THE MISSION.

Many nursing homes grew out of religious organizations--churches and synagogues--and there were also almshouses, poorhouses and, eventually, county homes. Many in the northeastern United States started as "rest homes," real Mom and Pop operations in large old homes. Medicare gave them a real push nationally, and then Medicaid became very important.

I would have to say that nursing homes don't get the credit they deserve for taking care of Medicaid patients, the poor. Perhaps their intentions weren't always for charitable purposes, but they did it and, by and large, did it very well. And they still are providing charity--everyday. I wonder what would happen if nursing homes decided not to take Medicaid patients anymore. The result would be shocking; the government would have to go into nursing home construction and operation in a big way.

At some point in the last 10 years, though, nursing home utilization peaked, and it has been declining ever since. This has largely been because of the changing market, as always. Almshouses and poor farms have gone by the wayside, and so will nursing homes. The new name for our industry is becoming assisted living.

Regarding the highlights and lowlights of recent long-term care history, I think I would have to nominate Medicare for both. It's been a highlight for patients gaining access to care they never could have afforded, but it has been the cause of both success and failure for organizations that developed too much reliance on it.

Another highlight has been the development in the marketplace of so many wonderful new long-term care "products." Compare the facilities of 5O years ago with the entries displayed in Nursing Homes' DESIGN '99. We've come a long way from the old homes for the aged and those residential "cells" inspired by the monastic orders sponsoring them.

Another highlight for me personally was the demise of our state's certificate of need (CON) program. St. Barnabas worked very hard to achieve that. I remember when we converted some skilled nursing beds in one of our facilities to assisted living. It took five months to gain state approval, and when it finally came through, we learned that the effective date was the date of our initial request. We lost 150 days and about $100,000 on that one.

A definite lowlight has been the incredibly poor and mostly undeserved public relations experienced by nursing homes. I don't blame the media for this. I blame those of us who sit idly by and say nothing when these horror stories come out. Are we as good as, say, the hospitals in dealing with government? I don't think so. Are our lobbying organizations as effective as the American Hospital Association? Again, I don't think so. Basically, we have met the enemy, and he is us.

As for the future, the facilities that survive will be those that stick to their mission. They will be those that serve the poor, as St. Barnabas does, for example, providing about $4.5 million of free care every year, with expectations of doubling that within a few years. Serving the poor applies to for-profits, as well. What is their mission--to serve only those with money? I don't think so.

We had a classic case in point in our area lately of what can happen when a healthcare organization loses sight of its mission. Allegheny General Hospital, quite possibly the most successful hospital in the United States five years ago--well established and making tons of money--was merged with another hospital and is effectively out of business. Allegheny had developed an ambitious plan, taking over a major medical school in Philadelphia, several area hospitals and many physician practices to feed and be fed by a captive insurance company it had created. Allegheny paid its executives handsomely--about $1.1 million for the CEO, $375,000 for a risk manager--and spent a lot of money in other ways. The auditors say that, when the full story comes out, it will be a case history for healthcare management on what not to do.

There's a message here for all of us: If an organization that successful can die because of poor management decision making, what about the rest of us? There are no guarantees that, just because of our name and reputation, we will survive. We have to stick with our purpose day in and day out.

William V. Day has been president and CEO of St. Barnabas Health System since 1967. During his tenure St. Barnabas has expanded from a 63-bed "free care" facility run by a religious order to a multilevel long-term care campus encompassing two skilled and subacute nursing facilities, assisted living, two retirement communities, a home healthcare agency, an outpatient medical center, a charitable foundation and the four-state PRESENTS FOR PATIENTS program. St. Barnabas celebrates its 100th anniversary next year.