resources most efficiently and effectively. Consequently, PACE may be a possible approach to costing out the care of patients on the basis of their needs and the services rendered. Finally, an important objective of phase II is the development of a survey and certification process that will be based on the quality of care provided rather than only the capability of facilities to provide care.

4. Future Developments

Planning for the future of long-term care in institutions is addressed in the long-term care facility improvement campaign-phase I-which established baseline data on the quality of care provided in long-term care facilities. Phase II provides a basis for substantive planning in the following areas:

(a) A complete analysis of the regulations for skilled nursing facilities and intermediate care facilities will be conducted in order to revise and restructure them to provide for the measurement of performance outcomes which reflect the quality of care.

(b) The present medicare and medicaid long-term care survey and certification forms will be studied and combined into a single survey and certification package that is responsive to the need for measuring the quality of care provided in the facility.

(c) Surveyor training will be thoroughly analyzed to determine whether training should be centralized or decentralized and to determine the most effective and efficient methodology.

(d) Provider training will be increased to include both health professionals and paraprofessionals working in the area of long-term care whether institutional or noninstitutional.

(e) Research and development activities will be conducted to develop both a quality-of-care index and a cost-of-care index which would create a mechanism for reimbursement incentives to nursing homes on the basis of performance and outcomes of care.

B. STANDARDS DEVELOPMENT

1. Policy Enforcement

Since its formation, the Office of Long-Term Care at headquarters has promoted an intensive campaign to carry out its responsibilities by developing more uniform and sophisticated evaluation and enforcement techniques as well as initiating and implementing educational and consultative programs to the States and providers. Using strong guidelines issued by its Federal office, the ROLTCSE's have identified hundreds of facilities which either did not meet or were in minimal compliance with Federal standards.

Although the majority of facilities have been upgraded, the remainder, which could not be brought up to standard, were terminated from participation in the medicare and/medicaid programs and arrangements were made for the orderly relocation of patients to more suitable facilities.

The number of demands on the ROLTCSE's has increased considerably so that there is a call for increased regional staff. Not only do regional offices monitor the adherence to all regulations dealing with long-term care facilities, they also provide technical assistance and training to State and local agencies and providers. In addition, certain requirements for SNF's, which have been introduced in the past year, will be very difficult to monitor and determine compliance. Among the new requirements are: (1) Medical direction of a facility; (2) nursing services on a 7-day rather than a 5-day basis; and (3) the patients' rights amendments.

In reorganizing the HEW effort to focus on problems of long-term care, the ROLTCSE's have strengthened their relationships with State health authorities, consumers, and provider groups by meeting with them to resolve common problems. State legislators have also become more aware of the plight of nursing home patients. HEW's efforts to remove substandard facilities from medicare and medicaid programs have encouraged the States to appropriate funds to upgrade facilities and to enact legislation requiring stricter compliances with regard to patient care.

2. Life Safety Code

Public Law 94-182, signed into law on December 31, 1975, mandated that under title XVIII and XIX of the Social Security Act, HEW enforce the applicable requirements of the 1973 edition of the Life Safety Code (LSC), a con

sensus standard published by the National Fire Protection Association (NFPA). The 1973 edition of the code was substituted for the 1961 edition by Public Law 94-182 as of June 1, 1976.

The LSC contains nationally accepted provisions for specifying minimum standards for fireproof construction, firewalls, exits, lighting, and alarm systems. Although the law applies only to skilled nursing facilities participating in medicare and/or medicaid programs, the Department has required, by regulation, that hospitals and intermediate care facilities also comply with the code provisions.

The principal enforcement mechanism is the direct survey of nursing homes by State surveyors. The ROLTCSE's review the results of the surveys to determine whether the SNF's comply with the LSC requirements and pass judgment on requests for waiver of specific requirements. The State survey agencies are responsible for determining whether the ICF's comply with the regulations and consider waiver requests. The waiver determinations are made on a case-by-case basis and are approved only if: (1) The waiver will not adversely affect patient health and safety; and (2) requiring compliance would result in undue hardship to the facility.

The OLTC promotes and participates with SSA and SRS in training sessions in fire safety in a continuing effort to improve the quality of surveys and to reinforce its strong stance on enforcing the LSC requirements. This approach has encouraged administrators of nursing facilities to make the necessary improvements or to be dropped from participation in the medicare and medicaid programs.

Continuing efforts to improve the enforcement of the LSC standards include ongoing training programs for State surveyors conducted by the ROLTCSE's and increased surveillance and review of State survey agency activities. Preliminary data for calendar year 1975 indicate that participation agreements for 134 SNF's were not renewed because of LSC deficiencies.

The ROLTCSE's, in cooperation with State and territorial fire marshals, began an intensive campaign to insure compliance with Federal laws. Consultation service and necessary technical assistance were offered to the hundreds of unprotected facilities so each could meet the fire safety standards.

3. Implementation of New SNF and ICF Regulations

A long-standing problem in the administration of the largely state-controlled medicaid program is the matter of insuring that State surveyors are certifying SNF's and ICF's in a uniform manner and in consonance with the Federal regulations. In a cooperative venture the Federal and State agencies are working to identify areas of abuse which, in some cases, have led to the termination of Federal financial participation (FFP). One such effort is a program of unannounced visits to SNF's and ICF's for the purpose of assuring continued high quality care in the Nation's nursing homes. Under this program all Federal validation surveys are conducted totally unannounced to the facility. States are also encouraged to adopt such a program and many have endorsed the concept. It is anticipated that by 1977, all States will adopt a program of unannounced visits.

Until the regulations governing ICF's were published in 1974, many States had used their own discretion in using medicaid funds to support individuals in facilities which do not offer the level of care of an ICF or cannot meet the new requirements for FFP. Regulations effective March 18, 1974, require that each facility be surveyed and certified. using the same procedures as those developed for the SNF's to determine eligibility for participation in the medicaid program within 1 year. Although it is still too early to predict nationwide trends, the phenomenon of SNF's under medicare (title XVIII) and medicaid (title XIX) converting to ICF's under title XIX has program implications, and raises the critical question of the impact on patients'/residents' needs for care. The following issues are being studied: (1) the reason behind conversions; (2) patient versus facility reclassification; and (3) the impact of the appropriate ratio of SNF's to ICF's required to meet care needs.

4. Intermediate Care Facilities for the Mentally Retarded (ICF/MR) On January 17, 1974, HEW issued final regulations, effective March 18, 1974, requiring all ICF/MR facilities to comply with higher standards in facilities, Life Safety Codes, staffing, environmental design, and patient care. In order to

participate in the medicaid program, facilities must meet minimum requirements and must develop acceptable compliance plans which would show how they would meet the higher standards by March 18, 1977. ROLTCSE's were responsible for approving such plans and for monitoring the actions taken by State survey agencies to promote progress toward the new standards. Although compliance plan requirements were clearly defined in the regulations, there was a lack of guidance given to the regions concerning the criteria to be applied in reviewing and accepting the plans. This deficiency resulted in a lack of uniformity among Federal monitoring programs and may have contributed to the variation among States in the degree of their compliance.

States have encountered difficulties in attempting to meet the March 18, 1977 deadline. The major areas of difficulty lie in the Life Safety Code and the environmental design of the facility. Many of the changes required are costly and time consuming; States must appropriate funds and approve plans before structural changes can be made to the facilities.

On February 25, 1976, the OLTC requested each region to undertake a major validation effort to determine how well the plans for compliance were being carried out, the status of each State's progress, and the likelihood of meeting the ICF/MR standards by March 18, 1977. An addendum to this report was later requested to include the recommendations of the regional offices on what course of action the Department should pursue in the implementation of the regulations. The data submitted by the regions indicates that 68 of the 197 State operated facilities are expected to comply with the ICF/MR regulations by the effective date; another 54 are expected to be in compliance with at least 80 percent of the standards by that date. The data represent a positive interest and commitment toward improving the conditions for the mentally retarded.

The majority of the regional directors of the OLTCSE's are satisfied with the content and effective date of the regulations. They recommended that the requirements remain as they are and that the facilities be certified on an individual basis with a plan of correction which would allow the facility additional time to correct any deficiencies after March 18, 1977. Such action would be conditional on the facility making a good faith effort to comply with the regulations.

C. MANAGEMENT INFORMATION SYSTEM-THE MEDICARE/MEDICAID

AUTOMATED CERTIFICATION

SYSTEM

(MMACS)

To assist in the certification of long-term care facilities, during 1976 OLTC developed a management information system formally known as the medicare/ medicaid automated certification system, using automatic data processing capabilities. Potentially, the system offers an efficient and economical approach to (1) the review and appraisal of State agency survey operations, (2) efforts to upgrade the quality of SNF's and ICF's, and (3) the uniformity and appropriateness of certification procedures and decisions.

As a result of its rapid response capability the system, when fully operational, will enable the regional OLTCSE's to review survey report form deficiencies prior to certification. The system is capable of producing every needed data aspect of the certification process in a systemized and codified fashion. The data can provide headquarters, regional office, and State agency staffs with the management tools required for a more efficient and effective administration of certification activities.

D. SURVEYOR TRAINING

The Bureau of Quality Assurance (BQA) within the Health Services Administration works with other Federal agencies to coordinate the operation of a continuing program designed to improve the effectiveness and uniformity of State health facility certification procedures. A major part of this mandate is the training of Federal and State personnel engaged in survey activities.

Six university based programs have been involved in surveyor training. However, because of budget constraints, this was reduced to one program at Tulane University, which had the lead responsibility until June 1976. Beginning October 1976, the University of Maryland working with Federal personnel, has taken the lead in the effort. As of June 1, 1976, over 2,500 surveyors have participated in these training programs. In addition, each HEW regional office plans and conducts surveyor training programs designed to meet the specific needs of the State and the region.

During fiscal year 1976, 38 surveyor training courses were conducted, including 21 basic surveyor training courses, 6 executive development institutes, 5 consultants courses, 3 advanced Life Safety Code Institutes, and 3 Training officer workshops. Over 650 State survey agency and regional office personnel participated in these programs.

A study, conducted in 1972 and 1974 to determine training needs of surveyors for the purpose of planning and developing future training activities, found that while the majority of the surveyors have received some training, there is a continuing need for entry-level training because of the rapid turnover in staff and the expanding number of persons needed at the State level to meet medicare/ medicaid demands. Furthermore, it is necessary to train staff working in specialty areas such as fire safety and laboratory services.

In an effort to upgrade the quality of fire safety surveys, the OLTC has participated in training courses on fire safety, of which the most recent were conducted in fiscal year 1976 for each of the 10 regions covering the 1973 Life Safety Code. The regional offices continually provide training and consultation to State surveyors.

During 1977, the OLTC expects to make available to State surveyors audiovisual training material which will enable them to train new Life Safety Code surveyors and improve the skills of others.

The OLTC is actively participating in the presentation of the new 2-week basic surveyor training course. Six courses have been scheduled as pilot courses. These courses are being conducted at the University of Maryland Center for adult education. The need for additional courses and other sites will be determined after an evaluation of the backlog of untrained surveyors.

Bi-tri-regional training sessions are planned for February 1977 to implement the consolidated ICF/MR regulations.

Future training mechanisms and materials will be designed to be responsive to the needs of persons working at the regional, State, and local levels so that a range of sophistication of skills is developed and available.

E. PROVIDER TRAINING

By September 1976, a total of 146,328 long-term care provider personnel received training designed to increase their knowledge and skills in the delivery of health services to patients/residents in facilities. The overall provider training has been diverse and developed under a variety of auspices in order to meet the varied needs of special groups of trainees throughout the country. The training has been supported by HEW and administered through the Division of LongTerm Care, Health Resources Administration, PHS. This effort has been a direct outgrowth of the 1973 Presidential Initiative.

Of the 146,328 trainees, 66,186 (45 percent) were nursing personnel, and 36 percent of these trainees are listed in the aide category. Forty-one percent (58,100) of trainees have been support personnel, such as pharmacists, social workers, housekeeping workers, dietary workers, and medical records personnel. Another 11 percent (17,148) were listed as administrative personnel; and the remaining 3 percent (4,904) included other direct care personnel such as physicians, dentists, occupational therapists and physician assistants.

From 1973 to 1975, long-term care education centers were established in each of the 10 HEW regions. In 1976, eight were operational under continuation contracts. One former regional center has continued training programs on a selfsupporting basis. Continued results from the centers' training has been shown in areas such as better utilization of nursing home staff and concerted efforts in patient education with the goal towards independent self-help and personal care. Training contracts have called for development of a series of workshops in areas of special need (for example pharmacy and dietary) in long-term care that have been conducted nationwide. Some curricula developed though the contracts have been adapted for use in professional university programs. Other benefits resulting from contracts have included curriculum modules, workbooks, guidebooks and publication of resource materials useful to long-term care trainers, trainees and nursing home personnel.

Long-term care training coordinators in each HEW regional office have continued to receive allocated funds by DLTC/HRA to design or plan for special training needs of States in that region.

The Division of Long-Term Care has prepared a publication entitled "A Promise Kept" which described Division activities and summarizes all past and current contract supported projects.

PART II. NONINSTITUTIONAL CARE

A. IN-HOME HEALTH CARE DEVELOPMENT

The approach to long-term care is now directed mainly toward institutional care. The passage of the Health Resources Planning and Development Act has increased the potential for a planned, comprehensive, community effort in longterm care. Through the health systems agencies, it will be possible to look at a community's needs in terms of a broader concept of long-term care. This broader concept would consist of a continuum of both institutional and noninstitutional settings and services.

Expansion of long-term care services must include noninstitutional care. The concept of care outside of an institution is a broader one than has been presently defined. It includes not only home health services but also in-home support and maintenance services as well as new setting for long-term care outside of an institution such as day care centers and day hospitals. The patient's home should be defined more broadly to include foster homes, boarding homes and other sheltered environments.

During 1976, the Inter-Agency Home Health Services Task Force, under the leadership of OLTC, has continued its efforts to develop short- and long-term objectives for home health care. The Department's attempts to enhance the role of home health care were further aided by the publication on May 25, 1976 of presumed coverage regulations that should result in fewer home health care cases being retroactively denied reimbursement. The home health grant program has also become operational with the September 1976 allocation of $3 million to assist in the establishment and expansion of home health agencies. In addition, as of August 25, 1976, finalized medicaid home health regulations clarify the requirement that States include home health care in their title XIX programs. The medicaid regulations also clarify who is eligible for home health care and dictate that specific services must be available.

In August 1976, in an effort to solicit public comment, the Secretary of HEW called for a series of public hearings on home health services. The OLTC was responsible for the development of the Federal Register notice of these hearings, in which basic issues were raised in seven areas of concern ranging from who is eligible for home care, to who should pay for such services. Hearings of 2-day duration were conducted between September 20 and October 1 in New York, Arlington (Tex.), Atlanta, Chicago, and Los Angeles.

The vast majority of the 540 witnesses testifying in person also provided written comments, as did 375 individuals and organizations which did not make oral presentations. An indication that the hearings successfully captured the public's attention and interest was the attendance of over 1,200 persons who came only to observe the proceedings. Staff of OLTC participated in these hearings and assisted in the development of a report which was sent to the Secretary identifying the priorities of public concern.

The Department is in the process of developing an option paper on home health services. During the next year, it is anticipated that comprehensive and coordinated departmental policy will be established in home health care in keeping with identified issues.

PART III. OTHER LONG-TERM CARE ACTIVITIES

A. INTERAGENCY ADVISORY GROUPS

Regular meetings of the interagency advisory groups for both policy and education/training in long-term care were convened during 1976. Representatives from concerned Department agencies and the regional offices met regularly to resolve issues, expedite actions, identify needs and coordinate activities. The meetings were chaired by the Special Assistant to the Under Secretary for LongTerm Care and Director, Office of Long Term Care, PHS, Dr. Faye G. Abdellah. B. CONSUMER/PROVIDER INTEREST IN LONG-TERM CARE

1. Consumer/provider meetings

In providing policy direction and coordination of long-term care activities throughout HEW, the Office of Long-Term Care (OLTC) deals directly with the