Health Care Institutions

A hospital is no place to be sick.
—Samuel Goldwyn

HOSPITALS

The first hospitals in the United States were established more than two hundred years ago. No records of hospitals in the early colonies exist, but almshouses, which sheltered the poor, also cared for those who were ill. The first almshouse opened in 1662 in the Massachusetts Bay Colony. In 1756 the Pennsylvania Hospital in Philadelphia became the first U.S. institution devoted entirely to care of the sick.

Until the late 1800s, U.S. hospitals had a bad reputation. The upper classes viewed hospitals as places for the poor who could not afford home care, and the poor saw hospitalization as a humiliating consequence of personal economic failure. People from all walks of life thought hospitals were places to go to die.

TYPES OF HOSPITALS

The American Hospital Association notes in “Fast Facts on US Hospitals” (October 23, 2007, http://www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html) that in 2007 there were 5,747 hospitals in the United States that were described as short stay or long term, depending on the length of time a patient spends before discharge. Short-stay facilities include community, teaching, and public hospitals. Sometimes short-stay hospitals are referred to as acute care facilities because the services provided within them aim to help resolve pressing problems or medical conditions, such as a heart attack, rather than long-term chronic conditions, such as the need for rehabilitation following a head injury. Long-term hospitals are usually rehabilitation and psychiatric hospitals or facilities for the treatment of tuberculosis or other pulmonary (respiratory) diseases.

Hospitals are also distinguished by their ownership, scope of services, and whether they are teaching hospitals with academic affiliations. Hospitals may be operated as proprietary (for-profit) businesses, owned either by corporations or individuals such as the physicians on staff, or they may be voluntary—owned by not-for-profit corporations or religious organizations or operated by federal, state, or city governments. Voluntary, not-for-profit hospitals are usually governed by a board of trustees, who are selected from among community business and civic leaders and who serve without pay to oversee hospital operations.

Most community hospitals offer emergency services as well as a range of inpatient and outpatient medical and surgical services. There are more than a thousand tertiary hospitals in the United States, which provide highly specialized services such as neonatal intensive care units (for care of sick newborns), trauma services, or cardiovascular surgery programs. Most tertiary hospitals serve as teaching hospitals.

Teaching hospitals are those community and tertiary hospitals affiliated with medical schools, nursing schools, or allied-health professions training programs. Teaching hospitals are the primary sites for training new physicians, where interns and residents work under the supervision of experienced physicians. Nonteaching hospitals may also maintain affiliations with medical schools and some serve as sites for nursing and allied health professions students as well as physicians-in-training.

Community Hospitals

The most common type of hospital in the United States is the community, or general, hospital. Community hospitals, where most people receive care, are typically small, with fifty to five hundred beds. These hospitals normally provide quality care for routine medical and surgical problems. Since the 1980s many smaller hospitals have closed down because they are no longer profitable. The larger ones, usually located in cities and adjacent suburbs, are often equipped with a full complement of medical and surgical personnel and state-of-the-art equipment.

Some community hospitals are not-for-profit corporations that are supported by local funding. These include hospitals supported by religious, cooperative, or osteopathic organizations. During the 1990s increasing numbers of notfor-profit community hospitals converted their ownership status, becoming proprietary hospitals that are owned and operated on a for-profit basis by corporations. These hospitals joined investor-owned corporations because they needed additional financial resources to maintain their existence in an increasingly competitive industry. Investor-owned corporations acquire not-for-profit hospitals to build market share, expand their provider networks, and penetrate new health care markets.

Teaching Hospitals

Most teaching hospitals, which provide clinical training for medical students and other health care professionals, are affiliated with a medical school and have several hundred beds. Many of the physicians on staff at the hospital also hold teaching positions at the university affiliated with the hospital, besides teaching physicians-in-training at the bedsides of the patients. Patients in teaching hospitals understand that they may be examined by medical students and residents as well as by their primary attending physician.

One advantage of obtaining care at a university-affiliated teaching hospital is the opportunity to receive treatment from highly qualified physicians with access to the most advanced technology and equipment. A disadvantage is the inconvenience and invasion of privacy that may result from multiple examinations performed by residents and students. When compared to smaller community hospitals, some teaching hospitals have reputations for being impersonal; however, patients with complex, unusual, or difficult diagnoses usually benefit from the presence of acknowledged medical experts and more comprehensive resources available at these facilities.

Public Hospitals

Public hospitals are owned and operated by federal, state, or city governments. Many have a continuing tradition of caring for the poor. They are usually located in the inner cities and are often in precarious financial situations because many of their patients are unable to pay for services. These hospitals depend heavily on Medicaid payments supplied by local, state, and federal agencies or on grants from local governments. Medicaid is a program run by both the state and federal government for the provision of health care insurance to people younger than sixty-five years of age who cannot afford to pay for private health insurance. The federal government matches the states' contribution to provide a certain minimal level of available coverage, and the states may offer additional services at their own expense.

TREATING SOCIETY'S MOST VULNERABLE MEMBERS . Increasingly, public hospitals must bear the burden of the weaknesses in the nation's health care system. The major problems in U.S. society are readily apparent in the emergency rooms and corridors of public hospitals: poverty, drug and alcohol abuse, crime-related and domestic violence, untreated or inadequately treated chronic conditions such as high blood pressure and diabetes, and infectious diseases such as acquired immunodeficiency syndrome (AIDS) and tuberculosis.

LOSING MONEY . The typical public hospital provides millions of dollars in health care and fails to recoup these costs from reimbursement by private insurance, Medicaid, or Medicare (a program run by the federal government through which people aged sixty-five and older receive health care insurance). Joel S. Weissman notes in “The Trouble with Uncompensated Hospital Care” (New England Journal of Medicine, vol. 352, no. 12, March 24, 2005) that the National Association of Public Hospitals and Health Systems (NAPH) estimates that nearly half of all public hospital charges are not ultimately paid. According to Weissman, this figure has grown sharply as the number of uninsured Americans has also increased. State and local governments provide subsidies to help offset these expenses. However, even with the subsidies, the unpaid costs incurred by the nation's public hospitals add up to billions of dollars' worth of care each year.

In “Charity Care at U.S. Hospitals on the Rise as Americans with No Health Insurance Grows” (April 1, 2006, http://www.fast-health-insurance.com/health-insurance-news-archives/2006_03_26_affordable-health-insurance-news-archive.html), the PricewaterhouseCoopers Health Research Institute reports that the dollar amount of uncompensated service, of which charity care is a component, provided by U.S. hospitals rose 30% since 1999—from $20.7 billion to $27 billion in 2005. Even though approximately 70% of hospitals surveyed said they provide discounted care to the uninsured as well as charity care, many fail to communicate adequately their charity policies to patients, which results in fewer needy patients requesting financial assistance. The institute exhorts hospital leaders to “proactively report to the community and local leaders through an annual community benefit report” to defend against accusations that they are not fulfilling their charitable missions.

PROVIDING NEEDED SERVICES. The NAPH (2008, http://www.naph.org/Content/NavigationMenu/About_Our_Members/Characteristics_of_NAPH_Members/Characteristics_of_NAPH_Members.htm) believes the mission of public hospitals is to respond to the needs of their communities. As a result, most provide a broad spectrum of services. Even though the need for trauma care exists throughout the nation and across all socioeconomic levels, in thirty cities including Albuquerque, New Mexico; Las Vegas, Nevada; Memphis, Tennessee; New Orleans, Louisiana; Richmond, Virginia; and San Francisco, California, NAPH-member hospitals are either the only providers of trauma center services or provide the highest level of trauma care.

According to Ron J. Anderson, Paul J. Boumbulian, and S. Sue Pickens, in “The Role of U.S. Public Hospitals in Urban Health” (Academic Medicine, vol. 79, no. 12, December 2004), almost half of NAPH-member hospitals provide prison services, and some hospitals have dedicated beds for prisoners. County and city revenues provide most, if not all, of the funds available for prison services. Many of the NAPH-member hospitals are also major academic centers, where they train medical and dental residents as well as nursing and allied health professionals. Anderson, Boumbulian, and Pickens explain that NAPH-member hospitals are just 2% of the nation's hospitals, but they provide 25% of uncompensated care.

SOME PUBLIC HOSPITALS IN PERIL OF CLOSING . New York City's cash-strapped public hospital system, the facilities that provide trauma and emergency care and are considered lifelines for the working poor, are imperiled because the bulk of their reimbursement comes from Medicaid and Medicare, which have failed to keep pace with rising inflation. In “Cabrini Medical Center Closes Its Doors” (The Sun [New York City, New York], March 18, 2008), E. B. Solomont reports that in 2006 a state health care commission recommended that five of the eleven public hospitals in New York City would close in the coming years. In late 2007 St. Vincent's Midtown Hospital closed and in March 2008 Cabrini Medical Center became the second hospital to close. The city's public hospital system projects an average annual deficit of $314 million between 2008 and 2012. The city has subsidized the Health and Hospitals Corporation for more than a decade. Between 2005 and 2008 the average annual subsidy was $1.2 billion, up from $290 million between 1999 and 2004.

The problems New York City faces are only compounded at the national level. In the press release “President's Budget Would Further Weaken Health Care Safety Net” (February 4, 2008, http://www.naph.org/naph/PressRoom/Press_Statement_2009_Budget_02_04_09_FINAL.pdf), the NAPH decries President George W. Bush's (1946–) fiscal year 2009 budget request, explaining that cutting Medicaid expenditures by $200 billion over five years will have a disproportionate impact on public hospitals and would threaten to close more public hospitals, further compromising the nation's “safety net”—its essential role in the provision of care for uninsured Americans. Citing economic uncertainty and heightened awareness about matters of national security, the NAPH asks Congress to reject this budget, and if needed, to enact legislation to prevent President Bush from implementing a budget that “will severely damage public hospitals nationally.”

Hospital Emergency Rooms: More Than They Can Handle

For many Americans, the hospital emergency room has replaced the physician's office as the place to seek health care services. With no insurance and little money, many people go to the only place that will take them without question. Insurance companies and health care planners estimate that more than half of all emergency room visits are for nonemergency treatment.

Poor or near poor children up to eighteen years of age of all races were more likely to visit emergency rooms (27.3% and 21.8%, respectively) in 2005 than those who were not poor (17.9%). (See Table 3.1.) In 2005, 28.5% of children on Medicaid visited emergency rooms at least once, as opposed to 17.4% of children who were privately insured and 18.4% of uninsured children. In the eighteen and older age group, 29.8% of poor people made one or more emergency department visits and 23.2% of the near poor made one or more visits in 2005. (See Table 3.2.) Of adults aged eighteen to sixty-four, 17.3% of people who were privately insured made one or more emergency room visits during 2005, as opposed to 40.1% of those who had Medicaid and 19.5% of those who were uninsured.

Even though any type of hospital can experience slow emergency room service, public hospitals are frequently underfunded and understaffed, and service can be exceedingly slow. All-day waits in the emergency room for initial treatment are not uncommon. Andrew P. Wilper et al. of the Harvard Medical School indicate in “Waits to See an Emergency Department Physician: U.S. Trends and Predictors, 1997–2004” (Health Affairs, vol. 27, no. 2, January 15, 2008) that the median waiting time to see a physician in a hospital emergency department rose from twenty-two minutes in 1997 to thirty minutes in 2004. The researchers attribute the longer waits to an increase in the number of emergency room visits and the closure of many emergency rooms. Uninsured patients and those who do not have a primary care physician account for much of the increase. When they use emergency rooms for routine care, the system becomes over-burdened. At the same time, hospitals provide so much uncompensated care through emergency rooms that they end up closing or stop offering emergency care.

MAJORITY OF EMERGENCY ROOM PATIENTS HAVE HEALTH INSURANCE . Because people without health insurance or a usual source of care often resort to using hospital emergency departments, many industry observers assume that the crowding and long waits in the emergency department are at least in part caused by uninsured patients seeking care for routine illnesses such as colds, flu, or back pain. In “Characteristics of Frequent Users of Emergency Departments” (Annals of Emergency Medicine, vol.48, no. 1, July 2006), Kelly A. Hunt et al. refute this hypothesis and characterize frequent users of emergency medical care (adults who made four or more emergency department visits in one year) as people with both insurance (84%) and a usual source for health care (81%). Between 2000 and 2001 frequent users accounted for just 8% of emergency department users and 28% of all adult visits. Contesting the notion that frequent users were generally inappropriate users, Hunt et al. find that frequent users were sicker than less frequent users and made more health care visits to other parts of the health care system for care. They conclude that most emergency department utilization by frequent users appears to be appropriate.

HOSPITALS TRY TO EASE THE PAIN OF WAITING . In an effort to distinguish themselves from competitors and increase patient satisfaction with care, some hospitals are promising patients in the emergency department that they will not have to wait more than thirty minutes to be seen. Even though this guarantee does not apply when the emergency department has multiple critical patients or is so full that ambulances are being diverted to other hospitals, Tammie Smith notes in “Hospital Offering a Time Guarantee” (Richmond Times-Dispatch, March 20, 2006) that under typical circumstances participating hospitals are attempting to reduce the average waiting time to see a physician—46.5 minutes—to under half an hour. When the guarantees are not met and patients have to wait longer, they may be compensated with an apology and movie tickets, prepaid gas cards, restaurant gift certificates, or even free medical care.

In “Hospitals Try Pagers to Ease the Pain of Waiting” (Pittsburgh Post-Gazette, January 1, 2006), Christopher Snowbeck states that other hospitals issue pagers to waiting patients, which allow them to roam the hospital campus or eat in the cafeteria rather than sitting in waiting rooms anxiously awaiting diagnostic testing or appointments. Friends and family are also offered pagers so they can be summoned quickly when physicians have updated information or a patient is ready for discharge.

HOSPITALIZATION

Table 3.3 shows that the discharge rate increased among people aged sixty-five and older from 1990 to 2003. From 2003 to 2004 the rate declined and stabilized through 2005. Discharge rates for all other age groups steadily declined during this period.

In 2005 the hospital discharge rate was 116.2 per 1,000 population. The rate for females was 132 per 1,000, and for males it was 101.3 per 1,000. (See Table 3.3.) Male patients had longer average lengths of stay (ALOS) than female patients—5.2 days compared to 4.4 days. ALOS and discharge rates varied by geography—ALOS ranged from 4.2 days in the Midwest to 5.3 days in the Northeast. Furthermore, the discharge rate per 1,000 population ranged from 100.6 in the West to 124.6 in the Northeast.

Organ Transplants

Organ transplants are a viable means of saving lives, and according to the United Network for Organ Sharing's (UNOS) Organ Procurement and Transplantation Network (OPTN; August 1, 2008, http://www.optn.org/latestData/step2.asp?), in 2007, 28,354 transplants were performed. UNOS compiles data on organ transplants, distributes organ donor cards, and maintains a registry of patients awaiting organ transplants. It reports that as of August 2008, 107,280 Americans were waiting for transplants. UNOS (May 1, 2006, http://www.optn.org/AR2006/114_dh.htm?o=1&g=2&c=15) also states that in 2004 there were 153,245 people living with functioning

organ transplants. Nonetheless, many patients died waiting for an organ transplant because demand for organs continued to outpace supply.

In February 2004 UNOS/OPTN revised and strengthened its policies to guard against potential medical errors in transplant candidate and donor matching. The policy revisions were developed in response to a systematic review begun after a medical error in February 2003, when a teenager named Jesica Santillan died after receiving a heart-lung transplant from a blood-type incompatible donor at Duke University Medical Center. News of this tragic error immediately prompted transplant centers throughout the United States to perform internal audits of their protocols and procedures to ensure appropriate donor-recipient matching.

The key policy revisions included stipulations that:

• The blood type of each transplant candidate and donor must be independently verified by two staff members

  	One or more emergency department visits				Two or more emergency department visits
  Characteristic	1997	2000	2004	2005	1997	2000	2004	2005
  *Estimates are considered unreliable. Data followed by an asterisk have a relative standard error (RSE) of 20%–30%. Data not shown have an RSE of greater than 30%.
  —Data not available.
  aIncludes all other races not shown separately and unknown health insurance status.
  bEstimates are for persons 18 years of age and over and are age-adjusted to the year 2000 standard population using five age groups: 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.
  cThe race groups, white, black, American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with 1999 data, race-specific estimates are tabulated according to the 1997 Revision to the Standards for the Classification of Federal Data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single-race categories plus multiple-race categories shown in the table conform to the 1997 standards. Starting with 1999 data, race-specific estimates are for persons who reported only one racial group; the category 2 or more races includes persons who reported more than one racial group. Prior to 1999, data were tabulated according to the 1977 standards with four racial groups, and the Asian only category included Native Hawaiian or other Pacific Islander. Estimates for single-race categories pri to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. Starting with 2003 data, race responses of other race and unspecified multiple race were treated as missing, and then race was imputed if these were the only race responses. Almost all persons with a race response of other race were of Hispanic origin.
  dPercent of poverty level is based on family income and family size and composition using U.S. Census Bureau poverty thresholds. Missing family income data were imputed for 27%-31% of persons 18 years of age and over in 1997–1998 and 33%–36% in 1999–2005.
  eEstimates for persons 18–64 years of age are age-adjusted to the year 2000 standard population using three age groups: 18–44 years, 45–54 years, and 55–64 years of age.
  fHealth insurance categories are mutually exclusive. Persons who reported both Medicaid and private coverage are classified as having private coverage. Starting wit 1997 data, Medicaid includes state-sponsored health plans and State Children's Health Insurance Program (SCHIP). In addition to private and Medicaid, the insured category also includes military plans, other government-sponsored health plans, and Medicare, not shown separately. Persons not covered by private insurance, Medicaid, SCHIP, public assistance (through 1996), state-sponsored or other government-sponsored health plans (starting in 1997), Medicare, or military plans are considered to have no health insurance coverage. Persons with only Indian Health Service coverage are considered to have no health insurance coverage.
  Health insurance status at the time of interviewe, f
  18–64 years:
  Insured	18.8	19.5	20.1	20.0	6.1	6.4	6.9	6.6
  Private	16.9	17.6	18.0	17.3	4.7	5.1	5.3	4.8
  Medicaid	37.6	42.2	36.8	40.1	19.7	21.0	19.8	20.1
  Uninsured	20.0	19.3	19.0	19.5	7.5	6.9	7.4	8.0
  Note: Data are based on household interviews of a sample of the civilian noninstitutionalized population.

  at the institution involved at the time blood type is entered into the national database.
• Each transplant program and organ procurement organization (OPO) must establish a protocol to ensure blood-type data for transplant candidates, and donors are accurately entered into the national database and communicated to transplant teams. UNOS will verify the existence and effective use of these protocols during routine audits of OPOs and transplant programs.
• Organs must only be offered to candidates specifically identified on the computer-generated list of medically suitable transplant candidates for a given organ offer. If the organ offer is not accepted for any candidate on a given match run, an OPO may give transplant programs the opportunity to update transplant candidate data and rerun a match to see if any additional candidates are identified.

UNOS resolved to continuously review national policies and procedures for organ placement and to recommend policy and procedure enhancements to maximize the efficiency of organ placement and the safety of transplant candidates and recipients, as well as to ensure public confidence in the transplant system. As of August 2008, there had been no further reported occurrences of unintentional blood-type incompatible transplants.

The risks associated with organ transplant were, however, publicized once again in 2005 and 2006, when two transplant recipients from the same organ donor contracted West Nile virus, a potentially serious illness transmitted by mosquitoes. Even though 28,113 transplants were performed in the United States in 2005, according to the OPTN (August 1, 2008, http://www.optn.org/latestData/step2.asp?), and these two recipients were the only ones reported to have become ill from West Nile virus, they suffered the worst possible outcome. Both developed encephalitis (a brain infection), fell into coma, and died. These cases catalyzed transplant physicians and public health officials to intensify organ safety protocols and procedures. Denise Grady reports in “For Two Transplant Patients, a Dire Complication: West Nile” (New York Times, May 16, 2006) that Matthew Kuehnert, an authority in transfusion and transplant safety at the Centers for Disease Control and Prevention (CDC), asserts, “I think organ safety as concerns infectious disease transmission is really underappreciated. It's something that really needs to be looked at more closely.”

SURGICAL CENTERS AND URGENT CARE CENTERS

Ambulatory surgery centers (also called surgicenters) are equipped to perform routine surgical procedures that do not require an overnight hospital stay. A surgical center requires less sophisticated and expensive equipment than a hospital operating room. Minor surgery, such as biopsies, abortions, hernia repair, and many cosmetic surgery procedures, are performed at outpatient surgical centers. Most procedures are done under local anesthesia, and patients go home the same day.

Most ambulatory surgery centers are freestanding, but some are located on hospital campuses or are next to physicians' offices or clinics. Facilities are licensed by their state and must be equipped with at least one operating room, an area for preparing patients for procedures, a patient recovery area, and x-ray and clinical laboratory services. Surgical centers must have a registered nurse on the premises when patients are in the facility.

Urgent care centers (also called urgicenters) are usually operated by private, for-profit organizations and provide up to twenty-four-hour care on a walk-in basis. These centers fill several special needs in a community. They provide convenient, timely, and easily accessible care in an emergency when the nearest hospital is miles away. The centers are normally open during the hours when most physicians' offices are closed, and they are economical to operate because they do not provide hospital beds. They usually treat problems such as cuts that require sutures, sprains and bruises from accidents, and various infections. Many provide inexpensive immunization, and some offer routine health care for people who do not have a regular source of medical care. Urgent care may be more expensive than a visit to the family physician, but an urgent care center visit is usually less expensive than treatment from a traditional hospital emergency department.

Clinics and Urgent Care Centers in Malls and Storefronts

In No Appointment Needed: The Resurgence of Urgent Care Centers in the United States (September 2007, http://www.chcf.org/documents/policy/NoAppointmentNecessary UrgentCareCenters.pdf), Robin M. Weinck and RenéeM. Betancourt indicate that since 2005 there has been a resurgence in the popularity of urgent care centers and clinics in retail settings. The updated versions of such centers offer more than simply convenient locations. Many offer extended hours, flat fees for physician visits, immunizations, comfortable surroundings, and welcome walk-in patients. They emphasize unscheduled care much more than most do most primary care practices. Most do not bill insurance companies; patients pay in cash or by credit card. Health care industry observers characterize these clinics as affordable alternatives as health care consumers assume a greater share of costs and the number of uninsured Americans continues to rise. Victoria Colliver notes in “The Instant Doctor: Health Clinics Popping up in Malls, Storefronts” (San Francisco Chronicle, February 21, 2006) that detractors believe the clinics undermine continuity and quality of care when the same practitioner rarely sees patients more than once and patients do not return for follow-up visits.

LONG-TERM CARE FACILITIES

Families are still the major caretakers of older, dependent, and disabled members of American society. However, the number of people aged sixty-five and older living in long-term care facilities such as nursing homes is rising because the population in this age group is increasing rapidly. Even though many older people now live longer, healthier lives, the increase in overall length of life has increased the need for long-term care facilities.

Growth of the home health care industry in the early 1990s only slightly slowed the increase in the numbers of Americans entering nursing homes. Assisted living and continuing-care retirement communities offer other alternatives to nursing home care. When it is possible, many older adults prefer to remain in the community and receive health care in their home.

Types of Nursing Homes

Nursing homes fall into three broad categories: residential care facilities, intermediate care facilities, and skilled nursing facilities. Each provides a different range and intensity of services:

• A residential care facility (RCF) normally provides meals and housekeeping for its residents, plus some basic medical monitoring, such as administering medications. This type of home is for people who are fairly independent and do not need constant medical attention but need help with tasks such as laundry and cleaning. Many RCFs also provide social activities and recreational programs for their residents.
• An intermediate care facility (ICF) offers room and board and nursing care as necessary for people who can no longer live independently. As in the RCF, exercise and social programs are provided, and some ICFs also offer physical therapy and rehabilitation programs.
• A skilled nursing facility (SNF) provides around-the-clock nursing care, plus on-call physician coverage. The SNF is for patients who need intensive nursing care, as well as services such as occupational therapy, physical therapy, respiratory therapy, and rehabilitation.

Number of Nursing Home Residents Rising

The National Nursing Home Survey (NNHS) is a continuing series of national sample surveys of nursing homes, their residents, and their staff. The surveys were conducted in 1973–74, 1977, 1985, 1995, 1997, 1999, and 2004. Even though each survey focused on different aspects of care, they all provide some common basic information about nursing homes, their residents, and their staff from two perspectives: that of the provider of services and that of the recipient. Data about the facilities include characteristics such as size, ownership, Medicare/Medicaid certification, occupancy rate, number of days of care provided, and expenses. The surveys gathered demographic data, health status, and services received by nursing home residents. The most recent NNHS for which data are available was conducted in 2004. The nursing homes included in this survey had at least three beds and were either certified (by Medicare or Medicaid) or had a state license to operate as a nursing home.

In 2004 the nation's 16,100 certified nursing homes housed more than 1.7 million beds and had occupancy rates of 86.3%. (See Table 3.4.) Nursing homes averaged 107.6 beds per facility.

In 2004, 61.5% of all nursing homes were proprietary (privately owned). (See Table 3.4.) More than half (54.2%) were affiliated with a chain, 30.8% were operated by nonprofit, volunteer organizations, and only 7.7% were operated by governmental agencies.

Most residents of nursing homes are the “oldest old” (people aged eighty-five and older). Out of the total 1.3 million nursing home residents aged sixty-five years old and older, the so-called oldest old accounted for 674,200 (51%) of all nursing home residents in 2004. (See Table 3.5.)

Diversification of Nursing Homes

To remain competitive with home health care and the increasing array of alternative living arrangements for the elderly, many nursing homes began to offer alternative services and programs. New services include adult day care and visiting nurse services for people who still live at home. Other programs include respite plans that allow caregivers who need to travel for business or vacation to leave an elderly relative in the nursing home temporarily.

One of the most popular nontraditional services is subacute care, which is comprehensive inpatient treatment for people recovering from acute illnesses such as pneumonia, injuries such as a broken hip, and chronic diseases such as arthritis that do not require intensive, hospital-level treatment. This level of care also enables nursing homes to expand their markets by offering services to younger patients.

Innovation Improves Quality of Nursing Home Care

Even though industry observers and the media frequently raise concerns about the care provided in nursing homes and publicize instances of elder abuse and other quality of care issues, several organizations have actively sought to develop models of health service delivery that improve the clinical care and quality of life for nursing home residents. In Evaluation of the Wellspring Model for Improving Nursing Home Quality (August 2002, http://www.cmwf.org/usr_doc/stone_wellspringevaluation.pdf), a report that examines one such model in eastern Wisconsin, Robyn I. Stone et al. of the Institute for the Future of Aging Services and the American Association of Homes and Services for the Aging evaluate the Wellspring model of nursing home quality improvement.

Wellspring is a group of eleven not-for-profit nursing homes governed by a group called the Wellspring Alliance. Founded in 1994, the alliance aims to improve simultaneously clinical care delivered to its nursing home residents and the work environment for its employees. Education and collaboration are hallmarks of the Well-spring philosophy, and this program began by equipping nursing home personnel with the skills needed to perform their jobs and by organizing employees in teams working toward shared goals. The Wellspring model of service delivery uses a multidisciplinary clinical team approach (nurse practitioners, social service, food service personnel, nursing assistants, and facility and housekeeping personnel) to solve problems and develop approaches to better meet residents' needs. Each of these teams represents an important innovation because it allows health professionals and other workers to interact as peers and share resources, information, and decision-making in a cooperative, supportive environment.

Shared resources, training, ideas, and goals have had a powerful impact on care at the Wellspring facilities.

Stone et al. observe more cooperation, responsibility, and accountability within the teams and the institutions than what was noted at other comparable facilities. Besides finding a strong organizational culture that seemed committed to quality patient care, the researchers also document measurable improvements in specific areas including:

• Wellspring facilities had lower rates of staff turnover than comparable Wisconsin facilities during the same time period, probably because Wellspring workers felt valued by management and experienced greater job satisfaction than other nursing home personnel.
• The Wellspring model did not require additional resources to institute, and Wellspring facilities operated at lower costs than comparable facilities.
• Wellspring facilities' performance, as measured by a federal survey, improved.
• Generally, Wellspring personnel appeared more attentive to residents' needs and problems and sought to anticipate and promptly resolve problems.

Stone et al. conclude that the organizational commitment to training and shared decision making, along with improved quality of interactions and relationships among staff and between staff and residents, significantly contributed to enhanced quality of life for residents.

The ambitious social outreach programs of one of the charter Wellspring organizations, St. Paul Elder Services, which serves a community of thirteen thousand in Kaukauna, Wisconsin, are described by James Fett in “Social Accountability: Building Bonds in Our Communities” (July–August 2004, http://www.aahsa.org/pubs_resources/futureage/best_practices/documents/BP_V3N4_JUL_AUG04/DEPT_Vision-Fett_V3N4.pdf). St. Paul Elder Services provides much uncompensated care as well as programs

and services to meet unmet needs of older adults in the community. Examples of these services include free blood pressure screenings at senior housing complexes, foot, nail, and ear cleaning services, adult day care for people suffering from dementia, warm-water exercise classes, diabetic menu planning classes, and continence management programs. The president of St. Paul Elder Services explains that “our community is the source of our residents, volunteers, associates and philanthropy … Social accountability … communicates our message of commitment, performance and excellence. Through this process, we have created and strengthened a level of trust and cooperation, improving the quality of life for everyone involved.”

MENTAL HEALTH FACILITIES

In earlier centuries mental illness was often considered a sign of possession by the devil or, at best, a moral weakness. A change in these attitudes began in the late eighteenth century, when mental illness was perceived to be a treatable condition. It was then that the concept of asylums was developed, not only to lock the mentally ill away but also to provide them with “relief” from the conditions they found troubling.

In the twenty-first century mental health care is provided in a variety of treatment settings by different types of organizations. The National Center for Health Statistics (NCHS) describes in “Mental Health Organization” (January 11, 2007, http://www.cdc.gov/nchs/datawh/nchs defs/mho.htm) the following mental health organizations:

• A psychiatric hospital (public or private) provides twenty-four-hour inpatient care to people with mental illnesses in a hospital setting. It may also offer twenty-four-hour residential care and less than twenty-four-hour care, but these are not requirements. Psychiatric hospitals are operated under state, county, private for-profit, and private not-for-profit auspices.
• General hospitals with separate psychiatric services, units, or designated beds are under government or nongovernmental auspices and maintain assigned staff for twenty-four-hour inpatient care, twenty-four-hour residential care, and less than twenty-four-hour care (out-patient care or partial hospitalization) to provide mental health diagnosis, evaluation, and treatment.
• Veterans Administration (VA) hospitals are operated by the U.S. Department of Veterans Affairs and include VA general hospital psychiatric services and VA psychiatric outpatient clinics that exclusively serve people entitled to VA benefits.
• Outpatient mental health clinics that provide only ambulatory mental health services. Generally, a psychiatrist has overall medical responsibility for clients and the philosophy and orientation of the mental health program.
• Community mental health centers were funded under the Federal Community Mental Health Centers Act of 1963 and subsequent amendments to the act. During the early 1980s, when the federal government reverted to funding mental health services through block grants to the states rather than by funding them directly, the federal government stopped tracking these mental health organizations individually, and statistical reports include them in the category “all other mental health organizations.” This category also includes freestanding psychiatric outpatient clinics, freestanding partial care organizations, and multiservice mental health organizations such as residential treatment centers. These so-called community mental health centers have sliding scale fees and accept Medicaid, Medicare, private health insurance, and private fee-for-service payment. Mental health care is also available from not-for-profit mental health or counseling services offered by health and social service agencies, such as Catholic Social Services, family and children's service agencies, Jewish Family Services, and Lutheran Social Services, that are staffed by qualified mental health professionals to provide counseling services.
• Residential treatment centers for emotionally disturbed children serve children and youth primarily under the age of eighteen, provide twenty-four-hour residential services, and offer a clinical program that is directed by a psychiatrist, psychologist, social worker, or psychiatric nurse who holds a master's or doctorate degree.

Where Are the Mentally Ill?

The chronically mentally ill reside either in mental hospitals or in community settings, such as with families, in boarding homes and shelters, in single-room-occupancy hotels (usually cheap hotels or boardinghouses), in prison, or even on the streets as part of the homeless population. The institutionalized mentally ill are those people with psychiatric diagnoses who have lived in mental hospitals for more than one year or those with diagnosed mental illness who are living in nursing homes.

Declining mental health expenditures have resulted in fewer available services for specific populations of the mentally ill, particularly those who could benefit from inpatient or residential care. Even for people without conditions requiring institutional care there are barriers to access. The U.S. surgeon general's landmark report Mental Health: A Report of the Surgeon General, 1999 (1999, http://www.mentalhealth.samhsa.gov/features/surgeongeneralreport/home.asp) describes the U.S. mental health service system as largely uncoordinated and fragmented, in part because it involves so many different sectors—health and social welfare agencies, public and private hospitals, housing, criminal justice, and education—and because it is funded through many different sources. Finally, inequalities in insurance coverage for mental health, coupled with the stigma associated with mental illness and treatment, have also limited access to services.

The U.S. Department of Health and Human Services observes in Trends in Mental Health System Transformation, 2005: The States Respond (2006, http://download.ncadi.samhsa.gov/ken/pdf/SMA05-4115/SMA05-4115.pdf) that state-level initiatives share the common challenge of providing the most effective treatment and services in the face of diminishing resources and increasing needs.

The NCHS reveals in Health, United States, 2007 (2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf) that the number of mental health organizations for twenty-four-hour inpatient treatment steadily declined from 3,942 in 1990 to 2,891 in 2004. (See Table 3.6.) Except for Department of Veterans Affairs medical centers, all other service sites and types of organizations diminished in capacity. The number of beds per 100,000 civilian population fell from 128.5 in 1990 to just 71.2 in 2004. This decline was not necessarily a result of better treatment for the mentally ill but a consequence of reduced funding for inpatient facilities. Many of the patients who were once housed in mental institutions (including some who had been lifelong residents in these facilities) were forced to fend for themselves, on the streets or in prisons.

Besides mental health units or beds in acute care medical/surgical hospitals and physicians' offices, mental health care and treatment is offered in offices of other mental health clinicians such as psychologists, clinical social workers, and marriage and family therapists, as well as in other settings. Private psychiatric hospitals provide outpatient mental health evaluation and therapy in day programs as well as inpatient care. Like acute care hospitals, these facilities are accredited by the Joint Commission on Accreditation of Health Care Organizations and may offer outpatient services by way of referral to a local network of qualified mental health providers. Figure 3.1 shows that depression, a common mental disorder, accounted for 13% of all outpatient department visits in 2005, up from 8.8% in 1995.

National Goals for Mental Health Service Delivery

Healthy People 2010 (2000, http://www.healthypeople.gov/document/tableofcontents.htm) is a set of health objectives for the United States to achieve during the first decade of the new century. Fourteen of the 467 health objectives enumerated in Healthy People 2010 relate to mental health and mental disorders. Even though nearly all the objectives intend to reduce the incidence and prevalence of mental illness in the United States and improve access to care and treatment, several specifically address service delivery issues related to mental health professionals and treatment facilities.

Healthy People 2010 (November 2000, http://www.healthypeople.gov/document/HTML/Volume2/18Mental.htm) objectives call for system-wide improvements in mental health service delivery. For example, number 18-12 calls on the nation to “increase the number of States and the District of Columbia that track consumers' satisfaction with the mental health services they receive.” Number 18-14 asks to “increase the number of States, Territories, and the District of Columbia with an operational mental health plan that addresses mental health crisis interventions, ongoing screening, and treatment services for elderly persons.”

HOME HEALTH CARE

The concept of home health care began as postacute care after hospitalization, an alternative to longer, costlier lengths of stay in regular hospitals. Home health care services have grown tremendously since the 1980s, when prospective payment (payments made before, rather than after, care is received) for Medicare patients sharply reduced hospital lengths of stay. During the mid-1980s Medicare began to reimburse hospitals using a rate scale based on diagnosis-related groups—hospitals received a fixed amount for providing services to Medicare patients based on their diagnoses. This form of payment gave hospitals powerful financial incentives to use fewer resources because they could keep the difference between the prepayment and the amount they actually spent to provide care. Hospitals suffered losses when patients had longer lengths of stay and used more services than were covered by the standardized diagnosis-related group prospective payment.

According to the article “Home Health Care” (Family Economics and Nutrition Review, spring 1996), home health care grew faster in the early 1990s than any other segment of health services. Its growth may be attributable to the observation that in many cases caring for patients at home is preferable to and more cost effective than care provided in a hospital, nursing home, or some other residential facility. Oftentimes, older adults are more comfortable and much happier living in their own home or with family members. Disabled people may also be able to function better at home with limited assistance than in a residential setting with full-time monitoring.

Home health care agencies provide a wide variety of services. Services range from helping with activities of daily living, such as bathing, doing light housekeeping, and making meals, to skilled nursing care, such as the nursing care needed by AIDS or cancer patients. The number of Medicare-certified home health agencies has varied in response to reimbursement, growing from 2,924 in 1980 to 10,807 in 1996, then declining to 7,519 in 2004. (See Table 3.7.) In 2005 the number rose to 8,090, the highest it has been in the twenty-first century.

In 1972 Medicare extended home care coverage to people under sixty-five years of age only if they were disabled or suffered from end-stage renal disease. Before 2000 Medicare coverage for home health care was limited to patients immediately following discharge from the hospital. By 2000 Medicare covered beneficiaries' home health care services with no requirement for previous hospitalization. There were also no limits to the number of professional visits or to the length of coverage. As long as the patient's condition warranted it, the following services were provided:

• Part-time or intermittent skilled nursing and home health aide services
• Speech-language pathology services
• Physical and occupational therapy
• Medical social services
• Medical supplies
• Durable medical equipment (with a 20% co-payment)

Over time, the population receiving home care services has changed. Since 2000 much of home health care is associated with rehabilitation from critical illnesses, and fewer users are long-term patients with chronic conditions. This changing pattern of utilization reflects a shift from longer-term care for chronic conditions to short-term, post-acute care. Compared to postacute care users, the long-term patients are older, more functionally disabled, more likely to be incontinent, and more expensive to serve.

Medicare Limits Home Care Services

The Balanced Budget Act of 1997 aimed to cut approximately $16.2 billion from the federal government's home care expenditures over a period of five years. The act sought to return home health care to its original concept of short-term care plus skilled nursing and therapy services. As a result of this shift away from personal care and “custodial care” services and toward short-term, skilled nursing services, some Medicare beneficiaries who received home health care lost coverage for certain personal care services, such as assistance with bathing, dressing, and eating.

The Balanced Budget Act sharply curtailed the growth in home care spending, greatly affecting health care providers. Nonetheless, the aging population and the financial imperative to prevent or minimize institutionalization—hospitalization or placement in a long-term care facility—combined to generate increasing expenditures for home health care services. Medicare expenditures for home health care rose from $5.1 billion in 2003 to $7.2 billion in 2006, which represented 3.1% of Medicare expenditures. (See Table 3.8.) In contrast, payments to skilled nursing facilities accounted for 10.4% of expenditures in 2006, whereas inpatient hospital expenditures were 63.1% of the total.

HOSPICE CARE

In medieval times hospices were refuges for the sick, the needy, and travelers. The modern hospice movement developed in response to the need to provide humane care to terminally ill patients, while at the same time offering support to their families. The English physician Cicely Saunders (1918–2005) pioneered the hospice concept in Britain in the late 1960s and helped introduce it in the United States over the next decade. The care provided by hospice workers is called palliative care, and it aims to relieve patients' pain and the accompanying symptoms of terminal illness without seeking to cure the illness.

Hospice is a philosophy, an approach to care for the dying, and it is not necessarily a physical facility. Hospice may refer to a place—a freestanding facility or a designated floor in a hospital or nursing home—or to a program such as hospice home care, where a team of health professionals helps the dying patient and family at home. Hospice teams may involve physicians, nurses, social workers, pastoral counselors, and trained volunteers. The goal of hospice care is to provide support and care for people at the end of life, enabling them to remain as comfortable as possible.

Hospice workers consider the patient and family as the “unit of care” and focus their efforts on attending to emotional, psychological, and spiritual needs as well as to physical comfort and well-being. The programs provide respite care, which offers relief at any time for families who may be overwhelmed and exhausted by the demands of caregiving and may be neglecting their own needs for rest and relaxation. Finally, hospice programs work to prepare relatives and friends for the loss of their loved ones. Hospice offers bereavement support groups and counseling to help deal with grief and may even help with funeral arrangements.

The hospice concept is different from most other health care services because it focuses on care rather than on cure. Hospice workers try to minimize the two greatest fears associated with dying: fear of isolation and fear of pain. Potent, effective medications are offered to patients in pain, with the goal of controlling pain without impairing alertness so that patients may be as comfortable as possible.

Hospice care also emphasizes living life to its fullest. Patients are encouraged to stay active for as long as possible, to do things they enjoy, and to learn something new each day. Quality of life, rather than length of life, is the focus. In addition, whenever it is possible, family and friends are urged to be the primary caregivers in the home. Care at home helps both patients and family members enrich their lives and face death together.

Ira Byock, the former president of the American Academy of Hospice and Palliative Medicine, explains the concept of hospice care in Dying Well: The Prospect for Growth at the End of Life (1997): “Hospice care differs noticeably from the modern medical approach to dying. Typically, as a hospice patient nears death, the medical details become almost automatic and attention focuses on the personal nature of this final transition—what the patient and family are going through emotionally and spiritually. In the more established system, even as people die, medical procedures remain the first priority. With hospice, they move to the background as the personal comes to the fore.”