BENEFITS for extended-care services following hospitalization became available on January 1, 1967, to persons enrolled in the hospital insurance program under the Social Security Act. The extended-care benefit is designed primarily for persons recently discharged from the hospital who continue to need full-time skilled nursing care for a relatively short duration. The benefits do not cover custodial care provided in nursing and residential homes.

Extended care represents a new level of care designed to provide skilled nursing services in a high-quality extended-care facility at less cost than in a hospital. For many patients, it will provide the necessary skilled nursing care to restore good health and enable return to independent living in the community. For those with a continuing need for long-term nursing care, it will provide the early stages of such care.

This article describes the new benefit and presents data on the number of extended-care facilities certified for participation under the program and on the characteristics of such facilities.

BENEFITS PROVIDED

The hospital insurance program covers up to 100 days of extended-care services in a certified facility during a single "spell of illness." The program pays the full cost of covered services for the first 20 days of extended care and all but $5 a day for the next 80 days.

Extended-care benefits are payable for eligible persons under the following conditions:

-A minimum of 3 consecutive days of hospital care is required

-Admittance, on a doctor's order, to the extended-care facility is made within 14 days from the date of hospital discharge

-Admittance to the extended-care facility is for further treatment of the condition for which patient was hospitalized

*Division of Health Insurance Studies, Office of Research and Statistics.

by DAVID ALLEN*

Covered services include room and board in a semiprivate room (private room is covered if medically necessary); nursing care under supervision of a registered nurse; physical, occupa tional, or speech therapy; drugs and biologicals; medical social services; diagnostic and therapeutic services ordinarily furnished by extendedcare facilities; and medical services of an intern or resident-in-training of the hospital that has a transfer agreement with the extended-care facility.

EXTENDED-CARE FACILITY DEFINED

An extended-care facility is defined as an institution, such as a skilled nursing home or rehabilitation center, which has a transfer agreement in effect with one or more participating hospitals and which is primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care or in providing services for the rehabilitation of injured, disabled, or sick persons.1

To be approved for participation under the program as an extended-care facility, each institution must meet special requirements, such as round-the-clock skilled nursing care, medical supervision of each patient, and an arrangement with a hospital for appropriate transfer of patients. In addition, each approved facility agrees to comply with title VI of the Civil Rights Act of 1964, which prohibits discrimination based on race, color, or national origin.2

As of March 31, 1967, a total of 3,669 facilities had been certified for participation in the health insurance program for the aged. The certifica

1 For a detailed definition of an extended-care facility see title XVIII, section 1861 (j) of the Social Security Act.

2 For a description of the conditions of participation see Social Security Administration, Health Insurance for the Aged: Conditions of Participation for Extended Care Facilities (HIM-3), 1966.

Skilled nursing home..
Extended-care unit of—
Hospital..

Domiciliary institution.

Rehabilitation center and other 1

Beds

262,321 179,303 32,864

50,154

TYPE AND CONTROL OF PARTICIPATING
FACILITIES

An extended-care facility may be a skilled nursing facility, or it may be a distinct part of an institution for custodial care or a rehabilitation center or other medical institution, where skilled nursing and related services are provided. A "distinct part of an institution" must be physically separated from the rest of the institution and represent an entire, physically identifiable unit such as a separate building, floor, wing, or ward. Various beds scattered throughout the institution would not comprise a distinct part for purposes of being certified as an extended-care facility.

The 3,669 extended-care facilities certified for participation include 262,321 skilled-nursing beds -an average of 71 beds per facility (table 1). Excluded from this count are the custodial beds in the facility. Skilled nursing homes comprise 77 percent of the total facilities and include 81 percent of the beds. The average number of beds in the participating skilled nursing home is 75. The remaining facilities are classified as extended-care units of various types of institutions. Most of these units are in hospitals. Of the 837 extended-care units participating under the program, 62 percent are parts of hospitals, 26 percent are parts of domiciliary institutions for custodial care or homes for the aged, and 12 percent are in distinct parts of rehabilitation centers or other special institutions, such as cancer research centers. Extended-care units of hospitals have relatively fewer beds than other types, averaging 53 beds per unit.

Analysis of the data on extended-care facilities,

by type of control or ownership, shows that they are predominantly proprietary. More than twothirds of the participating facilities are proprietary, about one-fourth are nonprofit, and less than one-tenth are non-Federal government hospitals. State and local extended-care facilities are by far the largest, averaging 104 beds per facility. The average number of beds in proprietary facilities is 72, and nonprofit facilities average 58 beds.

Distribution of the extended-care facilities by control and type of facility shows some variation. Skilled nursing homes comprise about nine-tenths of the proprietary facilities but less than half the nonprofit and State and local facilities. Extendedcare units of hospitals, on the other hand, constitute almost half the State and local facilities, about one-third of the nonprofit facilities but less than 4 percent of the proprietary institutions.

Although the average size of participating extended-care facilities is 71 beds, there is considerable variation in size of facilities, ranging from fewer than 25 beds to more than 500 beds. Approximately one-eighth of the facilities have less than 25 beds, half have 25-74 beds, and one-third have 75-200 beds. Only 3 percent represent facilities with 200 beds or more (table 2).

Size of facility varies considerably according to its type. Skilled nursing homes are the largest, with almost one-fourth of the total in this group having 100 or more beds. Extended-care units of hospitals have the highest proportion of small facilities, and one-third of these units have less than 25 beds. Although these extended-care units are relatively smaller than other types, they are hospital-based and distinct parts of larger facilities certified to render extended-care services as integral parts of comprehensive health care provided in the hospital.

GEOGRAPHIC LOCATION

The distribution of extended-care facilities and beds by geographic location shows some variation according to type of facility. In general, the skilled nursing home is the predominant type of facility. For the entire Nation, more than threefourths of the facilities are skilled nursing homes. In the New England States, however, skilled nursing homes represent more than nine-tenths of the facilities. By contrast, only three-fifths of the facilities in the West North Central States are skilled nursing homes (table 3). The distribution of beds by type of facility shows the same general pattern among the nine geographic di

visions.

Skilled nursing homes as proportions of total extended-care facilities and beds vary somewhat

more among the States. All of the eight participating extended-care facilities in Vermont are skilled nursing homes. In the District of Columbia, the largest proportion of beds, 71 percent, are in extended-care units of domiciliary institutions and only 29 percent are in skilled nursing homes. In Wyoming, less than a fourth of the 204 extended-care beds are in skilled nursing homes. In Alaska, Kansas, and Montana, extended-care units of hospitals are the most frequent facility, but skilled nursing homes have the most beds.

Analysis of the data according to control or ownership of facilities also shows some variation. among the geographic divisions and States. More than two-thirds of the participating extendedcare facilities and beds in the Nation are owned and operated for profit. In the West North Central States, however, about a third of the facilities and two-fifths of the beds are proprietary (table 4). For this geographic division, nonprofit facilities are the predominant type of control. In the New England States, on the other hand, proprietary extended-care facilities are significantly more numerous, comprising more than four-fifths of the total.

The proportion of all extended-care beds that are proprietary ranges from 16 percent in the District of Columbia to 98 percent in Mississippi. In 10 States and the District of Columbia, less than half the beds are in proprietary facilities. In Alaska, the District of Columbia, and Wisconsin, State and local facilities have the greatest number of beds.

Significant regional and State variations are evident when the total number of certified extended-care beds is related to the number of per

sons enrolled in the hospital insurance program as of July 1, 1966. The national average of beds per 1,000 enrollees is 14.0 and the median is 12.2,