing nursing home facilities may be fully utilized or may not be financially accessible to some community residents (e.g., Medicare or Medicaid patients) or may not be available to patients who have heavy skilled care needs, thereby making placement of such residents in a nursing home bed very difficult.
In view of these factors, it is expected that a hospital which converts underuti1ized beds to nursing home beds under this provision will set up and
41

staff the beds-to provide both skilled and heavy skilled nursing care as well as care to both Medicare and Medicaid patients. Heavy skilled nursing care means the application of recognized nursing methods, procedures and actions directed toward implementation of a physician's prescribed diagnostic and therapeutic plan for sub-acute care patients who require 8 to 24 hour nursing care because they are respirator or ventilator-dependent, require tube feedings, require IV therapy, require oxygen supplements or whose conditions are so debilitating that 24 hour observation is required to note symptoms or signs which may arise and which will require attention of a physician and a revision in their treatment regimen. Heavy skilled nursing care must be provided by or under the supervision of a licensed registered nurse.
F. DEVELOPMENT OF SERVICES (Continued) Criterion II - State Nursing Facilities
Standard 1 A proposed or expanded State Nursing Facility may be exempted from the provisions of these guidelines designated as B. Availability, Criterion I - Need for Service, Standard 1; C. Accessibility, Criterion 1Geographic Accessibility, Standard 1, and Criterion II - Financial Accessibility, Standard 1; and F. Development of Services, Criterion I, Standard 1 when the said facility meets each of the following:
(i) documentation that the proposed facility will be, or the existing facility is, owned and operated by the State of Georgia; and
(ii) documentation that the applicant will admit patients from any of Georgia's counties with a primary focus on a predesignated multicounty area or region; and
(iii) the facility intends to be accessible to patients whose care, because of income and other limitations would normally come under the jurisdiction of the State; and
42

(iv) such other considerations as may be considered necessary by the State Health Planning Agency at the time of the application.
Rationale for Standard The need to exempt state-owned and operated facilities arises out of the fact that these facilities serve a broad-based population which is either regional or statewide in nature. Further, the state-owned facilities are uniquely placed to serve a specialized population which would normally rely on the State for nursing care or special populations which receive care which is financed through 10ngterm entitlements, such as the veterans. Also, the State is in a unique position to provide statewide services which may not otherwise be provided through other arrangements.
The State Nursing Facilities are aimed at serving a regional or statewide population. In contrast, all other facilities serve a predominantly local population. Hence, the service area for the latter facilities is the county of location. The use of the county as the service area for the non-state nursing facilities is designed to assure maximum accessibility for the population in need of nursing care.
The State Health Planning Agency's inventory of nursing homes currently classifies nursing homes as either "general" if they care for the population primarily afflicted with physical and/or organic disabilities, or "special" if they care for a predominantly mentally retarded population. All existing (as well as those approved for Certificate of Need but not yet operational) general nursing home beds were ( and still are) included in the State Health Planning Agency's inventory of "available beds". Hence need is the net of all available beds.
While the government owned and operated "special" nursing beds were excluded from the inventory, the beds in the Department of Veterans Service (DVS) owned nursing homes were classified as "general" and were therefore included in the inventory of available beds.
43

The inclusion-~f the DVS nursing home beds in the State Health Planning Agency's inventory of available beds had the effect of overstating the availability of beds in the counties where those facilities are located. For example, the 3 nursing homes for veterans in Baldwin County have an aggregate total of 402 beds. At the same time, the 1993 Nursing Home Net Projected Bed Need (issued in April 1990) shows a surplus of 415 beds for the county. However, it should be noted that patient origin data indicate that an overwhelming majority of the patients at the three facilities originate from outside Baldwin County. To reflect the fact that the 3 facilities are targeted to serving a statewide veteran population, there is a need to create a separate inventory for these homes and to use the State as the logical service area.
Following approval of this Standard the State Health Planning Agency will create an inventory of all State Nursing Facilities and classify them into the following categories for inventory purposes only:
(a) State Nursing Facilities for the Mentally Retarded (StNF/MR)
(b) State Nursing Facilities for General Disabilities (StNF/GD)
(c) State Nursing Facilities for the Veterans (StNF/VA).
Aretroactive Certificate of Need will be issued for facilities falling into the first two categories as they presently do not have a Certificate of Need. The existing veterans facilities will be removed from the current inventory of general nursing homes into the new inventory of State Nursing Facilities.
44

APPENDIX
45

APPENDIX A
STATE OF
GEORGIA
Nursing Home Capacitj beds
G9 No Nursing Homes
1984 Inventory - 2/10/86
SOURCE: State Health Planning Agency
46

':'?:J::'i: ~X S NURSING HOMES APPROVED - July 1979-September 1985

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SOURCE: State Health Planning Agency - I

47

APPENDIX C

. Clal.wcauon or lervicet (or old.r p.rsona
Focu. of Servic. OeUv.ry

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r.c.cuc.I cia, .... P,yC""., are
A!lJwUDer Iamilr pou,.

HOlD. btlJlh are Prouctive ...-.. I.pice cuw II ....

Coacre.ata-Raid.aCW lAd IDICitl'tiaaBaNd
....... RaanaaeDc COIIUIUaaiti
Seaiar boulinc
Coqnpceoftlidear.iU houaU2e
Gtaup bcNut SIwI&Inci mid_ciU taci1iti" . . . .-ud<are (doaaici1W-l cu.
c.ciIicitt
.... are
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auniaa c.eiIicin
SkiUed IlUl'linc t.ciIit.i Hoapic. can ia a I.NCY

Tob;n t Sheldon t "The Funct;on t Form and Future of Formal Serv;ces", AGING 2000, Vol. II, p.197, Spr;nger-Verlag t New York, 1985.

48

APPENDIX 0

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GEORGIA 1 .co.. '-

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STATE OF

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7'

)". .."\" , .

~Counties with total
population equal to or greater than 62,000 eNI populati0n
in 1989.

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SOURCE: State Health Planning Agency
49

APPENDIX E INVENTORY OF STATE NURSING FACILITIES
GEORGIA 1990

NArlF LJUN Y
STATE NURSING FACILITIES/MR NW G. Inter. Facility (Floyd) (at NW Ga. ReQ. HOSD.) Ga. ReQ. HOSD. - Atlanta (DeKalb) Ga. Retard. Center (DeKalb)

OWNER/
State/DHR State/DHR State/DHR

Athens Unit - GRC (Clarke) Gracewood Dev. Ctr. (Richmond) Gracewood N.H. Unit 9 (Richmond) CSH - Allen Hall (Baldwin CSH - Nursing Ctr. #1 (Baldwin) CSH Pecan Manor (II I) (Ba1dwi n) CSH Piedmont Hall (Baldwin) SW Devel. Ctr. (Decatur) (Bainbridge) Rosehaven N.H. (Thomas)

State/DHR State/DHR State/DHR State/DHR State/DHR State/DHR State/DHR State/DHR State/DHR

EVAL.

LICENSED BEDS

BED
rAP

SNF ICF ICFMR TOT.

98

--

-- 98

98

67

--

-- 67

67

459

94

.- 365 459

40

--

--

40

40

700

--

-- 700 700

56 56 -- -- 56

270

--

-- 270 270

98

89

--

-- 89

149

--

-- 134 114

149

--

-- 149 149

216

--

-- 216 216

112

21

--

91 112

STATE NURSING FACILITIES/GENERAL CSH Riverside Nsg. Ctr. (Baldwin) STATE NURSING FACILITIES/YETERANS Ga. War Vet. N. H. (Richmond) CSH Russell BldQ. (Baldwin) CSH Vison Bldg. (Baldwin) CSH Joe T. Wood Bldg. (Baldwin) Reopened 3/23/89

State/DHR
State-DYS/MCG State-DYS/OHR State-OYS/OHR State-DVS/DHR

99 99 -- -- 99

192 192

--

-- 192

132 132

--

-- 132

120 120

--

-- 120

150 150

SUS BED

LICENSURE

SNF

ICF

ICFMR

TOTAL

CLASSIFICA-
rrON

PROGRAM

VAil

IlJn 11N

-- --

98

98 ICF (MR) Medicaid

-- --

67

67 ICF (MR) Medicaid

94 --

288

382 Distinct Medicaid

Parts

-- --

38

38 ICF (MR) Medicaid

-- -- 573 573 ICF (MR) Medicaid

54 --

--

54 SNF

Medicaid

-- -- 266 266 ICF (MR) Medicaid

78 --

--

78 SNF

Medicaid

-. -.

130

130 ICF (MR)

Medicaid

-- -- 130 130 ICF (MR) Medicaid

-- -- 202 202 ICF (MR) Medicaid

21 --

91 112 Distinct Medicaid Parts

76 --

--

76 SNF

Medicaid

185 --
126 -110 --

-- 185 SNF
-- 126 SNF
-- llO SNF
SNF

SOURCE: 1988 ANNUAL NURSING HOME QUESTIONNAIRE AND THE STATE HEALTH PLANNING AGENCY RECORDS.

50

REFERENCES 51

REFERENCES CITED

1. Long-term Care, National Center for Health Statistics, USPHS, Department
of Health, Education &Welfare, July 1979.

2. Vogel, R. and Palmer, HO., Long-term Care: Perspectives from Research and Demonstrations, Aspen Publications, Rockville, M.D., 1985, p.v.

3. Division of Health Care Statistics, U.S. Department of Health &Human
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4. Progress Report on the Implementation of the Community Care and Services for the Elderly Act (OC.G.A. 49-6-60 et.seq.), January 1985.

5. Status Report on Implementation of Community Care and Services for the Elderly Act, DHR-D04, June 1985.

6. Community Care Services Program Survey, DHR/Office of Aging Memo, March 20, 1986.

7. Performance Audit, DHR/Community Care Services Program, June 1985.

8. Palmer, H., 'The System of Provision', Long-term Care, Aspen Publications, Rockville, M.D., 1985, p.2.

9. Vogel, R., Long-term Care, National Center for Health Statistics, Aspen
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10. Stone, R.S., 'Keynote - Precedent and Prologue for the Aging', An Overview of Design for the Aging, October 17, 1983, Washington, D.C., Architectural Institute of America, Committee on Architecture for Health.

11. Kirchner, Marian, 'The Elderly, Sifting Fact from Myth', Medical Economies, April 29, 1985, pp.34-43.

12. Brady, E.M., 'The Informal Support System and Health of the Future Aged',

~ 2000 - Our Health Care Destiny, Vol.II, Springer-Verlag, New York, 1985

pp:T73-187.

.

13. Brady, p.184.

14. Kutza, Elizabeth, 'Needs, Wants and Preferences - Can a Long-term care System Resp~d', ~ 2000 - Our Health Care Destiny, Vol.II, Springer-Verlag, New York, 1985, p~-277.

15. Branch, L. and Jette, A., 'A Prospective Study of Long-term Care Institutionali~ation among the Aged', American Jour~al of Public Health, 72:12 (December 1982), pp.1373-~379.

16. Weissert, W. and Scanlon, W., Determinants of Institutionalization of the Aged, Rev. Washington: Urban Institute, 1983, p.19.

5~

17. DHR/Ofjjce of Aging, 'Alzheimer's Disease Study Committee Report', December 1985. 18. Weissert, W., 1983, p.19. 19. Weissert, W., 1983, p.12. 20. Smallegan, M., 'There Was Nothing Else To Do - Need for Care Before Nursing Home Admission', The Gerontologist, Vol.25, #4, 1985, p.367. 21. Joint proceddings of hearing before the Select Committee on Aging, Sustaining Quality Health Care under Cost Containment, February 26, 1985, p.4. 22. Conversations with four nursing home administrators and three hospital discharge planners, November 1985. 23. DHR/Office of Regulatory Services, July 1985. 24. Meiners, M. and Coffey, R., 'Hospital DRG's and the Need for Long-term Care Services: An Empirical Analysis', Health Services Research, August 1985, pp.360-380. 25. Mollisen, Andrew, 'Older Peoples' Money', Part III, Atlanta Journal/Constitution, October 2, 1985. 26. Rice, D. and Estes, C., 'Health of the Elderly:Policy Issues and Challenges', Health Affairs, Winter 1984, pp.25-49. 27. State of Georgia, Long-term Care Ombudsman Program Annual Report, FFY'85. 28. Institute for Health Planning, A Glossary of Health Care Delivery and Planning Terms, August 1981, p.2. 29. Living at Home Program, The Multi-Foundation Program to Help Elderly Americans Continue Living at Home, The New York Hospital-Cornell Medical Center, New York. 30. Laventhol and Horwath. L1fecare. Retirement Center Industry, 1985. 31. Gulich, Gary E., Independent Retirement Living, Life Care Corporation, Des Moines. 1979. p.ix. 32. Adelman. Nora (Editor), DirectorY of Life Care Communities. Kendal-Crosslands, 1980. 33. Raper, A.T. (Editor), National Continuing Care Directory, American
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53

37. Salter:_~ Sal lye, 'Homes for aged taking on new meaning', Atlanta Journal, January 20, 1986, pp.19-20.

38. 'News at Deadline', Hospitals, January 20, 1986, p.22.

39. Institute for Health Planning, A Glossary of Health Care Delivery and Planning Terms, August 1981.

40. Georgia State Health Plan, Long-term Care Section, 1981, 1983.

41. Division of Health Care Statistics, U.s. Department of Health &Human
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42. State Health Planning Agency, April 1985.

43. Conversation with Thomas Dean, Ph.D., economist with American Health Care Association, November 22, 1985.

44. MGT of America, Inc. for HSA of South Florida, Criteria and Standards for Nursing Homes, December 1978.

45. Butler, N., 'The Elderly - An Acute Care Hospital's Perspective', Health Care Financing, Spring 1984, p.57.

46. Laventhol and Howarth, Lifecare, Retirement Center Industry, 1985.

47. Peppard, N., 'Alzheimer's Special Care Nursing Home Units', Nursing Homes, September/October 1985, p.26.

48. Physical Plant Standards (Chapter 290-5-8-16), Rules and Regulations for. Nursing Homes, effective November 15, 1976; and Physical Plant Standards (Chapter 290-5-9-18), Rules and Regulations for intermediate Care Homes, effective November 15, 1976.

49. Heym, R., 'Expansion Planning and Design: The Vital Process', The Journal of Long-term Care Administration, Fall 1985, pp.100-104.

50. Palmer, H. and Catterill, P., 'Studies of Nursing Home Costs' , Long-term

CRaorcek: vPileler,spMec.Dtiv.,es19f8r5om,

Research and pp.665-72i.

Demonstrations,

Aspen

Publications,

51. Institute for Health Planning, A Glossary of Health Care Delivery and Planning Terms, August 1981.

53. IHP, A Glossarr of Health Care Delivery and Planninl Terms, August 1981. 54. IHP, op.cit.,August 1981.
54

ADDITIONAL REFERENCES

American Health Care Association. 'Trends and Strategies in long-term Care' , 1985.

Berkeley. Ellen P., 'Where People are Users'. Architecture. November 1985, pp.76-77.

Clark. PhilliP. 'The Social Allocation of Health Care Resources: Ethical Dilemas in Age Group Competition'. The Gerontologist. 1985, p.124.

Davis. Karen. 'Interview: What Medicaid and Medicare Did and Did Not Achieve'. Hospitals. August 1. 1985. p.41-42.

Gentile. B. and Mistarz. J 'Nursing Home Market Attracts Multis: Survey. Hospitals. June 1. 1985, p.M24.

Goggaro, Travis, 'The Use of Break Even Analysis in Long-term Care Facilities', Journals of Long-term Care Administration, Winter 1981, p.I-9.

Hamilton, K.l., 'A Cost-Benefit Analysis Mandatory Medicine Participation'. Journal of Long-term Care Administration, Winter 1981. p.7.

Heckler, Margaret, 'Alzheimer's Disease - A Top Priority', Human Development

News, August 1985, pp.1-16.

.

Kane, R. and Kane, R., 'The Feasibility of Universal long-term Care Benefits', The New England Journal of Medicine. May 23. 1985. Vol.312. #21. pp.1357-1364.

Kalb. D. and Krueger. D 'Controlling Expansion of the Nursing Home Industry - Effects of Prospective Payment Systems on Capital Formations'. Topics in Health Care Financing. Spring 1981. pp.78-87.

Lewis. M.A Kane. R Cretin. S. and Clark. V 'The Immediate and Subsequent Outcomes of Nursing Home Care'. American Journal of Public Health. July 1985. Vol.75. #7, p.758.

MacStravic. R.E 'Long-term Bed Needs for Long-term Care'. Journal of Long-term Care Administration. Winter 1981. pp.1-1.

McAuley. W. and Bleizner. R 'Selection of Long-term Care Arrangements by Older Commun1ty Residents'. The Gerontologist. Vol.25. #2. 1095. pp.188-193.

McMahan. K 'Saving Labor Dollars through Proper Design'. Contemporary lTC. October 1985. p.67.

Myers; G. and Manton. K 'Morbidity. Disability and Mortality: The Aging. Connection'. Aging 2000, Vo1.II, Chapter 3., Springer-Verlag, New V.ork. 1985.

Newnan. A. and Schwarz. K 'Conversion of Acute General Hospitals to Long-term Care. Institutions: The Problems and Possibilities'. prepared for Western Center for Health Planning. San Francisco. CA. April 1980.

55

Plant~ J. t 'Nursing Home Chains Reveal Strategies', Hospitals, A.H.A., June 1, 1985, p.M 10. Rabins, Peter, 'Establishing Alzheimer's Disease Units in Nursing Homes: Pros and Cons', Hospital and Community Psychiatry, Vol.37, #2, pp.120-121, February 1986. Tobin, S., 'The Functions, Form and Future of Formal Services', Aging 2000, Vol.II, Chapter 16, Springer-Verlag, New York 1985, pp.182-199.
56