purposes of licensure and evaluating resident outcomes. Residents are entitled to a private apartment (shared only by choice) that includes a kitchen, a bath with roll-in shower, locking doors, and temperature control capability. Routine nursing services and case management for ancillary services are provided. Data show that residents in these Oregon assisted-living facilities have a remarkably high level of disability: 84 percent have some mobility impairment, 75 percent require assistance with medications, and 63 percent require assistance with bathing. Most importantly, the orientation of staff toward the residents is to empower them by sharing responsibilities, enhancing choices, and managing risks (Wilson, 1994). Because of the lack of regulations and standards, consumers need to question providers about all aspects of services, including the philosophy of care, number and type of staff, staff training, staff supervision, and costs, to determine if resident and family needs will be met.

The sub-acute unit is another alternative long-term-care model. With the advent of the Medicare prospective payment system and use of diagnosis-related groups (DRG) as the basis for payment in hospitals, older adults began to be discharged "quicker and sicker" to nursing homes. In the United States, this early discharge of older adults from hospitals has led to a movement to create sub-acute care units in nursing homes, discussed more fully below in "Future Demand for Institutional Long-term Care." These units do not necessarily focus on frail older adults in the latter stages of life, but are in response to the economic changes affecting hospitals and tend to reinforce a medical model of care (Lyles, 1986; Ganroth, 1988; Swan et al., 1990).

Case-Mix Data

According to Fries (1994), case-mix refers to distinctions of residents related to resource use where resource use is primarily defined as a ratio of nursing time to costs. Nursing home residents are a heterogeneous mix of vulnerable adults whose ages may span more than 50 years. Residents are also getting older; those over the age of 85 years constitute about 42 percent of nursing home residents, up from 34 percent in 1980. Despite the dramatic increase in the number of nursing home residents who are age 85 or older, there are more than 181,000 (12 percent) residents under the age of 65 in nursing homes (McKnight's Long-term Care News, 1993). As noted earlier, a high percentage (around 75 percent) of persons who reside in nursing homes are reported to suffer from a chronic dementing process or some form of mental health or behavioral alteration. Most of these residents also have medical and personal care needs that require ongoing staff intervention and support. For example, about half (51 percent) of residents are incontinent of urine. Physical care issues, low staff ratios, regulatory issues, and inadequate staff preparation and training often mean that residents with behavioral impairment are still poorly understood and tolerated in the long-term-care environment (Hall, 1995).

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