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Practice of Geriatrics
Paul R. Katz, M.D.
Historical Perspective
Scope of Nursing Home Care
Who Pays for Nursing Home Care?
The Decision to Institutionalize
Length of Stay
The Acute Care–Long-Term Care Interface
Health Care Delivery in the Nursing Home: Staffing Issues
The Role of the Physician in the Nursing Home
Role of the Family
The demand for nursing home (NH) services has increased dramatically during the past several years, reflecting an aging population with its attendant high level of physical and psychosocial disability.1 Despite the large numbers of elderly people now receiving institutionalized long-term care, the NH, until very recently, was removed from the medical mainstream. Ageism, economic constraints, an overemphasis on cure at the expense of care, and a lack of commitment to geriatrics on the part of medical educators all contributed to the perception of the NH as a place devoid of intellectual challenge and one in which professional fulfillment is rarely achieved. By reviewing the scope of NH services, resident needs, and complexities of care, this chapter strives to correct any lingering misconceptions about the NH. It is hoped that a realistic portrayal of NH care, including the challenges that lie ahead, will serve as a lure for greater professional involvement in and commitment to this sector of health care.
The modern NH is, surprisingly, a relatively new phenomenon. Prior to passage of Titles XVIII and XIX of the Social Security Act in 1965 (Medicare and Medicaid), the federal government had a limited role in the provision of long-term care services. Private, often religious-affiliated groups provided many needed services to the frail elderly but were generally limited in scope. Indeed, even at the turn of the century, almshouses for the poor and handicapped were major sources of support for long-term care.2
With the enactment of Medicare and Medicaid, the federal government committed itself not only to significant funding for NH care but also to the oversight of such care. To be eligible as a provider of services for Medicare and Medicaid patients and thus receive reimbursement, long-term care facilities must abide by a set of standards established by law. The Health Care Financing Administration (HCFA), under the auspices of the Department of Health and Human Services, has been given the task of ensuring that all standards of care (i.e., conditions or requirements of participation) are adhered to on the state level. Although states must, at the very least, meet the minimum requirements established at the federal level, they may choose to exceed these and establish their own higher standards of care. To ensure compliance, states undertake periodic surveys of all nursing homes that include direct observation and documentation of a facility’s operation.
Despite seemingly intense scrutiny, a consensus developed in the early 1980s that quality care in nursing homes was spotty. Although facilities complied with the letter of the law, the benefits to individual residents were often not realized. In response to these concerns, the Institute of Medicine (IOM) in 1983, under the auspices of the National Academy of Sciences, undertook an extensive review of NH practices, culminating in a report entitled Improving the Quality of Care in Nursing Homes.3 The IOM report highlighted significant deficiencies and recommended a number of changes to improve the quality of care given in nursing homes. One of the major recommendations focused on the need to concentrate more on the actual outcomes achieved than on the processes used to achieve them. Less emphasis on “paper compliance” would, it was hoped, free facilities to concentrate on the actual hands-on care of the NH resident.
The majority of the IOM’s recommendations were incorporated into law with the passage of the Omnibus Budget Reconciliation Act (OBRA) of 1987. In addition, residents’ rights were more clearly articulated, especially those related to freedom from unnecessary medications or restraints. Further, a comprehensive assessment was to be completed on all NH residents within 14 days of admission and periodically thereafter when there was any significant change in condition. This resident assessment instrument, also referred to as the Minimum Data Set (MDS) encompasses a full biopsychosocial overview focusing specifically on 18 target conditions (Table 9-1). If one or more of these conditions is present or the resident has a risk for acquiring such, the care team is referred to resident assessment protocols (RAPs), which outline standard diagnostic and therapeutic approaches to the specific problem in question. These RAPs are, in essence, practice guidelines specific to long-term care. Although documentation is not required, clinicians should document the rationale for treatment that may vary from these guidelines.


Although OBRA 87 has, in many respects, revolutionized NH care, its impact on quality has been difficult to measure. Nevertheless, the dramatic reductions in the use of chemical and physical restraints seen in nursing homes during the past several years are, in large measure, a direct result of OBRA.4 Investigators are currently studying the role that specific questions in the MDS might play in measuring NH quality longitudinally.5
Finally, although the current regulatory system no doubt enhances patient care, at times such care is jeopardized by the fear and paranoia engendered by many state health departments. Such fear often distorts the real meaning behind many of the edicts and regulations emanating from the health department and results, unfortunately, in risk management strategies that seek to minimize exposure of the NH whenever possible. To ensure optimum care of each resident, physicians and other professionals in the NH must understand fully the principles of administrative law, particularly as it relates to rights of access to all pertinent regulations and opinions, the interpretation of statutes on the part of health department representatives, and the right to contest punitive judgments.6 Physicians should never lose sight of the fact that they are in a unique position to set medical care priorities in the NH and to ensure the protection of resident rights.
The number of NH beds in the United States currently exceeds those in acute care hospitals, and they have occupancy rates approaching 90%. Presently, there are over 16,000 nursing homes, and the bed capacity exceeds 1.7 million.7 * The majority of homes are proprietary and have an average of 106 beds. Depending on the assumptions one makes about mortality, the number of NH residents will probably exceed 2 million by the turn of the century and will range from 3.6 to 5.9 million by the year 2040. Indeed, the number of NH residents 85 years old and over in 2040 may be two or three times the number of all residents 65 years old and over who currently reside in nursing homes today!8
Of the elderly population 65 years of age and over, approximately 5% reside in a NH at any given time (3% males, 6% females). The chances of entering a NH sometime during one’s lifetime may approach 40%, and the risk of institutionalization increases with age.9 Whereas 1% of men and women aged 65 to 74 reside in a NH, 15% of men and 25% of women 85 years and over live in NHs.7 Minorities remain under-represented in nursing homes, although they are more functionally dependent at the time of admission.10
Understandably, the current cohort of NH residents is rather old (average age 86) and dependent, and has limited socioeconomic reserves.7 For example, compared to individuals residing in the community, NH residents are twice as likely to be widowed. Although over half of NH residents have difficulty with urinary or fecal incontinence, two thirds or more require assistance in performing basic activities of daily living (ADLs) such as bathing, dressing, and toileting. Although the average resident has a substantial level of disability, the NH population is not as homogeneous as one might surmise. The needs of individual residents, and thus the spectrum of NH services required, are extremely variable and range from custodial to short-term rehabilitative care. Because many NHs are reimbursed according to the actual care needs of their residents, a mix of residents is often sought. For example, the resource utilization groups (RUGs) system in New York State, a prototype for the rest of the country, has 16 classifications of resident needs, all of which have different levels of reimbursement.11 Unfortunately, under a prospective payment system such as this, there is often no financial incentive to decrease the care needs of individual residents. Even when monetary incentives have been employed, medical and functional outcomes of residents have not been appreciably affected.12
The heterogeneity of the NH population is a consequence not only of the manner in which nursing homes are paid but also of the way in which acute care hospitals are funded. With the advent of the prospective payment system under the guise of diagnosis-related groups (DRGs), many patients have been discharged from hospitals “quicker but sicker.” Although the need to avoid lengthy hospital stays is obvious, the prospective payment system places many elderly patients in jeopardy because functional disabilities, as opposed to diagnoses, are often not recognized in determining the allowed length of stay.
There is now ample evidence of the negative impact of hospital-based DRGs on the outcomes of older individuals. Fitzgerald and colleagues13 compared outcomes in elderly hip fracture patients before and after the advent of DRGs and reported decreases in the number of physical therapy sessions needed, the maximal distance walked in the hospital, and the percentage of patients discharged back to the community after the advent of prospective payment. Tresch and colleagues14 noted that, among 100 consecutive admissions to a hospital-based NH care unit after the use of DRGs, 27% required readmission to the acute-care hospital within 30 days. This was almost triple the incidence of readmission prior to the advent of DRGs. Indeed, of the 27 patients readmitted to the hospital, approximately two thirds were judged to have been admitted to the NH too early.
Reflecting the trend to discharge hospital patients before their illness has completely resolved, those people now receiving care in nursery homes are sicker and more disabled than those admitted just 5 or 10 years ago. The changing nature of the NH population can also be seen in recent trends that demonstrate an increase in the number of NH deaths across the United States coincident with a decline in hospital deaths.15 The percentage of NH deaths increased from 18.9% per year in 1982 (pre-DRG) to 21.5% in 1985 (post-DRG), whereas hospital deaths, declined from 65% to 61% in the same period. These figures reflect both an increased mortality rate among long-stay residents and a trend to transfer terminally ill patients to the NH for final care.16 Less aggressive care practices have also contributed to this trend.17 Although demonstration projects have documented the feasibility of treating acute disease in the NH setting when adequate financial incentives are forthcoming, such programs have yet to be applied on a large scale.18
In contrast to acute care, NH care is paid for almost entirely by two sources: “private pay” (the patient’s own resources) and Medicaid, the federal program for the poor. In 1993, Medicaid reimbursed nursing facilities almost $29 billion.
For persons who use nursing homes after the age of 65, 44% begin and end their stay as private payers, 27% begin and end as Medicaid recipients, and 14% eventually spend down their assets to qualify for Medicaid. Put another way, 17% of all persons who turn 65 years of age will reside in a NH at some time before they die and will be dependent on Medicaid for support.19
Ironically, Medicare,* the federal program specifically designed for the elderly, pays less than 10% of total NH costs.20 Private insurance for long-term care is growing rapidly, and most major insurance companies now offer coverage for both NH and home care; almost 4 million policies were sold between 1987 and 1994. Although long-term care insurance presently accounts for a very small percentage of NH payments it is likely to figure prominently in new health care reform policies. Interestingly, underwriting practices may reject up to 23% of Americans for long-term care insurance.21 The total cost of NH care is substantial and is rising rapidly; in 1985 the cost was $35 billion, but this is projected to increase to $139 billion by 2040.8
Even with the rapid growth of public contributions to pay for NH care, the burden on the elderly themselves is still great. Approximately 42% of the out-of-pocket costs of older persons goes for NH care, a larger percentage than is required for physician and hospital out-of-pocket expenses combined.20 Because the average yearly cost of a nursing home in 1995 was $30,000, this expense can be considerable.
In recent years, the advent of managed care has heightened interest in the development of more efficient and cost-effective health systems designed to enhance care for the frail elderly. Although managed care organizations are cautious in assuming risk for nursing home residents with their significant burden of chronic illness, it is hoped that more rational incentives will evolve under the rubric of managed care and will lead to innovations whereby the type and intensity of long-term care services will become more person-centered and less dependent on the site of care.
Contrary to popular belief, there is no magic formula that allows a clinician to predict with certainty whether or not a given individual is destined for a NH. Although several variables have been identified as potential predictors of institutionalization (such as cognitive impairment, incontinence, poor socioeconomic supports, and functional incapacity), quantifying the risk has been problematic. Much of this uncertainty can be attributed to variations in availability and accessibility of community-based long-term care services. For many frail elderly, the availability of services such as respite care, transportation, legal or psychological counseling, specialized housing, and in-home medical care are the major factors that determine the need for NH placement. Increasingly, caregiver burden has been identified as a key variable in predicting NH admission. The use of formal community services, interestingly, has been associated with an increased chance of NH use. Informal care, however, may lower the chances of NH admission. When a spouse or child can share caregiving responsibilities, the risk of a long NH stay is lowered by 9.3%; for childless individuals living alone, the risk increases to 18% and rises to 46% for elderly people living alone with adults other than a spouse or children.22,23
Unfortunately, services vary enormously from one locale to another. Even when services are available, they may not be accessible owing to a lack of knowledge about the scope of such services among families and health care professionals. The accessibility of services may also be a factor in personal or public financing (or the lack thereof).24 Whether innovative case management approaches will be effective in linking patient needs and services in the community, thus circumventing many of the availability or accessibility issues noted earlier, remains to be seen.25
In addition to an individual’s physical, mental, and socioeconomic health status and gaps in the continuum of care, other factors may play an important role in the decision to institutionalize an elderly person. These factors include discrimination based on payer status and on race.
Although inappropriate admissions to nursing homes are much less frequent today than they were in years past, physicians must be certain that all alternatives have been thoroughly explored. Notwithstanding the capacity for short-term rehabilitation for acute medical problems, many individuals, once admitted to a NH, become products of the institution. Learned dependency is a particularly difficult problem to overcome. Interestingly, the availability of home care services in itself has not been found to exert an appreciable impact on NH utilization rates.25
In view of the heterogeneity of the NH population, it is not surprising to find that a sizable number of NH residents have a relatively short length of stay (LOS), particularly those individuals with a terminal illness or those who suffer from acute orthopedic or neurologic deficits amenable to rehabilitation (e.g., stroke, hip fracture). Functional dependency and cognitive impairment may be less predictive of short NH stays than of long stays.26 Because nursing homes are not subject to the same prospective payment system that drives many acute care hospital-based rehabilitation centers, ample time may be allowed for rehabilitation of the older frail patient, thus facilitating the transition of these individuals back into the community. Although almost half of all NH patients have a LOS of less than 6 months, short stays account for only 5% of all NH days. The average LOS is currently approximately 19 months, and two thirds of discharges from the NH are accounted for by death.27 Nonetheless, one third of the lifetime NH risk relates to stays of 90 days or less. Although approximately 25% of patients discharged from the NH return home, only 7% remain alive at home at 2-year follow-up.28 Although this is not surprising in view of the frail nature of the NH population, the reasons for most deaths in the NH usually remain unverified, as demonstrated by a NH autopsy rate of less than 1%.29
Transfer of NH residents between the NH and an acute care hospital occurs frequently. In 1987, 816,000 persons (8.5% of all Medicare hospital admissions) were transferred from nursing homes to hospitals.30 Similarly, more than half of all NH admissions originate from short-stay hospitals; approximately one third of females 85 years and older discharged from hospitals are transferred to nursing homes.31 Unfortunately, there are significant problems with the coordination and content of the information that is transferred between acute care and long-term care providers. Recent national surveys have indicated that frustration exists on the part of both hospital discharge planners and NH admission coordinators. Discharge planners often do not clearly understand the services offered by nursing homes or the regulatory framework under which they operate. Many nursing homes believe, rightly or wrongly, that the true condition of patients is often hidden to facilitate a transfer. Not infrequently, discharge summaries are delayed or incomplete, thus jeopardizing the continuity of care; this is an especially important issue when the attending physician in the hospital is not the one attending in the NH. In the future, computerized linkages between hospitals and nursing homes will probably circumvent many of these difficulties as well as managed care practices that seek to establish a seamless flow throughout the continuum of care. The links between hospitals and nursing homes will continue to evolve as nursing facilities assume care for increasingly sick and unstable patients under the rubric of “subacute” care.
Although transfer of residents from the NH to the hospital is usually based on a need to treat an acute illness, most commonly one secondary to infection, a host of other reasons may be implicated. Many of these are administrative and social-structural factors not directly linked to the severity of the underlying illness.32 Such factors include a lack of adequately trained staff in the NH, an inability or lack of authorization on the part of nursing staff to administer intravenous therapy, a lack of diagnostic services such as radiography, physician convenience, and pressure from both staff and family to transfer difficult cases to a hospital. Nonetheless, many nursing homes remain reluctant to hospitalize residents because of the risk of incurring iatrogenic conditions. One study showed that 30% of patients transferred from a NH to a hospital return with new pressure sores!33
The NH is unique among health care institutions in two major ways. First, because the NH functions as a permanent home for many of its residents, it strives to maintain the attributes of a home. At the very least, this entails respect for privacy, self-determination, encouragement of independent functioning, and inclusion of family and friends within the framework of care provided. Second, nursing homes are unique in terms of the comprehensiveness of the medical care services that are required. Residents must be assessed as often as every 30 days but no less often than every 60 days, even when they are medically stable. In addition, dental and podiatry services are routinely offered, whereas ophthalmologic, gynecologic, and other specialty services are provided on an as-needed basis. Balancing the needs of home versus health care facility is often tenuous, particularly because many nursing homes continue to be based on a medical model of care. Although not necessarily desirable, the medical model of care is understandable in view of the more frail and acutely ill nature of the NH population noted earlier.
Although nursing homes resemble hospitals in many respects, their staffing patterns are widely divergent. NH nurses are relatively few in number, accounting for just over 10% of all NH employees. There is an average of only one registered nurse (RN) per 49 patients in the NH compared to one per five patients in acute care hospitals. This ratio results in an average of 7 to 12 minutes of daily contact between each NH resident and a nurse. Although the federal government has mandated minimum requirements for nursing staff (as well as training for nurses’ aides), one third of nursing homes have been unable to comply. The fact that both total nursing hours and the ratio of professional to nonprofessional nursing staff have been used as reliable markers of quality care has significant policy and clinical implications.34
Most hands-on care in nursing homes is provided by nurses’ aides, who constitute the majority of the work force. Only one third of nurses’ aides have a high school education, and they have turnover rates that average 70% to 100% per year. Vacancy rates for nurses in nursing homes generally exceed those in acute care hospitals. Salary disparities are significant, and RNs and nurses’ aides often earn from 35% to 60% less than their counterparts in acute care hospitals.
Even more than nurses, physicians traditionally have not been attracted to the NH setting. Lack of exposure and firsthand experience in long-term care during training cause many physicians to avoid nursing homes from pure ignorance. Unfortunately, increasing regulations and a demand for greater documentation of all activities that affect the care of residents have had a negative impact on physician recruitment into nursing homes. Currently, only one in five primary care physicians spends more than 2 hours per week in a NH.35 It is hoped that increasing recognition of the educational and research opportunities inherent in nursing homes as well as exposure of medical residents to physician role models devoted to long-term care issues will attract greater numbers of physicians to the NH. In addition, recognition by managed care organizations of the pivotal role played by professionals who are knowledgeable about long-term care will certainly help promote the cause.36
In the NH, care is optimal when all members of the health care team, including nurses’ aides, nurses, and physicians, cooperate in the planning and initiation of all treatments. Such a “team” effort ensures that all pertinent information about the rationale and goals of intervention will be effectively shared among all health care providers. Success in the NH depends on the physician’s willingness to seek out and listen to the opinions of others, regardless of their professional standing. Rather than feeling threatened by others, the physician must make every attempt to understand each individual’s role in the NH as well as the manner in which the NH is governed by state and federal regulations. This is especially important if the physician is to forge a successful constructive relationship with the NH administrator, director of nursing, and pharmacist consultant. Although the medical director is occasionally perceived as a source of aggravation and interference by other physicians, a better appreciation for the role of the medical director will go a long way toward reducing needless friction (Table 9-2).


In the context of the team and through interactions with staff, residents, and family, physicians often serve as role models for NH health care professionals. Skill at communication, clear and concise documentation in the medical record, and an overriding respect for individual rights and dignity are cornerstones of medical practice in the NH. The various roles of the attending physician in the NH are further outlined in Table 9-3.


As one might expect in a very frail and elderly population, much of the illness that becomes manifest in the NH presents atypically. Although the underlying pathophysiology remains the same no matter where care is being delivered, many of the problems encountered in the NH, such as incontinence, falls and syncope, infections, depression, delirium, malnutrition, and pressure sores, require specific diagnostic treatment strategies. Because of limited access to biotechnology, frequent dependence on nonphysicians for evaluation of medical problems, and cost constraints, the NH approach to these problems often differs from that found in the hospital or office setting. For example, whereas it might be feasible to care for a febrile resident with pneumonia in a NH where parenteral antibiotics are part of routine therapy and laboratory and radiologic services are easily accessible, the same patient might well be transferred to an acute care facility if such services are not readily available. Likewise, whereas evaluation of incontinence might entail extensive invasive tests and therapeutic trials in a functional 85-year-old who resides in the community, a similar strategy might be inappropriate for an 85-year-old NH resident who is severely demented and bedbound.
Although the interplay between acute and chronic disease adds a dimension of complexity that requires all the ingenuity of the physician and health care team, the opportunity to maintain health and prevent disease in the NH should not be forgotten. Mandated visitation schedules in the NH allow the physician ample opportunity to perform a complete and thorough geriatric assessment. Whereas review of medications, nutritional status, need for restraints and urinary catheters, and changes in physical or psychological status should be sought at each encounter, an annual review of immunizations, tuberculin skin test reactivity, and screening tests related to cancer detection is recommended. Screening in the NH must, of course, be individualized in accordance with its potential impact on the quality of life and the existence of cost-effective treatment interventions that are acceptable to the resident. Periodic review of Advance Directives should also be sought. Surprisingly, despite a dismal success rate for cardiopulmonary resuscitation in nursing homes, a majority of NH residents prefer to maintain the option of resuscitation. In one recent study, only one in eight residents with decision-making capability had had a previous discussion of preferences with their health care providers.37
Ensuring high-quality care in the NH setting remains a challenge. Numerous reports continue to document the presence of inappropriate care practices. For example, in a study of Maryland nursing homes involving almost 4000 residents in a 1-year period, only 11% of cases involving four common infections received even a minimally appropriate evaluation.38 In addition to individual physician traits, the characteristics of the medical staff (i.e., open versus closed) may predict the quality or intensity of the services delivered.39 The reader is referred to a number of texts devoted exclusively to NH care that discuss in detail many of the pertinent clinical and administrative issues alluded to here (see Additional Readings).
Contrary to popular belief, families do not abandon their loved ones following institutionalization. Indeed, only a minority of NH residents are truly “familyless” in a functional sense. Each family’s function obviously varies from patient to patient but may involve simple companionship, assistance with ADL, and advocacy of resident rights. Forging an effective alliance with the family so that they become an important part of the “total institution” will go a long way toward ensuring an optimal quality of life for each resident.
The continued growth of nursing homes and the increasing complexity of care required will present an ever-increasing challenge to the health care system during the next several decades. Needless to say, physicians, nurses, and other professionals require special skills and sensitivities to ensure delivery of optimum care in an environment that is likely to become even more highly regulated. It is hoped that the opportunity to affect significantly the quality of life of millions of elderly people in need will provide the lure to attract and retain dedicated health care professionals to the NH.

Doty P, Liu K, Wiener J: An overview of long-term care. Health Care Finance Rev 1985;6(3):69.

Johnson CL, Grant LA: The Nursing Home in American Society. Baltimore, Johns Hopkins Press, 1985.

Institute of Medicine, Committee on Nursing Home Regulation: Improving the Quality of Care in Nursing Homes. Washington, D.C., National Academy Press, 1986.

Elon RD: Medical practice in nursing facilities: Assessing the impact of OBRA. In Katz PR, Kane RL, Mezey M (eds): Quality of Care in Geriatric Settings. New York, Springer, 1995.

Zimmerman DR, Karon SL, Arling G, et al: Development and testing of nursing home quality indicators. Health Care Finance Rev 1995;16:107–127.

Kapp MB: Limiting medical interventions for nursing home residents: The role of administrative law. In Katz PR, Kane RL, Mezey M (eds): Advances in Long-Term Care, Vol. I. New York, Springer, 1991.

Strahan GW: An overview of nursing homes and their current residents: Data from the 1995 National Nursing Home Survey. Advance data from Vital and Health Statistics, No. 280. Hyattsville, MD, National Center for Health Statistics, 1997.

Schneider EL, Guralnik JM: The aging of America: Impact on health care costs. JAMA 1990;263:2335–2340.

Cohen MA, Tell EJ, Wallack S: The lifetime risks of costs of nursing home use among the elderly. Med Care 1986;24:1161–1172.

Mulrow CD, Chiodo LK, Gerety MB, et al. Function and comorbidity in south Texas nursing home residents: Variations by ethnic group. J Am Geriatr Soc 1996;44:279–284.

Feather J: Resource Utilization Groups (RUGs): An Introduction for Health Care Professionals. Information on Aging Series. Buffalo, Network in Aging of Western New York, 1986.

Meiners MR, Thorbum P, Roddy PC, Jones BJ: Nursing Home Admissions: The Results of an Incentive Reimbursement Experiment. A NCHSR Report. Washington, D.C., U.S. Dept. Health and Human Services, 1985.

Fitzgerald JF, Moore PS, Dittus RS: The care of elderly patients with hip fracture: Changes since implementation of the Prospective Payment System. N Engl J Med 1988;319:1392–1397.

Tresch DD, Duthie EH, Newton M, Bodin B: Coping with diagnosis related groups: The changing role of the nursing home. Arch Intern Med 1988;148:1393–1396.

Sager MA, Easterling DV, Kindig DA, Anderson OW: Changes in the location of death after passage of Medicare’s prospective payment system. N Engl J Med 1989;320:433–439.

Sager MA, Easterling DV, Leventhal EA: An evaluation of increased mortality rates in Wisconsin nursing homes. J Am Geriatr Soc 1988;36:739–746.

Holtzman J, Lurie N. Causes of increasing mortality in a nursing home population. J Am Geriatr Soc 1996;44:258–264.

Zimmer JG, Eggert GM, Treat A, Brodows B: Nursing homes as acute care providers: A pilot study of incentives to reduce hospitalizations. J Am Geriatr Soc 1988;36:124–129.

Spillman BC, Kemper P: Lifetime patterns of payment for nursing home care. Med Care 1995;33:280–296.

Waldo DR, Lazenby HC: Demographic characteristics and health care use and expenditures by the aged in the United States: 1977–1984. Health Care Finance Rev 1984;6:1.

Murtaugh CM, Kemper P, Spillman BC: Risky business: Long term care insurance underwriting. Inquiry 1995;32:271–284.

Boaz RF, Muelleur CF: Predicting the risk of permanent nursing home residents: The role of community help as indicated by family helpers and prior living arrangements. Health Services Research 1994;29:391–414.

Jette AM, Tennstedt S, Crawford S: How does formal and informal community care affect nursing home use? J Gerontol 1995;50:S4–S12.

Wallace SP: The no-care zone: Availability, accessibility and acceptability in community-based long-term care. Gerontologist 1990;30(2):254–261.

Weissert WG, Hedrick SC: Lessons learned from research on effects of community-based long term care. J Am Geriatr Soc 1994;42:348–353.

Liu K, McBride T, Coughlin T: Risk of entering nursing homes for long vs. short stays. Med Care 1994;32:315–327.

Spence DA, Wiener JM: Nursing home length patterns: Results from the 1985 National Nursing Home Survey. Gerontologist 1990;30(1):16–20.

Lewis MA, Kane RL, Cretin S, Clark V: The immediate and subsequent outcomes of nursing home care. Am J Public Health 1985;75:758–762.

Katz PR, Seidel G: Nursing home autopsies: Survey of physician attitudes and practice patterns. Arch Pathol Lab Med 1990;114:145–147.

Freiman MP, Murtaugh CM: Public Health Reports 1995;110:546–554.

U.S. Department of Health and Human Services: Vital and Health Statistics. Chart Book on Health Data on Older Americans, United States, 1992 (Series 3, No. 29). Washington, D.C., U.S. Department of Health and Human Services, 1993.

Kayser-Jones JS, Wiener CL, Barbaccia JC: Factors contributing to the hospitalization of nursing home residents. Gerontologist 1989;29(4):592.

Tresch DD, Simpson WW, Burton JR: Relationship of long term care and acute care facilities. The problem of patient transfer and continuity of care. J Am Geriatr Soc 1985;33:819–826.

Mezey M, Knapp M: Nurse staffing nursing facilities: Implications for achieving quality of care. In Katz PR, Kane RL, Mezey M (eds): Advances in Long Term Care, Vol. II. New York, Springer, 1993.

Katz PR, Karuza J, Kolassa J, Hutson A: Medical practice with nursing home residents: Results from the national physician professional activities census. J Am Geriatr Soc 1997;45:911–917.

Katz PR, Karuza J, Counsell SR: Academics and the nursing home. Clin Geriatr Med 1995;11(3):503–516.

O’Brien LA, Grisso JA, Maislion G, et al: Nursing home residents’ preferences for life sustaining treatments. JAMA 1995;274:1775–1779.

Warren JW, Palumbo FB, Fitterman L, et al: Incidence and characteristics of antibiotic use in aged NH patients. J Am Geriatr Soc 1991;39:963–972.

Karuza J, Katz PR: Physicians staffing pattern correlates of nursing home care: An initial inquiry and consideration of policy implications. J Am Geriatr Soc 1994;42:1–7.
Psychiatric Care in the Nursing Home. Reichman W, Katz PR (eds). New York: Oxford University Press, 1996.
Medical Direction in Long Term Care. Levenson SA (ed). Durham, NC: Carolina Academic Press, 1993.
Medical Care in the Nursing Home. Ouslander JG, Osterweil D, Morlew J (eds). New York: McGraw Hill, 2nd ed, 1997.
Principles and Practice of Nursing Home Care. Katz PR, Calkins E (eds). New York: Springer, 1989.

*Since the advent of the Omnibus Budget Reconciliation Act of 1987, nursing homes are referred to as residential health care facilities. The distinction between skilled and intermediate (health-related) facilities is no longer valid.
*Most health care professionals are probably familiar with the Medicare system, but for those who are not, the following is a brief overview. Medicare was created in 1965 as Title XVIII of the Social Security Act to assist the elderly and disabled to remain out of poverty by paying for the most expensive portions of health care. Medicare is an entitlement program, and those over 65 years of age and some specific categories of the disabled are eligible. Medicare has two parts: Part A pays mainly for acute hospital care and is free to the beneficiaries; Part B pays mainly for physician and outpatient services, and requires a monthly fee. For an excellent review of the history and current development of both the Medicare and Medicaid programs, see Health Care Financing Review 6 (Suppl), 1985.



  1. This is such an excellent article. I will reference this page on my blog. Regards.

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