residents receiving short-term rehabilitative care and other complex care requiring high technology such as ventilator-dependent patients discharged from the hospital who need subacute care skilled nursing services (AHCA, 1995).
In the 1980s, special care units (SCU) emerged as an important intervention for care of persons with special needs, ranging from care requiring high technology to care for dementia. Increasing numbers of nursing facilities are shifting from traditional custodial long-term care to a more specialized level of care (AHCA, 1995). Today more than 1 in 10 nursing facilities have a special unit or program for people with dementia, with more than 1,500 SCUs.
By 1994, nearly 90,000 beds were dedicated to special care. Most of these beds are dedicated to residents with Alzheimer's disease or those needing special rehabilitation services. The most dramatic increase has been in ventilator care beds, from 3,162 in 1993 to 13,291 in 1994. Beds dedicated to special rehabilitative patients increased by 2000 and beds dedicated to AIDS patients grew by 2,300 between 1993 and 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. These units do not focus only on older adults in the later stages of life, but their development is fueled by Medicare's hospital PPS and other payers of health care (Lyles, 1986; Ganroth, 1988; Swan et al., 1990; AHCA, 1995).
Nursing homes are also expanding to cover subacute care. Subacute care is increasingly becoming acceptable as an alternative to cost-effective health care delivery model. Subacute care units of nursing facilities are emerging in response to the need to provide care to patients who suffer from medical conditions or are recovering from surgical procedures and require a broad range of medical and rehabilitative services. More than 50 percent of nursing home admissions today come from hospitals, and most patients need care for unstable medical conditions. The subacute care option is favored by payers because nursing facilities generally can provide such care at lower cost than hospitals. Many subacute care programs are clinically and therapeutically comparable to the medical, surgical, and rehabilitation units of an acute care hospital, yet the cost of care in a subacute care unit is about 40 to 60 percent less than comparable care in an acute care setting. The higher reimbursement rate for subacute care is also attractive to nursing facilities. Although hospitals are ahead of nursing facilities in establishing subacute care units, several major nursing home chains are rapidly moving into this area. At the present time, more than 10 percent of nursing facilities offer