becomes greater than ever. With a shorter length of stay, clinicians have less opportunity to prepare the patient and family for care at home. This becomes more complicated with the aging patient who often exhibits functional decline requiring more intense teaching in preparation for discharge and care at home. The problem is compounded by language barriers.

As the population ages and develops chronic illnesses, the demand for long-term care services including nursing home services will increase. The number of dependent elders (especially those over age 75) is expected to grow as the proportion of total elderly in the population increases (Griffin et al., 1989; Strumpf and Knibbe, 1990). Dependence for assistance ranges from instrumental activities of daily living (IADL), such as cooking, shopping, and cleaning, to personal care ADLs, such as toileting, dressing, bathing, transfer and ambulation, and eating.

With increasing age and disabilities of the residents, shortened hospital stays, and early discharges from hospitals, the demand for nursing facilities to provide more complex services is growing (AHCA, 1995). The degree of medical instability, impairment, and severity of illness in nursing home residents is increasing (Hing, 1989; Shaughnessy et al., 1990; Kanda and Mezey, 1991; Schultz et al., 1994). Medical technology, such as the use of intravenous feedings and therapy, suctioning, rehabilitative services, respiratory care, ventilators, oxygen, special prosthetic equipment and devices, formerly used only in the hospital, has been extended to nursing facilities. These services require more professional nursing care, judgment, supervision, evaluation, and resources than in the past (Shaughnessy et al., 1990).

Only about 5 percent of elderly persons live in nursing homes. However, the total number of elderly persons living in nursing homes has increased in a manner consistent with the increase in the elderly population. Nursing home use increases with advancing age. Whereas 1 percent of those 65 to 74 years lived in a nursing home in 1990, nearly 1 in 4 aged 85 or older did (Schneider and Guralnik, 1990; Bureau of the Census and the National Institute on Aging, 1993a). If current use patterns continue, more than one-half of the women and about one-third of the men who turned 65 years of age in 1990 can be expected to enter a nursing home at least once in their lifetime (Murtaugh et al., 1990). About 43 percent of persons who were 65 years old in 1990 are projected to enter a nursing home some time before they die; more than half of them will spend at least 1 year of their life in a nursing home, and about 21 percent will spend at least 5 years there (Kemper and Murtaugh, 1991). This proportion increases with age. The growth of alternative long-term care settings appears to be having some impact on reducing the demand for nursing home care. Nevertheless, the need and demand for nursing home care is expected to continue. With the growing elderly population and the concomitant increase in the number of persons with multiple chronic conditions and disabilities, these facts have major implications for both medical and nursing practice and for the financing of long-term care.

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