ment loans, which excluded them from the strict federal nursing criteria and led to the creation of intermediate-level care facilities with criteria developed by individual states for reimbursement under Medicaid (Vladeck, 1984).

Altogether, between 1980 and 1990, there was a 24 percent increase in nursing home occupancy rates (McKnight's Long-term Care News, 1993). The percentage of residents requiring more hours of care, more services on a daily basis, and having higher acuity levels has also risen over the past few years. Indeed, 43 percent of all Americans who passed their 65th birthday in 1990 are expected to use a nursing home at least once in their lives (Murtaugh et al., 1990).

Development of Long-Term Care for the Mentally Ill Elderly

For the first half of the 20th century, the mentally ill elderly were systematically admitted to state hospitals, which provided them with custodial care (Kermis, 1987). By the late 1950s and early 1960s, however, the indoor relief policy regarding care of the mentally ill began to change as mental health programming was reoriented to a system of outpatient psychiatric treatment, rehabilitation, and prevention. Both the Kennedy and Johnson administrations supported deinstitutionalization of mental patients in the large state hospitals and the creation of community mental health centers to provide outpatient treatment. Thus, the population of the state mental hospitals, which included many elderly, decreased by as much as 66 percent (Kane, 1984), and those elderly who continued to require institutionalization were most often placed in nursing homes to receive care (Mechanic, 1980).

Unfortunately, the medical focus of most nursing home administrators and personnel left them unprepared to care for those elders with cognitive, behavioral and affective disorders, and nursing homes were faced with large numbers of residents who failed to respond to programming in a conventional manner, did not sleep at night, and became violent when confronted with other residents (Hall and Buckwalter, 1990). Research by Zimmer and colleagues (1984) found that 64 percent of elderly residents of skilled nursing homes had significant behavioral problems, of which nearly 23 percent were classified as "severe." Despite the fact that 58 percent of these patients were receiving psychoactive drugs, both psychiatric diagnoses and consultations were absent. Similarly high rates of mental illness and cognitive disorder (70 to 80 percent) in the absence of active treatment were reported by Roybal (1984) and Rovner and Rabins (1985). By and large, health planners and economists failed to recognize the additional staffing and financial burdens these mentally ill and cognitively impaired residents placed on the nursing home system (Vladick and Alfano, 1987). The current trend, however, is for integrated interdisciplinary treatment teams to provide psychiatric care in nursing homes, an approach that allows for the use of psychopharmacologic, psychoeducational, behavioral, and family or social interventions. Preliminary outcome data suggest, moreover, that this more comprehen-



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