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OCR for page 259
8
Alliec} Health Personnel and
Long-Term Care
EARLlER CHAPTERS OF THIS REPORT discussed whether the supply of
allied health personnel will be sufficient to meet the future demand.
This demand has been understood as effective demand, or the number of
allied health practitioners for whose services purchasers would be willing
to pay, given probable economic constraints. In constrast, this chapter shifts
the focus from the number of workers needed to fill jobs to the qualitative
improvements that may be necessary if the allied health labor force is to
be responsive to the needs of a particular segment of our society those
requiring long-term care. These improvements relate not only to whether
care givers have the right technical skills to offer but also to whether services
are organized and delivered in a way that enhances the quality of life for
long-term care consumers.
Clearly, financing policies are a key to quality care, although the available
evidence on nursing homes at least has not shown what the minimum
reimbursement, staffing levels, and staff qualifications must be to provide
adequate care (Institute of Medicine, 1986a). Resolving these financial is-
sues is beyond the scope of this study. However, the committee believed
that it could contribute to policy discussions of long-term care reform by
addressing human resource management and educational issues that emerged
during the course of its inquiry. As a means of gaining insight into these
issues the committee supplemented its review of the literature, discussions
with experts, and its own experience with site visits to 11 long-term care
facilities in urban and rural areas of California, North Carolina, and Vir-
ginia. These site visits guided the committee's selection of the issues it could
reasonably address in the context of its overall report. The collaboration
259
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260
ALLIED HEALTH SERVICES
of allied health personnel with one another and their interactions with
other health care givers was one recurrent issue. The extent to which allied
health curricula prepare students for long-term care settings was another.
LONG-TERM CARE AND ITS CONSUMERS
Although long-term care is defined in a number of different ways, for
the purposes of this study, it is a broad range of clinical, social, and personal
supportive services for people who need assistance over a sustained period
of time to maintain or improve their well-being. The goal of long-term
care is the maintenance or restoration of the highest possible level of phys-
ical, mental, and social functioning of individuals within the constraints of
their illnesses, disabilities, and environmental settings (Meltzer et al., 1981;
Kane and Kane, 19821.
In emphasizing the many types of services necessary to achieve the high-
est attainable quality of life and personal autonomy, this definition has two
important implications for those who provide care and for how those care
givers interrelate. First, care givers of many different professions and dis-
ciplines, as well as a patient's family and friends, must be involved. Second,
this is a process that relies on a flow of information concerning an indi-
vidual's needs, required services, and potential for recovery.
Long-term care can be provided in institutional settings such as nursing
homes (mostly skilled nursing and intermediate care facilities), institutions
for the mentally retarded, residential care facilities (e.g., board and care
homes), long-stay hospitals (e.g., psychiatric hospitals), specialized schools,
and hospices. It is also provided in ambulatory care settings, in community
day care programs, and through home care services. Some rehabilitation
facilities provide long-term inpatient care but also offer specialized am-
bulatory care over an extended period of time.
Although much of this chapter is about the elderly, others need long-
term care services, including infants with birth defects, developmentally
disabled children, adolescents who have suffered head trauma or spinal
cord injury, laborers with emphysema, and elderly people with multiple
sensory deficits. Also in need of such services are the chronically mentally
ill and the severely retarded. In addition, the AIDS epidemic has focused
attention on the long-term care needs of persons with chronic infectious
diseases.
Because demographic projections suggest that the largest increase in the
need for long-term care will come from the aging population, the service
needs of the elderly have received the most attention of late. Indeed, the
committee's examination of this topic coincides with the release of two
major reports. The first, mandated by Congress, was cochaired by the
directors of the National Institute on Aging and the Bureau of Health
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
261
Professions in the Health Resources and Services Administration. Their
report examines "the adequacy and availability of personnel prepared to
meet current and projected needs of elderly Americans through the year
2020" (National Institute on Aging, 19871.
A second study was conducted by the National Task Force on Geron-
tology and Geriatric Care Education in Allied Health. Established by the
American Society of Allied Health Professions, the task force explored the
implications of demographic and disease pattern trends for allied health
professional education and practice (National Task Force, 1987~.
The two studies reinforce some of the themes developed in this chapter.
An aging population in need of long-term care will increasingly dominate
the practice of most health care workers and will create pressure for greater
numbers of personnel in total. Preparation for this future will require
significant interventions in the way we educate and "socialize" students to
treat patients and work with other health colleagues in the long-term care
environment.
DETERMINANTS OF NEED FOR LON~TERM CARE
A number of factors—health and functional status, income, living ar-
rangements, marital status influence who among us are likely to become
long-term care consumers and the types of services we will receive. A review
of these factors reveals why there is concern about the capacity of the health
care system to meet these future challenges.
· The need for the formal support of nursing home care increases
sharply with age, as do the effects of chronic disabling disease. The nursing
home utilization rate is 2 percent for persons 65 to 74 years of age, 6
percent for those 75 to 84; and 23 percent for those 85 and older (Rice,
1985).
· If current morbidity, disability, and functional dependence rates and
patterns continue, by the year 2000 about 50 percent more noninstitutional
elderly people will require the help of others in daily living activities than
required such help in 1980. At the same time, the number needing nursing
homes could increase by 77 percent. In addition to the elderly, it is estimated
that the number of individuals under 65 years of age who are functionally
dependent as a result of chronic disabling disease may well equal that of
those over 65 (Institute of Medicine, 1986b).
· Marital status influences the use of long-term care services (especially
nursing homes) because people without spouses may not have anyone to
provide the personal care that would allow them to stay in the community.
In 1985, 84 percent of the elderly in nursing homes were without spouses,
compared with 56 percent of functionally impaired people living in the
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ALLIED HEALTH SERVICES
community (Macken, 1986; National Center for Health Statistics, 1987b).
If women continue their more rapid (compared with men) mortality im-
provements (Institute of Medicine, 1986b), there will be more unmarried
. . .
spouses requiring nursing come care.
· Infectious disease patients are likely to cause a noticeable increase in
the demand for long-term care and the services provided by allied health
personnel. The number of AIDS patients jumped from 183 in 1981 to
more than 49,000 at the end of 1987 (Centers for Disease Control, 1987a).
The U.S. Public Health Service estimates that 1.5 million people are already
infected with the AIDS virus (Centers for Disease Control, 1987b). A1-
though relatively small proportions of AIDS patients may need long-term
institutional care (e.g., those with dementia), there are indications that
community care could bring a large demand for home health services
(Braun, 1987; R. Widdus, IOM Committee on a National Strategy for
AIDS, personal communication, 1987; Long-Term Care Management, 19881.
· More than 250,000 infants are born in the United States each year
with physical or mental defects (March of Dimes, 19871. Despite advances
in prenatal detection of the diseases that cause disability, data from the
Centers for Disease Control show that the incidence of most types of birth
defects remained substantially unchanged during the period 1970-1971
to 1981-1983 (Edmonds and James, 19841.
· For the past 15 years, the level of the severely developmentally disabled
in the U.S. population has remained steady at approximately 1.6 percent.
However, the type of care that they receive has changed dramatically during
that time. In 1967, many of these individuals lived in large public or private
institutions. Today, there is an increasing demand for relatively small,
community-based facilities. The number of such facilities has grown from
about 4,400 in 1977 to 20,000 in 1986. With these structural changes, some
researchers have detected a substantial increase in staff-to-client ratios that
is likely to continue (Braddock, 1988~.
Ideally, an assessment of changing demographic and epidemiological
patterns, such as those described above, should lead to an understanding
of the preventive, curative, and rehabilitative needs of persons who become
elderly or ill. Understanding care requirements clarifies the type of edu-
cation and training programs care givers should have to be able to meet
the needs of patients which should lead to the development of appro-
priate educational programs.
Unfortunately, this idealized sequence does not occur for many rea-
sons. Chief among these is the lack of adequate financing, which limits who
gets into the formal care system; the amount and quality of services pro-
vided; and the attractiveness of long-term care employment to health care
workers. The scope of this study did not permit an exploration of the
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
263
broader financing problems of long-term care; the committee devoted its
attention to possible educational strategies and human resource manage-
ment interventions in nursing homes, home care, and rehabilitation facil-
ities three settings in which allied health personnel play vital but different
roles. The committee also explored the problems of integrating allied health
services with those of other care givers in these settings, including aides,
who may collaborate with or at times substitute for allied health personnel.
Nursing Homes
The majority of institutional long-term care is provided in nursing homes.
In 1985, there were 19,100 nursing homes with 1,624,200 beds. These
figures reflect a 22 percent increase in the number of homes and a 38
percent increase in the number of beds since 1974 (National Center for
Health Statistics, 1987a).
Despite the demographic and disease pattern changes described earlier,
the nation's stock of nursing home beds is not keeping pace with the growth
in demand let alone the probable need. The result is that nursing homes
usually have high occupancy rates and long waiting lists, thus allowing
operators to select "light" care and private-pay patients. This policy ob-
viously works to the detriment of those who are poor and most in need of
care. Efforts to change this situation are constrained by the states, which
often seek to limit their Medicaid budgets through certificate-of-need reg-
ulations that control the building of new beds (American Health Care
Associations, 1985, 19861. Future growth will depend on the federal gov-
ernment increasing its funding of long-term care or helping to create
incentives for the small but growing private insurance market.
In 1985 there were approximately 1.2 million FTE nursing home em-
ployees. More than 700,000 provided personal care, of which nurse's aides
and orderlies were the largest group (71 percent). The number of allied
health professionals providing nursing home care on a salaried basis is
comparatively small: in 1985 there were approximately 7,000 dietitian/
nutritionists, 2,900 registered physical therapists, 2,600 registered medical
record administrators, and 1,500 registered occupational therapist FTE
employees (National Center for Health Statistics, 1987a; G. Strahan, per-
sonal communication, 1987~. Despite efforts to constrain bed growth, BLS
projects that nursing home employment will grow through the year 2000
at an annual rate of 3.8 percent, or about three times the projected growth
for the overall economy (Personik, 19871.
Personal communication regarding unpublished data from the National Nursing Home
Survey, Division of Health Care Statistics, National Center for Health Statistics.
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d
264
ALLIED HEALTH SERVICES
Nursing Home Residents and the Organization of Care
The typical nursing home resident is an 80-year-old white widow who
has several chronic medical conditions and was admitted to the nursing
home about 1-~/~ years earlier after being a patient in a hospital or other
health care facility. Seventy-five percent of elderly nursing home residents
in 1985 were women; only 6 percent were black, and less than 1 percent
were of other races. The fact that a higher proportion of the elderly white
population (5 percent) receives nursing home care compared with black
(4 percent) and other races (2 percent) is probably due to the substitution
by nonwhites of informal care in the home for institutionalized care (Na-
tional Center for Health Statistics, 1987b; Macken, 1986~.
A patient enters a nursing home by physician referral or by direct ap-
plication of the family. All services must be prescribed by a physician and
furnished according to a written plan initiated by the physician. The care
plan is developed in consultation with the appropriate nursing and allied
health personnel. For example, an occupational therapist assists the phy-
sician by evaluating the patient's level of functioning, helping to develop
the plan, preparing clinical and progress notes, educating and consulting
with the family and other agency personnel, and participating in in-service
programs. Occupational therapy assistants, under the supervision of a qual-
ified occupational therapist, perform the services that have been planned
and delegated by the therapist. They also help to prepare clinical notes
and progress reports and help educate the patient and family (American
Occupational Therapy Association, 19871.
To be certified under Medicare's conditions of participation, nursing
homes must ensure the availability of allied health services. Yet the number
of full-time allied health personnel actually employed there is small because
most nursing homes find that reimbursements do not cover many of these
. ~ ~ .
services. . .o conserve resources, consu sting arrangements and part-time
work are the norm for therapists and other allied health workers. When
funds are available to hire allied health personnel, many facilities appear
to have difficulty in attracting such staff.
Registered nurses supervise or coordinate the direct care of patients in
nursing homes, and one tool for enhancing communication among care
givers is the team meeting. The regularity of these meetings varies among
facilities. Often headed by nurses, the team may not necessarily include
allied health personnel. Optimally, the meetings should not only provide
an opportunity to exchange information about patients but should also
serve as a way to organize the care that best responds to an individual
patient's needs.
One approach to incorporating allied health personnel into such a team
effort was described to IOM's Committee on Nursing Home Regulation.
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
265
In this model, allied health specialists played a strong educational rather
than direct patient care role:
Each nursing unit has a primary care team composed of the physician, head nurse
and social worker for that unit. The primary care team guides the resident care
planning. All members of the team have an equal voice in this planning. Auxiliary
staff such as physical therapists, occupational therapists, leisure activity specialists,
dietetic technicians, etc., are assigned to each unit and work with the primary care
team. In addition to individual relationships, unit team members plan and assess
resident care in a variety of organized meetings. These types of meetings may have
a different focus. For example, unit clinical meetings focus on residents' psycho-
logical problems, rehabilitation rounds focus on physical therapy. These meetings
have one thing in common, however; they include all care givers including the
nurse aide staff. (Boehner, 1984)
As a practical matter in today's nursing home environment, the reha-
bilitation services that allied health personnel might be providing directly
are either absent or stretched across a large patient base. The linkage of
allied health expertise to the activities of nurses and aides becomes a critical
element in how well patients can improve their functioning. This linkage
is dependent on opportunities for effective communication between allied
health personnel and the nursing staff, as well as on the ability of other
care givers aides in particular to receive and act on the advice of the
allied health practitioner.
Nurse's Aides
The quality of life for patients is significantly affected by the quality of
care provided by the care givers who have the most frequent contacts with
them the aides. The typical nurse's aide is a woman who is about 35 years
old and who has no more than a high school education. She has little or
no training in nursing skills. She has been employed in her current job
less than 2 years and has less than 5 years' total experience as a paid care
giver (National Center for Health Statistics, 1987b; G. Strahan, personal
communication, 1987~. Most aides are white, but a sizable proportion (32
percent) are black or other minorities, which is higher than their repre-
sentation in the labor force as a whole (13 percent) (Kahl, 19871.
On an average day, the aide has a wide range of activities. For example:
The aide is expected to do passive range-of-motion exercises for stroke or paralysis
patients. If hemorrhaging occurs, she must immediately elevate the body and apply
pressure before calling the nurse. She must use correct body mechanics or seek
help in moving patients. The aide is expected to reconcile food service deliveries
with patient's dietary restrictions. She regularly observes changes in patient status
such as whether a patient's toe nails need to be cut and whether decubiti are present.
She monitors food and water intake, and emotional states. A capable aide would
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ALLIED HEALTH SERVICES
notice potential circulatory problems, changes in temperature, and paralysis. Aides
also provide clean, wrinkle-free bed linens. They receive and return linens to the
laundry or food trays to the kitchen. Aides are expected to initiate and facilitate
interaction with residents and to assist in and encourage ambulation (Brannon and
Bodnar, 1988~.
As the foregoing list of duties illustrates, aides have major responsibilities
for which they may have little training or experience to prepare them.
There is also little status, recognition, or compensation for this key role.
While most often viewed as part of the nursing staff, the problems aides
encounter are, nonetheless, ones that also concern allied health practition-
ers or that overlap the responsibilities of allied health assistants. For ex-
ample, both nurse's aides and occupational therapy assistants play a role
in patients' daily hygiene and rehabilitation exercise programs.
The recent IOM report on nursing home regulation, in relating the
improved functioning of residents to their sense of well-being, noted how
aides shaped the residents' social world:
. . . 80 to 90 percent of the care is provided by nurse's aides and the quality of their
interactions with the residents how helpful, how friendly, how competent, how
cheerful they are and how much they treat each resident as a person worthy of
dignity and respects makes a big difference in the quality of a resident's life.
(Institute of Medicine, 1986a)
Because of their importance to the quality of care provided in nursing
homes, as well as in home care, the levels and content of aide training have
been focuses for reform. It is interesting to note that the recommendation
from the IOM Nursing Home Standards Committee to make aide training
a regulatory standard was one of the few exceptions to an approach that
relied principally on patient outcome measures to ensure quality. Following
IOM's recommendation, the Health Care Financing Administration pro-
posed a rule to require that aides receive a minimum of 80 hours of training
(Federal Register, 1987~. Shortly thereafter, a provision of the Medicare
law requiring 75 hours of aide training was enacted through the Omnibus
Budget Reconciliation Act of 1987.
In many nursing homes, annual turnover is extremely high for aides,
and in some cases, all of the aides may be replaced in the course of a year.
High turnover has been linked to several factors, most important of which
are employee pay and benefits. Aides generally earn only about $10,000
per year (Kahl, 19871. It is not surprising, then, that during site visits the
_ ~ 1 (A'
committee heard reports of aides changing jobs for a 25- to 50-cents per-
hour pay increase.
In addition to turnover, earnings play a part in a growing aide recruit-
ment problem. Earlier chapters in this report noted the general tightness
of the labor market for technically oriented personnel. Similarly, young,
.
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ALLIED HEALTH PERSONNEL AND LONG-TER1\I CARE
267
low-wage service workers will also be at a premium. Some employers in
the nursing home industry see themselves in direct competition for these
employees with the fast-food industry, for instance, which is beginning to
offer higher starting salaries and the attraction of greater opportunities to
socialize with peer workers in a less onerous atmosphere (Kerschner, 19871.
Because of this competition, there is increasing interest in targeting older
individuals for recruitment. These older workers (who are also being re-
cruited by McDonald's fast-food restaurants), whose cohort will be ex-
panding in the population in the future, already are a sizable proportion
of the aide-level work force: 40 percent of aides are over the age of 35
(Kahl, 19871.
Pay alone, however, will not solve recruitment, retention, and turnover
problems. Aides' poor self-perceptions and lack of involvement in the de-
cision-making process regarding their responsibilities will require action by
management (Waxman et al., 19841. The lack of career ladders, work
scheduling, management attitudes, and understaffing are other common
frustrations voiced by the aides themselves.
In light of their critical role in patient well-being and rehabilitation, the
questions of how much training aides need to function effectively, how
they relate to others who provide nursing and allied health services, and
what kinds of pay and careers suit their level of responsibility are issues
that nursing home management cannot avoid. If, in the future, there are
to be sufficient numbers of people to carry out the responsibilities that
aides presently assume, the nursing home industry must not only improve
low wages and working conditions but confront the organizational chal-
lenge of deploying staff wisely. Allied health care givers in nursing homes
will necessarily become involved in these issues. Enhanced pay and re-
sponsibility for aides will require that allied health personnel forge new
working relationships and increasingly accept pedagogical roles.
HOME CARE
Home health care, which A: often viewed as a substitute for nursing home
placement or extended host talization, shares many of the same generic
problems faced by nursing homes. Agencies find it difficult to recruit and
retain staff at the aide level, and teamwork is frequently inadequate among
nursing and allied health personnel. These problems are exacerbated in
home care, which by its very nature requires staff to operate with less direct
. .
supervlslon.
.
Home Health Care Agencies and Personnel
Although formal community care, such as that provided by home health
care agencies, now accounts for only 15 percent of public long-term care
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ALLIED HEALTH SERVICES
expenditures, this area has been one of the fastest growing segments of
the health care industry. The number of Medicare-certified agencies nearly
tripled from 2,212 in 1972 to 6,007 in 1986; the number dropped slightly
to 5,877 in 1987 as agencies reacted to restrictions in Medicare rules. In
1986 there were 105,038 salaried, full-time employees. Registered nurses
were the largest category (34 percent) of personnel, followed by aides (25
percent). About 6 percent of home health care employees were physical
therapists, 2 percent were occupational therapists, and 3 percent were
speech therapists (National Association for Home Care, 1987~. Because
some therapists operate on a contract basis or work in agencies that are
not certified by Medicare, these proportions probably understate the actual
number working in home care. For example, about 22 percent of physical
therapists work at least part of their week for home health care agencies
(American Physical Therapy Association, 1987~.
Home health care is not covered by PPS, but since 1985 limitations have
been applied to reimbursement for home health care services. As a result,
many agencies choose not to participate in Medicare and limit their clientele
to private-pay patients. The National Association for Home Care (1987)
has estimated that there were an additional 3,700 agencies in 1987 that
were not certified for Medicare. Few data are available on recipients or
reimbursement under private insurance. Medicaid can also include home
health care benefits, but payment levels have fluctuated greatly over the
past decade and vary considerably by state. In 1987 New York accounted
for 77 percent of all Medicaid home health expenditures, compared with
California's 7 percent (Rabin and Stockton, 19871.
Home Health Care Clients and the
Organization of Care
About 80 percent of home health recipients are posthospital referrals.
The typical process of referral from physician to nurse to allied health
personnel can operate smoothly, but it may also mask a set of uneasy
relationships.
The nurse's view of her role has been characterized by Mundinger (19831:
"When the referral and physician's plan of care are received by the agency,
an initial nurse assessment visit is made within three days. When the nurse's
plan is approved, it becomes the operational one for patient care and
replaces the original physician order":
The plan devised by the nurse includes all of the care to be given as well as
recommendations for referrals. For example, if physiotherapy tsic] is being con-
sidered as care needed, it is the nurse who makes the assessment visit to determine
whether it is in fact really necessary. The nurse decides on the need for a home
health aide. The nurse also can make referrals for other home health services such
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
?69
as occupational therapy, speech therapy, and social worker services. The plan that
is submitted to the physician for signature includes all reimbursable care the nurse
deems necessary. It also includes illness prevention and health maintenance care
required by the patient.
Physicians, as do most professionals, tend to implement the therapies that they
know best, value, and use in their own work. Therefore, home care, traditionally
a low-technology and low-cost venture, under Medicare has become a service filled
with high-cost care. It is not unusual for a physician to order a battery of expensive
blood tests rather than make a home visit, or utilize physical therapists for routine
range of motion or ambulation of homebound patients. Physicians should be aware
that nurses can teach families to carry out these exercises or that a visiting nurse's
assessment and history can tell more than blood tests in many cases. (Mundinger,
1983)
The nurse arranges for various services to be delivered separately by
therapists or aides, none of whom may meet with each other as a team.
Such separation of services means that, although important information
can be exchanged through the record, the amount of direct collaboration
for patient problem solving among care givers is often minimal.
Because of this pattern of care, growing attention has been paid to the
issue of who is the care manager, who controls the mix of services, and
how multiple care givers coordinate their services. The care manager (or
case manager) is responsible for ensuring the coordination and continuity
of services (Levine and Fleming, 1986~. As the quotation above illustrates,
nurses currently see themselves as fulfilling this function. Physicians and
allied health personnel, however, are not necessarily willing to concede this
point.
The following represents the viewpoint of the Health and Public Policy
Committee of the American College of Physicians, which has argued that
physicians ought to be actively involved in assessing the continuing func-
tional as well as medical needs of homebound patients and advising patients
on the use of home health care services:
Although Medicare requires the physician to certify a home health treatment plan,
typically the physician describes the patient's medical condition to a home health
agency, and a registered nurse actually develops and implements the home care
plan.
Physicians should play an important role in home health care, not only as providers
of medical care, but also as case managers and coordinators of care. Physicians
should assure that their patients continue to receive high-quality medical care after
discharge from a hospital and while receiving treatment in the home.
Unfortunately, the current reimbursement system does not provide any incentives
for physicians to become more involved in home health care. Time spent com-
municating with home health care personnel, devising home treatment plans, com-
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ALLIED HEALTH SERVICES
pleting certification forms, consulting with the patient and family by telephone, or
traveling to a patient's home is not reimbursable. Indeed, HCFA tHealth Care
Financing Administration] maintains that these costs are subsumed in physicians'
payments for office visits and home visits. (American College of Physicians, Health
and Public Policy Committee, 1986'
From the perspective of the allied health fields, the interdisciplinary
group that constitutes the home health care team "is overly dependent
upon a single type of profession, the physician, to write orders." Patient
needs should determine whether case management is accomplished by an
individual therapist, social worker, nurse, or a team. Yet current reim-
bursement practices, allied health leaders have argued, do not give the
team adequate control over how resources are allocated for the patient's
care plan (National Task Force, 1987~.
Without a reimbursement mechanism that creates incentives for coor-
dinated and appropriate use of the home care services that are potentially
available from a wide array of providers, it will be difficult to overcome
problems of fragmentation, duplication of services, and interprofessional
competition. Short of such a payment scheme, the solutions commonly
cited in the home care and case management literature offer the best hope
for improvement. These include greater use of team conferences, more
complete documentation of patient records, increased attention to defining
the functions of different types of practitioners in home care, more vigorous
case management on the part of home health care agencies, and educational
experiences that prepare students for interdisciplinary collaboration and
case management (Steinhauser, 1984; Trossman, 19841.
REHABILITATION
In moving from a consideration of nursing homes and home care to a
discussion of rehabilitation facilities, a major distinction is soon apparent:
the team approach to clinical management is a well-recognized fixture in
the rehabilitation world. Collaborative behavior among health care prac-
titioners is reinforced by the fact that rehabilitation patients are generally
treated for a functional rather than a medical disability. For Medicare
reimbursement, regulations mandate that patients must receive a minimum
of 3 hours of physical therapy, occupational therapy, speech therapy, or
orthotist and prosthetist services per day for 5 days per week (Medicare
Intermediary Manual, Section 3101.11 (Did), Part A). Intermediary Manual).
The patient who regresses or no longer improves in function must be
discharged into another care environment. The current payment system
places a premium on functional assessment and progression toward im-
proved functioning.
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
271
There has been significant growth in rehabilitation programs in the last
30 years and a 50 percent growth in the number of rehabilitation beds in
the last 5 years. Today, there are 73 rehabilitation hospitals with 6,225 beds
in the United States. There are also 512 distinct rehabilitation units with
about 13,000 beds in general hospitals. Rehabilitation facilities are currently
exempt from the Medicare prospective payment system because an equi-
table predictor of resource consumption on which to base payment has not
yet been found. (Rehabilitation services in intensive care and in medical-
surgical units of acute care hospitals, however, are not exempt.) Approx-
imately 32 million people are physically disabled, and 12 million people
are severely disabled. The number of severely disabled people has increased
and will continue to increase as the population ages and as technological
advances improve the prospects of children with birth injuries or congenital
defects (England et al., 1987; Lesparre, 19871.
Because patients in rehabilitation settings need specialized and intensive
services, the staff typically includes full-time departments of physical, oc-
cupational, and speech therapy, radiological and laboratory services, and
sometimes respiratory therapy. Social, psychological, and vocational services
are also provided but on a consultant basis. Although the staff in rehabil-
itation hospitals typically work in teams, some experts call for an additional
category of case managers to help ensure appropriate and timely referrals,
reduce admission delays, and assess insurance gaps (England, 1987; Les-
parre, 1987~.
By tradition, allied health practitioners, together with nurses, play a
central role in the delivery of team health care. For example, the ratio of
FTE physical therapists to registered nurses is 1 :2 in rehabilitation hospitals,
compared with 1:43 in acute care hospitals (American Hospital Association,
1987~. A recent survey by the National Association of Rehabilitation Fa-
cilities showed that 65 percent of the total costs in rehabilitation hospitals
were attributable to staff salaries, wages, and fringe benefits. This per-
centage compares with an average of about 57 percent for all hospitals.
The intensive use of physical therapists, occupational therapists, and spe-
cialized nurses results in higher personnel costs in rehabilitation hospitals.
Salary increases of 7 percent a year for physical therapists, 6 percent for
occupational therapists, and 5 percent for nurses since 1985 reflect the
difficulties these hospitals are experiencing in attracting personnel. Com-
petition for these employees has also resulted in growing recruitment costs
and the increased use of contract personnel (National Association of Re-
habilitation Facilities, 19871.
A survey of 43 rehabilitation facilities in California found vacancy rates
of 15.6 percent for physical therapists, 8.6 percent for occupational ther-
apists, and 10.7 percent for speech-language pathologists. Vacancy rates
for physical therapy and occupational therapy assistants exceeded 20 per-
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ALLIED HEALTH SERVICES
cent. Among the consequences of these staffing problems, 24 percent of
the respondents experienced admission restrictions, 76 percent showed an
impact on outpatient waiting lists, and 58 percent delayed the initiation of
new services or curtailed existing ones (California Association of Rehabil-
itation Facilities, 19871.
Rehabilitation hospitals see themselves as being at a disadvantage in
competing for allied health personnel in tight labor markets. They attribute
their difficulties to students' lack of exposure to the potential of a career
in rehabilitation, which is perceived to be an arduous, unattractive job,
bringing little recognition. Rehabilitation administrators fear a continuing
diversion of personnel to more attractive practice settings in which patients
are less incapacitated and earnings are higher.
A brief examination of the experience of the Veterans Administration
(VA), a major provider of rehabilitation services in the nation, offers some
insights into the problems often faced by many rehabilitation facilities,
especially the public institutions. Although the VA labors under personnel
and other constraints peculiar to public facilities in recruiting and com-
pensating its employees, the implications of personnel shortages and coping
strategies are an instructive preview of what the future could be for all
rehabilitation facilities in the face of widespread shortages.
The VA's Experience
Interviews with central office officials and chiefs of physical therapy and
occupational therapy at a number of VA medical centers revealed a con-
sensus on a number of points. Many of the centers' recruitment and re-
tention problems are due to competition for these occupations in the
nonfederal sector. The substitution of less qualified care givers was infre-
quent, although health care delivery services were sometimes curtailed as
a result of the shortage. The problem appears to be worsening; patient
loads are increasing while physical therapy and occupational therapy staffs
continue to decrease.
At one medical center in a mid-Atlantic state, half the physical therapy
slots were vacant. Although physical therapy assistants were employed, they
were not used in lieu of licensed physical therapists because they are not
permitted to evaluate patients. The medical center employed six corrective
therapists (a type of rehabilitation personnel used mostly in the VA), but
they were also comparatively limited in the type of care they were permitted
to provide. A corrective therapist was assigned to the unit to assist patients
in walking. In addition, because of a lack of staff, the physical therapy
treatment room in a newly built nursing home care unit remained closed.
The chief of physical therapy, who carried a full patient load in an effort
to off.~et the shortage, stated that nonfederal employers in the area were
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
273
paying $24,000-$28,000 for new graduates while the VA started them at
$18,000. She added that the presumption among many recent graduates
was that, ultimately, they will enter private practice. In her experience, this
differed markedly from the goals and assumptions of physical therapists
in the past, most of whom spent their entire careers employed by medical
~ . . .
tea sties.
In another instance, a large medical center in Southern California had
a substantial geriatric patient population, a spinal cord injury unit, and an
extensive orthopedic caseload. The center also employed a number of well-
known specialists in physical therapy. As a result, recent graduates flocked
there for the quality of the training they could receive. Recruitment success
was high and vacancy rates were relatively low, but physical therapists
typically remained there no more than 2 years. Thus, patients were treated
for the most part by young, inexperienced personnel.
At a relatively small southern medical center, administrators cited both
physical therapist and occupational therapist recruitment problems as lim-
iting the number of bedside treatments provided. There were physical
therapy and occupational therapy education programs offered in this city,
but the institution had been unable to recruit graduates before they relo-
cated to other geographic areas where the pay was higher. Because the
department was too small to require a chief of service, the medical center
needed an experienced occupational therapist before it could recruit recent
graduates who would need seasoning.
The lack of occupational therapists in another southern medical center
resulted in slight modifications of the duties of assistants and such adjust-
ments as program cutbacks and delays in starting new programs. The chief
of occupational therapy stated that nonfederal occupational therapy jobs
in that city paid $4,000-$5,000 more than what the VA paid, and that it
was virtually impossible for the VA to hire experienced therapists. The
situation seems unlikely to improve, as a recent survey found that there
are 54 job openings in occupational therapy in that city.
At a small rural VA medical center in the Northeast, physical therapy
slots have remained vacant for as long as 2 years. In addition to its lack of
salary competitiveness in a region with high demand, this hospital also
believes that its large geriatric population does not offer the variety that
many practitioners seek.
As discussed in Chapter 6 and in the VA case examples, health care
administrators who face personnel shortages have relied on several strat-
egies to handle the deficiencies over the short term. These strategies include
extensive use of overtime, service targeting to the patients most likely to
benefit from them, and downward substitution (or cross-substitution) of
allied health personnel to the extent that regulations permit. In the long
run, unless rehabilitation facilities are willing to become reconciled to the
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ALLIED HEALTH SERVICES
sort of adaptations described in the VA cases, they will have to improve
their capacity to compete for allied health graduates.
The committee believes that the public will neither wish to nor should
accept service compromises in the quality and availability of rehabilitative
care that are due to major shortages in allied health personnel. Current
data and analytic techniques cannot specify the number of personnel needed
beyond those who are likely to be demanded under current reimbursement
and human resource policies and practices. Yet in the committee's judg-
ment, rehabilitation facilities will not fare well unless the personnel pool
grows substantially along with an increase in the share of those choosing
to engage in this difficult work.
As we have noted throughout this report, salary adjustments are an
inevitable response to this competition. Indeed, the VA has sought ex-
emptions from Congress on salary scales. Along with these adjustments,
however, must come a more careful and sustained rethinking of the services
that are to be provided and of who provides them. The initiatives to do
this will likely come from health care delivery sites that are attempting to
cope with service demands and constrained budgets, but educators should
not distance themselves from this rethinking process. A new relationship
between health care and academic institutions must be forged. Our rec-
ommendations in the next section address the nature of this partnership.
CONCLUSIONS AND RECOMMENDATIONS
In this chapter, the committee has concentrated on three generic human
resource problems that plague the provision of long-term care.
1. Minimally trained personnel are often the primary patient care givers,
especially in nursing homes and home care. As a result, there is too little
attention to the linkage between nursing and allied health services in the
hands-on care activities of aides.
2. (Jurrent efforts to incorporate the care of the aged and chronically
disabled into the allied health curriculum are inadequate in view of the
important impact these patients will have on the health care delivery system
of the future.
3. Collaborative behavior among allied health practitioners, as well as
between allied health practitioners and other health care workers, is in-
suff~ciently promoted by management in nursing homes and home care
agencies and by educational institutions in the educational experiences
provided to students.
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
Education of Nurse's Aides
275
The passage of the provision in the Omnibus Budget Reconciliation Act
of 1987 requiring a minimum of 75 hours of initial aide training should
mark the beginning of a long-range educational effort. The act specifies
that the content of nurse's aide training is to include basic nursing skills;
personal care skills; cognitive, behavioral, and social care; basic restorative
services; and residents' rights (U.S. Congress, House of Representatives,
1987).
The committee views this training requirement as a reasonable starting
point to raise the skills and knowledge of entry-level workers who provide
most of the direct patient care in long-term care facilities. There is also an
urgent need, however, for a visible pathway leading to higher levels of
education for aides who wish career progression and improved remuner-
ation. Such a pathway into nursing or allied health fields would contribute
to raising the morale and self-image of these workers and ultimately reduce
the costly turnover of personnel.
In recognition that the greatest amount of direct patient contact and
care in long-term care settings and programs is provided by personnel
at the nurse's aide level, the federal government and other responsible
governmental agencies should require education and training to raise the
knowledge and skill levels of these individuals. Demonstration projects
should be funded to encourage joint efforts by educators and employers
in creating viable career paths for aides.
Tolerance of and empathy with old, chronically ill, disabled, or demented
patients is an elusive but critical attribute to be sought among care givers.
Without this attribute, individuals are not likely to choose work in long-
term settings as a career. Long-term care employers and educators should
identify and nurture those with this "people-oriented" attribute. One ap-
proach might be for employers and educators to develop local plans in
which service in long-term care settings would earn employer-paid edu-
cational credits that could be used by personnel to further their educational
objectives. Such an investment would yield at least three desirable results:
(1) an improved quality of care for patients; (2) the enhanced recruitment
of minorities, young people, and minimally educated individuals; and
(3) increased stability in the segment of the labor force that provides direct
care. This approach would be particularly attractive if educational pro-
grams in the established allied health professions would reserve a small
proportion of their entry positions (e.g., 10 percent) for applicants from
such long-term care settings.
Other innovative programs that could be jointly sponsored by academic
institutions (e.g., community colleges) and employers should also be con-
sidered in creating a career path. The committee was impressed with the
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ALLIED HEALTH SERVICES
concept of an apprenticeship model, which has had some success in the
skilled trades but which has not received the attention it perhaps deserves
in the health care fields. The model stresses on-thejob, practical experience
combined with formal training. A key element in its success is that the
student-worker's prospects for a "good job" in terms of pay and respon-
sibility should be rewarded at the end of the program. These good jobs,
while not plentiful in today's long-term care industry, must be developed
in the decade ahead if the industry expects to compete in tomorrow's labor
market and improve the quality of service it provides.
Enhancing the Curriculum
Although allied health students gain technical expertise in particular
areas of concentration during their education, many have only limited
exposure to chronically ill and disabled persons. They may therefore have
only a superficial understanding of the complexity of the physical, mental,
emotional, and social problems of impaired persons and their families.
When in training, allied health students may not rotate through long-term
care facilities or programs to experience personally the technical difficulties
that arise in evaluating and caring for older or chronically disabled persons.
The committee recommends that all allied health education and tra~n-
ing programs include substantive content and practical clinical exper~-
ence in the care of the chronically ill and aged. In general, such curricula
should include information on the demographic shifts and changing epi-
demiological patterns of diseases and disabilities, the biological and psy-
chological aspects of chronic illness and aging, the common medical problems
seen in patients, legal and ethical dilemmas, the medical and psychological
aspects of death and dying, health promotion and disease and disability
prevention, interdisciplinary team participation, the evaluation and assess-
ment of patients' needs, the roles of related health professionals, admin-
istrative and management techniques, and communication and supervisory
skills.
Among these topics, the committee was particularly impressed during
its site visits by the need for assessment, pedagogical, and coping skills.
Because of shortages or the uneven distribution of allied health profes-
sionals, a member of each allied health speciality may not be available to
make an assessment of a patient from his or her own disciplinary per-
spective. Therefore, it is important that all professional care providers
acquire enough knowledge to enable them to make physical, psychological,
and environmental assessments of an individual patient and to develop an
appropriate care plan. The providers need this broader knowledge even
though some of the patient's needs may be outside the narrow area of
expertise of a given allied health profession. Because allied health practi-
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE
277
tioners may be employed as consultants with responsibility for a large
number of patients or residents, they must also have the skills to instruct
aides and family members in care plan activities and be able to monitor
the effectiveness and quality of the assistance given to patients.
A major barrier to curriculum reform is the shortage of faculty who are
appropriately trained and experienced in the care of the chronically ill and
disabled. In an effort to combat deficiencies in the training of personnel
and faculty, the Health Resources and Services Administration established
regional resource centers through its Geriatric Education Centers program.
The program, which began in 1983, supports the multidisciplinary training
of medical, dental, osteopathic, optometric, pharmacy, pediatric, nursing,
and allied health students, faculty, and others in geriatric health care. Other
governmental programs that have provided multidisciplinary training in-
clude special project grants and the Area Health Education Centers (also
sponsored by HRSA), Long-Term Care Gerontology Centers (sponsored
by the Administration on Aging), and VA's Geriatric Research, Education,
and Clinical Centers. Despite these programs the National Institute on
Aging task force estimates that the current number of faculty members
specializing in aging and geriatric care ranges from 5 to 25 percent of the
total number needed (National Institute on Aging, 1987~. A major focus
for the faculty development grants recommended in Chapter 5 should be
the encouragement of more faculty specializing in geriatric care.
Orienting allied health education toward geriatric care will not make
salaries more competitive or improve working conditions; neither will it
change the fact that such patient care is physically and emotionally difficult.
The committee believes, however, that education in geriatric care will help
those who do choose work in these settings to remain longer by giving
them the necessary knowledge and coping skills. It will also allow more
students the opportunity to consider the possible rewards of such a career
and will encourage more faculty to engage in health services and clinical
research that is relevant to the problems faced by long-term care providers.
Improved Teamwork
The committee noted that the collaborative behavior seen among re-
habilitation hospital staff is frequently absent in nursing homes and home
care. In the absence of financing incentives that encourage teamwork, the
responsibility rests with managers to organize their personnel in ways that
maximize interaction among allied health practitioners and other care giv-
ers. The committee therefore recommends that because the problems
associated with chronic illness do not fall within the boundaries of any
single discipline, administrators and care coordinators in long-term care
settings should develop effective means for ensuring that all personnel
involved in patient care work closely together to meet patient needs.
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ALLIED HEALTH SERVICES
Health care managers would be greatly helped in these endeavors if
educators provided the foundation on which to build collaborative behavior
in later practice. Allied health practitioners need to understand and ap-
preciate the special skills and roles that their fellow allied health workers
play, together with the assets and limitations of others on the long-term
care team.
The issues of recruitment, education, personnel utilization, and regu-
lation that have been raised throughout this report take on a special sig-
nif~cance in the nation's struggle to achieve humane care for its growing
numbers of elderly and chronically ill patients. Society will be under great
pressure to accommodate larger numbers of patients in the settings dis-
cussed here. It will also be under at least as great a pressure to limit the
resources that may be necessary to raise the standard of care. Allied health
practitioners who are caught up in this struggle will be challenged to use
their ingenuity both on a personal level, as care providers, and collectively,
as an important force for reshaping the care system.
The remedies suggested in this chapter are not new: they can be found
in the work of current committees and task forces and even in past Institute
of Medicine studies on nursing and health care teams (Institute of Medicine,
1972, 19831. But the time to move teamwork and geriatric education ahead
is long past due.
No single recommendation the committee can devise will accomplish this
movement. It must come from leaders in the health professions who are
willing to concede a measure of control and autonomy in favor of the
common goal of collaborative patient care. It will require the ingenuity of
educators in seeking additional resources for curriculum reform. It will
also demand the resolve to initiate a painful process of resource allocation
that places a higher value on care giver collaboration and preparation for
the demands of long-term care.
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Representative terms from entire chapter:
health personnel
