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committees that closely monitor federally funded research involving ani-
mals or humans. If abuses occur, committee members are obliged to
report them to the National Institutes of Health. (For more information on
biomedical research and biomedical research facilities, see Chapter 4.)

Education In a hospital setting, education and training may occur at
many levels. Hospital personnel are given on-the-job training in infection
control and safety procedures; laboratory and radiology technicians are
trained; nursing students are provided with undergraduate education or
specialty training; graduate students earn master's degrees in nursing,
dietetics, or physical therapy; other graduate students work on research
projects in hospital departments or laboratories as part of doctoral degree
work; medical students go through rotations, which lead to M.D. degrees;
physicians are given postgraduate education as residents or fellows; and
allied health care professionals in all disciplines attend hospital-sponsored
in-service programs or continuing education courses to retain their certifi-
cation or licensure or to update their knowledge and skills. To this end it is
not uncommon for hospitals to have an education department, or for
medical departments to hire managers to deal primarily with education.
Hospitals may also provide the clinical facilities necessary for programs
that they do not sponsor. In addition, hospitals often provide trustee
education and management development courses. (See Chapter 5 for
information on educational institutions and programs for health care-
related occupations.)

Certain hospitals are identified as teaching hospitals. According to the



NURSING HOMES 33



American Hospital Association, a teaching hospital is "a hospital that
allocates a substantial part of its resources to conduct, in its own name or
in formal association with a college, courses of instruction in the health
disciplines that lead to the granting of recognized certificates, diplomas, or
degrees, or that are required for professional certification or licensure. "^^
Although this definition does not mention research, the reality is that the
majority of teaching hospitals also engage in biomedical research, and
hospitals that engage in research are also usually defined as teaching
hospitals.

Historically, the majority of teaching hospitals in the United States
were public hospitals; today, however, the majority of teaching hopitals
are voluntary. ^^ For-profit hospitals generally avoid engaging in teaching
and biomedical research because they are not profitable activities; how-
ever, a few investor-owned companies began purchasing or leasing teach-
ing hospitals in the early 1980s, for a variety of complex reasons. ^° In
1991, 19 percent (1,238) of all hospitals were teaching hospitals. Of these,
30 percent were government owned (18 percent state and local, 12
percent federal) and 70 percent were privately owned (67 percent not-
for-profit, 3 percent for-profit). Although the term "teaching hospital"
traditionally referred to affiliation with a medical school, today it also
denotes affiliation with other educational institutions. The Veterans Ad-
ministration Hospital in Ann Arbor, Michigan, for example, is affiliated
with the University of Michigan Medical School and thirty-four other
educational institutions.



NURSING HOMES

Nursing homes and hospitals are similar in many respects. For example,
they both provide in-patient medical care, are heavily regulated, are
licensed by the JCAHO, and provide training for health care professionals.
Yet they have one basic difference: nursing homes are primarily places
where people live and secondarily where they receive medical care. For
this reason health care professionals play a less significant role in control-
ling and operating nursing homes. ^^

Until relatively recently, hospitals provided long-term health care for
elderly and convalescent people. Although hospitals still provide long-
term care, nursing homes provide most of it. In fact, the nursing home
industry is the third largest element of the health care system. ^^ In 1991
there were 15,913 certified nursing homes in the United States,^^ and
$59.9 billion (about 7.5 percent of the total spent on health care) was
spent on nursing home care.^'^



34 FACILITIES THAT DELIVER HEALTH CARE



Most likely the first nursing home began in the early 1930s in Chicago
or Detroit. 55 The Social Security Act of 1935 increased the number of
people who were able to purchase nursing home care and caused proprie-
tary nursing homes to dominate the market. Until World War II, nursing
homes generally were small, run by the owner, and staffed by the
immediate family. With increasing governmental regulation of the indus-
try, especially Social Security Act amendments in 1950, 1972, and 1974,
these "mom and pop" nursing homes were forced out of business because
they could not afford to comply. Nevertheless, proprietary nursing homes
are still the norm. Since the late 1960s, publicly held corporations have
owned and operated nursing homes, and in 1991 for-profit organizations
owned 67.3 percent of the nursing homes in the United States, while 25.9
percent were owned by nonprofit organizations and 6.8 percent by gov-
ernment. ^^

Until 1989 nursing homes were licensed to provide two types of care:
skilled care and intermediate care. Skilled care provided services that "(1)
require the skills of technical or professional personnel . . . [andl (2) are
provided either directly by or under the supervision ... of such person-
nel. "^'^ Intermediate care consisted of "health-related care and services to
individuals who do not require the degree of care and treatment which a
hospital or skilled nursing facility is designed to provide, but who . . . require
care and services (above the level of room and board) which can be made
available to them only through institutional facilities. "^s Nursing homes
were designated either as skilled nursing facilities, which the federal govern-
ment reimbursed under Medicare and Medicaid, or as intermediate care
facilities, which were reimbursed under Medicaid only; or they provided
both levels of care. Since 1990, all nursing homes are referred to as nursing
facilities and are required to provide the same level of care.

Nursing homes engage in four of the five functions in which hospitals
engage: administration, patient care, health promotion, and education
and training. The most important function, patient care, includes nursing
and medical care (e.g., injections, catheterizations, and physical therapy),
personal care (assistance in eating, dressing, and bathing), and residential
services (food preparation, cleaning, and organizing social activities).

For skilled nursing facilities to participate in Medicare and Medicaid,
they must provide or provide for the following services: nursing, dietetic,
specialized rehabilitative, pharmaceutical, laboratory, radiologic, dental,
and social. They are also required to keep medical records, have infection
control and utilization review committees, provide activities for nursing
home residents, meet local health and safety standards, have a transfer
agreement with a hospital, and meet disaster preparedness require-
ments. ^^



HOSPICES 35



HOSPICES

Hospice is a term used to identify both institutions and programs. The
National Hospice Organization defines a hospice as "a centrally adminis-
tered program of palliative and support services which provides physical,
psychological, social, and spiritual care for dying persons and their fami-
lies. Services are provided by a medically supervised interdisciplinary
team of professionals and volunteers. Hospice services are available in
both the home and inpatient settings. . . . Bereavement services are
available to the family. "^° This definition covers the five basic elements of
hospice care: (1) patient and family are treated as a unit, (2) care —
consisting at a minimum of medical direction, nursing services, social
services, spiritual support, volunteer services, and bereavement counsel-
ing — is managed by an interdisciplinary team, (3) patient care is palliative
rather than curative, (4) care is available in the patient's home, and (5)
bereavement care is provided for the family after the patient's death. ^^

In the past, "hospice" referred to inns run by religious orders. The first
health care-related hospice opened in London in 1967 under the direction
of Dame Cicely Saunders. The first hospice in the United States was the
Hospice of Connecticut, in New Haven, which opened in 1974, and by
1992 the number of hospice programs had grown to about 2,000.^^ The
hospice concept caught on in part because the roles of hospitals and
nursing homes changed with the increase in governmental regulation of
their utilization and because the federal government no longer viewed
them as the most appropriate (i.e., cost effective) institutions to deal with
terminally ill patients (those with less than six months to live). In 1983
federal laws that allow Medicare reimbursement for home hospice care
went into effect.

Just as there is a variety of types of hospital, so is there a range of types
of hospice. The ownership of hospices may be private and for-profit,
voluntary, or governmental. Hospices may be independent or part of
larger institutions such as hospitals, skilled nursing facilities, HMOs, home
health agencies, or psychiatric facilities. In addition, there are several
models for hospices owned by hospitals. They may be freestanding institu-
tions, a discrete unit within the hospital, or beds scattered throughout the
hospital. Community-based hospice programs usually do not provide
direct care. Instead, they coordinate care by contracting for services from
existing agencies and hospitals. In 1992 26 percent of hospices were
divisions of hospitals, 41 percent were owned by independent corpora-
tions, and 20 percent were affihated with home health agencies.^'

Hospices perform four of the five functions of a hospital: administra-
tion, patient care, education, and biomedical research activities. Hospices



36 FACILITIES THAT DELIVER HEALTH CARE



have little involvement in health promotion because of the nature of the
patient clientele, although services to families might be classified under
this heading. Educational activities in a hospice may include the training
of residents and interns if the hospice is connected to a teaching hospital-
otherwise these activities are limited to the hospice staff, who most likely
did not receive training or education specific to hospices before working in
one. Although hospices seem unlikely settings for research, some of them
engage, for example, in studies of approaches to palliative care or antitu-
mor therapies.^*

Because hospices are a relatively recent development in the health
care system, their regulation by the government did not become an issue
until the 1980s. In 1983 the JCAHO and the National Hospice Organiza-
tion developed standards for evaluating hospice programs. Also, Blue
Cross/Blue Shield, Medicare, and Medicaid reimburse providers for cer-
tain hospice services.



AMBULATORY CARE SETTINGS

Ambulatory care is generally provided in one of two settings, physician
offices or clinics. ^^ Although most ambulatory care is provided by physi-
cians in office-based practices, it is also common for individuals to go
directly to a hospital clinic for primary care, often because they do not
have health insurance. ^^ Physician offices may be organized as individual or
group practices, although the number of solo practices is declining as the
number and size of group practices increase. ^^ Solo practitioners are most
often specialists who provide secondary care only. Physicians may also
contract their services out on a part-time basis or may be part of an
independent practice plan or association, in which they contract with a
prepaid group health plan but see patients in their own offices.

The term group practice refers to a variety of legal and financial
arrangements. Legal arrangements include sole proprietorships, associa-
tions, professional corporations, and partnerships. Financial arrange-
ments most commonly include situations in which the patient pays and
the physician is remunerated on a fee-for-service basis, or the patient
prepays and the physician is either remunerated at a flat rate for each
patient or on salary. ^^ A growing trend is hospital-based group practices.
This may mean that the group of physicians comprises the hospital's
medical staff; alternatively, the group and hospital may be independent,
and, while the group treats all of its in-patients in the affiliated hospital,
the hospital also accepts patients from other physicians. The first group
medical practice was organized in 1887 in Minnesota by Dr. William W.



ARCHIVES PROGRAMS IN HEALTH CARE DELIVERY FACILITIES 37



Mayo, who formed a partnership with his two sons. Today the trend is
away from solo practice and toward group practices, which may be
devoted to the practice of general or family medicine, a single specialty
(such as ophthalmology or obstetrics and gynecology), or multiple special-



ties



69



Until the early part of the twentieth century, the term dink connoted
medical charity. Today a clinic is usually defined as a setting in which
diagnostic or therapeutic services are provided on an ambulatory basis
rather than to in-patients.^^ Clinics are numerous and varied. They may
be general or specialized, and freestanding or part of a larger institution.
(See Table 2-2 for a categorization of clinic types according to the clientele
served and the condition diagnosed or treated.) Non-institutionally based
clinics may be sponsored by private individuals or corporations (e.g.,
American Medical International Diagnostic Services); local, state, or na-
tional government (East Boston Neighborhood Health Center); voluntary
entities (the American Cancer Society's cancer detection clinics); or a
combination of these groups. Freestanding ambulatory care facilities pro-
viding emergency and urgent care services were first established in 1973
in Delaware and Rhode Island.

Institutionally based clinics are found in institutions whose primary
function is health care related as well as in those whose primary function
is not health care related. Institutions such as HMOs, holistic or alternative
health centers, and hospitals (emergency services, ambulatory services,
and satellite clinics) are in the first category. Business and industry
(employee health clinics and wellness programs), prisons, private homes
(home care"^^ programs sponsored by hospitals, visiting nurse associations,
public health agencies, and health care companies),''^ and schools are in
the second category.



ARCHIVES PROGRAMS IN HEALTH CARE DELIVERY FACILITIES

HOSPITALS

Although some hospitals and academic health centers have active archival
programs, the percentage is small. The Society of American Archivists'
1 99 1 directory lists only twenty hospital archivists; the New England
Archivists' 1991 handbook and directory lists an additional three hospital
archivists; the Guide to Repositories of the Science, Technology and Health Care
Round Tahle"^^ mentions another twelve archival programs collecting hos-
pital records. (The archives program at Children's Hospital, Boston, is too
new to have been listed in any of these directories.) The American
Hospital Association's Guide to Historical Collections in Hospital and Healthcare



38 FACILITIES THAT DELIVER HEALTH CARE



Administration adds about 250 institutions (including state universities) to
the number collecting hospital records, but most of these institutions do
not have programs run by professional archivists. Although these num-
bers do not include city and state archives that collect hospital records,
they still indicate that only a small percentage (somewhere in the neigh-
borhood of 5 percent) of hospitals have programs to preserve their
historical records.

A cursory search of Research Libraries Information Network on-line
data base (RLIN) provided more evidence that hospitals are underdocu-
mented. A corporate heading search of "hospitals" uncovered 2,250
entries; the same type of search for "colleges and universities" yielded
21,000 entries. Even if one takes into account the fact that academic
institutions are more likely than freestanding hospitals to have listed their
records in RLIN, there are approximately ten times as many entries for
colleges and universities than for hospitals.

HOSPICES AND NURSING HOMES

If hospitals are underdocumented, hospices and nursing homes are virtu-
ally undocumented. In searching the various guides to archival reposito-
ries, I did not find a single hospice or nursing home that had its own
archives program. A search of RLIN yielded no entries for hospices and
only 59 for nursing homes.

It is unlikely that health care facilities other than hospitals will choose
to maintain in-house archival programs. Perhaps the most reasonable way
to document nursing homes, hospices, and ambulatory clinics is to iden-
tify selected records to be placed with a city or state archives, historical
society, or other appropriate repository.

Although the data presented here are more impressionistic than
scientific, they clearly demonstrate that health care delivery facilities are
in need of systematic documentation. I am not advocating that all health
care delivery facilities maintain in-house archival programs that docu-
ment in detail their every aspect. I do believe that these institutions should
consider developing archival programs (in-house or external) to suit their
specific needs and capabilities. The purpose of this work is to facilitate
development of such programs.



NOTES

L Lois Rakus Keefe, "A Conceptual Model of Ambulatory Care Programs and
Delivery Systems in the U.S." (unpublished thesis in partial fulfillment of the



NOTES 39



requirements for fellowship in the American College of Hospital
Administrators, Chicago, December 1981), 15.

2. Morris J. Vogel, review of The Care of Strangers: The Rise of America's Hospital
System, by Charles E. Rosenberg, Bulletin of the History of Medicine 62 (Summer
1988): 284.

3. American Hospital Association, Hospital Statistics, 1992-93 Edition (Chicago:
American Hospital Association, 1992). The statistics in this publication are
based on 1991 figures. Unless otherwise noted, all subsequent statistics are
from this source.

4. The editors of The Chronicle of Higher Education, The Almanac of Higher Education
(Chicago: University of Chicago Press, 1991).

5. Katharine R. Levit et al., "National Health Expenditures 1990," Health Care
Financing Review 13, no. 1 (1991): 29-54.

6. Stephen J. Williams and Paul R. Torrens, eds.. Introduction to Health Services
(New York: John Wiley & Sons, 1984), 172.

7. American Hospital Association Guide to the Health Care Field, 1987 Edition
(Chicago: American Hospital Association, 1987), A13.

8. Anthony R. Kovner, and contributors. Health Care Delivery in the United States
4th ed. (New York: Springer Publishing Company, 1990), 305.

9. The Clinical Center provides patient care only to individuals with illnesses
that are being studied at one of the institutes; general diagnostic, treatment,
and emergency services are not offered.

10. J. Rogers Hollingsworth, A Political Economy of Medicine: Great Britain and the
United States (Baltimore: Johns Hopkins University Press, 1986), 80-81.

11. Ibid., 5.

12. Ibid., 75.

13. It is interesting to note that Jewish hospitals fall into the last category rather
than the first, for they are supported by members of the Jewish community
but are not controlled by the synagogue. Similarly, black hospitals are
community hospitals supported by the African-American community.

14. Revised and updated from Florence A. Wilson and Duncan Newhauser,
Health Services in the United States (Cambridge, Mass.: Ballinger, 1985), 9.

1 5. Hollingsworth, Political Economy of Medicine, 74.

16. J. Rogers Hollingsworth and Ellen Jane Hollingsworth, Controversy about
American Hospitals: Funding, Ownership, and Performance (Washington, D.C.:
American Enterprise Institute for Public Policy Research, 1987), 63.

1 7. Ekaterini Siafaca, Investor-Owned Hospitals and Their Role in the Changing U.S.
Health Care System (New York: F & S Press, 1981 ), 117.

18. Russell C. Coile, Jr., The New Medicine: Reshaping Medical Practice and Health
Care Management (Rockville, Md.: Aspen Publishers, 1990), 29.

19. Most health maintenance organizations do not own hospitals but have
agreements with specific hospitals where their members are treated.

20. National Medical Enterprises, Inc., Annual Report, 1992.

21. "The Hospital World's Hard-Driving Money Man," New York Times, 5 Oct.
1993, DI.



40 FACILITIES THAT DELIVER HEALTH CARE



22. Kovner, Health Care Delivery, 143.

23. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign
Profession and the Making of a Vast Industry (New York: Basic Books, 1982), 202.

24. "Frustrated Firms Open Their Own Clinics to Try to Control Workers' Medical
Costs," Wall Street Journal, 23 March 1993, Bl.

25. Siafaca, Investor-Owned Hospitals, 62.

26. Rollings worth and Hollingsworth, Controversy about American Hospitals. 27, 62.

27. Ibid., 26-27.

28. Donald W. Light, "Corporate Medicine for Profit," Scientific American 255
(December 1986):42.

29. Diagnosis-related groups (DRGs) are a form of prospective payment under
Medicare for in-patient hospital services. Under this system, hospitals are paid
a specified amount for services provided based on a patient's classification
into one of approximately 500 DRGs, regardless of what the care actually
costs and with some adjustments made for teaching hospitals and regional
variations in cost of living. Psychiatric, rehabilitation, children's, and long-
term hospitals are excluded from DRG regulations.

30. Luther P. Christman and Michael A. Counte, Hospital Organization and Health
Care Delivery (Boulder: Westview Press, 1981), 28.

3 1 . Coile, The Nev/ Medicine, 242.

32. Jonathon S. Rakich and Kurt Darr, eds.. Hospital Organization and Management:
Text and Readings (New York: SP Medical and Scientific Books, 1983), 597-
600.

3 3 . Kovner, Health Care Delivery, 161-62.

34. Siafaca, Investor-Owned Hospitals, 29.

35. American Hospital Association, Hospital Regulation: Report of the Special
Committee on the Regulatory Process (Chicago: American Hospital Association,
1977), 2.

36. Siafaca, Investor-Owned Hospitals, 33, and American Hospital Association,
Hospital Regulation (1977), 113.

37. American Hospital Association, Hospital Regulation (1977), 11.

38. Donald I. Snook, Jr., and Edita M. Kaye, A Guide to Health Care Joint Ventures
(Rockville, Md.: Aspen Publishers, 1987), 195.

39. William C. Hsiao et al., "Resource-Based Relative Values: An Overview,"
Journal of the American Medical Association 260 (October 1988): 2347-53.

40. The American Hospital Association defines licensure as "the process by which
an agency of government grants permission to an individual to engage in a
given occupation, upon finding that the applicant has attained the minimal
degree of competency necessary to ensure that the public health, safety, and
welfare be reasonably well protected." American Hospital Association,
Guidelines: Licensure of Health Care Personnel (Chicago: American Hospital
Association, 1977), 1.

41 . James M. Rosser and Howard E. Mossberg, An Analysis of Health Care Delivery
(New York: John Wiley &- Sons, 1977), 16.

42. Williams and Torrens, Health Services, 287.



NOTES 41



43. Milton I. Roemer, Ambulatory Health Services (Rockville, Md: Aspen
Publishers, 1981), 48.

44. Myra E. Madnick, Consumer Health Education: A Guide to Hospital-Based
Programs (Wakefield, Mass.: Nursing Resources, 1980), 1.

45. Coile, The New Medicine, 152.

46. For a discussion of scientific/teclinological research from the standpoint of its
component activities, see Joan K(rizack) Haas et al.. Appraising the Records of
Modern Science and Technology: A Guide (Cambridge: MIT, 1985).

47 . Coile, The New Medicine, 3 5 .

48. "Definition of a Teaching Hospital," American Hospital Association
Memorandum, 11-15 Nov. 1967, as quoted in William E. Hassam, Hospital
Pharmacy (Philadelphia: Lea & Febiger, 1986), 45.

49. Hollingsworth and Hollingsworth, Controversy about American Hospitals, 47.

50. Committee on Implications of For-Profit Enterprise in Health Care, Institute



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