of concern because they may limit access for those in need of services. This overall high occupancy rate reflects both the shortage of beds discussed above and the increase in patients discharged from hospitals needing subacute care and rehabilitative care (HCIA and Arthur Andersen, 1994).

The likely consequence of this shortage is that nursing facilities can be somewhat selective in their admission practices, and some have limited the access of individuals who may have the greatest need for services (Nyman, 1989a).

As the population ages and develops multiple chronic conditions, the need for long-term care (LTC) services, including nursing home care, will increase. The demand for nursing facilities to provide more complex services is growing in response to several trends, including increased age and disability of residents, medical technology, cost containment pressures, and government policies (Hing, 1989; Shaughnessy et al., 1990; Kanda and Mezey, 1991; Schultz et al., 1994).

The magnitude of the potential growth in demand is illustrated by the projected growth of the older population discussed in the previous chapter. Medical technology, formerly used only in the hospital, is being transferred to nursing facilities. The use of intravenous feedings and medication, ventilators, oxygen, special prosthetic equipment and devices, and other complex technologies has made nursing home care more difficult and challenging (Harrington and Estes, 1989; Shaughnessy et al., 1990). The kinds of services that are increasingly being provided in some nursing facilities are also creating a greater need for skilled nursing care, in particular, greater professional nursing involvement in the direct care of patients and in supervision, more clinical evaluation, and more financial and human resources.

Several federal government policy changes in the 1980s have contributed to