dent in multiple ADLs, have multiple chronic illnesses, and be cognitively impaired. Because of continued short hospital stays for acute illnesses and increased use of home care services where possible, residents in nursing homes will tend to be sicker and more acute illnesses will be treated in the nursing home. At the same time, alternative settings, such as assisted living and group home facilities, will be more available and will house more of the younger elderly with fewer or less severe impairments (O'Connor, 1995). More emphasis in these facilities will be placed on rehabilitation to maintain and improve function. Convalescent nursing homes are also expected to be more prevalent, with many elderly discharged to their own home after a short stay for recovery and rehabilitation.

Nursing homes will also include greater numbers of residents with AIDS, more residents with infections like methacycline-resistant Staphylococcus aureus and tuberculosis, elderly who are developmentally disabled, residents requiring rehabilitation, and hospice residents. Special units devoted to the care of residents with these conditions, as well as residents on ventilators and with pressure sores, are expected to increase.

Although it is positive that more alternatives to nursing homes will be available for the elderly, the downside is that the majority, if not all, of the residents of nursing homes will require more complex and intensive nursing care, and most will be highly functionally debilitated both cognitively and physically. Logically, this changing case-mix has clear implications for the types and numbers of staff that will be required to deliver quality care. More professional nursing staff (registered nurses) with gerontological training and greater use of gerontological nurse practitioners will be needed, both to plan and provide care and to direct and supervise the care provided by assisting staff. The nature of the work with mostly "old old," highly debilitated residents will provide quality-of-care challenges for assisting staff that they will not be able to meet without professional leadership and direction, and it will exacerbate stress, burnout, and turnover problems that are already of great concern.

Subacute Care

As home- and community-based long-term-care options (e.g., assisted-living facilities, continuing care retirement communities) erode the market share served by traditional nursing homes, subacute medical and rehabilitation services are emerging as a viable discharge option for patients who are suffering from cardiac conditions and cancer, recovering from surgical procedures and transplants, who require wound management, or who are ventilator dependent. More than 50 percent of nursing home admissions currently come from hospitals, with most needing care for unstable medical conditions.

According to a report on a subacute care demonstration project in Illinois (McKnight's Long-term Care News, 1993), subacute care includes physician supervision and RN care and physiological monitoring on a continuous basis. Fa-



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