Nursing home administrators and their changing landscape.

The decade of the 1950s has become synonymous with a simpler life. It was an era of good feeling. The post-war baby boom, along with a building boom, helped to create a vibrant and thriving economy. American society was brimming with new and expanding industries. Television was in its infancy. The notion of a car in every driveway was taking hold. Shopping centers were springing up to serve the housing boom. And the health care industry was exploding, as well.

In the early fifties, people were aware of two kinds of health care institutions: acute care hospitals and nursing homes. Most of the latter were thought of only as "warehouse for the elderly." State mental hospitals existed as well, but were invisible to the general populace. As for the costs of medical care and medical insurance, they were manageable for most working-class and middle-class families and the companies that provided the benefits. Physicians were generous in keeping patients in the hospital for lengthy recuperations. (Imagine an insurance company today authorizing a seven-day hospital stay for a routine delivery of a baby). With the advent of the Medicare program in the 1960s and its subsequent growth in the 1970s and 1980s, we saw the dramatic increase of for-profit acute care hospitals, psychiatric hospitals, rehabilitation hospitals and, yes, nursing homes. And, today in the 1990s, the health care landscape has changed again, and will continue to change dramatically over the next five to ten years.

For the past ten years, with health care costs skyrocketing, the federal government has been looking for ways to control them. The cost of health insurance and health care are now beyond the grasp of most of America's work force and many of their companies.

This new focus on cost control prompted a variety of organizations to conduct research into the planning, development and operation of subacute units in nursing homes, now more accurately called skilled nursing facilities. In this new system, patients who were normally treated in acute care hospitals or acute rehabilitation hospitals at $800 to $1,000 per day could be provided the same care in a subacute setting in a nursing home at $300 to $500 per day. The research has included everything from the construction of subacute units, to outfitting the units with the appropriate equipment and staffing, to case management and rehabilitation. It did not however, touch upon one important aspect of operating a subacute unit in a nursing home - the qualifications of the administrator.

The successful operation of any nursing home depends heavily on the skills, qualifications and education of the person responsible for directing its operation. To be successful, an administrator must be a hands-on manager who is aware of the concerns and issues - medical, social, legal, and financial - not only of the resident but also of the family members and the facility's staff. A successful nursing home administrator must be willing to be much more involved in the day-today operations of the facility than a hospital administrator. Hands-on management is imperative to succeed in today's constantly changing health care environment.

While this description fits many of our present day administrators, the addition of subacute units to skilled nursing facilities adds a level of complexity and sophistication that has not been required in the past. It is true that some organizations have taken the position that, in order to manage a subacute unit, it is enough simply to be a licensed nursing home administrator. Other organizations, though, have determined that an administrator's qualifications must include experience as an acute care or acute care rehabilitation administrator with an advanced degree in health care.

To grasp the significance of this, consider this change: in the 1950s, a small, for-profit hospital could thrive under the administration of a savvy R.N. who had moved up the ranks of hospital management. The focus was on patient care. Cut to 1994: a well-educated, capable administrator of a skilled nursing facility must be a cost containment whiz. Financial acumen is paramount in keeping a facility running well. It is further necessary to have a firm grasp of many facets of health care as it is delivered today.

It is certain that administrators of these newly evolving units must have an education and background in health care administration, as well as an understanding of the health care system, including regulatory issues, cost containment, managed care, and federal health care reform. He/she must be receptive to innovation and to new ways of doing things. In addition, today's administrator must also understand where rehabilitation, IV therapy, recreation therapy, case management, physician relations, and JCAHO and CARF accreditation fit into the operation of a subacute unit.

Limited studies have been conducted on the educational levels of today's nursing home administrators. Studies conducted in the 1980s showed the average nursing home did not require its administrators to have a college education. As we enter this new and evolving health care era, it is obvious that if subacute units in a nursing home are to be successful, the educational level of the administrators who manage these units must exceed today's norm.

This is why individually-owned facilities or chains that are considering establishing subacute units need to evaluate seriously the qualifications of their administrators. The need for administrators to be able to interact effectively with physicians, rehabilitation personnel, case managers and hospital personnel, and to understand the role each of these groups play in developing and implementing successful units, is extremely important. And administrators who can demonstrate competency in these areas have a bright future.

In sum, administrators must understand and be able to function in a new and ever-changing environment. They can no longer sit back and expect patients to come to them. The continuum of care is changing, and the long-term care industry needs administrators who will accept and enhance this change. This will require a change in the way administrators are trained and licensed. The future success of subacute units in nursing homes will depend on the industry's success in upgrading the skills and education of its administrators.

Richard Ebersole is Chief Operating Officers of Vanguard Health Services, Inc., a Boston-based firm providing comprehensive management services in skilled nursing and long-term care facilities. Mr. Ebersole was formerly Regional Vice President of Operations for Hillhaven Corp., and helped start up several nursing homes and sub-acute care programs.