Pusiic Hearty Monocrapu No. 46 Nursing Homes f US Their Patients And Their Care DOCUMENTS DEPARTMENT MAY 30 1957 LIBRARY UNIVERSITY OF CALIFORNIA U. S. DEPARTMENT oF HEALTH, EDUCATION, ann WELFARE Pusuiic HEALTH SERVICE ''PUBLIC HEALTH MONOGRAPHS Public Health Monographs, edited and issued by Public Health Reports under the general] direction of the Board of Editors, present contributions to knowledge in the fields of public health, particularly material that is extensive, detailed, or specialized. All manuscripts considered for publication as monographs receive the same technica] and scientific review as papers submitted to Public Health Reports. The opinions expressed are those of the authors and do not neces- sarily reflect the views of Public Health Reports or the Public Health Service. Trade names are used for identification only and do not represent an endorsement by the Public Health Service. 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Stamps are not acceptable. BOARD OF EDITORS Epwarp G. McGavran, M.D., M.P.H. Chairman Marcaret G. Arnstein, R.N., M.P.H. Manpe E. Conen, M.D. Cart C. Dauer, M.D. H. Trenntey Dean, D.D.S. Harotp M. Erickson, M.D., M.P.H. Lioyp Fiorio, M.D., Dr.P.H. Vicror H. Haas, M.D. Vernon G. MacKenzie Sewarp E. Miuuer, M.D. Leo W. Simmons, Pu.D. Mary Switzer Frankuin H. Top, M.D., M.P.H. Managing Director G. Sr.J. Perrotr Chief, Division of Public Health Methods Executive Editor: Marcus Rosenblum Winona Carson Janet V. Easdale Managing Editor: Monograph Editor: U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Marion B. Fotsom, Secretary PUBLIC HEALTH SERVICE Leroy E. Burney, Surgeon General ''Nursing Homes, Their Patients and Their Care A study of nursing homes and similar long-term care facilities in 13 States Jerry Solon, M.A. Dean W. Roberts, M.D., M.P.H. Dean E. Krueger, M.A. Anna Mae Baney, B.A. A joint project of the Commission on Chronic [Iness and the Public Health Service PUBLIC HEALTH MONOGRAPH NO. 46 ''PUBLIC HEALTH LIB, The Authors Mr. Solon, health program research analyst with the Di- vision of Hospital and Medical Facilities, Public Health Service, was detailed as a research associate to the Commission on Chronic Illness for the purposes of this study. Mr. Solon is now associated with the Beth Israel Hospital in Boston, Mass., as director of its medical care studies unit. Dr. Roberts, director of the Commission on Chronic IIll- ness at the time of the study, is now executive director, Na- tional Society for Crippled Children and Adults, Chicago, Iil. The commission completed its activities in 1956, after 7 years of intensive educational and research work. Mr. Krueger, research associate with the Commission on Chronic Illness, was detailed to the Commission by the Public Health Service. Mr. Krueger is now engaged in re- search studies at Columbia University School of Public Health and Administrative Medicine, on assignment from the Na- tional Heart Institute, Public Health Service. Miss Baney is a health program research analyst with the Division of Hospital and Medical Facilities, Public Health Service, engaging in various studies in the medical care field. ? GP * 1793 ~* Public Health Service Publication No. 503 Issued concurrently with the March 1957 issue of Public Health Reports, vol. 72, No. 3 Received for publication August 1956 Library of Congress Catalog Card No. 57-60014 UNITED STATES GOVERNMENT PRINTING OFFICE, WASHINGTON, D. C.: 1957 For sale by the Superintendent of Documents, U. S. Government Printing Office, Washington, 25, D. C. Price 40 cents ''Foreword This study has demonstrated how effectively a voluntary organization, official State agencies, and the Federal Govern- ment may work cooperatively on a problem engaging their mutual interests and responsibilities. The Commission on Chronic Illness, a national voluntary organization founded by the American Hospital Association, the American Medical Association, the American Public Health Association, and the American Public Welfare Associa- tion, spearheaded a drive to learn what role nursing homes and related types of facilities are filling today. The Public Health Service lent its personnel and other resources to help make the Commission’s goal a reality. The 13 States which participated in the study served their own direct needs for information about nursing homes while adding important segments to the total study. The survey methodology designed by the Commission on Chronic Illness and the Public Health Service served a triple purpose: it provided each of the surveying States with a ready-made device for conducting the study ; it produced com- parable data for the study States so that any one of them might evaluate its nursing homes in the light of the situation in other States; and it permitted the survey results of the 13 participating States to be consolidated and projected to a national appraisal. That the cooperative roles of this partnership have blended so productively is a tribute to the spirit of the many individ- uals in the State agencies and national groups which partici- pated in this study. JOHN W. CRONIN Assistant Surgeon General Chief, Bureau of Medical Services 686 iil ''iv Agencies in the 13 Participating States Centrally Responsible for the Study California State Department of Public Health State Department of Social Welfare Colorado State Department of Public Health Connecticut State Department of Health Georgia State Department of Public Health Indiana State Board of Health Maryland State Department of Health Commission on Chronic Illness Minnesota Minnesota Department of Health New Mexico New Mexico Department of Publie Health New York State Department of Social Welfare Oklahoma State Department of Health Rhode Island State Committee on Aging Vermont State Commission on the Chronically Ill and Aged State Department of Health Wyoming State Department of Public Health ''Contents Page Foreword 1.2... 0. ce eee eee eee ee eee eet enna iil Introduction 2... cc eee eee teen eee eee nee ix I. Setting for the study .....054 3 csesewans tae eae Mes i Hees aK 1 Why a study developed ....... 0.0000 c cece cece eee eee 1 Method and scope of the study .............022 00000 n 1 Nursing homes in the Nation ............ cece ee ce eee (4 Il. Proprietary nursing homes ...........0 0s cece e eee eee ee 7 Survey Coverage 2.0.0... cee eee ee tees 7 Personal characteristics of patients ...............005. 8 Medical condition of patients ......... 0... cece ewes 10 Care of patientS ..... 0.06. c eee eens 15 Staffing of MOMiGS «24 ieweawnr see seme es cae wae iwi ne 17 Attendance by phySiCiaNs! sass cssswsiss seaeemenwewnns 19 Sources of funds and charges for care .......... 000005. 22 ‘Age and occupancy of homes ......... 0500s ee eee eeee 24 Nursing homes and near-nursing homes ........-...+-- 25 IlJ. Other nursing and domiciliary care homes ..............44. 27 Survey COVCVALE 2... ee eee ee eens 27 Personal characteristics of patients ................06. 28 Medical. condition of patients <4: ccaaeevdns seve ce ewens 29 Care Of PALIENES: 2 n.0. 2. cniiwane MARAE EG COMMA ERE Oe 30 Staffing of homes ......... ec ce cece cence cece nee enees 31 Sources of funds and charges for care .......... 00000 e 32 Age and occupancy of homes ...........00 eee e cence oo IV. Chronic disease hospitals ..........--cce ce cccccr ec ceeeees 33 Survey Coverage ....... cece cee eee eee eee eee 33 Personal characteristics of patients .............+-0055 34 Medical condition of patients ........ 0c ee eee eee eee 35 Care of patients .......... csc cece rece ee ee eee cette 36 Staffing of hospitals ... 0.0.0... cee eee ee ee eee 37 Sources of funds and charges for care ...........+-000- 38 Age and occupancy of hospitals .............0. 02 ee ee 38 V. Nursing homes in perspective ......... 000.2 e eee eee eee ees 39 WL. Goneltisi0tis .2cssnass te cee eedns cee egos ¢ womens BRAGS OH 44 RefEKENGES 2k ve acne o SWART FST MTS © ESOS ANS BEE es 46 Appendix A. Representativeness of sample States and con- solidation of data ....... 0... eee teens 47 Representativeness of States in sample ........-.-0+55- 47 Consolidation of data, ....00008 Kaw Ee Te ER ee 48 Sampling error ...... 0.2 c cece eee eee eee eens 51 Appendix B. Tables 1-15 ........cce see cue ewe e eee ar teines 53 ''List of Illustrations Figure No. Page 1. Thirteen States participating in study of patients in nursing homes......... 2 2. Nursing homes and related types of facilities ............0 0.00 cc eee ee eeee 6 3. Age of patients in proprietary nursing homes ............0.00 cc ee eeeeeee 8 4. Disability among patients in proprietary nursing homes ................+- 12 5. Diagnoses of patients in proprietary nursing homes ..............0....00% 14 6. Length of stay to date of patients in proprietary nursing homes ........... 16 7. Skill-level of staff in proprietary nursing homes ..............0.00e000% 18 8. Average number of patients per nurse in proprietary nursing homes......... 20 9. Attendance by physicians in propriétary nursing homes .................. 21 10. Public assistance recipients in proprietary nursing homes ................. 22 11. Charges for care of patients in proprietary nursing homes ..............005 23 12. Age of patients in nursing homes and similar long-term care facilities; 5 States: aay sais said sais sido Wy cut acumen vec oe inoue v wus; oie ot ea eiece sume 40 . Disability of patients in nursing homes and similar long-term care facilities, 5 States 2... cc cece cece eee cence beeen eevee eaes 41 . Primary diagnoses of patients in nursing homes and similar long- term care facilities, 5 States 2.0.0.0... 0c cece cece eee cence ebeeeae 42 List of Tables Table No. 1. Types of facilities included in survey by each State ..............0.0 0005 3 2. Estimated number of nursing homes and related facilities in the United States, 1954 2... cece cnet en eee eens 6 8. Survey coverage of proprietary nursing homes ................c cee eeeeaee 7 4. Patients in proprietary nursing homes, by age, sex, and race .............. 9 5. Marital status of patients in proprietary nursing homes, by sex ............ 10 6. Relationship of disability to age among patients in proprietary Nursing homes: « <3 «swe ew es .w eww ewe swe a Ee EHR RRR EOE EEA wO ES OTT A@ OOS 11 7. Diagnoses reported for patients in proprietary nursing homes ............. 13 8. Length of stay of current patients in proprietary nursing homes, by type of primary diagnosis .......... 0.0 cece cee cece cee eee eens 15 9. Services received by patients in proprietary nursing homes, by level of care needed, sé ive iaje dais se 686 oes we CAE ad tie emu ne mend ded dmb ain’ 17 10. Highest skill-level of staff in proprietary nursing homes, by size Of HOME 2... eee ee eee ee eee e eee e een eenes 18 11. Personnel in proprietary nursing homes, by type of staff and full- or part-time status «ew « sv + sis wis ow 8 Se & Bid FE BF Gnd §Sib wees e pure mow ew eae miniuns 19 12. Patients in proprietary nursing homes who had been attended by a physician within 30 days of survey, by number of visits and age of patient 2.0... 6. eee ce eee ee eee eee nee enaennens 21 18. Sources of funds for care of patients in proprietary nursing homes......... 23 14. Average amount charged for care of patients in proprietary nurs- ing homes, by condition of patient ........... 000... cee cece cence eens 24 15. Rate of occupancy in proprietary nursing homes, by size of home ........... 25 vi ''Table No. Page 16. Comparison between two component types of homes which compose the “nursing home” category in the study, upstate New York Ond. WYOMING rs nnn Colorado. _.-.---------- =e xX X = [_..-----------|------------ Connecticut_-_------- eee xX xX xX x Georgia__--_------ ee xX x Mle eee ANGI AN Bien cscers execs wists atin mmm eee Here aimee meee cere ees aera tiem een Maryland_____--.___________-_-___--_---_--__--_---- xX xX x xX Minnesota_-_.-------- eee x xX x x New Mexico_.__--___.---..---_------- xX x IR, | Sicsttraserdleasaeonsiarias New York (upstate)?____--. 222 ee ee etree | eel Oklahoma__-.---------- ee xX x xX xX Rhodé: Islatids sgeecnce osc. asic seem mincme omeemeenn oe xX X x x Vermont. -.------------.-.--_____--------- eee eee x x > rs Wyoming____-_----- eee xX x X [ine ee eee eee 1 Excluding mental and tuberculosis hospitals. . . *Represents 1954 civilian population, which numbered 159,084,000 for continental United States. 5 excluding New York City. Public Health Monograph No. 46, 1957 3 ''be treated later in the report, are those which provide personal services as distin- guished from skilled nursing services. Skilled nursing care available as an “‘ad- junct” service in a home primarily for board- ing and personal care would theoretically not qualify an establishment as a nursing home under these definitions. In actual prac- tice, however, it was discovered that the prevalent looser type of interpretations ex- ercised considerable sway over the classifica- tions made of individual homes in the field. The end result, it must be recognized, is that the facilities classified as nursing homes in the study actually represent a combination of homes which provide skilled nursing care as their primary function and of homes which give a measure of skilled nursing care only incidentally to their prime function of personal care. In two study States, New York and Wy- oming, this combination can be subdivided clearly into the two component groups. How the two subgroups vary in these States in the types of patients and care found in the respective homes are examined in the next section (see pages 25-27). Survey Procedures The model survey plan which was de- veloped out of the pilot study in Maryland was furnished in guide form, together with personal consultation, to the States which joined in the overall study. Carrying out the survey under the basic plan was the re- sponsibility of the sponsoring agency in the State (see list on p. iv). The general survey pattern involved a visit to the nursing home by a field agent, usually a nurse, who, with the assistance of the nursing home administrator and other staff members, completed a schedule of informa- tion on each patient in the home on that day. Patient records maintained in the nursing home were used as needed and available. Alternative methods allowed for completion of the schedules by the nursing home staff themselves. In any event, it should be rec- ognized that a basic limitation of the survey data is that these data cannot go beyond what the nursing home administrator and his staff know and report about each patient. 4 Information gathered on the patients in- cluded personal data, date of admission to the nursing home, diagnoses as available, nature and extent of disability, nursing and personal services received, physician’s care, charges, and source of funds for payment. Certain information about the homes them- selves was obtained, including the length of time they had been in operation and the number and types of staff employed. (The physical characteristics of the homes, often studied in the course of inspections under licensing programs, were not covered in this study.) Each State did its own field work, proc- essed its own schedules and tabulated the results, using the uniform procedures, classi- fications, codes, and tabulations outlined in the standard guide. This guide has been published in essentially the form followed in the study (8). With the continuing cooperation and par- ticipation of the responsible agencies in the 13 participating States, the Commission on Chronic HIness and the Public Health Serv- ice jointly processed and consolidated the survey findings, using a standard set of tables furnished by each State. Time of Survey The States joined the study at various periods during 1953 and 1954. The field data were gathered during those 2 years. The time consumed in processing the schedules and machine tabulating the results varied among the States. The last of the State findings became available at the end of 1955, and consolidation of the data was com- pleted during 1956. Nursing Homes in the Nation Stocktaking of existing nursing homes and related long-term facilities would assume more meaning if we knew the number of such homes in the country and the number of people they accommodate. Absence of reliable national figures on these elemental points was a major gap in information which hampered the Commission on Chronic Illness in its investigations. Because the Division of Hospital and Medical Facilities of the Nursing Homes, Their Patients and Their Care ''Public Health Service was similarly hamp- ered for lack of such information, this di- vision conducted a national inventory of nursing homes and related facilities in 1954. Reports (9-12) have been published which present in considerable detail the back- ground, methods, and findings of that na- tional inventory. Some of the resulting basic information is reviewed here as a helpful setting for the present analysis. The National Inventory The variety of facilities covered by the national inventory represented essentially all types of nonhospital facilities providing nursing or supportive services to chronically ill, convalescing, aged, disabled, or infirm persons. Specifically, it included nursing or convalescent homes, homes for the aged, boarding care homes for aged persons, public homes, children’s convalescent homes, and special nursing homes for alcoholics, drug addicts, or mentally disturbed patients. Ma- ternity homes and domiciliary facilities for children were excluded, as well as institu- tions for the blind and the deaf and institu- tions for the mentally deficient if they did not meet the study’s definition of a nursing home by giving primarily ‘skilled nursing care.” The States and Territories submitted the survey data during the period April—October 1954. New field surveys were not requested for purposes of the inventory. Instead, the State agencies administering the Hill-Burton Hospital Survey and Construction Program were asked to furnish data on existing es- tablishments, utilizing information already available to them or to other agencies and organizations or which was readily obtain- able through such sources. The findings, therefore, lack some degree of accuracy and completeness. They are considered, how- ever, to have sufficient scope and reliability to meet the current pressing needs for information. The difficulties experienced with classifica- tion of homes in the patient study already described were analyzed carefully in develop- ing the classification scheme of the inven- tory. The groupings of homes which came out of the patient study were essentially Public Health Monograph No. 46, 1957 those conventionally regarded as “types’”— in effect the patient study took familiarly known types of homes and proceeded to ob- serve their actual character as revealed through information about their residents. The national inventory, in contrast, broke more sharply with conventional labels and established a classification structured more rigorously on rationale. It was built on the same basic definitions as were used in the patient study for ‘skilled nursing care” and “personal care’ (see “Method and Scope of the Study’). In addition, it defined a third level of care: ‘shelter,’ representing room and board, minimum services of a custodial nature such as laundry, and personal cour- tesies such as occasional help with corres- pondence or shopping and an_ occasional helping hand short of the routine “personal care” defined earlier. Then, without regard to popular ways of designating homes—for example, nursing home, home for the aged, public home, boarding care home, and so on—the inventory classified facilities into four categories, based on the predominant level of care furnished: skilled nursing homes, personal care homes with some skilled nursing, personal care homes without skilled nursing, and sheltered homes. Findings of the National Inventory The national inventory revealed a total of about 25,000 homes with approximately 450,000 beds. These facilities range from the boarding home for aged persons, which gives only the simplest supportive services, to the professional type of nursing home providing highly skilled and intensive nurs- ing care. Table 2 shows the number of facilities in the different categories of the inventory classification. Skilled nursing homes ac- count for 40 percent of the total beds of all types reported. Most of the homes in each of the types of facilities are under proprietary auspices (fig. 2). However, because voluntary and public homes are typically larger than com- mercial homes, they provide more of the total nursing home beds than might be ex- pected (table 1, appendix B). In the case of skilled nursing homes, 9 out of every 10 are 5 ''Table 2... Estimated number of nursing homes and related facilities in the United States, 1954 Beds |. Per Type of facility 1,000 Homes Total pope: ation Tot: ‘ Woe 25 ,000 | 450 ,000 2.8 Skilled nursing homes_ — - 7,000 180 ,000 1.1 Personal care homes with skilled nursing--_.__-_-| 2,000 80,000 5 Personal care homes with- out skilled nursing - — _- 7,000 | 110,000 7 Sheltered homes_ ___ ~~ ~~ 9,000 | 80,000 b SOURCE: Tventary of nursing hemes and related facilities (9). operated under proprietary ownership; these provide, as a result of their generally smaller size as compared with voluntary and public institutions, 7 of every 10 beds in all skilled nursing homes. Relationship of National Inventory to Patient Study A common tendency discovered among most of the States in the patient study was Figure 2. SST ea ella & RELATED TYPES IN THOUSANDS SKILLED NURSING HOMES to classify as proprietary nursing homes not only the type of facility which in the later terms of the national inventory was desig- nated as “skilled nursing homes,” but also the type identified in the inventory as “‘per- sonal care homes with skilled nursing.” In other words, in the patient study, most of the States did not distinguish between homes which provide skilled nursing care as their primary service and homes which function primarily for personal care but have some minor extent of skilled nursing services. The basic definitions and classifications of the national inventory and the patient study had, to be sure, a close tie-in. However, in the patient study, the force of local custom and understanding often overrode the in- tended classification of homes. The defini- tions employed in the patient study nar- rowed the range of interpretation of the term ‘nursing home” but did not eliminate it. The national inventory sought to draw sharper distinctions and to make clearer, more objective provision for categorizing homes into successive levels of skill. As a Nursing homes and related types of facilities. NUMBER OF BEDS IN THESE Pe IN THOUSANDS ha he ‘ts a ate) 7. ened CARE > leh tye Aaa ee SKILLEO Cte SHELTERED HOMES az" , zm)! | a. TARY VOLUNTARY & PUBLIC Nursing Homes, Their Patients and Their Care ''result, it was successful in achieving a classi- fication of facilities which was less ambig- uous than the patient study classification. In general, then, differences between the number of facilities in the States involved, as reported by the national inventory and by the patient study flow from differences in classification and in interpretation of defini- tions, as well as from differing degrees of completeness of coverage. Differences in time period, where establishment or closing of individual homes may have occurred be- tween reporting dates, would also have had a considerable influence; the rapid rate of accession of proprietary nursing homes will be observed later in the report. The data of the national inventory have served as the principal means for gauging the proportion of the country’s facilities represented by the 13 States in the patient study. Appendix A explains how projection of national estimates from the patient study was tested and developed through the inven- tory findings and other data. II. Proprietary Nursing Homes Survey Coverage The burgeoning sector of the nursing home field represented by proprietary nursing homes is a difficult one to circumscribe, as was recognized earlier. General standardiza- tion of what is construed as a nursing home will come about slowly and doubtless some- what painfully. At this stage of our knowl- edge and capacity to deal with the problem, the extent of the field is rather hazy but it is beginning to take some form. For this analysis, as explained earlier, the facilities included as nursing homes may be generally said to be those which provide skilled nursing care, either as a primary function or incidentally to provision of per- sonal care. Even here, the inclusions were subject to each State’s interpretations, so that there is a tendency toward conformity with the prevailing conception of nursing homes in the subject area. With approximately 25 percent of the Na- tion’s population, the study States were judged to have 30 percent of the proprietary nursing home beds in the country (table 1, appendix A). Projecting from this, there Table 3. Survey coverage of proprietary nursing homes Percent Total Number reported! of total State patients Homes Beds Patients? | Homes Beds Patients | reported! Total, 13 States reporting --- 2,715 47 ,322 39,179 1,686 28,891 23 , 242 59.3 California! ________-_-_-___------- 464 8,356 6,784 120 2,635 1,687 24.9 Colorad Oweceecnese emeccemmemseews 140 2,571 2,093 136 2,476 2,016 96.3 Connecticut__.-.----------------- 183 4,197 3,819 180 4,134 3,763 98.5 GGOPD18......o nneeeceemenenoeemenen = 53 1,235 998 51 1,136 918 92.0 Indiana___.---------------------- 340 5,768 4,277 339 5,751 4,264 99.7 Maryland___--------------------- 102 2,385 2,029 96 2,203 1,874 92.4 Minnesota__.-------------------- 199 3,335 3,202 187 3,087 2,964 92.6 New Mexic0.scseccusensosccanuens 82 333 254 32 333 254 100.0 New York (upstate)!___-_____-__-- 752 13 ,653 11,609 96 1,651 1,391 12.0 Oklahoma___--------------------- 248 3, 166 2,291 248 3,166 2,291 100.0 Rhode Island____----------------- 79 1,111 911 78 1,107 908 99.7 Vermont®_____-_--------------_-- 95 980 754 95 980 754 100.0 Wyoming. ----------------------- 28 232 158 28 232 158 100 0 1California and New York used a planned sample of homes. (In the other 11 States complete coverage was the objective.) The analysis will provide for expansion of the samples to the corresponding totals for those States. This expansion will yield reported totals for the 13 States of 2,686 homes, with 46,614 beds and 38,557 patients. ?Partly estimated. ’Total in State not reported. total. Public Health Monograph No. 46, 1957 In absence of other evidence, assumption made that reported group represents ''are in the United States an estimated 160,- 000 beds in 9,000 homes of the type con- strued in this study as proprietary nursing homes. As table 3 shows, the 13 study States reported 2,715 such homes with 39,179 pa- tients. The study States achieved nearly complete coverage in the survey except that California and New York employed a plan- ned sample. The information presented in this section is based on actual reports for 1,686 proprie- tary nursing homes with 23,242 patients. The samples employed in California and New York will be expanded to represent the totals for those States so that they will carry their proper weight in the 13-State summa- tion. The resulting 13-State totals which will be cited in the analysis will therefore be 2,686 homes with 46,614 beds and 38,557 patients. Figure 3. UNDER 65 65-74 & OVER Ind. Rul. NY. Okla. Minn. Conn. Calif. Colo. Vt. Ga. : (upstate) Personal Characteristics of Patients Personal data gathered for the patients include age, sex, marital status, and race. The detailed findings by State are shown in table 2, appendix B. Age Nursing homes take their prime character from the age of their patients. The average patient is 80 years old. Less than one-tenth of the patients in pro- prietary nursing homes are under 65 years of age (table 4). Very few indeed—little more than 1 percent of the total—are less than 45 years old. Figure 3 emphasizes how extreme is the age characteristic. As many as one-fourth of the patients are 85 years of age or older. The chart also depicts the striking similar- ity in the age of patients among the survey Age of patients in proprietary nursing homes. AGE OF PATIENTS PERCENT 100 Md. Wyo.N.Mex. 80 60 40 20 | = Nursing Homes, Their Patients and Their Care ''States. Whatever other characteristics may be found to vary from one State to another, the age makeup of the patient population is distinctly standard. Nursing homes in con- temporary society, it appears, are character- istically a form of home for the aged. Some individual homes will depart from this pat- tern for one reason or another—in catering to short-term convalescents of any age or to patients in a younger age group—but the predominance of patients in the older ages is clear. Table 4. Patients in proprietary nursing homes, by age, sex, and race Sex! Race! Total }———_,———_ |—- 2 — Age pa- Fe- Non- tients} Male | male | White} white Number, 13 States. _/38 ,657|12 , 468/25 ,943/37 ,031 745 Percentage distribution Total ______- 100.C 100.0, 100.0} 100.0} 100.0 Under 45.2 secccus 2 1.4 2.0 1.0 1.3 5.0 45-54. === 2.1; 2.6 1.8 2.0) 6.6 55-64 _ - - - mess 5.5 6.4 5.1 5.3] 13.6 65-74__----------- 20.6) 24.0) 19.0) 20.5} 27.9 75-84_____-------- 42.3) 40.4) 43.3) 42.6) 27.9 85 and over__------ 26.2| 22.5) 28.0) 26.5) 13.6 Unknown_--------- 2.0 1.9 1.8 55 Median age (years) 80 78 | 80 80 73 Number per 100,000 general population in category? Total__..---- 102) 66 136, 10¢] ~—-26 Under 40 i cccecsccn 2 2 2 2 2 45-94..- os sscesees 18 15 21 18 17 55-64.......-.- s=sesece 62 47| ad 61 60 65-74__---- eee | 365 289) 432 367) 183 75-84_..---------- | 1,870) 1,278) 2,347) 1 1889) 581 85 and over_______-| 6,383] 4,387) 7,692) 6,534) 1,237 | | Under 65_ ~~~ -----) 10 8| 12 10 7 65 and over- 1,071 725 1,365 1,088 327 1 Sex unknown, 146. Race unknown, 781. ? Based on 1950 population census. Note: Figures in this and other tables are indi- vidually rounded and therefore do not necessarily add precisely to their totals. The highly selective nature of the patient population of nursing homes stands out boldly when viewed in relation to the gen- eral population. For every 100,000 of the total population in given age groups, the number of patients in proprietary nursing homes mounts sharply with age, as table 4 Public Health Monograph No. 46, 1957 shows. Of the population 65 years of age and over, 1 percent are in these homes. Lit- tle as this is, it is 100 times the correspond- ing rate for the population under 65 years old. The strong effect of age on the propor- tion of the population in nursing homes is similarly seen among persons over 65 years old—the proportion in nursing homes is one- third of 1 percent for those aged 65-74 years, but over 6 percent for the group 85 years of age or older. Sex Two-thirds of all patients in proprietary nursing homes are women. This is not merely a consequence of the large propor- tion of older women in the general popula- tion. The rates in table 4 demonstrate that of the total population of given ages, much larger proportions of women than of men are in proprietary nursing homes. This un- doubtedly reflects the greater longevity of women in this indirect respect: Many more women than men are widowed. Widowhood, in turn, more strongly disposes to residence in a nursing home or other protected en- vironment than if a marital partner is present. This differential experience results in a somewhat older average age for women pa- tients than for men patients—80 years com- pared with 78 years. Marital Status The significance of widowhood is empha- sized by the fact that two-thirds of all pa- tients in proprietary nursing homes are widowed. Those who are partnerless because they have never been married or have been divorced or separated make up an additional sizable proportion of the patients in these homes (table 5). Only one-tenth of the pa- tients are married with the spouse living. Proportionately more women patients than men patients are widowed—nearly three-fourths against one-half. Race About 8 percent of the general population in the 13 study States are nonwhite. Only 2 percent of the patients in proprietary nursing homes in these States are nonwhite. 9 ''\ ~ This difference cannot be wholly accounted for by the fact that proportionately fewer nonwhites attain the advanced ages char- acteristic of nursing home residents. Even among nonwhites living into the higher ages, the rate at which they are found in proprie- tary nursing homes is substantially lower than the rate among white persons. For ex- ample, of the total population 85 years of age or older in the study States, the propor- tion in proprietary nursing homes is 6.5 per- cent among white persons and only 1.2 per- cent among nonwhites. Economic and social factors would seem to hold likely ex- planations and would merit more detailed yg Study. In net result, white and nonwhite patients in proprietary nursing homes are sharply distinguished in their average age—80 and 73, respectively. A curious fact revealed in the study is that the nonwhite patient group is made up about equally of men and women while among the white patients there are twice as many women as men. Perhaps related to this is the fact that in the nonwhite popula- tion of the study States, equal proportions of the men and women are 65 years of age or older—5.5 percent in either group. Among the white population, however, of whom 8.7 percent are 65 years of age or older, the pro- portion for women is higher (9.3 percent) than for men (8.1 percent). Table 5. Marital status of patients in proprietary nursing homes, by sex Sex! Marital status Total ——— ;— patients Male | Female Number, 13 States 38,557 | 12,468 | 25,943 Percentage distribution Total. ____ a. 100.0 100.0 100.0 Widowed _ _ ___- 65:3 51.5 72.1 Single mie Sine aire eee o LT 21.8 15.8 Married__________ | 10.5 16.3 7.7 Separated or divorced ____ 2.7 5.7 1.3 Unknown_____--_-_ ===. 3.8 4.8 3.1 * Sex unknown, 146. Medical Condition of Patients Physical and mental status is at the heart of the description of the patients in this 10 study. Information available on this score relates to the extent of disability among the patients and the types of diagnoses reported for them. Ability to Walk Somewhat less than half of the patients can walk alone or with no more help than a cane or crutch. Others need some major mechanical or personal assistance for get- ting about, while nearly one-third do not walk or get about at all, even in a wheel- chair (table 6). Considerable variations appear among the States in the extent of disablement of nurs- ing home patients. Figure 4 summarizes these variations by showing the range among the 13 study States in percentage of patients suffering given forms of disability. The proportion who cannot walk alone even with the help of a cane or crutch varies from two-fifths in Wyoming to two-thirds in California. (Detail for all 13 States is given in table 3, appendix B.) Less relationship than might be expected appears between walking status and age of the patients (table 6). Surprisingly little variation shows among the different age groups in the proportion who can walk en- tirely independently or, on the other hand, in the proportion completely unable to walk. Consistent differences do appear among the age groups, however, in the proportions of patients able, but with some severe limita- tion, to get about. The proportion of patients who maneuver themselves about with the aid of major appliances such as walkers and wheelchairs decreases with age, while the proportion dependent on an attendant’s help- ing hand increases with age. Thus, for those for whom it is difficult but possible to get about, increasing age brings greater reliance on personal help and decreasing ability to manipulate mechanical appliances. Bed Status Twenty percent of proprietary nursing home patients are completely bedfast. An additional 14 percent are in bed most of the time. Others are in and out of bed for por- tions of their time. Somewhat less than half are normally out of bed. Nursing Homes, Their Patients and Their Care ''Table 6. Relationship of disability to age among patients in proprietary nursing homes Age! Condition of patient Total patients | Under 55 55-64 65-74 75-84 | 85 & over Number, 13 States_._-.---------------- 38 ,557 1,321 2,123 7,955 16 ,300 10,106 Percentage distribution Totalixcveceeceeescee ceca 100.0 100.0 100.0 100.0 100.0 100.0 Walking status: Alone or with cane or crutch__-------------- 45.6 40.3 39.6 46.8 47.6 43 6 With walker, wheelchair, ete.__-_----------- 8.0 16.4 11.0 9.3 7.4 6.2 Only with attendant’s help_---------------- 14.1 U7 11.3 13.0 14.3 16 0 Does not walk or get about_---------------- 31.4 33.5 37.4 3041 29.9 33 2 Unknown_-___----------------------------- 1.0 2.1 7 8 8 10 Bed status: Out of bed except to sleep or rest__-.-------- 46.9 51.4 44.9 48.5 47.8 44.4 In bed part of the time__.-----.------------ 18.7 12.7 17.7 18.4 18.8 19.7 In bed most of the time_____--------------- 13.8 11.6 13.0 14.6 13.3 14.3 In bed all of the time____-.-.-------------- 20.4 23.8 24.4 18.4 19.9 21.5 Unknown____--_-------------------------- 2 5 0 ol 2 wl Mental condition: Always clear____-------------------------- 43.5 71.2 54.9 49.5 42.2 35.1 Confused part of the time_-_---.------------ 33.7 18.5 30.6 31.5 34.7 36.3 Confused most of the time____-------------- 22.4 8.8 14.0 18.9 22.6 28.3 Unknown____.---------------------------- 4 1.4 4 .2 4 3 Continence: Continent. << =< cace sexe peewee aces coueeeen 64.5 72.7 69.0 67.7 64.6 60.5 Incontinent, feces only__------------------- 1.4 8 8 1.4 1.6 1.4 Incontinent, urine only___------------------ 7.4 5.6 4.6 6.8 7.5 8.5 TIncontinent, urine and feces___------------- 26.2 20.4 24.7 23.6 25.8 29.1 UnknOW sewers ce ee eee 5 20 9 5 a) 4 1 Age unknown, 752. Again the situation varies from State to State, as figure 4 shows. The proportion completely confined to bed ranges among the study States from 12 percent to 35 percent of the patients. We would expect that confinement to bed would increase with the age of the nursing home patients. As already observed above with respect to ability to walk, however, there is no strong pattern demonstrating that the older patients in nursing homes are more heavily disabled in this regard. This suggests perhaps that disability at any age is a large selective factor in bringing pa- tients into the nursing home. Often the dis- ability will have to be more severe to induce placement of a younger person than of an older person in a home. Some older people enter a nursing home not so much because of a severely disabling condition but rather because of general infirmity or because of social difficulties in housing arrangements. People not quite so old would be more apt Public Health Monograph No. 46, 1957 to be cared for at home particularly if a husband or wife is still living. It may be that by such selectivity, the patients in nurs- ing homes would not show the extent of in- creasing disability with age which might ordinarily be expected. Mental Condition More than half of the patients in proprie- tary nursing homes are disoriented, at least part of the time. About 1 out of 5 disori- ented patients show this state of confusion most of the time. All of the study States reported large pro- portions of patients as being confused. The range (fig. 4) is from about one-half to two-thirds of the patients in the different States. In contrast to the physical disabilities dis- cussed above, disorientation shows a decided relationship to age (table 6). The propor- tion of confused patients mounts sharply from about one-fourth of those under 55 il ''Figure 4. Disability among patients in proprietary nursing homes. DISABILITY AMONG PATIENTS RANGE AMONG I3 STATES SEVERELY LIMITED IN WALKING HIGHEST BEDFAST CONFUSED &. MENTALLY — INCON- TINENT PERCENT : Calif. Calif. 21 LOWEST 4] PERCENT Conn. & Md. Wyo. Ga.& Wyo. years of age, to half of those aged 65-74, and on up to nearly two-thirds of the pa- tients who are 85 and over. Most of the mental confusion among the older patients stems from arteriosclerotic processes, while among the younger patients it is more likely to result from other dis- eases affecting the central nervous system and from mental disorders. Continence Large numbers of nursing home patients do not have control of elimination. Fully one-third are incontinent of either urine or feces or both. One-fourth lack both bladder and bowel control. Although a range in the severity of this problem is exhibited among the different States, its extent is very impressive for all States. As figure 4 indicates, in none of the 12 surveying States is the proportion of incon- tinent patients less than one-fourth. Incontinence may have its basis in either organic or psychological difficulties. The ex- tent of its prevalence in relation to age of the patients may reflect its twin origins, for incontinence in patients in nursing homes shows an increase with the age of the pa- tients to an extent which is between the observed increase in physical disabilities and in disorientation. Approximately 25 percent of patients under 55 years of age are incon- tinent, with increasing proportions among the older group, up to about 40 percent of those 85 years and older (table 6). Diagnoses The observable physical and mental limita- tions of the patients which have been dis- cussed above have a degree of validity not Nursing Homes, Their Patients and Their Care ''matched by the diagnostic information avail- able. Nursing home administrators and staffs, it has been observed, often do not have reliable diagnostic information on pa- tients. Many patients have not had current medical diagnoses made or, when diagnoses have been made by physicians, they often have not been transmitted to the nursing homes. The medical records in many nurs- ing homes are particularly inadequate and unrevealing. For these reasons and because of possible inaccuracy of reporting for the survey, reliance on the diagnostic data must be guarded. Despite this necessary reserve, these data permit some enlightening observations. They certainly reveal (table 7) that chronic diseases predominate among nursing home patients. They also point out how large loom the cardiovascular diseases among this group. Two out of every five patients have a cardiovascular condition which represents the main medical reason for their need for care in the nursing home (that is, the pri- mary diagnosis). Fully 2 of every 3 patients have some heart or circulatory difficulty, either as a primary or contributory condi- tion. Heart disease and hemiplegia resulting from stroke are two major components in the circulatory group of diagnoses. Large numbers of nursing home patients are vic- tims of these diseases. One in six patients suffers residuals of a paralytic stroke and, more than for any other type of diagnosis except multiple sclerosis, having this condi- tion means having it as the principal path- ology: In both types of diagnoses, more than 9 out of 10 patients who had the condition had it reported as their primary diagnosis. About one-tenth of the patients are re- ceiving care for fractures; in most cases, hip fractures. These fractures particularly as- sume a chronic rather than an acute char- acter since the aged person with a hip fracture requires so prolonged a period of care. Arthritis and rheumatism affect a goodly proportion of these aged people. Various forms of paralytic conditions, mental disor- ders, and diabetes were reported for more than 5 percent of the patients. Nearly as Public Health Monograph No. 46, 1957 Table 7. Diagnoses reported for patients in proprietary nursing homes All Primary Diagnostic group diagnoses | diagnoses Number, 18 States___--_---- 61,867 38 ,557 Percent of patients Total_____- eee ees oe wee & 100.0 Cardiovascular diseases. ______ .- 65.6 40.3 Heart disease______--_-____-- 17.2 11.6 Hemiplegia (mainly from BUDOKC) arcpeeeieaeemiermmew « 16.3 15.2 Other circulatory diseases - - - - - 32.0 13.5 Senility. __...---------- oe os 25.6 17.0 Fractures__--_ .- = 5 == 11.38 8.8 Tip iesce as See coon 8.0 6.4 Other: Se sameenisee ok 3.3 2.4 Arthritis and rheumatism _- ——_- 9.5 6.3 Paralyses (excluding hemiplegia) and degenerative diseases of central nervous system_-_- --- é. 4.9 Paralysis agitans....2-..==-<=-== 2.5 2.1 Multiple sclerosis.______-__--_- 1.0 1.0 OWer. .- wien nee eee renin den 2.3 1.8 Mental disorders___.__--------- 5.8 3.6 Psychoses____---.- Sree aes 2.2 | 1.7 Psychoneuroses and other be- | havior disorders_____-_- ~~~ 32 | 1.9 Diabetes_._..--.-------------- 5.3 | 3.4 Neoplasms_------------------- 4.5 3.3 Genitourinary diseases___—_ ~~~ _- 3.8 1.5 Gastrointestinal diseases __—_ ___- 3.0 1,1 Total blindness__ ~~~. ~~ ------- 3.5 | to) All other diagnoses______-_~_-_- 14.0 | 5.3 No disgnosises. acc cccecccmecs 2.2 | 2.2 Unknown... ...=-----=<-. wees 1.0 | 1.0 | many were reported as having cancer or other neoplasms. One out of 30 patients is totally blind, although for less than half of them is blindness the main problem requir- ing that they be under nursing home care. The frequency with which senility is re- ported points up a special problem. For one thing, the term “senility” is quite undefini- tive; it identifies the nature of the difficulty only in a vague and unsatisfactory manner. Moreover, the reported prevalence of senility undoubtedly reflects not so much the true prevalence of the condition as it does a fail- ure to have any more definitive diagnostic information on the patients. If the patient is not attended by a physician, if the physi- cian’s diagnosis does not find its way to the nursing home, or if the nursing home does not employ adequate medical records then 13 ''Figure 5. DIAG NOSES ~ RANGE AMONG 3 ee Diagnoses of patients in proprietary nursing homes. PERCENT OF PATIENTS WHOSE PRIMARY CONDITION IS: ‘CARDIO- VASCULAR [\ Y i MENTAL Conn. W.Mex. Okla. 5 States iN js /s [! FRACTURE DIABETES Ga Vt. Wyo. R.1. N.Mex. pp ARTHRITIS or , ys NEOPLASM RHEUMATISM 4 Sates Minn. Okla. T States : Wyo. PARALYSIS* or DEGENERATIVE "SENILITY" DISEASE OF CNS N. Mex. RA. Wyo. Conn. * Except hemiplegia the blanketing term ‘‘senility’” may be con- veniently assigned. Many of the patients have a multiplicity of diseases, so characteristic of older, chron- ically ill people. More than half again as many diagnoses were reported as there were patients. Figure 5 shows for some of the diagnostic groups the variation among the States in the extent to which the given conditions are reported as primary diagnoses (see table 4, appendix B, for complete detail). It is in- teresting to observe that Connecticut, where relatively high standards of care prevail, re- ports the highest proportion of patients with cardiovascular diagnoses among the study States and the lowest proportion under the term “senility.” Men and women patients show a not very dissimilar picture on diagnoses (table 5, ap- pendix B). A few differences come to light, 14 however, which are worth noting. More women suffer fractures, particularly of the hip. Disorders of the genitourinary and gas- trointestinal systems seem to be more preva- lent among men. On the whole, however, differences are quite few and minor. Age has a more decided effect on diagnoses than does sex (table 5, appendix B). A sharp distinction may be seen between pa- tients under 55 years of age and those over 55 in diseases of the heart and circulatory system; considerably fewer of the younger patients have these conditions. Certain other diagnoses, on the other hand, appear more frequently among the younger pa- tients; outstandingly, multiple — sclerosis. This may reflect the hypothesis offered in the earlier discussion relating disability to age: In the absence of severe identifiable condi- tions, younger individuals may be brought into the nursing home infrequently. Nursing Homes, Their Patients and Their Care ''The condition which brings the patient to the nursing home has much to do with the length of stay. Table 8 gives the median stay, to date of the survey, of patients with different primary diagnoses. Patients with neoplasms show the shortest average time in the home, 7 months, doubtless attributable largely to the number of terminal cancer cases. Multiple sclerosis patients show the longest stay, averaging 21 months. Signifi- cantly in this connection, persons with mul- tiple sclerosis generally have recourse to the nursing home earlier in life than do the pa- tients with any of the other diagnostic con- ditions studied. Half of all patients with a primary diagnosis of multiple sclerosis are under 55 years of age, a proportion not re- motely approached by the patients of any other diagnostic group. Table 8. Length of stay of current patients in proprietary nursing homes, by type of primary diagnosis Median Number length Selected primary diagnoses of of stay patients | (months)! Total patients, 13 States} 38,557 12 Multiple sclerosis........-.-.--- 369 21 Total blindness_____-_-_-------- 563 20 Arthritis and rheumatism__-__-- ~~ 2,489 17 Senility. ___.------------------ 6,538 14 Paralysis agitans_----------_-- 826 13 Hemiplegia (mainly from stroke) 5,854 12 Heart disease... ----------- 4,488 12 Dig bGUESs oc wemeecmier aerers eee 2 1,298 12 Fracture of hipecs-we sssce asc 2,464 Li Psychosés.......- --6.6 -awen enme + 662 i Gastrointestinal diseases_____~__- 408 11 Fracture (other than fracture of the hip).-------------------| 913 9 Psychoneuroses and other be- havior disorders. ____-_.-_-__- 729 9 Genitourinary diseases______--_- 595 | 9 Neoplasms. << ac s sesesamsemwerssececes 30.9 care homes with skilled nursing- - ~~~ 32.0 ‘From U. S. Bureau of the Census. Total popula- tion for 1954 from Current Population Reports, Series P-25, No. 108, January 3, 1955. Other data from Census of Population, 1950. °1954 data, from Survey of Current Business, September 1955. 48 *1950 data, from Public Health Service, Health Manpower Source Book, sec. 5. “From State hospital plans for 1953, submitted to Public Health Service under the hospital and med- ical facilities survey and construction program. °*From Public Health Service, 1954 national inven- tory of nursing homes and related facilities (9). Nursing Homes, Their Patients and Their Care ''to produce more refined estimates than would be derived by simple pooling. Three factors, or indices, were hypothe- sized in an attempt to account for the differ- ential results among the States. These were: proportion of population aged 65 years and over, number of professional and practical nurses per 100,000 population, and per capita income, Table 2. Averages for 13 States compared with United States averages for relevant items of information United Item 13-State States average average Median age (years)_----.------- 30.8 30.2 White population (percent of COC) cece erence cineca 92.4 89.5 Urban population (percent of OCG) soc cetera a cence 66.7 64.0 Per capita income. < --