ESTABLISHING AN INTERMEDIATE - CARE UNIT IN EDWARD W. SPARROW HOSPITAL Thesls for The Degree of M. A. MICHIGAN STATE UNIVERSITY Louis Edwarcl Goréon 1957 wuvqtg: LIBRARY Michigan State University I } I Q ESTABLISHING AN INTERMEDIATE-CARE UNIT IN EDWARD W} SPARROW HOSPITAL By Louis Edward Gordon A THESIS submitted to the School for Advanced Graduate Studies of Michigan State University of Agriculture and Applied Science in.partial fulfillment of the requirements for the degree of MASTER OF ARTS School of Hotel, Restaurant and Institutional Management 1957 ACKNOWLEDGMENT This study was made possible through the assistance and interest of many who contributed generously of their knowledge and time. Appreciation is expressed to the Michigan Department of Public Health for its cooperation in providing valuable statistical data; to the Library of the American Hospital Association; the United States Department of Health, Education, and Welfare; 0. J. Munson, A Associates, architectural and engineering firm; and to those physicians, nurses, hospital administrators and rehabilitation workers, whose assistance has been very helpful. Especially is the writer grateful to Donald H. Pound and 3. Earl Thompson, in the School of Hotel, Restaurant and Institutional Management, at Michigan State University, for their wise counsel and patient guidance. \l \I \ \l \ \I \ \l I \I \I \ 7nn1-Ini-In'nr-3‘J‘m Kati/h? ii TABLE OF CONTENTS CHAPTER I II III mTRODIJCTION....C.....‘C..........I...O...OO00......0.0... Purpose and ScOpe of This Study........................ TeChnioal Tm Defined..0...OOOOOOOOOOOOOOOOOOOOOOI.00 HOSPITAL GARE m TIE UNI‘TED STATEOOOOOOO0.00.00.000.000.0 Factors Influencing the Growth of the Modern Hospital.. Emphasis on.Long-Term Gare in.The General H03pital..... Commission on Chronic Illness Points the way........... INTERMEDIATE HOSPITAL CARE IN INGHAM COUNTY Existing Facilities.................................... Need for Additional Facilities......................... Benefits Derived from.Adequate Facilities.............. The Nursing Home in Ingham County...................... STANDARDS FOR THE ESTABLISHMENT AND OPERATION OF AN mmmmE UNIT.’COCO...C.................O..0C. Provision of Standards for Patient Care................ Consideration.of’Basic Standards....................... PROPOSED PLAN FOR ESTABLISHING INTERMEDIATE-CARE FACILITIES AT THE EDWARD W} SPARROW HOSPITAL........... Organization of The Hospital........................... Selection of Site...................................... Description of Prepertyy............................... Patient.Accommodations and the Concept of Grouping..... Integration.of Intermediate-Care Needs with Acute FaCilitieSOOOOOOOIOOOOO0.00000000000000000000......I. Recreational Therapy Facilities........................ Service Department Facilities.......................... Food Service........................................... Administrative Facilities.............................. The mrSing Uni-to.IOOOOIOOOOOOIOOOOOOO000.000..00.0.0.0 Building Facilities and Proposed Remodeling............ Staffing-éProfessional'and NonéProfessional Personnel.. 111 Page RDF’ O\OO\ 0‘ 13 13 16 19 21 23 23 25 TABLE OF CONTENTS - Continued CHAPTER Page VI FINANCIAL RESOURCES AND COST.ANALYSIS..................... 89 Source of Funds........................................ 90 Estimated Costs........................................ 90' Operating Budget....................................... 92 VII CONCLUSIONS.AND RECOMMENDATIONS........................... 96 INTERVIEWS....................................................... 99 APPENDIX......................................................... lOO Bm’IomPHYOOOOOOOOOIOOOOOOOOOOOOO0......IOOOIOIOOOOIIOOOOOOOOOO 111 iv TABLE 1. LIST OF TABLES Percentage Distribution of Cases with.Respect to Care RequiredDOOOOOOOOOOO0.0.0....0.0.0.000...OIOOOOIOOOOOOO000. Percentage Distribution.by Ability to Mbve About of Patients Seeking Long-Term Care in.Institutional Facilities Patient ACCOMda-tion cmtOOOOIIOOOOO I... .0 00.000.00.00 0.. Patient Staff RatiOOOOOOOOO'OOOOOOOOOOOOOIIOOOOOOOODOOOIIOO converSiDn cost EstimateOOOOOOOOOCOOOOODOOO....0.0.0.0.0... Income and Expense Budget-First Fiscal Year............... Page h2 AB 81 87 91 93 L IST OF FIGURES FIGURE Page 1. Proposed Intermediate-Care Unit—Location Mao............. 37 2.GroundFloor—RoomDistribution............................ A6 3. First Floor-:e-Roomflistributionnnn....................... S3 14. Second Floor—Room Distribution............................ 55 5. Third Floor-«Room Distribution............................. 59 6. Fourth Floors-Room Distribution............................ 62 vi CHAPTER I INTRODUCTION Purpose and Scope Of This Study This paper is intended as a pilot study for the establishment of an intermediate-care unit in.a general hospital. The writer sincerely hopes that this study will aid those individuals responsible for provid- ing similar care in their own community health centers, wherever they be. In an attempt to accomplish this goal the following separate but interrelated areas of interest are explored: l) The great progress which has been made in hospital care and medical science during the past century; 2) A statistical analysis of disease and its evolution since the turn of the century; 3).An evaluation of those community needs felt important in.providing an effective program Of health care; and, h) The role of the Federal government in helping to solve a national health prOblem. This paper deals primarily with the case study of but one heapital community. The reader's focus is, therefore, purposely narrowed to a consideration of that community. 'While it is impossible in.a paper of this type to provide a set pattern for organization, establishment, and administration to fit exactly the requirements of each hospital, this studyadoes present basic concepts that are adaptable to specific situations. It is hoped that in.many cases these concepts may assist those who are responsible for the planning of intermediate-care facilities. If this paper provides no more than a stimulus to the minds of those responsible for the future of health care it will have achieved its intended purpose. Technical Terms Defined The following definitions are presented in an effort to clarify certain terms used throughout this study. They are taken from the Commission on Chronic Illness, with the exception of "Intermediate-Care," for which the writer proposes a definition for purposes of clarification. Chronic Illness .Chronic Illness and/Or disease comprises all impairments or deviations from normal which have one or more of the following character- istics: are permanent; leave residual disability; are caused by non- reversible pathological alterations; require special training of the patient for rehabilitation; may be expected to require a long period of supervision, Observation, and/Or care. Lonngerm,Patient Long-term patients include only those individuals suffering from a chronic disease or impairment who require a continuous or prolonged period of care. Included in this group are: patients who are likely to need, or who have received, care for a continuous period of at least 30 days in a general hospital; or, care for a continuous period of more than 3 months in another institution or at home. In the latter case care includes medical supervision and/Or assistance in achieving a higher level of self-care and independence. Acute Illness Acutely ill patients include those individuals suffering from an illness of a short and relatively severe course, which does not usually leave a residual impairment or deviation from normal. Short-Term Patient Short-term patients include those suffering from acute illnesses who are hospitalized for a period of less than 30 days. Such patients require those acute services usually offered by the general hospital. As contrasted with the long-term patients, these patients commonly require skilled nursing care throughout their period of hospitalization. Intermediate Care Intermediate care is defined as service provided for patients requiring hospital care who are not acutely ill. It includes the care of those who suffer from chronic illness requiring long-term hospitali- zation and those who may be convalescing from an acute illness. Such care makes available skills and services not available at home or nursing unit, yet does not require those costly facilities and services of the general hospital. Skilled NursinggCare Skilled nursing care includes those procedures employed in caring for the sick which require some technical nursing skill beyond that which the ordinary untrained person can adequately administer. These may include full bed baths, enemas, irrigations, catheterizations, application of dressings or bandages, administration of medications by whatever method the physician orders (oral, rectal, hypodermic, intra- muScular), and carrying out other treatments prescribed by the physician which involve a like level of complexity and skill in administration. They may be provided by either professional or practical nursing personnel, so long as they extend beyond personal care as described below. Personal Care This type of care includes such personal services as help in walking and getting in and out of bed, assistance with general bathing, help with dressing and feeding, preparation of special diet, supervision over medications which can be self-administered, and other types of personal assistance of this nature. Sheltered Care Sheltered care includes room, board and minimum services of a domiciliary nature. These services may include laundry, personal courtesies as occasional help with correspondence or shopping, and an occasional helping hand short of routine personal care, as described above. Total Patient Care Total patient care is defined as the integration of community health care facilities for providing complete medical service upon demand. The "whole man" concept of patient care is synonymous with this term. CHAPTER II HOSPITAL CARE IN THE UNITED STATES Patient care provided in the modern hospitals of this era, when compared with the makeshift hospitals of yesterday, presents convincing proof of the tremendous progress made as a result of man‘s desire to preserve life. Earliest attempts at providing organized care for the ill by establishing hospitals were sporadic and confined to specific local needs. Factors Influencing the Growth of the Modern Hospital HOspital care was first provided in the colonies for sick soldiers in 1658, at the suggestion of a Dutch west Indies Company surgeon.1 In addition to caring for soldiers, this first recorded hOSpital also provided care for the company's negro slaves. Another hospital estab- lished on Manhattan Island in 1663, was also used for the purpose of caring for slaves and soldiers.2 It was nearly a hundred years after these initial attempts to provide organized hospital care for the sick that the first successful general hospital was established. This hospital incorporated in 1751, lAmericana Corporation, The Encyplgpedia Americana. New York, Vol. XIV, p. h28. 2Malcolm T. MacEachern, HOspital Organization and Management, Physicians' Record 00., Chicago, 19747, p. D4. 6 was located in Philadelphia.3 Dr. Thomas Bond, with the aid of Benjamin Franklin, opened the Pennsylvania Hospital, which today stands as a giant memorial to the advancement of modern hospital care in the United States. Another hospital established in 1771, the New York Hospital, is considered the second oldest in the United States. This general hospital apparently fell into the hands of the British during the Revolutionary‘war and was used as a barracks. It was reopened in 1791.4 The Revolutionary war, as have subsequent wars, vividly outlined the results of medical unpreparedness in time of war. Out of the unpreparedness and heavy mortality of such encounters, many of the simple principles of sanitation, ventilation, and modern hospital care have been developed. The early nineteenth century has been labeled as a period of ignorance, and error, Quackery became almost universal throughout Europe. In the United States surgeons filled the hospital wards with discharging wounds encouraging suppuration as a desirable post-operative occurrence. Hospital care during this period was even more degraded than was medicine and surgery. Pain, hemorrhage, infection, and gangrene is said to have fostered surgery mortality rates up to one hundred per cent. Nurses were recruited from the lower class and Often. from among criminals. Unlike the religious attendants of the previous century these infidels professed no devotion to service or spirit of 3Loc. cit. 4Ibid., p. 15. self-sacrifice. As was often the case these characters not only abused their patients but exploited them as well. Historical accounts indicate that such conditions continued even until the mid-nineteenth century.5 Florence Nightingale, at this time, revolutionized the art of nursing. It was she who during the Crimean war in 185k successfully organized a military hospital. Her influence was felt around the world and especially did it have an effect in the United States. It would seem that from the efforts of this one woman an important link in the modern concept of hospital care was molded. Contributions from men such as Pasteur, Lister, Roentgen, Long, Simpson and others, brought to a fitting climax a century of first regression and then great progress. The achievements accomplished during the latter part of the nineteenth century along with the terrible experience of those earlier years has provided this present century with a firm foundation upon which to develop. Hespital care in the United States has continued to grow as the result of past and present experiences. Surgical techniques were changed considerably with the discovery of anesthesia and the principle of antisepsis. These developments have given impetus to the advancements made in modern hospital care. Other discoveries have similarly influenced the rapid progress made during this era toward preserving and extending the life of man. 51bid., p. 16. Emphasis on Long-Term Care in the General Hespital During the twentieth century, hospitals have become organizations wherein comprehensive facilities and services may be readily obtained by the physician for purposes of research, diagnosis, treatment and care. Significant of this modern concept of care is that medical progress is today directing considerable attention toward the needs of the chronic long-term patient cared for both at home and in the hospital. In the past the tendency in some cases has been to provide sub-standard medical attention and inadequate housing accommodations for the patient requiring extended care. The Federal Government, realizing the magnitude of this health problem, is providing large sums of money to aid in building and equipping medical facilities. Undoubtedly, the most progressive health legis- lative action taken in recent years is the Hill-Burton.Act. This act, knownalso as the Hospital Survey and Construction.Act of l9h6, was amended by the Medical Facilities Act of 195b, Public LaW'h82, 83rd Congress. Provision is made in the act for categorical state grants to assist in the construction of chronic disease units, nursing homes and rehabilitative facilities, in addition to out patient diagnostic and treatment centers. In conjunction with the Federal program, the University of Michigan, School of Public Health is currently conducting a Medical Facilities 6 Survey and Study. This survey and study is being conducted throughout 6University of Michigan, Michi Medical Facilities Survey, School of PUblic Health, July 1, l9g7. l0 the State of Michigan. It is designed to provide the Federal Govern- ment with a more sound basis upon which to allocate funds for construct- ing and equipping health facilities. This study was scheduled for completion by July 1, 1957, and was financed through a Federal grant. It is evident that financial aid for constructing and equipping chronic facilities can be available wherever a true need exists. Every accredited hospital in the United States is either directly or indirectly affected by the distribution of this Federal aid. It is to the progressive institution, realizing the significance of total patient care, that these funds are directed. It is most important then that the alert hospital focus its attention on future patient care demands. In doing so, the inevitable influx of long-term or chronic patients will present no real problem. It is apparent that the general hospital of tomorrow will not be providing total patient care unless adequate provision is made for this type of patient. Commission on Chronic Illness Points the way Changes are continually taking place within the realm of hospital care. For more than six years the Commission on Chronic Illness has studied the community and its relationship to the problem of chronic illness. Although but one segment of the total scope of care rendered by the hospital, chronic illness looms continually more significant in the minds of those bearing the responsibility Of our nation’s health. 11 Dean W} Roberts, M. D., director of the Commission on Chronic Illness, in a recent article, spelled out the future of hospital care as concluded by the commission‘s studies. He states that there is a shift from preoccupation with the accent on the medical emergency, surgery and obstetrics to a focus on the more prevalent chronic illness and rehabilitation services requiring supervision of the patient for prolonged periods of time. The Commission recommends that the community general hospital become the central point in the development of health facilities essential for the long-term patients. Indiscriminate admission and maintenance of chronically ill patients by the general hospital is not the intended purpose of such a program. It is intended rather that a balanced program be established within the community which provides an appropriate place for every type of patient. It is then.believed that through proper integration all may receive that amount and quality of care needed:7 Dr. Roberts points out that the Commission has rejected the con- cept of the independent chronic disease hospital. The concept of the acute general hospital is also rejected. In resolving this approach the Commission suggests that for most communities the practical approach is what might be called the general, general hospital. It is described as a general hospital which.undertakes to admit and treat those patients who require hospital services for such periods as the services may be needed-~whether this be a day, week, a month, or a year. 7Dean‘W} Roberts, M. D., "The Future of Hospital Care-~The General, General Hospital," Hogpitals, 30 (February 1, 1956), pp. 38-441. 12 The Commission on Chronic Illness urges general hospitals to be truly "general" by making available care for both long and short term patients. This is considered by the Commission as a reasonable com- munity responsibility of the general hospital in all areas. CHAPTER III INTERMEDIATE HOSPITAL CARE IN INGHAM COUNTY The reader has thus far been exposed to a brief background of hospital care and its rapid growth in an attempt to justify the vital importance of preparing for the future health requirements of the population. At this point, the reader is invited to narrOW'his focus to the present needs and future demands of Ingham County, Michigan, (population 203,520, Michigan State Bureau of Census, 1955). Consideration is also given to national health statistics in an attempt. to determine health trends and population changes. Existing Facilities Exclusive of tuberculosis and mental hospital facilities, there are at present only 162 hospital beds in Ingham County considered by the writer as being adequate for chronic and long-term.patients. The Ingham County Hospital and Rehabilitation Center, a long-term facility, accounts for this entire number. An additional 30 beds are soon to be opened to increase the capacity of this hospital. In a recent survey, conducted for future allocation of Federal funds in the state of Michigan, it was noted that h5'beds were designated fer long-term purposes at the East Unit of Edward‘W} Sparrow Hospital. There is a logical contention that this unit is inadequate for chronic and/6r long-term care. The writer in arriving at this conclusion SOliCited 13 1h the opinions of several local physicians and the director of the Sparrow Hospital concerning the adequacy of the unit for long-term and/Or chronic-care purposes. Each of those men offering an Opinion are actively interested and engaged in some phase Of chronic care in Ingham County. The consensus of their opinions may be summarized as follows: 1) Inadequate therapeutic facilities; 2) Inadequate service facilities, i.e., dining and recreational areas for ambulatory patients; and, 3) Absence of acute facilities in the event of acute excerbations. Because of the above opinions this unit does not seem desirable as a facility from which intermediate-care might be rendered. Two other general hOSpitals are also operating in this area, neither of which offer care specifically for the chronic and/Or long- term patients. These hospitals are the Mason General Hospital, a 194bed facility, and St. Lawrence Hospital with a 276-bed capacity. Other sources of accommodation for the long-term and convalescent type patients of this county come from some 21 licensed convalescent- geriatric nursing homes (Appendix, page 107). In a discussion with Mildred Caldwell, Superintendent of Nurses, Ingham County, it was discovered that these homes are scattered throughout the county and make available nearly 300 beds for semieprofessional and nondprofessional nursing care. Miss Caldwell, indicated that few, if any, of these homes, are directly affiliated with an acute general hospital program. A majority of them provide at the most, only sheltered or personal care. Patients cared for in the Ingham.County Hospital and Rehabili- tation Center are convalescent to whatever extent is possible and 15 capable of responding to an active program of therapy and rehabilitation. Often when continuing medical supervision is required, patients may be admitted to this center for a period of convalescence prior to being discharged from the hospital system. It was, however, found that only a few private cases are being cared for in the center with the majority of cases being county welfare of geriatric patients. Sparrow Hospital, as opposed to nursing home facilities and the County Rehabilitation Center, is capable of playing a consequential role in the active treatment phase of chronic disease. Through the establishment of an intermediate care unit, as proposed in this paper, Sparrow Hospital would be able to provide a continuum of active treat- ment and care facilities. Such a unit could easily be a prototype of what is inferred by the term "skilled nursing facility" as used in the amended Medical Facilities Survey and Construction Act passed by Congress in 195D. It could provide a type of nursing facility which would be intimately incorporated into the administrative structure of a general hospital. Although the present situation in this county does not appear serious, the real consideration rests in the demands of future health care. Pages 100, 101, and 10h of the Appendix point up the trend of chronic disease not only in Michigan but throughout the entire nation. It seems evident that a thorough evaluation of health needs must be made in preparing for the inevitable demands of the future. 16 Need for Additional Facilities Chronic diseases are today the major cause of illness and dis- ability. They are responsible for over 70 per cent of all deaths (Appendix, page 100). Outstanding examples of those chronic diseases contributing so heavily to this high rate of morbidity and death, excluding tuberculosis and mental disorders, include: diseases of the heart; cancer, vascular lesions affecting the central nervous system; diabetes mellitus; arterio-sclerosis; cirrhosis of the liver; nephritis; arthritis; and asthma. These are but a few of those dreaded diseases which yearly are responsible for nearly a million deaths (Appendix, pages 101, 102) and are directly responsible for the loss of almost a billion days of productive activity during this same period of time. More than 2,000,000 of the 25,000,000 persons in the United States suffering from chronic diseases-other‘than.menta1 and tuberculosis-- require long-term care.8 Chronic illness is to a great extent replacing acute illness as the major health prOblem, in the minds of medical researchers. Acute infectious diseases common in Michigan at the beginning of the present century have, to a large degree, been brought under control (Appendix, page 105). This result has'been achieved primarily through the application of medical research findings. In realizing such con- trol over these diseases science has greatly advanced the average life r RAmerican Hespital Association, P1anning_for the Chronicall Ill 191.7, pp . 2-3 . (Reprint from OotoberT'i9L7 issue of "Pu‘b'i'io' w"'e'1";rar' "e .5 17 span of man. The prObability of chronic illness during the later years of man's life has been accentuated. It is noted that the death rate in Michigan due to both chronic and acute infectious diseases compared to the national rate, follow a similar pattern (Appendix, page 101). Both verify the trend toward decreased acute deaths with a corresponding increase in chronic deaths during later life. 'we may conclude, then, that infectious acute diseases such as diphtheria, typhoid fever, scarlet fever, whooping cough, dysentery, srallpox, and pneumonia, are rapidly becoming of secondary interest in the field of medical health. As a result of the untiring effort exerted by medical science in conquering the problem of acute diseases the average life expectancy of man has increased from h7 years in 1900 to slightly over 69 years in 1956.9 This shows a gain of 22 years since the turn of the century. Infant mortality has also been reduced nearly 70 per cent during the last twenty years.10 The odds of life over death have been literally reversed in man‘s favor. Since the beginning of this present century the entire concept of health care and man‘s perspective of life itself appears to have been revolutionized. With ever greater achievements in the medical sciences yet to come it is quite likely that the average age of the population will continue to climb. In all probability, new and more complex problems will result from such advancement in the average age of man. 9George Bugbee, "Population Change and Health Care," Hogpitals, 30 (May 1, 1956), pp. 32, 35. 1°Loc. cit. 18 The chronic health problem has progressively advanced in importance in Michigan since 1900. There is no indication that this trend will reverse itself. (Appendix, page 101..) Page 109, of the Appendix, shows the per cent of change in pOpu- 1ation for the State of Michigan from 19h0-1950, to be +21.2 per cent. The population change by county is shown in the Appendix, page 108. Ingham County, it is noted, accounted for an increase of at least 21.2 per cent. Subsequent statistics published by the Michigan Department of Commerce show a continuation of these trends. Although a leveling- off point may be reached, these statistics, nevertheless, illustrate the importance of planning for the future. The population trend of this area, and the increased life span of the average man, in addition to an increasing prevalence of chronic long-term diseases clearly under- scores the importance and timeliness of this subject.~ One authority11 suggests the need of the population for chronic hospital beds as 1.7 beds per 1000 pOpulation. This does not refer to nursing home facilities. From this ratio a theoretical bed compliment can be deduced for Ingham County as approximately 3h6 beds. Based on present active available chronic hospital beds (192) the need for acceptable chronic facilities in the county is hS Per cent unmet. A recent statistical publication12 shows the nation‘s need for chronic beds to be about 86 per cent unmet. Additional beds required 11John W} Clissold, M. D., "Meeting the Nations' Health Needs," Hespital Management, 29 (March, 1955), p. h7. 12Loc. cit. 19 in the United States, figured at the rate of 1.7 per 1000 pOpulation, number 266,897. Another 5,05h beds are estimated as being needed in territories outside of the United States. From this it is recognized that the prOblem does not limit itself to any one geographical area, but is rather one of national concern. Benefits Derived from Adequate Facilities As chronic illness becomes an increasingly greater factor to the health of the nation, so provision for adequate facilities in which to care for this type of patient becomes of concern. Many progressive communities throughout the nation are thinking in terms of future health needs by planning for and developing adequate total health care programs. Every community is obligated to analyze its own situation in view of its future needs. 0f first concern is the benefit derived by the community as a result of making available to the chronic long-term patients those acute services common in the general hospital. It is anticipated that patients cared for in a unit such as is proposed in this study, as opposed to the conventional means of care, would be returned more rapidly to a productive status. The extent to which patients might be completely rehabilitated is, of course, limited only by the degree of disability. The Objective of all chronic disease programs should be that of providing active continuous treatment for the long-term patient. It is all the more important then that such.patients have direct access to 20 acute facilities provided in the general hospital if intensive continuous service is to be realized. Physical and emotional restoration of the patient would be obtained only within the limits set by his illness. Services such as physio-therapy, occupational therapy, and other rehabilitative services so essential in treating the chronically ill patient would be readily available. Acute services (i.e., x-ray, surgery, laboratory, etc.) are becoming more and more important because of the unpredictable nature of chronic diseases prevalent today. Acute emergency services frequently necessary in caring for certain chronic patients should be readily available whenever indicated. It is perhaps more likely that the physician's attitude toward acute symptoms might be even more alert in the general hospital than in an institution providing care solely for chronic diseases. Some acute general hospitals having developed chronic care facili- ties are experiencing increases in net income.13 Decreased costs per patient day results from providing services where services are actually needed. It is not uncommon to see chronically ill patients requiring, at the most, only personal care, being cared for in the acute wards as acute patients. In actuality, it appears that rehabilitation for many of these patients becomes retarded under such circumstances. It is anticipated that a substantial net cost decrease could be realized in cost per day for patient care. Both the patient and the hospital would, as a result, benefit. 13Eugene walker, M. D., "Advantages of a Chronic ward in an.Acute Hospital," American HOspital Association Convention Papers, 19h7, p. 321. 21 The Nursing Home in Ingham County Nursing homes in this country are carrying a considerable portion of the total chronic and convalescent load. A recent survey14 for licensing of nursing and convalescent homes was made in Ingham County. This survey indicated that those homes which are licensed have met certain requirements as outlined by the State of Michigan Department of Healtho It is recognized that many non-licensed homes do exist provid~ ing unsatisfactory conditions. In addition to such facilities many patients are being cared for in their own homes while leading a totally unproductive existence. The survey showed most licensed homes filled to near capacity. Even though these homes are authorized to operate and meet the require~ ments as interpreted by those performing the survey, it is imprObable that even a few are capable of providing those services most conducive to rapid rehabilitation. Because of their economic situation most of the homes cannot possibly offer services beyond personal or sheltered care. Consequently, in many instances the individual patient becomes lost in.the maze of the unproductive millions. The real burden must then be assumed by the general hospital if adequate provision for patient care is to be realized. Progressive hospitals throughout the country seem to recognize the necessity for providing intermediate accommodations for the patients 14Michigan Department of Health, Inspection and Licensing Survey of Convalescent Homes and Homes for the Aged, Hospital Services Section, 1957. 22 not regularly requiring acute services and professional care. The preceding discussion vividly suggests the importance of preparing for the future demands of health care in this community. CHAPTER IV STANDARDS FOR THE ESTABLISHMENT AND OPERATION OF AN INTERMEDIATE CARE UNIT Obviously the type and quality of care which a patient care facility may become capable of rendering depends upOn a great many factors. In planning for and organizing such a unit certain standards should be adhered to in assuring acceptability for its intended purpose. Legal requirements and professional standards should be investigated. As an essential part of planning, these requirements and standards must be met with respect to the building and services provided. Careful consideration then must be given to the legal as well as professional aspects involved in.providing this type of facility. Provision of Standards for Patient Care The State of Michigan rigidly enforces certain requirements as outlined for hospitals and their facilities. Any violation of these legal requirements is punishable as provided in the law. The Michigan Department of Health and the State Department of Social welfare are the two primary organizations responsible for the enforcement of this legislation and should be consulted at the outset. The Department of Health has made available its Rules and Minimum Standards for HOspitals, as approved by the Attorney General. All of the state offices and I professional organizations associated with hospitals were involved in 23 2h the formulation of this publication making it both authoritative and practical. Another publication, Rulesfiand Regglations for Inspecting45gd Licensinggof Convalescent Homes and Homes for the Aged, provides additional guidance. The requirements outlined in this publication were prepared by the Department of Social welfare. Although affecting only those facilities privately operated for profit, these rules and regulations as outlined should be carefully reviewed prior to the establishment of a unit of the type proposed. A second form of accepted standards or requirements which should be investigated are those of professional organizations in related fields of activity. The Joint Commission on the Accreditation of Hospitals has outlined certain requirements which should be carefully reviewed. For purpose of full accreditation by the JCAH, these Specifi- cations must be met. Other professional organizations, as well, should be consulted. The unit should operate in conformity with such standards as those set by the American.Association of Nursing Homes, the National Association of Methodist Homes and Hospitals, and, in addition, those official associations of nurses, social workers, dietitians, physical therapist, occupational therapists, etc. Governmental agencies, such as the United States Public Health Service, also require conformity to certain standards and regulations. An institution accepting its responsibility should go beyond the minimum requirements of the law endeavoring constantly to operate in accordance with standards fully acceptable to groups such as those noted above. 25 Consideration of Basic Standards Some standards must be recognized in.an attempt to provide accept- able patient care. In striving to improve care certain agencies and organizations have done extensive research in preparing those standards by which institutions offering patient care may be guided. Those organizations mentioned above are but a few which continually strive to foster "quality" care as applied to nursing service, diagnostic pro- cedures, medical staff organization, physical facilities, and other components of patient care. Shown below is a partial list of rules and standards outlined by the Michigan Department of Health in their publication.Rules_and Minimum Standards for Hospitals. These standards present basic criteria for guidance in this study for the establishment and operation of the patient care unit. A. The Physical Plant, Facilities, Equipment and Operation 1. Compliance with Codes a. The hOSpital shall comply with the local and state building code. b. The hospital shall comply with the requirements of the state fire marshal. c. The hospital shall comply with the state plumbing code. 2.‘Water and Ice Supply a. A public water supply shall be used if available. b. The entire plumbing system and all plumbing facilities shall.be so designed and maintained that the possibility of back-flow or back-siponage shall be reduced to a minimum. 26 c. There shall be no physical cross connection between water supply systems that are safe for human.use and those that are or may at any time'become unsafe for human use. d. All ice shall be handled in such a way as to prevent contamination. 3. Garbage and waste Disposal a. Garbage containers shall be emptied at frequent intervals and thoroughly cleansed and aired before further use. b. Facilities shall be provided for the disposal of infectious dressings,...and similar materials by incineration or in a manner approved by the state health commissioner. h. Heating and Ventilating a. The temperature in tients' rooms shall be maintained at approximately 72 F throughout the entire season. b. The hospital ventilating system shall be regulated so that objectionable drafts shall not be created. 5. General Maintenance a. The use of a common towel is prohibited. b. Storerooms shall be clean and well ventilated. c. Refrigeraged storage space shall be kept at approxi- mately to F. d. Kitchens and utility rooms shall be provided as needed. e. Insects such as flies, roaches and mosquitoes shall be properly controlled. B. Patient Care 1. Patient Care a. All persons admitted to a hospital shall be under the continuing daily care of a physician licensed to practice in Michigan. C. Records 27 The hospital shall require that an admitting diagnosis be recorded promptly on each.patient. The hospital shall provide personnel, space, equip- ment and supplies for routine laboratory analyses. The hospital shall employ professional and auxiliary personnel to give patients necessary services. The nursing service and nursing shift shall be in charge or supervised by a graduate nurse, registered to practice in Michigan. Meals shall be>prepared and served in a sanitary manner. Rooms for adult patients shall provide a minimum of 80 square feet of floor space per bed. In multiple bedrooms beds shall be at least 3 feet apart. There shall be sufficient equipment for care according to the type of patients accepted by the hospital. Individual linens shall be provided each patient. Rules governing visitors shall be posted in a con- spicuous place. Hospitals shall isolate patients with communicable disease, carriers of communicable diseases, or those suspected of having communicable diseases. Hand washing and toilet facilities shall be provided within the isolated areas. The hOSpital shall make written policies concerning isolation techniques available to all personnel concerned. 1. Records 8.. b. The hospital shall require that accurate and complete medical records be kept on all patients admitted. The administrative records of the hospital shall include as a minimum: 28 1) Records of admission and discharge 2) Patients' records 3) Daily census records h) Narcotic register 5) Statistics regarding number of deaths, autopsies and consultations. CHAPTER V PROPOSED PLAN FOR ESTABLISHING INTERMEDIATE-CARE FACILITIES.AT THE EDWARD Wk SPARROW HOSPITAL Before entering into the problem of establishing an intermediate care unit in Sparrow Hospital, the reader is first asked to briefly acquaint himself with the organization of this institution. With such understanding a more thorough evaluation of the study can be accomplished. Organization of the Hospital Since November 6, 1912, the Edward W} Sparrow Hospital Association has maintained its status as a nondprofit corporation. The American Hbspital Association lists the institution in its publication.as a general short-term acute hospital.15 A Board of Trustees composed entirely of men, and a'Wbmen's Board of Managers, act as a dual govern- ing'body. These two groups are represented by an Executive Committee regarded as the active segment of the dual board. This group is ultimately responsible for the activities of the hospital.. The hospital is comprised of three separately located but integrated units providing hospital service. The main hOSpital provides facilities for care of medical, surgical, obstetrical, pediatric, and other types f 15American Hospital Association., Listing of Hospitals, Hbspital-- Guide Issue, Part II, 30 (August 1,1956), p. 166. 29 30 of patients common to a large general hospital. It accommodates 251 patients, including adults, children, and new born infants. Oak Park Annex was leased to the hospital in 19h8, on.a 33-year tenure. This second unit is used primarily for patients unable to secure accommodations in the main hospital. Located several.blocks from the main hospital, this hSAbed unit is closely coordinated with the main hospital. The East Unit, a Soébed facility, provides accommodations similar to those of the Oak Park Annex. Originally the East Unit was organized to accommodate, polio, psychopathic, contagious and convalescent type patients. In addition, this unit presently houses the Physical therapy and Occupational therapy department for the entire hospital. It is apparent that the location of the East Unit and Oak Park Annex, being geographically separate from the main hospital, presents a patient care problem. Consolidation of the two units with the main hospital appears necessary for maximum efficiency, economy, and adequacy of patient care. By establishing intermediate-care facilities adjacent to the main hospital favorable results could be realized. Adequate provision for care of the chronically ill would provide the community with a more complete centralized health care program. Selection of Site In selecting a location for the development of an intermediate—care unit for Sparrow Hospital the writer was confronted with three alternate locations. To justify the final selection these alternatives are briefly outlined. At the outset, it becomes apparent that the extent 31 to which such a unit is able to meet the needs of its patients and the community is directly affected by its location and the kind of building in which it Operates.16 Of importance, too, is the accessability of such facilities to the main artery of acute medical care. For maximum benefit to the patient and economy of operation the location of this proposed unit in regard to the main hospital building should be a determining factor in selecting the final location. Alternative I The first observation.which comes to mind is that of negotiating for the outright purchase from the City of the land upon which the present East Unit is situated. This pr0perty, if purchased by the hosPital, could very adequately allow for considerable expansion in providing for intermediate-care facilities. Favorable Considerations: 1. The pr0perty is of sufficient size to allow for consider-' able expansion of the present facilities. 2. It is centrally located midway between.Lansing and East Lansing. 3. Adequate parking facilities are available. h. The site could be developed to provide complete chronic care while maintaining some integration with acute facilities of the general hospital. 5. Access to public transportation, churches, shopping area, and University activities is good. o.‘ Hill-Burton funds could be secured. 16Edna E. Nichelson, Plannin New Institutional Facilities For Long-Term Care, Putnam, New Ybrk, 19g6, p. 228. 'fi 32 Unfavorable Considerations: 1. Decentralization from the main hospital would tend to minimize the degree of control affecting efficiency and economy of operation. 2. Duplication of some facilities would be necessary, i.e., housekeeping, nursing, etc. 3. The "Paper location? of a highway to be constructed to by- passLansing.1'7 h. Distance from.acute services prohibits maximum integration of facilities. as??? 7361: 1‘43“ "3‘. Alternative II A second consideration is that of constructing an intermediate 1'13“"- care unit adjacent to the main hospital. Such a unit could be con- structed at the east end of the main hospital building with direct entrance to the hospital. Favorable Considerations: 1. Immediate access to all acute facilities of a general hospital. 2. Access to adjacent churches, shopping center, recreational facilities, and public transportation. 3. Possibility of receiving large percentage of total con- struction cost through Hill-Burton funds. h. Centralized control with minimum duplication. Unfavorable Considerations: 1. WOuld eliminate valuable parking facilities now utilized by staff personnel. 17A recent interview with John Meyer, State Highway Department official, revealed that a portion of this property is a "paper location” through which the U. S. 27 bypass will be constructed. The term "paper location" was defined as being "the most likely spot." 33 Only one-half of this proposed site belongs to the hospital. The other portion is not expected to be available within the near future. Hill-Burton.priority would be indefinite with a consider- able time and study element involved. Dietary department and ancillary facilities would be located at the extreme end of the building, thus creating a traffic prdblem for both patients and staff. Limited expansion due to available Space and location. Community funds for construction of a new addition on this site could not be easily acquired at this time. The com- munity is at present carrying out a 3-year United Fund Campaign for construction of hospital facilities in the area. Alternative III This alternative considers the feasibility of converting the structure presently used as a domiciliary and classroom unit for student nurses and instructors into an intermediate-care unit. Favorable Considerations: 1. 3. A. Direct access to acute facilities of a general hospital, by means of a proposed connecting corridor, could be made available. . Access to adjacent shopping center, churches, recreational facilities, and public transportation would be good. ‘Would entail little or no financial obligation on the part of the community. Financial assistance from Hill-Burton funds for remodeling purposes may'become available on.a percentage basis. . Direct entrance to main cafeteria area would be possible by way of the proposed connecting corridor. There would be sufficient space for expansion should the need arise. 3h 7. Centralized control could be maintained with minimum duplication. 8. Building layhout is such that it could be adapted for use as an intermediate-care unit with relative ease. Unfavorable Considerations: 1. Construction of a neW'domiciliary unit for student nurses would become necessary'(HilléBurton funds could be secured on.a‘priority'basis). 2. Some remodeling would be necessary. 3. Construction of a connecting corridor to the main building would be necessary. h. Parking facilitieswould be limited (A problem to be considered in.any expansion.program on the present hospital site) . The third alternative is selected by the writer as the most accept- ably alternative for immediate consideration. In preferring this selection over the second alternative, several factors were considered. From reliable sources, it is understood that considerable thought has been given to the construction of a new'nurses' home, within the near future. This, if accomplished, would allow the present nurses' home to be used for other purposes, undoubtedly some type of patient or employee accommodation. This writer assumes that patient accommodation would, at this time, be preferred. Since this building would eventually be used for inipatient purposes, careful thought should be given to its acceptability as an intermediate-care unit. Favorable considerations for conversion of this building are listed above. The property described under Alternative II, presents several unfavorable factors which render selection of this site unacceptable. 35 This site would not allow sufficient area for additional expansion in view of’any further requirements. The property is bordered on three sides by'a city street. Only if the city were to close off an adjacent street would this property be sufficient in area. It is the writer's understanding that a portion of this prOperty is privately owned and priced unreasonably high. Another unfavorable consideration which should be further emphasized is the relatively decentralized position of the unit should it be con- structed on this site. The writer is thinking primarily in terms of food service and ancillary facilities. Immediate construction.plans designate these services for relocation at the extreme opposite end of the existing hospital. It is understandable that such an arrangement would be neither economical or efficient without mention of the effect upon traffic flow and inconvenience to the ambulatory patient. It is felt that the third alternative, although not free of un- favorable considerations, most adequately meets the needs of the long- term patient in the most efficient and economical manner. The remain- ing portion of this study establishes those elements, which in the opinion of this writer, are essential to adapting this domiciliary unit to the needs of intermediate care. Description of Property The size of the property and type of structure under consideration would be sufficient to allow for expanded facilities should expansion become necessary. The site is situated on the southdwest corner of the 36 main hospital property overlooking Michigan Avenue, a main thoroughfare. The building is constructed of reinforced steel with brick facing; and, is considered a fire-resistant structure. This E-type structure is 'rectangular in shape with three wings extending to the rear. Maintenance of the building, as evidenced by its general appearance, has been adequate. The building is well oriented for sunshine and ventilation with its front face overlooking the landscaped central grounds of the h03pital. A balcony above the front porch would allow convenient facilities for patient enjoyment and relaxation. In consideration of future remodel- ing a portion of the roof area could be easily remodeled as a year- around solarium for.patient use. It is the opinion of this writer that only limited remodeling would be necessary in.providing the unit with adequate facilities for chronic and long-term patient care. The three major items of importance being: 1) installation of a nurses' call system; 2) modernization of the present elevator; and 3) construction of an enclosed corridor to connect this building with the main.hospital. Minor remodeling needs are con- sidered and proposed throughout the study as the need becomes apparent. The ground floor, at grade, is two feet above street level, allow~ ing for adequate drainage. Heat, light, and power facilities would be of minor concern since the building has been in continuous operation with adequate utility service. Complete telephone service is presently available at each floor level from a central switchboard located in the main hospital. 37 Figure 1. Proposed Intermediate-Care Unit-éLocation Map \\\\\\\\\T as 2 7//\ _—-----—-—__--- lO O I C O SWGJNOU‘L 5' UNI—J F‘F‘ lord Proposed Intermediate Care Unit Proposed Connecting Corridor First Level Roof Covering Open Breezeway First Level Roof Over Emergency Area Patient Area-Ne “Wing Four-bank Elevator Shaft New Wing Under Construction Present Hospital Area . Corridor Front Entrance- ll 38 It is assumed that a considerable portion of the work necessary in remodeling this building could be supplied by the hospital maintenance department. Only those three major projects listed above should be let out on bid. A considerable saving in cost of remodeling could be expected as the result of such an arrangement. Patient Accommodations and the Concept of Grouping After remodeling and final allocation of space the building could easily allow 76 rooms for patient care. In utilizing this number of rooms a total complement of 123 beds could be comfortably installed in the unit. In addition to patient accommodation one area could be blocked off for medical intern and resident accommodations. This section.could be located in the south wing of the fourth floor and should include at least five rooms. It is expected that these rooms would be used primarily as single intern and resident quarters with one room set aside for group discussion and educational purposes. At the present time a house adjacent to the hospital is being used for this purpose. Since those utilizing the facilities of this intermediate-care unit as patients would present varying degrees of disability, consider— ation should be given to the concept of grouping. By grouping, this writer proposes the predetermination of the types of patients to be admitted to the unit and classification of patients by groups according to the extent of disability or amount of service required. Flexibility in patient classification to any group would seem important since no fine line can be drawn between degrees of disability. For the purpose 39 of this study four basic groups of patients, according to the amount. of service needed and degree of disability, are considered. These four groups are listed below: I -Ambulatory II - Semi-ambulatory III -‘Bedriddeni IV ~ Special: Isolation 3 Psychiatric Children under 15 years of age. The usual.plan, as observed in some institutions, is that of providing one section, or floor, for the fully ambulant patients and a separate section, commonly known as the infirmary for patients who are bedridden. A third section would be set up to care for the semi- ambulatory patient. This latter type of patient would usually be up part of the time-or might require some-special supervision or care, i.e.,_regular administration of insulin, close Observation'because of .a heart condition, mild psychiatric illness. A fourth group prOposed for this unit includes sub-groups for isolation, psychiatric, and patients under 15 years of age. Dividing chronically ill and long-term.patients into Specialized groups in order to more adequately care for patients appears logical and most efficient. However, according to one authority,18 it should be kept in mind that as the degree of specialization increases A; 18Ibid., p. 229. hO flexibility in utilization of available facilities decreases. As a direct result of decreased flexibility cost of patient care tends to rise. Some problems could be expected to develop as a result of the grouping system suggested above.) Gradual transition of Some patients from one group to another as the degree of disability subsides or increases would likely give rise to emotional problems and behavior difficulties. This is inevitable because with most chronic diseases infirmity and disability gradually increases. .As a result, this type of patient tends to resist the transition from one group to another. This is particularly evident if such a move is interpreted as indicat- ing increased loss of ability for self-care.19 Grouping facilities in this unit should be so arranged that the number of times a patient must be moved to a new location could, be held to a minizmm, consistent with patient requirements. It should be expected that additional Specialty groups may be designated from time to time. Such would be the case if one or more of the chronic diseases suddenly became prevalent, as in the case of a polio epidemic. In this instance a Specified area should be designated to accommodate those polio patients admitted to the unit. It should also be expected that patients with objectionable ill- nesses would occasionally be admitted to this unit for intermediate care. .Adequate provision for care of offensive ailments is necessary. V fl 7* lgIbid o ’ pp. 230-232 I hl Patients with offensive odors, such as is common to oral cancer, would usually require an above average amount of care. Such.patients would normally be admitted as bedridden.patients and assigned to a private room. In selecting the room or rooms to be used for this purpose con- sideration should be given to effective ventilation and proximity to other patient‘s rooms. Singleébed rooms should, in most instances, be provided. Deodorizing machines, which would contribute considerably to the comfort of both.patient and personnel, should also be considered in.preparing for this type of patient. Single-bed rooms for the mentally disturbed and for terminal cases are also desirable and Should be provided in this unit. To prevent undue injury in case of attempted escape by mentally disturbed patients consideration Should be given to placing the psychiatric ward as near ground level as is practical. Adequate security measures should be. taken asra preventive measure in.minimizing the possibility of injury. Isolation from the mentally alert patients must also be anticipated in consideration of the nuisance factor. This ward or section for pschiatric treatment should be situated so that the area might easily be divided from normal patient area. The figures given in Table I are highly significant for purposes of planning facilities for this unit. Assuming a 90 per cent occupancy the fellowing patient load, based on degree of disability could be anticipated: A2 TABLE 1 * PERCENTAGE DISTRIBUTION OF CASES WITH RESPECT TO CARE REQUIRED Type of Case 7 Per Cent 14 Requiring minimum care only: 7 h Includes only board, room, laundry, housekeeping ' service, general health supervision, a responsible person on call, and having medical and nursing care available in case it should be needed 2. Requiring chiefly personal attention and routine care: 3h.0 Large amounts of care may be needed but most of it is of a simple type which can.be given by aides, attend- ants, and matrons with general supervision.by the physician and professional nurse 3. In need of regular nursing services ' 58.6 ' TOTAL 100.0 L4 ' ' ‘ “. “Since mm, the Central Service for the Chronically 111 of the Institute of Medicine of Chicago has maintained an informational service through A which help is provided in arranging long-term care for individual patients. Some 17,000 patients known to the organization represent al- most all gradations of need. They may be regarded as roughly typical of the entire group of persons requiring such care, with the exception of persons in need of care because of tuberculosis or mental illness. These figures tabulated from.records on the cases have been reviewed and compared year by year. Comparisons were made in relation to figures drawn from studies made in other locations, including, among others, a study of the characteristics of patients in nursing homes in.the state of Maryland (see News Letter, Commission on Chronic Illness, October 11953),a summary ofexperienc‘e in Cleveland, Ohio (Goodman, J. 1., M. D., Causes of Disability in.Patients with Chronic Disease, Journal of the American Medical Association, Vol. 152, August 1953, No. 1h, 1336-38), and unpublished studies made in California, Texas, and a rural area in Michigan. ‘The comparisons showed so little variation between localities that, for purposes of‘planning institutional facilities, it appears that these figures may be accepted as a generally reliable indication of the type of patients in.need of long-term care in institutional facilities in the United States.3° 2°Ibid., p. 15. 113 Patients Per Cent 1. Requiring minimum care only 9 7.h 2. Requiring chiefly personal attention and routine care h2 3h.0 3. In need of regular nursing services 72 58.6 Total 123 ‘ 100.0 Another set of figures provide additional guidance in determining a bed distribution ratio. Distribution of patients, according to their ability to move about is noted in Table 2. TABLE 2 PERCENTAGE DISTRIBUTION BY ABILITY TO MOVE ABOUT OF PATIENTS SEEKING LONG TERM gARE IN INSTITUTIONAL FACILITIES Type of Case Per Cent Ambulant and mentally alert 8.9 Ambulant but mentally confused 16.9 Ambulant with help 11.9 Semi-ambulant 30.1 Bedridden 32.2 Total 100.0 fi fi v—w ‘— *American Hospital Association, Listing of Hospitals, Hospital-«Guide Issue, Part II, 30 (August 1, 1956), p. 166. M4 .Ambulant and mentally alert patients comprise less than 10 per cent of the anticipated patient load. These are patients who are physically and mentally capable of caring for their own needs without close supervision or assistance. Nearly 17 per cent, as indicated above, are also ambulant but would require constant supervision as a safeguard against hazards which might be encountered if left alone. Another 12 per cent of all patients requiring intermediate care, as indicated above, are able to be up and around with some degree of assistance. Most of this group could be expected to get around, aided by crutches or walkers, on a level surface for Short distances. Semi- ambulant patients seeking long-term care in this unit could be expected to total approximately 30 per cent of all patients admitted for care. This group would require, for the most part, only routine and personal care. As indicated above, between 30 and 35 per cent of the anticipated patient accommodations should be set aside for'bedridden.patients. .Although not acutely ill this type of patient would require complete .nursing care. 'With the ambulant but mentally confused patient supervision throughout the entire day should also be maintained. Being capable of getting about without aid yet not alert enough mentally to control their own activities, these patients actually require a considerable amount of nondprofessional supervision. These factors are significant to the over-all patient distribution and organizational planning of this intermediate-care unit. AS In converting the nurses' home for use as an intermediate-care facility each floor should be carefully evaluated in view of its intended use. Ground Floor-Treatment and AdminiStrative Facilities The present lay-out of the ground floor would in general be acceptable for administrative and treatment purposes. However, certain minor adjustments would become necessary in.providing adequately for all the needs of the patient. Figure 2, page h6, shows a proposed scheme for this floor. The facilities located at ground level are at present being used for administrative and classroom.purposes. In addition to classrooms and offices there are three lounge areas, several utility closets, a spacious ldbby, and an auditorium situated on this ground floor. .At present there are no living accommodations at this level and no such accommodations would be necessary with convertion of the unit for intermediate-care purposes. OThe present Physical Therapy section could be conveniently re- located in the south wing at this level. In selecting an adequate location and allotting space for physical therapy, consideration should be given to several important factors. The recognized purpose of any Physical Medicine department is to provide a means by which every patient within his physical and mental limitations, may become capable 21 of being useful to both himself and society. It is expected that *‘ fl ——~ 21United States Employment Service and.American Hospital.Associ- ation, JOb Description and OrganizationalgAnalysis for Hospitals and Related Health Services U. S. Government Printing Office, washington, 1935, pp. 396-398 0 Figure 2. Ground Floor .1- to T a a ll 12 . 13. 1h. 16: 9_ls 10 Physio -Therapy Suite Auditorium Occupational-Therapy Suite Service Room Lavatory Kitchen Storage Lounge Lobby Reception Office Social Service Office and Interview Room Barber-Beauty Shop To Connecting Corridor To Rear Recreation Area Main Entrance Elevator h? during pre-ambulation the physical therapist would spend considerable time at the patient‘s bedside. It may then be assumed that as the patient becomes progressively more ambulant and sufficiently able to be transported further rehabilitation would be more effectively pro- vided within the physio~therapy treatment rooms. It seems most important that, at this stage, the patient be provided with adequate facilities '6‘" capable of allowing for maximum rehabilitation. It is for this reason ' that careful consideration should be given to allotting sufficient A space for use of the physio-therapy section in accommodating the needs A of a top quality Physical Medicine department. L!L__ Five large rooms with an adjoining office are located in the south wing of the ground floor. The physio-therapy equipment needs could be adequately provided for in this area. This suggested location would allow for adequate ventilation and maximum sunlight. It would also be accessible from an outside entrance adjoining the suite of rooms. Sufficient water facilities are presently available as are electrical outlets, thus minimizing necessary revision. One area located to the front of the suite is presently being used as an extension to the main lounge. Construction of a partition could be easily accomplished to separate the area from.the main lounge. No real prOblems would be anticipated in locating the therapy equipment fer maximum efficiency in this area of the building. This writer is of the opinion that the proposed location for both the physio- therapy and occupational-therapy sections would prove workable. 148 Occupational Therapy is the other section of the Physical Medicine department for which space should be allotted on this ground floor. The location suggested consists of three rooms situated in the north wing. This type of therapy suggests a dual purpose.22 Its first purpose is that of providing vocational exercises, diversional activities and entertainment for both ambulatory and non-ambulatory patients. A second obj ective is that of teaching personal activities of daily living to thOSe who have, through disuse of limbs, lost the habit. To adequately Provide for those facilities necessary for maximum rehabilitation Sufficient space could be provided in the north wing of the ground 1100]? . The three rooms suggested for this purpose would allow sufficient work area and storage facilities in anticipation of future demands. ’ BY locating this section adjacent to the corridor, connecting the main h°®ital with this unit, patients with acute illnesses could easily take advantage of its rehabilitative facilities. It is assumed that a majority of the patients would be encouraged to participate in mamr 0f the therapeutic activities. The three rooms which could be assigned for occupational therapy purposes are nicely oriented for sufficient ventilation and natural sunlight . For outpatient convenience the area would be accessible from an on"T'szkie entrance located at the north end of the main corridor and adjacent to the main hospital emergency entrance. This section, as N v_. V 22I-tlid o ’ PP 0 393.3950 )49 the physical therapy section, would be conveniently situated just off the front lobby. One room suggested for the occupational therapy section could be used as a patient laundry room equipped for washing, drying and ironing of personal clothing by the patients. Many patients would undoubtedly be hospitalized for long periods of time and wear their own clothing throughout the entire period of hospitalization. A double benefit could be accomplished. The hospital would be relieved of this additional laund ering of personal items while the patient would benefit thera- Peutically from performing one of the routines of daily living.23 Medical Social Service is another service which undoubtedly will become progressively more important to the voluntary non-profit hospital . The social worker in this type of unit should be expected to cOl'l'bribute considerably to the welfare of both the patient and his fmly. Indirectly, the department should aid the administrative and medical staff by preventing or relieving behavior difficulties that framerltly create complications in caring for patients.24 with the responsibilities of the Medical Social Service department in Mind consideration should be given to proper location for maximum effectiveness and convenience of the service. Two locations, one in the Main hospital building and the other in this unit, were considered. Primal~“—"='LZI.y because of its proximity to those patients who would utilize N w—‘f —* Di 'I-‘homas P. Galbraith and John w. Cronin, M. D. "Planning Multiple p agility Rehabilitation Facilities," Hcflitals, 30 (March 16, 1956), 23 aq‘Nicholson, _p_. cit., Po 150- So its services to the greatest extent, locating the Medical Social Service department in the proposed unit would seem most practical. The area suggested for the Social Service Office would be adjacent to the main lobby. It includes two rooms, one of which could serve as an office and the other for the purpose of interviewing patients and their families. If additional counseling space should become necessary at a later date another room adjoining this area could be utilized. A Visitor Rec_epticn Area could be located in a small room directly accessible from the front entrance and adjoining the main lobby. From this office the nurse in charge of the unit could easily coordinate _- the various activities and functions related to patient care. This Off ice could, in addition, serve as a reception or information center for the unit. A buzzer system is presently in operation from this office to each room in the building. This system would, however, be of little or no value as a comminication device following the conversion or the building. All direct communication to the various nursing Stat-ions throughout the unit should be by inter-departmental telephone as is now in operation throughout the hospital. An audio paging system “mughout the unit could also be installed. \Pe-I‘lor and Lobby facilities would be accessible from front and side entrances. Upon entering the building by the front entrance, Vigitere would immediately be in an attractively decorated lobby. To the left or south side of this lobby would be French doors leading to 8‘ °°nveniently located parlor with comfortable lounging area- The only remodeling to affect this area would be a proposed partition in the Sl parlor which, as previously discussed, would allow for one additional room for the physical-therapy section. Just off the corridor leading from the main lobby to the proposed physio-therapy section is the house elevator. This elevator in its present condition is a "self-Operated" device and extends to all floors. Modernization of this facility is discussed in a subsequent section. An auditorium with a seating capacity of approximately 200 is located on the ground floor level. Entrance to the auditorium could be made from the lobby. It is presently used primarily as an assembly area. for student and professional educational activities. This audi- torium could continue to serve as an assembly area for staff, patient and community functions. It should be anticipated that considerable use Wild be made of it for audio-visual therapy as controlled by the Physical Medicine department. Mscellaneous Areas located at this level would include storage rooms for equipment and supplies, a barber shop, toilet accommodations, and a. " Snack" kitchen which could be situated adjacent to the auditorium. In addition to these facilities a small service room located in the north. Wing would continue to provide maintenance space and a hot-water boiler . Personal appearance, as a strong force affecting the morale of b°th Patients and staff, is recognized as being most important. Pr“vision should be made in this unit for care of the nails, haircuts, shaves, and shampoos for male patients, and for washing, waving, and T’.".—Il’-I‘wdt.~ Mn. 5'2 25 cutting of female patients‘ hair when so desired. Portable equipment should be made available for those patients who are bedridden. It is suggested that a commercial barber or hair stylist be contracted for this purpose or the area leased under specified conditions to a quali- fied individual for such purpose. First F].oor--Acconunodations for Ambulatory and Semi-Ambulatory Patients Fifteen patient rooms could be located at this level. All but three of these rooms would have adjoining toilet and bath accommodations. As indicated by the Patient Accommodation Chart (page 81), these 15 room would allow for a 27-bed patient capacity. The entire floor could be served from one nursing station centrally located adjacent to the library room. A floor scheme, page 53, presents a suggested plan for this level. n The room presently used as a school of nursing library is centrally 10GELI-Zed at this level. This room is attractively decorated and could be used for patient-staff library needs. Few problems would be antici- pated in the actual process of converting this room from its present status as a student library. It could be made equally accessible to those acute patients located in the min hospital by means of the proposed connecting corridor. Adequate lighting and ventilation would be no PrOblem since sufficient window area borders the room. French doors on one side of this room would allow direct entrance to a roof \ ‘ w 25:331.. p. 251.. 53 Figure 3. First Floor T 11 LEGEND One-Bed Room .llllllllll - # '7 Two-Bed Room Lavatory and Closet Area Storage Linen Room Treatment Room Nursing Station Library . Sun.Porch Patient Lounge To Connecting Corridor 10 12. Elevator Kitchenette m H \n m \Om-xl OxU‘urwmt-J H O N H H Ci E1 . Upper Part of Auditorium . Incinerator and Clothes Chute Room . Stairwell oo \0 F‘ e1 0\ v1 Sh terrace overlooking the hospital grounds and Michigan Avenue. Current newspapers, magazines, and approved books could be made available for the convenience and therapeutic benefit of all patients wishing to take advantage of this library's services. A room adjacent to the library could be utilized for eye, ear, nose, and throat treatment. Dental treatment could also be administered here. The room should not be intended for out-patient purposes, but used specifically for those in-patients requiring its facilities during their course of hospitalization. For visual testing a long narrow room directly across the hall could be used. This room is at present being used as a kitchenette. W-Accomodaticns for Bedridden, Isolation, and Psychiatric len s . Most of those patients requiring regular nursing care could be accommodated at this level. In addition to the bedridden patients facilities should also be made available for isolation and psychiatric care. Psychiatric patients would be admitted for diagnostic purposes rather than for permanent, long-term care . A 130";al of 23 patient rooms with a capacity of 37 beds could be made 8‘Vélilable in this second floor nursing unit. The unit should be divided into two sections with a main nurses station and a sub-station, the latter located near the isolation area. Figure 14, page 55, shows a Preposed floor scheme. Flexibility is recognized as an important consideration in planning a . - ' cco"moda‘bions for both acute and chronic patients. This aspect and 55 Figure h. Second Floor \ooo-xl Omt'wmt—J LEGEND One-Bed Room . Two-Bed Room . Lavatory and Closet-Private Treatment Room Nursing Station To Connecting Corridor Stairwell Lavatory Kitchenette . Employee Lounge Bath Tub Room . Linen Room Incinerator and Clothes Chute Room Mental ward Isolation‘Ward Elevator Storage Area 56 the process of grouping patients according to degree of disability is discussed in a subsequent section of this study. Two of the three specialty sub-groups felt necessary for this intermediate-care unit could be located on this floor. They are, as mentioned previously, isolation and psychiatric wards. The suite of rooms suggested for isolation purposes includes 2 rooms which,'according to need, could easily be expanded to include a third room. The rooms suggested for this purpose are located on the south wing of this second floor. They are well oriented for sunshine and natural ventilation. Special consideration should be given to the particular needs of the Patient when selecting an area to be used for isolation purposes. Such accommodations should be apart from the non-isolated areas to minimize any possibility of inter-patient contamination. If, at some future time, complete seclusion of the area proposed in this study becomes necessary, a partition could be easily constructed with access to the ward by means of a door in the partition. In converting the building for patient care purposes, lavatories should be installed to provide for adequate patient hygiene. Such facilities would especially become necessary in areas where chance of contamination and spread of contagious diseases is evident. It follows that adeql-lflte cleaning facilities should also be made available for thoseanployees coming in contact with these isolated cases. The proposed psychiatric ward includes 3 rooms having a 5-bed capacity, One room, a private accommodation, could be used primarily for those patients having violent or incompatible tendencies. The lard should be situated as far from the nuisance of the commercial thoroughfare, Michigan Avenue, as possible. This would be primarily for the benefit of the patient, and secondarily, to minimize unfavorable public opinion. It has been observed that patients with most mental disorders require surroundings devoid of nuisances for therapeutic reasons . The ward area suggested would be located in the north wing in " of this floor overlooking an inner court of the hOSpital grounds. For patient protection bars should be installed at each window in the ward. By locating the psychiatric section in this area, the possibility Li m“ or PUblic curiosity or criticism could be minimized since this location would not be observed by the general public. The primary reason, however, for selecting this area for the use of mental patients iS because 05 its central, yet isolated, location. Acute facilities of the general hOS'pital would be readily available, by means of the proposed connecting Corrier . AS in the isolation ward, a complete lavatory should be installed to accommodate mental patients. Since complete lavatory facilities are Presently available directly below both this ward and the isolation ward: the expense of installing the new facilities could be minimized. Mficcomodations for Semi-Ambulant, Children and Bedridden Patlen‘ts This nursing unit should be planned to accommodate the "overflow" from the other three floors with emphasis on semi-ambulatory patients. 58 A ward for children under 15 years of age could be located in the south wing. The total of 19 patient rooms proposed for this level would allow a. 30-bed capacity. In addition to patient room accommodations, there is presently located at this level a large recreation room. This room could be equipped exclusively for those patients desiring its facilities. It occupies the entire center wing at this level and I includes a small kitchen which would be of sometherapeutic value if maintained under pr0per supervision (see floor scheme, Figure '5, page 59). By placing mainly ambulatory patients in this nursing unit a greater Proportion could be encouraged to take advantage of the recreation room facilities. These patients should be able to spend at least part of 93-011 day on their feet. Most of them, however, would require some degree of supervision or physical assistance. Bedridden patients and Children housed at this level could also be conveniently situated for easy a.<3c:ess to the recreation area. This room and its facilities should be made accessible to every type of patient accommodated in the building. Some inconvenience could be anticipated, however, in transporting patients to this area who might require partial or total conveyance. The childrens? ward planned at this level would present no problem of inc‘flr‘reiltlience because of its nearness to the recreation area. Children unable to transport themselves could be easily carried or wheeled to the room. The south wing at .this level would be adequate as a children‘s ward. This ward , as proposed, would include four rooms allowing for an 3 . . -bed corIlplement. The rooms could accommodate up to 14 additional beds Figure 5 . .IIIIIU " 13 2 1:1» l 8 l s h 12 5 lo 1‘ 9 1 I u 1 I is 1 8 2 3 3 1 2 59 Third Floor LEGEND One-Bed Room Two-Bed Room Storage and Closet Area Treatment Room Nursing Station To Connecting Corridor Stairwell Lavatory Kitchenette Recreation Room Bath Tub Room 12 . Linen Room Incinerator and Clothes Chute Room . Children‘s Ward . Elevator \OCID-NIOUlt’UJNI-J p—w—l t-‘O Lit: 15 60 26 should extra space be required. One survey, Conducted in an Eastern state, indicates that approximately 6 per cent of the total bed capacity in a long-term facility should be set aside for children under 15 years of age. Another survey conducted as a joint program by the Commission on Chronic Illness and the Instructive Visiting Nurse Association of Baltimore, Maryland, verified this percentage. The unit suggested in this study would normally be capable of providing 6. 5 per cent of the total bed capacity for this specialty group. Fourth Flo or—Ambulatory Patients Accommodations at this top floor level should be primarily for those patients who are mentally alert and physically capable of caring for their own personal needs. Since flexibility is important in a. unit Operated for the purpose of patient care, other types of patients could, however, beadmitted to the floor. It is felt essential that care be exerted in screening patients, other than the ambulatory, to this mlrsing unit. One of the main objectives in grouping patients according to degree of disability should be to provide care where it is actually needed, i.e., "skilled mlrSing care" for the bedridden, "personal care" for the semi-ambulatory, and "sheltered care" for the hilly ambulatory and mentally alert. Since fully ambulatory patients umally do not require skilled nursing care this floor could be staffed ‘ 2 Care oSHE-I'li‘iett L. Wilcoxin, "Study of Long-Term Illness Patients Under 68 (J Public Health Nursing Services," Connecticut Health Bulletin, 3 19Sh); 68 (OctOber, 195h). ‘* 9'? 61 primrily with unskilled personnel who should, of course, be supervised by a professional nurse. Patient accommodations at this level would consist of 19 rooms with a. 29-bed capacity. None of the rooms on this floor would have access to private lavatory facilities. As on second and third floors, tm conveniently located lavatories would be accessible for patient needs . These two lavatories should adequately provide for the needs of both male and female patients. A proposed floor scheme is shown on Page 62 . In addition to patient housing at this fourth floor level five rooms in the south wing could be used as lounge space for intern and resident physicians. No adequate quarters are now available for these manbers of the professional staff. For an institution which is con- tim‘allqr expanding and maintains a house staff of more than 20 intern and resident physicians, such consideration would seem justifiable. These Physicians, by means of the connecting corridor, would have comen-1am access to all parts of the main hospital building yet would be Pa~‘t31'1er secluded from the main flow of hospital traffic. Integration of Intermediate-Care Needs with Acute Facilities The needs of chronic and/or long-term patients are complicated by the muCL'tiplicity of ailments or diseases which may affect the chronic- 2'7 type Patient. It has been established that most chronic patients \ T szean W. Roberts, M. D., "Hospital Unit for the Long-Term Patient," he Modern Ho ital 83 (September, 19514), p. 68. Figure 6. —4 F_— 13 2 2 y 8 /s—“ 2 9 2 II .- .- 10 l l 4. 0- ll 2 2 5 7 _¥ 6 L '2 2 12 1 3.3 D 1 p ‘r—J xm 1 ‘\ , 3 lo 2 u_\ t 5 \ 3 3 1 h 62 Fourth Floor LEGEND (he-Bed Room Two-Bed Room Intern Quarters Patient Lounge Storage and Closet Area Nursing Station Treatment Room To Connecting Corridor Incinerator and Clothes Chute Lavatory 11. Bath Tub Room Linen Room Stairwell Elevator O O O CD-flChUIR‘UNQ-J O H O\O EEK; 63 can. be treated best under the auspices of a general acute hospital with its technical and scientific orientation.28 Problems are expected to exist in organizing and maintaining adequate integration. Many of these same problems would, no doubt, prevail in any given hospital Situation without regard to type of service rendered. A broad range of institutional services would be necessary in order to provide for the cOmplete requirements of the long-term patients. Unless these services are gauged for both acute and chronic care, Hanna-um effectiveness in caring for the chronically ill patient cannot be achieved.29 Adequate integration of services would depend, to a large extent, upon a basic understanding of the needs of the intermediate- care patient. A patient admitted with a chronic disease diagnosis would require, not only those services commonly available in a general hospital, but additional facilities as well.30 Ehcainples of these additional services include comprehensive dental care, intensive social service casemrk, PWSical medicine, religious ministry, vocational guidance, and rec’3'1‘eational therapy. Provision for such service should be anticipated in Planning for the complete integration of acute and chronic care facilities. It should be expected that patients accommdated in this inter- medlate-care unit might be subject to episodes of acute illness or \ g _ 28th Cherkasky, M. D. "The General Hospital is the Place for the Care of the Chronically Ill," The Modern Hospital, 79 (July, 1952), 1313- 98, 100, 102. 29Roberts, __p_. cit. 3°Leonard A. Scheele, M. D. "New Opportunities for PWg Heflth Facilities, Hog. 1138.18, 30 (MBICh 16, 1956), p. 38. exacerbations of their chronic conditions. Such conditions would require facilities of the general hospital. By proper integration of chronic facilities with acute services a readymade means would be available for accurate diagnostic evaluations leading to a definitive diagnosis. From such evaluations an appraisal of the potentialities for rehabilitation could be accomplished in addition to services 31 required for treatment. It is evident then that proper service at the proper time should be the prime objective in maintaining a smooth f“Incisioning program of service integration. Those services involved in this problem of integration may be ‘ listed as follows: 1 . Physio-therapy- 2 . Occupational Therapy 3. Medical Social Service h . Dental 5. Eye,.ear, nose and throat 6 7 8 9 . Nursing . Dietary . Pharmacy . Laboratory 10. Electrocardiography and basal metabolism 11 . Outpatient clinic 12. Outside service groups, i.e., visiting nurse association, and various welfare agencies. These services would, for the most part, comprise the nucleus around Which should evolve the entire program for the integration of medical service. Coordinating efforts of the various services should result in & Well-integrated program consisting of periodic diagnostic re- mllations of the patient' s condition, treatment, and rehabilitation \ V V . _ vi 3J-Roberts , 93. cit. mans-walla?» 5.. 17;.-. r. n c . 65 progress. In essence, continuity of patient care would be the result of such a program if properly administered. Continuity in care is considered important to the patieht‘s health and his well-being. It may be even more important to his feeling of security and his emotional health. With continuity of patient care canes functional Specialization. Provision for specialization of facilities in this unit should. not be carried beyond the point of absolute necessity. At every point where separate personnel or services must be used, provision should be made ’00 a-Ssure a smooth transition for the patient from one facility to another . The fewer changes that a patient must make throughout the entire period of his diagnosis, treatment, rehabilitation, and care, the less suffering he will experience, the fewer duplications and gaps "11]- exist in services, and the lower will be the total cost. of provid- 32 ing Adequate. care . Recreational Therapy Facilities Recreational therapy activities should be provided in this unit for 85L2]. three groups of patients-«ambulant, semiambulant, and bedridden. These activities should be in conjunction with the Dapartment 01' Phys-“3&1 med"‘~(3'-'Lne. Supervision for these activities would be delegated through the c3hief of Physical Medicine to a committee assigned specifically for this purpose. This group should be held reSponsible for coordinating \_i __. 32Nicholson, 22. git” pp. 314-37- 66 prescribed patient recreational activities according to prearranged schedules in cooperation with the nursing staff. Those who actually administer this type of therapy may well be members of a volunteer group under the direct supervision of a pro- fessionally trained individual. The Ladies Auxiliary of Sparrow'HOSPital is especially designed to provide service of this nature. The entire recreational therapy program, it is recognized, could not be placed in the hands of volunteer groups. Nevertheless, with proper supervision, many of the activities could be handled by voluntary workers. The following types of therapeutic activities are suggested for incorporation.into the overall program of recreational therapy: Radio and television Library and bed-side reading Music Mbvies Religious functions Lectures Public visiting Game area (inside and outside) Outdoor areas for sitting, walking, watching traffic, etc. Barber and beauty shOp Canteen HOWCIDNOUIJI’WNH rer The activities outlined present a diversification of activities in which any patient, depending upon degree of disability, would be able to participate. For the purpose of recreational therapy several locations may be considered. The entire center wing of the third floor, as previously mentioned, would alloW' ample room for games, visiting, television, radio, musical activities, etc. The room is at present being used by the student nurses for similar activities. Conveniently situated off 67 the room is a small kitchen which, as previously mentioned, could be made available for patient use with proper supervision. An air-conditioned auditorium, as described earlier in the study, is located at ground level. The auditorium is accessible from the main lobby by two French doors. Capable of seating approximately two hundred persons, this room would be adequate as an assembly area for religious, secular, and staff events. An attractively draped stage enhances the value of the auditorium for diversified activities. The patient-staff library, centrally located at first floor level, is another area which should be utilized for recreational therapy. This library could provide literature on a loan basis to those patients requesting reading material. An experienced librarian could be secured ’00 act as coordinator of the library program. The library is presently in Operation and maintains a lending status with state and municipal Wblic libraries. This arrangement could be continued. For the con- Vmience of the staff as well as the patients current popular newspapers, maga-Zines, and books should be made available. Other areas within the building which could be used for purposes of recreational therapy include patient lounges on first, second and fourth floors, a visitor lounge at ground level, and an occupational therapy section which is proposed at ground level. Recreational facilities outside the building would also be quite adecimate for the needs of the patient. The main hOSpital grounds offer an interesting and pleasant atmosphere. Benches could be made available at atarategic locations for those unable to take advantage of walking 68 over the grounds. To the rear of the proposed intermediate-care unit an enclosed tennis court has been constructed. This court would allow ample space for outside games and sumling during the warmer seasons of the year. Direct access to this court could be had from the building by way of a rear door adjacent to the location suggested for the physical therapy section. Another form of therapy concerns personal appearance. Since Personal appearance is a strong force affecting the morale of both Patients and staff, provision should be made at ground level for a barber-beauty shop. The area designated for this purpose would be equiPPEd, decorated, and operated like any other small commercial barber Shop or beauty parlor. This service'could be made available to all Patients admitted to the hospital. For patients capable of controlling their own activities and who are able to be up for extended periods of time, many community services Should be made available. Both Protestant and Catholic churches are Within close proximity to the hospital. A shopping area is only a Short, distance away. Other local activities could occasionally be made available for interested patients. TranSportation should, from time to time, be provided for those interested in certain activities 8pm'13<>3:‘ed at Michigan State University. Cultural programs such as those Soheduled in various lyceum courses would be of considerable theraI’e'utic value to many patients. 69 Service Department Facilities Many of those services which appear to affect the patient only indirectly, such as maintenance and housekeeping, are actually quite essential to the . over-all program involving total patient care. From this it is apparent that in contemplating the construction of a new hospital unit great care should be exercised in planning for lay-out, equipment, and those facilities upon which the effectiveness of the unit depends. This is equally true in adapting a building for a use other than that for which it was originally intended. In addition to careful planning of physical layout, substitution and improvisation becomes important. As with the conversion of this building, the establishment of various facilities and services become altirely dependent upon the existing physical layout and available facilities. Because this building" was originally constructed as a nurses residence only a minimum amount of major remodeling would be necessary in Preparing it for its proposed use. With the construction of a connecting corridor, duplication of service department facilities could be practically eliminated. Essential services such as laundry, house- keeping , food service, maintenance, medical records, and others could be centralized in, and controlled from, the main hospital building. N° service department need be duplicated in the proposed unit.» The incremsed bed capacity would rake it necessary to have additional persormel in some departments while in other departments no appreciable immase Would be necessary. 7O Entrance and Exit Areas In addition to the min entrance leading to the lobby, two other means of entering and leaving the building at ground level would be available. The front or main entrance is located at the front center of the building. At the present time this entrance is well lighted, attractive, and easily reached from the visitors' parking area as well as from the main thoroughfare. A second entrance at this level is located at the north end of the building. This could suffice as a SerV‘ice entrance as well as a patient admitting entrance. From this door an open passageway would lead to the main hospital building. Directly above and serving as a. roof for this passageway would be the Proposed connecting corridor. The third means of entrance to this ‘ unit would be thedoor, mentioned previously at the rear of the bufl—ding adjacent to the proposed physical therapy section. On each of the four proposed patient floors would be three methods 0f entrance or exit. At the north end of each floor access could be- had to a stairwell leading to the ground level and outside entrance. An elevator would be available toward the center of the building. Another stairwell located to one side of the elevator would also be am’esaible. All modes of exit or entrance in the unit would be well lighted and strategically located for mimum convenience and safety . W Adequate storage facilities for both the patient‘s personal belongings , and hospital equipment should be carefully analyzed. 71 In addition to drawer space and closets for clothing and other personal items used regularly by the patients, a central storage area should be considered on each floor as a convenience to all concerned. Trunks, off-season clothing, and other possessions brought to the hospital by patients should be placed in these rooms and identified for safe- keeping. To minimize storage problems, each patient should be encouraged to bring to the hospital only those personal articles essential to daily use. In addition to centralized patient storage at each floor level, an area should also be designated for equipment storage, i.e., wheel Chairs , stryker frames, apparams, etc . Storage facilities for other than routinely used supplies should continue to be maintained in the min hospital storeroom controlled by a central supply clerk. Any S“PFC-Lies requisitioned from this central supply room should be placed in maligned shelves or closets until put into circulation. Adequate Storage shelves and closets should be available to each nursing unit for this purpose. All of the departments represented in this proposed unit Should be provided with sufficient storage facilities according. to their needs . Food Service Food, service to this intermediate-care unit could be provided from the Central kitchen and cafeteria. The dining and kitchen facilities located at ground floor level in the main hospital building could, upon 00114318131011 of the present building program, provide adequately for the 72 needs of the pr0posed unit. A recent addition to the dining area, doubling its space, has greatly increased the seating capacity. An additixni to this department was purposely planned with expansion of patient accommodations in mind. In the very near future a completely :mnvkistchen is to be constructed concurrently with the construction of an 106-bed acute wing. These new and considerably enlarged. food service facilities are to be constructed with even further expansion of patient accommodations in mind. From this projected expansion program it is evident that food service for patients who may be housed in the inter- mediate unit would be of minor concern. at ]portion of the dining area could be designated for patients who are “fibulatory. Consideration should also be given to scheduling of Patient meals so as not to coincide with the main flow of the employee mafl-E16nriods. This.presents no real problem'but should require some degree of control. Those patients who would be unable to take their meals in the dining area should be served in their rooms. Heated carts, as presently “59d fiairjpatient food service, could also be utilized in.conveying warm bed tn: the unit's patient areas. For the purpose of uniformity in procedhlnre the same food service system presently in use should be continued for patients in the new unit. The procedure is basically as 1.0110513 : 1. All food prepared in central kitchen 2 . Patients' food preference acknowledged 3. Cold food placed on individual trays and conveyed on cart to patient area .Hflnllulflii zit}! . j 73 )4. Warm food placed in heated cart and conveyed to patient area 5. Warm food placed on prearranged individual tray and served 6. Special diet trays prepared entirely in the special diet kitchen and transported directly to the patient in "meal pack" containers 7. Beverages served directly from portable thermos containers. All food for patients in this unit would be conveyed by elevator directly to the patient floor in the main hospital. From this area the carts would then be tranSported by way of the proposed connecting corridor to the corresponding floor in the intermediate-care unit. This process would be both convenient and. efficient since the proposed connecting corridor muld enter the main hospital adjacent to the h-bank elevator area presently under construction. Administrative Facilities The administrative functions of this 1mit should not be separate from those corresponding areas of activity in the main building. Final responsibility for this unit should rest with the parent department. Since the departments represented, in this unit would be autonomous With those of the main hospital, little duplication of facilities or personnel should be necessary. Functional control of the entire unit- could be directed from the min administrative offices. In actuality, this unit would be treated simply as a closely integrated wing of the main hospital plant. AdMission and discharge of all patients in this unit should be accomplished through the main admitting offices. The same would be 7h true of ancillary services required in providing for patient care. Medical records should also be processed in the same manner as they are now processed and through the same offices. The medical records section is scheduled for relocation in the present building program as are some of the other departments. The new location assigned to this section should be sufficient to allow for adequate work and storage area in view of any future hospital expansion. Other administrative space should be provided in this unit. For the convenience of patients housed in the unit and their relatives, one area should be set aside for interviewing purposes. This room should be accessible from the main lobby of the unit. The main office of the unit, as pointed out previously, could be situated to the left 01' the front entrance. This location would be directly accessible from the main lobby. Administrative Space for the department of PhyBical Medicine, as previously mentioned, would also be located at ground floor level, but adjacent to the physical therapy section. Throughout the entire unit it may be assumed that the Ladies Guild, 8° vOlunteer group, would continue to carry on the program which they now S"Donsor. The reception area could be partially staffed by these ladies . Their services should also be solicited for the library, (Ruffian and recreational program. Because of the type of patients anticipated in this unit, considerably more of those duties usually perfOI‘med by professional personnel could be accomplished through volunteer groups . 19' - \1 Ln The Nursing Unit Nursing units for care of the long-term or chronically ill patient should ideally range from 20-30 beds.33 As shown by the Patient Acconn'mdation Chart, page 81, the suggested number of patient beds per nursing unit in the proposed intermediate-care facility would range from 27 to 37 beds. On the second floor (37 beds) the nursing unit could be divided into two sections to comprise a main nursing station and a sub-station. The sub—station on this floor would then provide service primarily to those patients accommodated in the proposed isolation area. In addition to the isolation ward, care could also be rendered from this sub-station *0 8llrrounding rooms assigned to the station. In breaking down the Patient load of this floor into two sections the number of beds for one Section would then fall well within the range as suggested above “1th 23 beds. The other section, a specialty area, would provide care to a madman of 11 patients. On each of the other three floors (first, third and fourth) only one nursing station centrally located should be provided. From this station the entire floor could be adequately controlled. Each nursing Station should be equipped to care for those types of patients to be 8‘c‘mmltlodated on the floor. Grouping of patients according to degree of disability and assigning each group to a specific area would be a unique feature of this patient care unit. \ 33Ibid., p. 227. Logically it would seem most expedient to house the more ambulant type of patient at progressively higher levels. With this in rind the bedridden patient would be accommodated at the lowest patient level. For practical reasons, however, the lowest patient housing level in this unit is suggested for the antmlant or semi-ambulant patient requesting more luxurious accommdations. On the first floor all of the rooms except three private rooms would have direct access to lavatory facilities. The three private rooms without lavatory facilities would be in close proximity to joint toilet facilities thus presenting no inconvenience to the patient. ;_ An outside porch would also be available from this level as would be the Patient library. In addition to these conveniences, the entire corridor floor could remain carpeted as it is at the present time. Rooms at this level are also carpeted. Obviously the bed-ridden patient, unable to control his activities, could not take advantage of such faCilities . These facilities are presently available at this level and could remain intact for the convenience of patients. The facilities of the other three patient floors should be equally adequate and conveniently located for the patients! benefit. Unless additional lavatories are installed, only three rooms on the second floor “Onld have direct access to private facilities. Those patients without, direct access to private lavatories at the second, third and fourth floor levels would use one of the two joint lavatories available at each level 77 The nursing stations on the floors would require some attention in making them suitable for their intended purpose. Adequate shelving and cupboard space should be installed for storage of equipment and supplies. Each station should also have access to running water and refuse diaposal facilities. Other equipment such as desks, chairs, chart racks, etc., should be installed for the convenience of the professional staff . Segegtion Closely allied to the concept of patient grouping according to degree of disability is the problem of segregating senile patients from those who are mentally alert. Segregating those who might possibly be rehabilitated from those who cannot be rehabilitated. And, of course, segregating according to sex. As previously stated, patients with a marked psychosis should be admitted to the mental ward only on a diagnostic basis. Senile patients who present no symptoms indicating potential danger to themselves or to others could be cared for in the same facilities with other elderly or chronically ill people. In this unit certain rooms my be designated for those senile patients, who from time to time, could not be placed side by side with those who are mentally alert. However, no specialized area would be necessary for the purpose of, senile patients alone since the purpose of this unit is not that of providing care solely for the geriatric type patient. An important factor to consider in segregation might be the desir- ability of a separate unit for those who could become rehabilitated. 78 A separate unit for this type of patient is, however, not generally adVisa.ble.:34 Such a section separated for rehabilitation might imply that only certain patients should receive rehabilitation services. Those patients housed in other sections of the institution it may appear, would not be worth rehabilitating, thus being destined topurely custodial care. Patients admitted to this building should be assigned to the different nursing units on the basis of the kind and amount of care which they may require. Within the mirsing unit these patients should then be assigned to rooms on the basis of their personalities and congeniality of interest. In most instances the age differential must be carefully considered prior to room assignment. It is the ' observation of this writer that compatibility of patients assigned to one room is of paramount importance in a hospital situation. This fact would appear to be even more important under long-term circumstances. AS a. result of such considerations, administrative problems concerning Patients could be expected to be minimized while concurrently increasing Patient susceptibility to rehabilitation. Segregation according to sex is an important factor which must be considered for the benefit of the patient. For the convenience of those patients cared for in this unit segregation according to sex of the ambulant and semi-ambulant patients capable of providing for their “’1‘ Personal hygiene should be favored. Bedridden patients should also be accommodated according to sex. \ fl 34Ibid., p. 233. Nursi_ng Unit Corridor Corridors throughout any hospital building should be well lighted and attractively decorated. The homelike atmOSphere and general appearance of the corridors in this unit would necessitate a minimum amount of remodeling or redecorating. On each floor the main corridor, running the length of the building, is 9' in width. Corridors in the three wings extending to the rear of the building are 6‘ wide. One authority:35 states that an ideal measurement for hospital corridors varies from 7‘6" to 8’0" in width, and in addition, suggests that doorways to patient rooms should ideally be 3'10" wide. In this unit all of the doorways are standardized at 3'0" in width. Considering the benefit which would be derived from enlarging each doorway the estimated cost of approximately $2.00 each seems prohibitive. To confirm the possibility of transporting a patient by standard stretcher into a patient's room, a test was made. A standard stretcher used for transporting patients was wheeled from the 6' corridor through a 3' doorway into one of the typical rooms designated for patient accommodation. No particular inconvenience or obstruction we encountered in the process of this experiment. A question my be raised concerning the use of carpeting in a unit such as considered in this study. One authority:36 suggests that carpet- ing and/or rugs be limited in use to a library or parlor. By using an 35Committee on Designing, Constructing and Equipping of Public Hoopitals in Canada. A Guide to Hospital Building in Ontario, University of Toronto, 19514, pp. 2376, 257. 3E’Ann Friend. "Carpeting Long-Term Facilities ," Hospitals, 30 (May 1, 1956), p. 2b. 80 attractive synthetic type of flooring in halls, the expense and hazards involved in the use of carpeting would be eliminated. Asphalt tiling could be used to replace the carpeting on all of the corridor floors. Because of its relative durability, cleaning qualities, and original cost (approximately 20;! per square foot, installed) this type of flooring is suggested as being the most practical for the intended use. Other types of tile should also be considered and compared price-wise. Ceramic tile is currently priced at $2.75 per sq. ft., installed, and rubber tile at 75¢! per sq. ft., installed. From this a comparative cost figure could be reached bearing in mind the relative durability and practical aSpects of each type of flooring. Installation of handrails throughout the patient corridors could be expected to serve a dual purpose. In addition to the patient safety factor involved, such handrails strategically located and at a height convenient for patients to grasp easily would encourage self-rehabili- tation on the part of the patient. Handrails could also prevent damage ’00 walls and bases resulting from frequent bumping by wheel-chairs, stretchers, and various other forms of equipment. Patient Rooms It is recommended” that a minimum of 100 sq. ft. per patient bed he allowed in patients' bedrooms with at least a 3'0" clearance on each side of the bed. In rooms housing more than. one person it is also I‘ecmumended that 6'0" or more be allowed between beds. With these _¥ 3'7Nicholson, 92. cit., p. 209. recommendations in mind, a suggested Patient Accomdaticn Chart for this proposed unit is shown in Table 3. TABIS3 PATIENT ACCG'Q‘IODAT ION CHART floor 4:. I II III Iv v f Ground Ambulant Bedridden Semi-Ant) . Anbulant To tal Semi-nib. and Chil. 1. Bed Capacity - 27 37‘5L 3o 29 123 2. No. of Rooms - 15’ 23 l9 l9 s 76 A 3. l-Bed Rooms - 3 9 8 9 29 fl h. Hulti-bed Rooms - 12 11. ll lo L? 50 SpeCial - ." Sb he ~"' 9 _‘ aDivided into two nursing units bIsolation - 2 rooms; psychiatric - 3 rooms cChildren's Ward - 1; rooms As indicated in this table, patients could be accommodated in L7 multi- bed rooms, and 29 private rooms located on the first, second, third and fourth floors. Sufficient storage space would be available for personal items within each room. In addition to closet and drawer space allotted each patient, a central storage room, as previously pointed out, should also be made available at each floor level. Patients wishing to nake use of this facility could be assigned a cubicle for their own personal belongings . (n Ix) 'lding Facilities and Proposed Ramdeling Flaming the conversion of this building for long-term patient care necessitates careful consideration of the needs of those individuals who my utilize its facilities. Even though the building in its present condition is remarkably well constructed for relative ease in converting for long-term use, certain factors should be considered in adapting the building for its intended purpose. Traffic-flow would be an important aspect contributing to the efficiency of such a unit. The building being remrkably well laid out, should present no real problan in this respect. With wide corridors throughout the building, stairwells at the end of each main hall, a building elevator, and direct access to a bank of four elevators in the 1min hospital building, both vertical and horizontal traffic would be provided for adequately. Location of stairwells merits special consideration. The stairwells in this building are conveniently situated. Constructed at the north end of the main corridor on each floor is a stairwell. The other stair- well, also extending to the top level is located next to the elevator shaft toward the middle of the building. These stairwells are presently PPOVided with several safety factors. The steps are constructed of non-slip material. Handrails are also installed. At the entrance to each landing are exit lights clearly indicating the location of the Stairs. Both stairwells are adequately lighted and well constructed for safety . g, 83 ConnectgniCeridor To allow direct passage from this proposed intermediate-care unit to the main hospital building, a S-level connecting corridor should be constructed. For direct passage from the front parking area to the emergency suite, now under construction in the new wing, it is sug- gested that this connecting corridor at ground level be designed as an ,T Open breezeway. This in effect would allow direct access to the . emergency area without entering the hospital building. The five-story corridor should be constructed in harmony with the over-all hospital design. It should also be constructed of reinforced Steel with brick facing. As noted on page 37, the corridor would enter the new wing of the min hospital adjacent to the bank of elevators. One room would be elinulnated on the north-east corner of the intermediate-care unit at 35011 level to allow for adequate passageway into the unit. A151 architectural firm, 0. J. Munson, of Lansing, Michigan, estimates the cost of constructing such a corridor between the two buildings at $16 Per sq. ft. of floor space. The distance between the two buildings is 17'0", and the width of this proposed corridor would be 15'0". Total Square feet, based on tr; stories (open ground floor), would be approxi- Mtely 111;? sq. ft. From this an approximate total cost of $18,352 would 1'-’e sult . W At present one elevator is being operated between all floors of the Proposed patient unit . It may be assumed that the main traffic 81: Load for this unit would be taken care of by a bank of four elevators, to be located in the new lOé-bed acute wing. The unit would then be accessible by way of the recommended conrmecting corridor. Cost for complete replacement of the present elevator in this unit by a larger standard size hospital elevator would appear to be prohibi- .. tive, approximately $35,000, as quoted by the Otis Elevator Co., I E Lansing, Michigan. Remodeling of the present elevator could be accomplished at a cost of approximately $20,000. The elevator, after remodeling, should be automatic with a self- ‘ I leveling device in addition to fully automatic closing mechanisms. _ ._‘ It should be adjusted so that its operation could be maneuvered slowly and easily by disabled patients. Special safety devices should also be installed to avoid danger should a patient operating the elevator become confused or frightened. Under normal circumstances, it should be capable of lifting 1800 lbs., rising 200 ft. per mimlte, and transport- ing a capacity of 12 people at one time. use Only limited use of ramps should be considered in this unit. Placement of some ramps at strategic locations is most important and Shun-d be considered. Although only two ramps are suggested for con- atmetalion in the entire unit, these two ramps are considered a very nece"Wary convenience for the disabled and wheel chair type patient. Without a ramp it would be necessary for patients wishing to take Gui“flirt-age of the tennis court recreation area to walk up a h-step incline and then down another h steps to the outside area. 85 A ramp should be constructed at such a point for the'benefit of those patients who might have some difficulty in maneuvering the steps. Another ramp should be constructed just outside the front entrance. At this point entrance is trade by descending two steps to the front door of the unit. The steepness of incline or decline should be carefully considered in view of the types of patients using the ramp. An incline or decline, in excess of 5 degrees, should be avoided. V .Nlli'ses ' Call System A nurses' call system identical to that now in Operation in the main hospital should be installed in this unit. The present system W “39d in the main hospital consists of a locking button type calling Station located at the bedside of each patient. When Operated a dome Corridor lamp station immediately lights up. Concurrently with the mmination of this dome light another light appears on the nurses? call annunciator in the mirsest station. 'The anmmciator is designed for use at the nurses! stations to indicate to a nurse the room or bed caill—us. In addition, a mild toned buzzer gives audible notice of the call and may be silenced simply by touching a switch mounted at the 13°th of the annunciator . , In each patient lounge a wall station should also be installed . This type of station is commonly used in solariums, lavatories, and lounges, where no cord set is required. The station should be equipped "1th the same push mechanism as is used in the cord type bedside station. EQCh lavatory should also contain an emergency call mechanism. 86 Reasons for proposing this type of system over other systems investigated (centralized radio system and centralized television system) are as follows: 1. For the sake of uniformity throughout the hospital 2 . Comparatively low original cost 3. Low upkeep and maintenance cost )4. A simple but yet effective system 5. Relative ease of installation. For technical details concerning this system the reader is referred to Edwards and Company, Inc., Norwalk, Connecticut. The Barker-Fowler Electrical Company, of Lansing, Michigan, submitted an approximate cost to include installation of the system in this unit. The projected cost of approximately $11,000 compared favorably with two other contractors quotations submitted on a similar system . Lil scellaneous Facilities Many of those facilities essential to the operation of a hospital unit are presently provided in this building. Facilities such as incin- erator, laundry chute, fire alarm apparatus, telephone service, and utility rooms are a few of those items already available for effective oPeration. Other services common to an acute general hospital would also be readily available to this unit, i.e., maintenance service, 1% service, linen supply, garbage disposal, central supply, and general storeroom . 8? Staffing-~Professional and. Non-Professional Personnel It is expected that one resident physician and an intern could adequately supervise the care of 122 long-term patients, assuming 100 per cent occupancy. This may be compared to the usual ratio of one intern to twenty-two patients on the acute medical-surgical wards of the general hospital. I Personnel needs of this unit could be expected to vary from time to time depending upon the types of patients admitted and the amount of care demanded. Other factorswhich would also affect the ratio of . Personnel to patients are: kind and amount of labor-saving equipment PrOVided, the adequacy of selection and supervision of employees, and the quality of persons employed. It is felt that a minimum number of fu-11~time professional nurses WtMild be required for this type of care. Consequently a higher ratio of Practical nurses and aides to professional nurses could be selected in caring for patients admitted to this unit. Based on a 90 per cent occupancy (100 average daily census) the projected ratios shown below are considered adequate by the writer in reflecting the staffing needs of this proposed intermediate-care unit. TABLE h PATIENT-STAFF RATIO \ - \ r—r—r w __._:—‘ r W *7 ‘ fl Number of \ __ _ __ __ Ratio m Personnel Patient-«professional nurse 13:5 9 Pa‘tient-ipractical nurse 5:3 23 P;“tifnt-aide and/ or orderlies h : 9 25 88 These ratios allow for days off, sick leave and annual leave. They include all personnel assigned, exclusive of supervisors. A hO-hour week, 8-hour day is assumed. A general nurse supervisor, an assistant supervisor, and one relief supervisor would be assigned to the over- all supervision of the unit. It is this writer‘s Opinion that, exclusive of nursing service r personnel, the percentage of additional employees necessary to the successful operation of the other departments would at the most not - I exceed 15 percent of the present employee load. CHAPTER VI FINANCIAL RESOURCES AND COST ANALYSIS It is impractical within the scope of this paper to go into the details of the complex problem of financing the cost of establishing an intermediate-care unit and provision for continued income for operation. Nevertheless, some basic consideration should be given to such an 1J'IPOI'tant aspect in attempting to justify the establishment of such a pro gram in conjunction with this general hospital. In being realistic concerning the concept of establishing an i1'1“;ermediateucare unit in a general hospital it is apparent that the intivating interest stems from the desire to provide a more complete health program for the community. Yet, one other motivating interest can-net be taken lightlynthat of greater economy in cost per patient- day. Consideration of these two motivating interests has a dual effect. Both the community and the hospital reap the resulting benefit of decreased cost of hospitalization and increased health care. The cost factor involved in the establishment of a new medical facility, second only to the values derived from its effectiveness and prud'I-lcztivity, becomes most significant. Cost is of great importance throughout the entire process of planning developing, and operating a facility as proposed in this study. 89 90 Source of Funds Several means of acquiring financial aid for the converting of this building to the needs of intermediate care should be evaluated. 1. Federal aid through the Hill-Burton program 2. Public contributions 3. Legacies h. Operating surplus 5. Loans 6. Foundation or industrial grants. These and other sources should be exploited in an effort to accumulate Sufficient funds. For each source the availability of funds would undoubtedly be contingent upon the hospital's ability to meet certain requirements. These requirements should be investigated and discussed in detail to determine eligibility. Estimated Costs The figures below show a cost estimate for converting at current Prices. It is highly probable, that, as the time approaches for definite °°8t comments, the final total would be higher than that shown. The Same Day be said of projected operating expenses, should the establish- ment or this unit be realized. Continually rising costs rendera pm-jetrted cost analysis worthless, except as it provides a guide at Var ions stages of the planning process. 91 TABLES CONVERSION COST ESTIMATE l. Modernize elevator $20,000 2. Nurses" call system 11,000 3. Connecting corridor . 18,500 14. Assphalt tile for corridors 962 5. Nknvable equipment and furnishings 16,000 r”“ 6. Original inventory of supplies 11,000 I 7. Reserve to cover initial operating deficit 13,500 8. Miscellaneous expenses 10,000 Total 3 100,962 Wtion of Cost Estimates r 1. As estimated by the Otis Elevator Co., Lansing, Michigan 2 . As estimated by the Barker~Fowler Electrical Company, Lansing, Michigan 3 . Estimated at approximately $16 per sq. ft. for approximately 111;? sq. ft. of area-Munson Architectural Firm, Lansing, Michigan , )4. Estimated at 20¢! per sq. ft. (installed) for 1:812 sq. ft. Installed on first, second, and third floor corridor halls only 5 . Estimated cost of furnishings and equipment needed in addition to that which would be moved in from the East Unit. Most of the furnishings now used in the rooms of this domiciliary unit could continued to be used for patient purposes. 6 . Includes estimated initial costs of towels, sheets, medical supplies, and other items ready for use upon admittance of the first patient. 7 . To cover initial deficit due to low occupancy during the first three to six months of operation. 8. To cover costs of additional lavatories, ramps, a partition in the present lounge area, moving costs, and any additional insurance required. 92 Operating Bud get Ikljprojecting a budget for the operation of the proposed inter- mediate care unit the relationship between quality and cost is emphasized. To sacrrifice good care for low total costs does not seem reasonable. Yet a facility serving only those patients requiring non-acute care should operate at lower costs than one serving the seriously sick or acute purtients. Good care should not be sacrificed, for the amount of care provided should be determined directly by the amount of care required. Ekhna Nicholson suggests in her book, Planning New Institutional “Facilities for Long-term Care,38 five factors which influence operating °°3t3o These factors are: JJ) The kinds of patients accepted for care, with.particu1ar reference to their physical condition, mental alertness, and the amount of service required. 2) The standards at which the services of the institution are maintained. 3) The location of the facility as this affects wage and price levels. )4) The adequacy of the building and equipment as these influence the efficiency with which the necessary activities can be maintained. 5) The competence with which the institution is managed and operated. With these factors in mind a proposed operating income and expense budget is distributed among the various items as shown below. \ 38 id., p. 339. M TABLE 6 INCOME AND EXPENSE BUDGET—FIRST FISCAL YEAR ._ -_. .-.__ -.i .--.--———-—_.-_~-_.—_— _.-.-.~ _- --—.- —————~_ ~ 93 Approximate Per Cent "”1. From patients' fees 3385,1040 99 2. Miscellaneous IMOOO 1 ‘- Total ' 389,uh0, 100 3. Deficit covered by Reserve 13,110 _ Total $h02,550 " ”2 ems. - (Based on normal fiscal year at 80% occupancy) 1:. Payroll . 277,900 67 5 Food Sumplies 59.550 1h ~6. Plant maintenance and operation: Heat, light, power 11,000 Laundry 10, 000 Maintenance, repair 10, 000 Water and gas 1:000 , 32,000 8 w ‘ 7. Drugs, medical and . nursing supplies 25,000 6 8. macellaneous 20,550 J h15,000 100 9. Less 3% to allow for - 12 ,hfio ' initial period of low occupancy Total $h02,550 9h Explanation of Budget Items 1.. Patient Income - Based on an average $12 per patient day at an anticipated first year occupancy of 72 per cent. Includes both in- patient and out-patient fees paid either by patients and their families from their own resources, or on behalf of patients by welfare agencies and others. 2. Miscellaneous Income - Includes income from vendor machines, barber and beauty sh0p, and funds received in the form of contributions and income from endowments . 3. Deficit Covered by Reserve Fund - This deficit would be provided from the reserve set up in the original Conversion Cost Estimate- Reserve to cover initial operating deficit. )4. Payroll - Based on a normal 80 per cent occupancy. Adequate Personnel coverage must be maintained despite the anticipated low daily c’ensus during the early part of the initial year. Estimated Payroll Average Annual Total Number of Wage or Salary Annual 2213:3393 Employees iate Cost R- Nae - Supervisor 3 $3,600 $10,800 3 Nds - General and Head Nurse 9 3,360 30,2h0 I‘3-(3ensed Practical Nurses 23 2,760 63 ,h80 Aides, attendants, and orderlies 25 2,520 63,000 lel‘ks 7 2,6h0 16,h80 HouSekeeping (janitors) ll 2,1.00 26,1400 P Ciel Service 2 11,200 8,1400 haraio and Occupational therapists 6 1.550 27,300 Intern 1 3,600 3,600 Others (i.e., X-ray, laboratory tSChnician dietary and laundry help, etc .3 v {81300 Total 3 277 p900 95 ”above payroll estimates are based on the average rates paid, as of ” 1 1, 1957. "Other" payroll is based on an approximate 10 per cent total annual payroll of departments other than those listed. l 5. Food Supplies - Includes raw food costs and supplies at 56¢ patient meal, and based on 80 per cent occupancy. Does not include r costs involved in food preparation (106,215 meals at approximately ‘1 per meal). 6. Plant Maintenance and Operation - These figures are based upon gflle net operating experience of the building as a domiciliary unit. - ~= . criate adjustments are made to compensate for anticipated additional J’ 1“ ... es. 7. Drugs, Medicines, and Nursing Supplies - Based on approximately Per cent of total budgetary expenditures. ‘I 5 8. Miscellaneous Expenses - based on approximately 6 per cent of i‘ " “ m budgetary expenditures . 9. It should be expected that during the early stages of operation 0-- 17"": occupancy of this unit would be somewhat below normal. Due to this :1" Occupancy the cost of operation would also tend to be less than ‘1 1y anticipated, however, not in direct proportion. Most expenses ’ be expected to remain fixed while others tend to vary with 1:“ hinge of occupancy. The relationship between anticipated cost and quality of care is . 1 whasized. As stated by one writer, the most economical care is Lt which returns a person as quickly and as fully as possible to the ' 1 39 ;" - '- 5+ attainable state of health and social effectiveness. .‘ mobert L. James, "Factors for Consideration In Establishing A and Geriatric Unit in a General Acute Hospital ," Unpublished mitosis, Northwestern University, 1955, P- 26- CHAPTER VII CONCLUSIONS AND RECOMMENDATIONS 1. This study presents an approach for one community to the problem of providing adequately for the needs of the chronic patient. As a pilot study it may be of value to other communities faced with a similar health care problem. Although but one small part of the national scene this one community could well serve as a prototype for others who have 8- growing concern over future health care needs. 2. Chronic illness is the challenge of our time. Those individuals responsible for the health needs of the community must recognize this in Planning for total health care. 3. As the population has grown progressively older, chronic disease has increased steadily. The real difficulty lies not in lack of knowl- edge concerning these diseases, but rather in the absence of facilities where the modern care concept for the chronic and aged sick can be carried out . )4. The present inadequacy of chronic facilities in some areas thro‘Lighout the nation presents a serious problem. Although this problem In Ingham County, does not at present appear alarming, it is the demands of the near-future which must be carefully evaluated. 96 97 5. The continual shift of population throughout the estate and nation gives steady rise to the frequency of chronic disease. 6. The construction of hospital facilities for the chronically ill has been encouraged by the passage of the Hospital Survey and Construction Act. This act provides federal aid for such facilities up to a maximum of two beds per 1000 population. 7. In planning facilities for care of the chronically ill plans should be made for the community as a whole and not for the indigent alone. All sections of the population must be served. 8. On a local, state, and national basis the loss of manpower, . Wage and tax revenues, as a result of chronic disease, appears astound- ing. These costs, in terms of economics, present a problem of national i"lportance . 9. The general hospital of today can provide a solution to this PrOblefi by planning for the health care needs of the future. It is reCOmmended that hospital facilities for long-term illness be estab- lished in close proximity to general hospitals. The establishment of an intermediate-care unit in a general hospital environment would mks available care for the "whole patient.“ Preper care for the chronic ill, aged, and the patient convalescing from a serious operation or medical illness should be the primary function of the intermediate—care unit. ‘4’ 98 10. The need for intermediate-care facilities should be carefully considered and evaluated in all communities throughout the nation. This paper presents one community where special study should be given to such a program. However, in all planning, bear in mind the importance of planning for progress. 10. 11, l2, 13. 99 INTERVIEWS Caldwell, Mildred, Supt. of Nurses, Ingham County, Lansing, Michigan. Duxbury, Doris, Chief of Statistics, Michigan Department of Health, Lansing, Michigan. , Fausey, Glen W., Director - Edward W. Sparrow Hospital, Lansing, Michigan. Fowler, Bob, Engineer, Barker-Fowler Electrical Company, Lansing, Michigan. Hesse, Charles, Supervisor, Department of Physical Medicine, Edward W. Sparrow Hospital, Lansing, Michigan. Larson, A. 0., Director - Hinsdale Sanitarium and Hospital, Hinsdale, Illinois. Magdalen, Sister M., R. S. M., Director - St. Lawrence Hospital, Lansing, Michigan. Meyer, John, Supervisor for the Michigan State Highway Department, Lansing, Michigan. Rush, Lillian, Associate Director of Nursing Service, Edward W. Sparrow Hospital, Lansing, Michigan. Stanley, Arthur L. , M. D., Assistant Director, Ingham County Chest Hospital, Lansing, Michigan. Stien, George, Sales and Service Manager, Otis Elevator Company, Jackson, Michigan. Swartz, Frederick 0., M. D., Lansing, Michigan. Tableman, Betty, Administrative Analyst, Michigan Hospital Survey and Construction, Lansing, Michigan. Wolcott, Lester E., M. D., Director of Ingham County Hospital and Rehabilitation Center, Okemos, Michigan. ‘3: n _ m m on.-. a, '13in }_.;-_;Ll.-';s a:.-‘,.‘;.;‘;5 C." L'...~.'.f‘.z 1.; ;:\....;'..=....-.é.3...'.} 1300. 1955 100 HROMIC DISEASES INCLUDED AMONG 10 LEADING causes as PROPORTION OF ALL DEATHS 1900 y.‘ s. Number Percent 1., L1 '3 '1‘“? 3‘. 3'2} “4,1: I’ r ' swig: a. 7- - .1 -- —\ These 4 2o Tuberculosis 2,500 7.6 ‘\ 3. Pneumonia 29388 7.4 \\ Chronic 4. Diarrhea & Enteritis ‘\ Diseases (under 2 years of age) 2,337 7.2 \ are 50 Accidents 1,740 5.4 \30 31 ’ a. F, ”-1 ca»— .1. mm 41.5...- e ---;‘f.. :53 of 811 7 or. 1:W* ‘a--~—-’ . T735: " "a." l Gil \ 3‘ c"’ Deaths . --'_e...‘~ -.- ) t, “cw-m-.— 9o Typhoid Fever 869 2.7- 100 Bronchitis 802 2.5 Total (10 causes) 17,265 53.3 All other causes 15,188 46.7 Total Deaths 32,453 7 100 1 Number Percent 1;. :11'2“.l..«’s?'; V 2 mm. '- P36;£ 37 Qua-“fl’ -\ These 6 :2. :27; 323,297 1:31 3-—- -—\:\\ Chronic 9 V...’,“' 7 - \ -...-- / fur 95.; r‘ .- r". 7" 33‘: 13_7— ‘at .- -\ \é“, Disedb"; _.‘, .1- ..‘-.- '2 ‘~ \ \1\ are 4. Accidents 4,213 6.7 ‘ ”:35 .‘a “7. 5. Pneumonia and Influenza 1,599 2.5 .' ,,‘=;37 C1. EFL-2f t; a: {if Elli-.4; 1.,‘515 3'.Z-""“‘— ‘I’ v“ //// Of aé ' 1’ '. 70 Immaturity (unquali fled) . 1,272 2.0 I / // Deaths 3‘1.1:.x'lo;‘.t?.e1:c:'.:lc 1 217 2 {'"T‘, // 9o Congenital malformations 19013 1.6 l/ 10. C'it‘rtwsia of Live: 395 13--F" " Total (10 causes) 52,653 83.5 All other causes 10o434 1505 Total Deaths - «—.~--. -. on“..- 101 5—9»: we East—Koo 53221 cotuom £3502 _ou:m:2m ._= .= ._o> 6.2.5 12:5 as 3:385 _2_> was .3 sick .5 ._o> .530: 38:22 9:225 ”2% 3:5 page: 3 350m .qu—devmv 3533.: .o 5:23.: 1:0 .nEeoEo 621.65 63‘6va 023:... d Ecosaocn. as 878: .325 2.2.5 .572: 25...: ass: recess .37: £33223 .3 sizes .39 £98 338.; .63 .23 3.8,“ .83 a... 22...: n . . .Smmv b2,: 3 fluofgu was 53.39 E28126 3 goose.» .0 .35 .Agm.~omv £32..ro onuoamca was 3:935 .8365 too..— wo mom—coma .Avmmdmmv E293 wooing .223 actuate 287.c— .o_:umo> .808 3.2.1.5 .Gomév—v .850 I m on 5 _ 3 330:3 me 93:52 .3... you—.200 :o_m_>om foam 95233230 its monuoflw mops—ufifi 16 0mm. O¢m_ 0mm. ONE 05. com. . q . I .Iozzl .wj lmwm ICON mlllmdmmoz 2 6:52.00 mmb‘m Ik~QN~$§ Wu Q§1. .\\ - HEART ”361% s U’." >5 4 J l .5 £3, V‘- I“: 1“- "J .' :'J‘ J n .. ’ _....‘. ‘1. -_-),}.:'. , -n f. i p. -‘ 4| ’2‘ '4 {.1-“'.:‘;"" of ”14". ‘. ‘ 3‘.‘."—'.‘ ..' ‘1- _ V‘. -I v‘ ~ ' . .10. I '\ 70.5 % of all deaths CANCER —16.0°/. ---—-----—‘ VASC. LESIONS — ".47. OF C.N.S. 4 ACCIDENTS- 7.0 7. PNEUMONIA e -2,9o/. 5 INFLUENZA 6 DIABETES -2.3% 7 ARTERIOSCLEROSIS '2.0°/. 8 IMMATURITY It”, 9 CONG.MALFORMATIONS II.5°/. .0 NEPHRITIS a I 1.3% _1 NEPHROSIS ll.8 % of all deaths I7.7% of all deaths ALL OTHER — .77 7, CAUSES Ct 30' 251 20¢ ISI 0 - .1: «3°. to-“ -59! IV Rate per IO0,000 population CHRONIC - DISEASES WITH .1 INCREASING MORTALITY RATES MICHIGAN -I900'I950 250“- 95’ V 063' .6 2oo~~ 26'" I505- .ofl'el‘“ e. .“.'.. R "1“ I00" E GANG V “"'.. .‘j.'... ... ‘ ..‘ Q ¢ I Pact so<~ DIABETES L L I 1 L I900 I9IO I920 ‘ I930 I940 I950 Chronic diseases appear to be among the maior problems of health in the future. Heart disease, the leading cause of death since 1900, has been steadily in- creasing with a rate today nearly three times the rate at the beginning of the century. Cancer, also one of the leading causes of death, today has a mortality rate of 136.3, compared with 60.3 in 1900. III-I l IHlllkll 105 |900 ISfO ISIZO l330 l9|40 I950 I00“ . TUBERCULOSIS W (ALL FORMS) 60v 40- 0 EAL COMMUNICABLE DISEASES 2° 3 5L 3 WITH DECREASING 0 I; l MORTALITY RATES 130 5 MICHIGAN-I900-I950 I: I. “TL g ’ g"; 8° 5° TYPHOID ”foo"; 3° 5° 5; 5 g DIPHTHERIA-“mm- °~\ 5 ‘° SCARLET FEVER ......... {2° 5%., é.» WHOOPING comm--- I~II‘.'=.§°‘O§ Ea ’3'!" :l‘ 3.: °: 1" 'l‘ ’I-ll'flt ll‘ '° W ILV g7 ivz‘x ,5": 'lI ‘2? if: M'th." .' '- "x‘li‘ . A 3 I401; '- ' . x. I 2, 5T ‘3: 5. l .79..\ I 2% .° 0' ”‘5‘ 3, 5 I 2.; u‘o":\<- -. "..‘2’°o “r.- 1 I l ”AMI ._ _ I900 I905 I9'I0 I9|L5 I920 I355 l930 l935 I940 I945 I950 Progress in the field of preventive medicine during the past half century has re- duced the mortality rate due to communicable diseases to negligible proportions. For example, had the I900 Tuberculosis mortality rate of l03.3 prevailed today, there would have been 6,582 deaths due to Tuberculosis instead of the 1,270 recorded for I950. 75 LIFE EXPECTANCY LENGTHENS MICHIGAN, l920---|950 106 65 454 35 25. I54 white male white female II.4 ears oflie gained i since 55:V‘“ 'I920 I920 I930 I940 I950 , I920 I930 I940 I950 Note: Data for total population not available for all years. Source: U.S. Bureau of Census Life Tables. Statistical Methods Section Michigan Department of Health gigijl I5.8 years 9- at life .. gained '3‘ Slflce 31' I920 107 CURRENT LIST OF LICENSED HOMES FOR AGED CONVALESCENT HOMES Beadle Convalescent Hospital 1300 High Street, Lansing 23 men or women Bogue Nursing Home h2S.Ann Street, East Lansing 15 women Buehler Convalescent Home 2095 Hamilton.Road, Okemos 5 women Capital City Convalescent Home 616 S. Capitol Ave., Lansing 27 men or women Cedars Convalescent Home 61L 3. walnut, Lansing 1h men or women Emmons Convalescent Haspital h27‘W} Hillsdale, Lansing 17 women Fairview Convalescent Heme 1217 N. Grand River, Lansing 11 men or women Ferris Convalescent Home 6311 Quail Street, Haslett 5 women Holben Nursing Home 3lS‘W} Genesee Street, Lansing 17 men or women Holloway Nursing Home 231 E. Oak Street, Mason 20 women Holt Nursing Home h233 E. Delhi, Holt 21 men or women 1956 Lilly Nursing Home 2hl State Street, Mason 6 men or women Maple Shade Convalescent Home 322 W. Chestnut St., Lansing 18 men or women Northrup Convalescent Home 313 S. Main Street, Leslie 13 men or women Poston Convalescent Home Slh‘W} Maple Street, Mason 8 men or women Robart Nursing Home 118 E. Oak Street, Mason 21 men Roselawn Hospital hob W; St. Joseph, Lansing 29 men or women Shady Lawn Convalescent Hespital 721 N. Chestnut, Lansing 1h men or women Sunset Haven Dansville, Michigan 5 women ‘Williamston Convalescent Home 503 Middle St., Williamston 6 men or women LaMott Nursing Home Leslie 5 women 64 108 s CHANGES IN MICHIGAN POPULATION .BY COUNTY_ I940-I950 “.A“ l .*.¢ PERCENTAGE CHANGE SINCE I940 STATE .INCREASE ._ 2|.27o ‘ DECREASE OOOOOOOOOO Most of Michigan's 2l.2% population increase during the past decade occurred in the lower peninsula, particularly in the lower hall. Only 4 of the 68 counties in the lower peninsula, all located in the upper half, decreased in population where- as there were population decreases in II of the IS counties in the upper pen- insula. It is interesting to note that while Detroit increased by l3.9%, the sur- rounding counties of Oakland, Washtenaw, and Macomb increased by 55.9%, 66.6%, and 7l.8%, respectively. Macomb county ranks highest among all counties with increases in population. Although the Wayne County increase was only 20.8% this represents more than l/3 ol the population increase in the State. PERCENT OF CHANGE IN TOTAL POPULATION OF STATES: I940 TO I950 109 V .0 ~o 0000 o 9 . 0 O O o e 0.0 9.0.0 e .Q. 0 . . O O Q. O V . ’ . Q 0.000. q . .. e °:e e ' . 0 . ‘ ' O 0. Q s .. . . . -?1.\ ‘ e 0 e .- ._ . e .. . ... 0 e . - V r ' 4 . ' ‘.' e . 0 I \ ..‘ ’3’ O ' o 90 O O 0 O O O Q O O O * 0.000 0000 O 9 O O’QQOOQ O. O. O 0 Q0... 0 C O 0...... LEGEND PERCENT OF INCREASE - 20.0 AND OVER m IO.O TO I9.9 5.0 T0. 9.9 m 0.0 T0 4.9 PERCENT OF DECREASE 0.0 T0 4.9 UNITED STATES AVERAGE m I4.5°/o INCREASE \__ . BUREAU OF THE CENSUS DEPARTMENT OF COMMERCE I. ,"-__,__ com. 0* 00m. ”MNIFQFUI MIC zc-Fq unnaca udVIth...‘ 2. uqz