cilities will be responsible for developing for every admission a comprehensive plan of care that includes measurable objectives and timetables designed to meet a broad range (e.g., medical, psychosocial) of patient care needs. Rules related to quality assessment and quality improvement, personnel requirements, and admissions practices have been set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which has recently incorporated subacute care into its survey process. Increased staff levels will be necessary to accommodate patients receiving subacute medical, nursing, and rehabilitation services. Outcomes, physical plant, and physician credentials are three major areas addressed in JCAHO accreditation standards for subacute units (Stahl, 1995). It is noted that RN credentials are not included, a curiosity since RNs will obviously play a large role in the care of residents in subacute units in nursing homes. A further concern is that the medical focus will continue to compromise implementation of a social-behavioral model of care in nursing homes.

Special Care Units for Dementia

Special care units (SCU) emerged as an important environmental intervention for care of persons with dementia in the 1980s. Today more than 1 in 10 nursing homes has a special unit or program for people with dementia, with more than 1,500 SCUs providing in excess of 50,000 special care beds. Data indicate that the number of SCUs is continuing to grow rapidly, with more than 2,500 units projected to be in operation by 1995 (NIA, 1994). Although there is much diversity among SCUs, most incorporate some type of physical modification, including security measures to limit egress, specialized activity programming for residents, and special training for staff, who are often permanently assigned to the unit.

There are several reports of studies to evaluate the effects of SCUs; however, most have not employed designs with sufficient control to rule out competing explanations (Greene et al., 1985; Hall et al., 1986; Cleary et al., 1988; Matthew et al., 1988). Experimental research by Maas and Buckwalter (1990) is one exception. Analysis revealed no significant changes in cognitive or functional abilities over time and no significant differences in these abilities between Alzheimer's disease patients on the SCU and on traditional integrated nursing home units (Swanson et al., 1994). Patients on the special unit were restrained less than those living on traditional units, but the SCU patients fell significantly more, on the average. The total number of medications for each patient was not significantly different for SCU versus traditional unit patients, and the number per patient did not increase over the 1-year study period. A multicenter collaborative initiative, funded by the National Institute on Aging and designed to explore the effectiveness of SCUs, evaluate specific interventions and family involvement in care, and compare SCU outcomes to those of traditional nursing home care, is currently under way.

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