with approximately 650,500 beds. Other community-based long term-care settings include adult day care programs, in which disabled elderly individuals receive supervision, personal care, and social integration in a group setting, usually during the work week and normal work hours (Stone and Wiener, 2001).

Home health care was the fastest-growing employment setting for all nursing personnel throughout the 1980s and 1990s (Buerhaus and Staiger, 1999). As of 2001, there were more than 20,000 home care agencies, approximately 7,000 of which were Medicare-certified. Free-standing, for-profit agencies represented 40 percent of that total and experienced the greatest growth. Hospital-based agencies made up another 30 percent of the total.

These free-standing and facility-based (usually hospital-based) Medicare-certified agencies, home care aide organizations, and hospices employ licensed nursing staff (as well as physical, occupational, and speech therapists) to provide such skilled services as illness management, medication management, infusion therapy, wound care, ostomy instruction, and end-of-life care to clients in their homes and other locations. Licensed home care nurses also supervise home care aides who provide such personal care services as assistance with bathing, eating, and ambulation, as well as monitoring of vital signs and patient status. NAs make up 54 percent of the nursing personnel working in home health care (GAO, 2001b).

The home care industry has experienced substantial turbulence. Since the 1960s, the National Association for Home Care (the home care industry association) has documented periods of rapid expansion and decline in the numbers of home care agencies (National Association for Home Care, 2001). In particular, the Balanced Budget Act of 1997 changed the way the Medicare program pays Medicare-certified home health agencies from a cost-based method to a prospective payment system of fixed, predetermined rates. Subsequently, the number of Medicare-certified home health agencies decreased by 32 percent—from 10,556 in 1997 to 7,715 in 2000 (Office of Inspector General, 2001). As with nursing home care, however, demands for home health services are expected to continue to grow because of reduced lengths of stay in acute care hospitals, advances in technology, and the aging of the U.S. population.

Public Health Agencies

Public health agencies comprise state, county, and local health departments that provide such health care services as immunizations, health education, case management for frail elders, and community assessment. All states have a public health structure and staff at the state level; some also have such a structure and staff in all counties or regions. Although many



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