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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 factorshealth 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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262 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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266 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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268 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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270 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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272 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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274 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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276 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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278 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. REFERENCES American College of Physicians, Health and Public Policy Committee. 1986. Home health care. Annals of Internal Medicine 105(3):454-460. American Health Care Association. 1985. Trends and Strategies of Long-Term Care. Washington, D.C.: American Health Care Association. American Health Care Association. 1986. Nursing Homes, A Sourcebook. Washington, D.C.: American Health Care Association. American Hospital Association. 1987. Unpublished data from the Annual Hospital Survey and Survey of Rehabilitation Hospitals and Units. American Hospital Association, Chicago. American Occupational Therapy Association. 1987. American Occupational Therapy. Rockville, Md.: American Occupational Therapy Association. American Physical Therapy Association. 1987. Active Membership Profile Study. Alex- andria, Va.: American Physical Therapy Association.

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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE 279 Boehner, E. M. 1984. Managing to achieve quality of life. Background paper prepared for the Institute of Medicine Committee on Improving Quality in Nursing Homes. Washington, D.C. October. Braddock, D. 1988. Challenges in community integration. In Integration of Developmen- tally Disabled Individuals into the Community, 2nd ea., L. Healy, I. Harvey, and S. R. Novak, eds. Baltimore, Md.: Brookes Publishing Co. Brannon, D., and l. Bodner, 1988. The Primary Care Givers: Aides and LPNs. Mental Health Consultation in Nursing Homes. New York: New York University Press. Braun, S. April 1, 1987. Hospices for AIDS cases: A beginning. The Los Angeles Times, p. 1. California Association of Rehabilitation Facilities. 1987. Survey on rehabilitation man- power. Unpublished data. California Association of Rehabilitation Facilities, Sacra- mento. December. Centers for Disease Control. 1987a. AIDS Weekly Surveillance Report United States, December 29, 1987. Atlanta, Gal: CDC. Centers for Disease Control. 1987b. Human Immunodeficiency Virus Infections in the U.S.: A Review of Current Knowledge and Plans for Expansion of HIV Surveillance Activities. Special report. Atlanta, Gal: U.S. Department of Health and Human Ser- vices. November 30. Edmonds, L., and L. lames. 1984. Temporal trends in the incidence of malformation in the United States, 1970-71,1982-83. Morbidity and Mortality Weekly Review 34:255. England, B., C. Armkraut, and M. Lesparre. 1987. An agenda for medical rehabilitation, 1987 and into the 21st century. American Hospital Association, Chicago. Federal Register. October 16, 1987. Medicare and Medicaid, Conditions of Participation for Long Term Care Facilities. Vol. 52(200):38582-38606. Institute of Medicine. 1972. Education for the Health Team. Washington, D.C.: National Academy of Sciences. institute of Medicine. 1983. Nursing and Nursing Education: Public Policies and Private Actions. Washington, D.C.: National Academy Press. Institute of Medicine. 1986a. Improving the Quality of Care in Nursing Homes. Wash- ington, D.C.: National Academy Press. Institute of Medicine. 1986b. A Study Plan "Toward a National Strategy for Long-Term Care of the Elderly." Institute of Medicine Committee to Plan a Major Study of National Long-Term Care Policies and the National Academy of Sciences. Pub. No. IOM-85-05. Washington, D.C.: National Academy Press. April. Kahl, A. (Bureau of Labor Statistics). 1987. Remarks at a symposium on nurses' aide training. Sponsored by the National Citizens Coalition on Nursing Home Reform, Washington, D.C. November. Kane, R. L., and Kane, R. A. 1982. Values and Long-Term Care. Lexington, Mass.: Lexington Books. Kerschner, P. 1987. Staffing: Getting the edge on McDonald's and Pizza Hut. Provider 13(4):39. Lesparre, M. 1987. Paradoxes of medical rehabilitation. in Perspectives, a supplement to Medicine and Health. New York: McGraw-Hill. November 16. Levine, I., and M. Fleming. 1986. Human Resources Development: Issues in Care Man- agement. Rockville, Md.: National Institute of Mental Health. May. Long Term Care Management. 1988. AIDS: What role for nursing homes? Long Term Care Management (Newsletter). February 4. New York: McGraw-Hill. Macken, C. 1986. A profile of functionally impaired elderly persons living in the com- munity. Health Care Financing Review 7(4):33-49. March of Dimes. 1987. Birth Defects, Tragedy and Hope. White Plains, N.Y.: March of Dimes Birth Defects Foundation.

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280 ALLIED HEALTH SERVICES Meltzer, I., F. Farrow, and H. Richman.1981. Policy Options in Long-Term Care. Chicago: The University of Chicago Press. Mundinger, M. 1983. Home Care Controversy. Rockville, Md.: Aspen Publishers, Inc. National Association for Home Care. 1987. Home health agency statistics. Unpublished -data. National Association for Home Care, Washington, D.C. August. National Association of Rehabilitation Facilities. 1987. Letter of August 7, 1987, to the U.S. Department of Health and Human Services Health Care Financing Administra- tion from Carolyn C. Zollar, General Counsel. Washington, D.C. National Center for Health Statistics. G. Strahan. 1987a. Nursing Home Characteristics: Preliminary Data from the 1985 National Nursing Home Survey. Advanced Data From Vital and Health Statistics No. 131. DHHS Pub. No. (PHS) 87-1250. Hyattsville, Md.: Public Health Service. National Center for Health Statistics. E. Hing. 1987b. Use of Nursing Homes by the Elderly: Preliminary Data from the 1985 National Nursing Home Survey. Advanced Data From Vital and Health Statistics No. 135. DHHS Pub. No. (PHS) 87-1250. Hyattsville, Md.: Public Health Service. National Institute on Aging. 1987. Personnel for Health Needs of the Elderly Through the Year 2020. Washington, D.C.: U.S. Department of Health and Human Services. September. National Task Force on Gerontology and Geriatric Care Education in Allied Health. 1987. An aging society: Implications for health care needs, impacts on allied health practice and education. Journal of Allied Health (Special Issue) 16(4). Personik, V. A. 1987. Projections 2000: Industry Output and Employment Through the End of the Century. Monthly Labor Review 110(9):45. Rabin, D. L., and P. Stockton. 1987. Long-Term Care for the Elderly: A Factbook. New York: Oxford University Press. Rice, D. 1985. Health care needs of the elderly. In Long Term Care of the Elderly, C. Harrington, R. Newcomer, and,C. Estes and Associates, eds. Beverly Hills, Calif.: Sage Publications, Inc. Steinhauser, M. 1984. Occupational therapy and home health care. American Journal of Occupational Therapy 38(11) :715-716. Trossman, P. 1984. Administrative and professional issues for the occupational therapist in home health care. American Journal of Occupational Therapy 38(11):726-733. U.S. Congress, House of Representatives. 1987. Omnibus Budget Reconciliation Act of 1987. Conference Report, H.R. 3545, Report No. 100-495. 100th Cong., 1st sess. Waxman, H., M. Carner, and G. Berkenstock. 1984. Job turnover and job satisfaction among nursing home aides. The Gerontologist 24(5):503-509.