Nursing home care in the United States

In the United States, there are different kinds of residential "nursing" facilities (community facilities and institutional facilities) which have in common Medicaid federal funding and approvals through a state health department, no matter which categorical state department (e.g., intellectual disabilities, mental health, health) operates, staffs or oversees the facilities. The newer community versions, small in size rather than the exposed institutions (operated similar to "group homes" and even apartments),[1] were developed around 1970s as part of the movement to the community (Racino & Schwartz, 1978).[2] Assisted living came from community living (CL) groups (not from the nursing home industry) who advocated for the separation of facility funding to home and supports in the communities (for information on residential services and reform, see supportive housing and supported living).[3] Board and care homes have never been approved by community planning as intermediate care facilities (ICFs), or even the emblematic group homes, often falling far short at health and community gates. The leading practice in the US is to advocate for community Long Term Services and Supports (LTSS) led by groups such as the Consortium of Citizens with Disabilities representing over 200 national disability organizations.[4]

History

In the United States, the national social insurance program Medicare, was established by the U.S. federal government in 1965, which guaranteed access to health insurance for Americans aged 65 and older. This program prompted many new nursing homes to be set up in the following years, although private nursing homes were already being built from the 1930s as a consequence of the Great Depression and the Social Security Act of 1935. Medicaid, the Nation's poverty program, often funds programs such as nursing beds as residents may be "impoverished" to access the facility.

In 1987, a report examined the nursing home problem in Wisconsin which involved 4,000 people, 80% under 65 years of age with an average of 110 patients per facility. 5% had developmental disabilities. They reported that 13 large institutions were certified as SNFs (skilled nursing facilities), that all were "absolutely inappropriate" placements for the developmental disabilities' clients (the federal GAO then reported a need to upgrade services in the homes, including day services), and the facilities resembled the institutions that resulted in the national exposés of institutions such as Willowbrook in other fields.[5][6]

Board and Care homes were the subject of exposés for lacking medical personnel at the time of the 1990s reviews.

Nursing home reform

Nursing homes have been the subject of decades of efforts by states and at the national levels to reform health and residential care for "frail" elders, especially those with lower incomes in the US.[7][8] Regulations have been added to assure that basic good care (i.e., humane, accepted good human standards) will take place in these facilities (e.g., personnel, education, activities and services, ancillary and professional services, advocacy and reviews). The facilities have been upgraded according to the Medicaid groups and departments, and expectations for high service delivery at a skilled level. The cost is born by the taxpayer from the General Fund.

A major nursing home reform initiative occurred in 1996 when the Health Care Financing Administration studied its own facilities and reported to the US Congress on the effectiveness of its current system and certification of nursing homes. By 1998, the President announced new steps for federal oversight including monitoring of poor performance, collection of new fees, and increased focus on nutrition and basic personal care like pressure sores.[9] By 2000, minimum staffing ratios and implementation of Nursing Home Quality of Care were introduced. These actions followed the Omnibus Budget Reconciliation Act of 1987.

The Centers for Medicare and Medicaid Services in the Department of Health and Human Services now publish the "Nursing Home Data Compendium" annually,[10] which show various statistics related to nursing homes and residents, as well as health deficiencies and substandard care.[11] The results of the 2015 edition were generally positive, showing a decrease of substandard care reports from 4.4% in 2008 to 3.2% in 2014, reversing a previously increasing trend.

Intermediate care facilities

Intermediate care facilities (small) were developed by the state categorical systems (intellectual disabilities, mental health), back in the 1970s, as a reaction to exposés on institutional conditions resulting in required active treatment in institutions and the new building of community facilities recommended under 16 in size.[12] These facilities, which resembled homes in their smaller sizes (e.g., 4-6)[13] are operated by community services management (sometimes civil servants) and are separately regulated. All need a state health department approval for federal Medicaid and Medicare.

Nurses may be hired as a staff supplement, as may be therapists (e.g., speech, occupational therapists), adult day who may be civil servants or BA/AA human services personnel, or clinic services (e.g., psychologist, audiologist). Conversion of group homes or community residences into intermediate care facilities was of great concern due to its "overly medical" nature and requirements not meeting the community needs of the population group.[14]

Regulations

In the U.S. Centers for Medicare and Medicaid Services ensures that every Medicare and Medicaid beneficiary receives health care, both within health care settings such as nursing homes, and among health care settings during care transitions. The states in the US have health departments also responsible for oversight of the facilities and regulation.

Home and community services are new developments in the 1970s in the US for long-term services and supports (LTSS) populations and parallels the move to ambulatory versus facility care which was a US hospital and institutional (e.g., nursing facilities) to community transition.[15] LTSS services have diverse oversight and regulations, and these vary by facility type, by population group, and by financing as well as traditional regulatory agencies. The LTSS movement was involved with increasing autonomy and control of services which was recommended in professional texts, national forums, research studies and state directives in the 1980s and 1990s.[16][17][18]

To ensure that nursing homes meet the necessary legal standards, the authorities conduct inspections of all nursing home facilities; as often as quarterly. Surveyors conduct on-site surveys of certified nursing homes on average every 12 months to assure basic levels of quality and safety for beneficiaries. The authority might also undertakes various initiatives to improve the effectiveness of the annual nursing home surveys, as well as to improve the investigations prompted by complaints from consumers or family members about nursing homes.[19]

Alternative care models

Other fields have introduced new community care models into fields dominated by the hospital and nursing care industries, such as assisted living facilities or the older PACE, All-Inclusive Care for the Elderly from the 1990s or service-enriched housing from the 1970s.[20][21] In recent years, there has been a general movement toward implementing alternative care models. Some have tried to create a more resident-centered environment, so that they should become more "home-like" and less institutional or "hospital-like". In these homes, units are replaced with a small set of rooms surrounding a common kitchen and living room. The staff giving care is assigned to one of these "households". The reason, in part, is because the population is aging, and over half of the people in nursing homes are over age 85.[22]

Residents have more choices about when they wake, when they eat, and their schedule for the day. They also have access to pets. The facilities utilizing these models may refer to such changes as the "Culture Shift" or "Culture Change" occurring in the Long Term Care, or LTC, industry which includes the LTSS industry termed Long term Services and Supports in the Community.[23] Sometimes this kind of facility is called a "greenhouse". Most residential care models are considered to be community services operated by community agencies rather than nursing facilities; an example of different kinds of "community-based care" are "Alzheimer's demonstrations" which originally included: mobile day care, rural geriatric dementia evaluation, El Portal services for Latinos, Client Advocates, and AL-Care services for clients who live alone (Starns, Karner and Montgomer, 2002).[24]

Task-oriented care

In 1953, a leading American nurse educator, Eleanor Lambertson, proposed a system of team nursing to overcome the fragmentation of care resulting from the task-oriented functional approach. Team nursing would ideally respond to the needs of both the patient and the staff. The team leader's function is to stimulate the team to learn and develop new skills. The team leader instructs the team members, supervises them, and provides assignments that offer them potential for growth. Team nursing is characterized by the following:

Basic to team nursing are the team conference, nursing care plan, and leadership skills.

Eleanor Lambertson describes reform of the hospital nurse within the context of hospital management in which nursing facilities are considered independently managed entities without a hospital-physician structure. The "functional approach" is also the common term used for community programs which are homes (not operated by nurses), and operated by other than nursing personnel; and most recently was reviewed as one of three community approaches (also, competency-based) related to self-determination theories in the field of intellectual disabilities field (Wehmeyer, et al., 2003).[25]

Resident-oriented care

With resident-oriented care, residents are able to make more choices and decisions about their lifestyle. Their families are more involved in the residents care, and employees have a greater degree of participation with the residents. Resident-oriented care combines the clinical models of care with a flexible social models.

Nursing Facilities that implement this approach to elder care strive to respond to each resident's spiritual, physical, and emotional needs. Every member of a facility's team, care for the residents, from administrators to the nurse aides. For example, all call lights are answered immediately. Whoever is close when the call is placed, responds - even if this is a member of the administration.[26]

Facilities

Long term care

Originally loosely regulated, convalescent or rest homes may include foster group living, room and board facilities, and group care which may often be private, for-profit based on Social Security and Social Security Disability Insurance.

Facility personnel

Long-term care personnel (LTC) who work in facilities are now considered part of the new workforce funded through the federal government and its Medicaid and Medicare programs which are undergoing change in conjunction with the Patient Protection and Affordable Care Act of 2010. The Institute on Community Integration at the University of Minnesota with the Lewin Group, has been providing online education for the Direct Support Professional who also work in facility-based programs not just in the new community long term services and supports (LTSS)[27]

Intermediate care facility personnel

Many intermediate care facility personnel may be civil servants in states who have been part of the deinstitutionalization movement in the US. Otherwise, these are government contracted facilities from categorical departments (e.g., intellectual and developmental disabilities) who require education in their targeted population group, often function under a primary generic personnel model, and have high clinical related groups and programs (e.g., psychologists, social workers, nurses and nutritionists). Small intermediate care facilities, together with group homes, were supported by the non-profit sector in the US, while the large facilities over 16 have not been approved for the most part (e.g., "residual institutional populations").

As an example of the federal and state financing involved, the state of Louisiana in 1988 was at $22,399,971 federal funds for intellectual and developmental disabilities with $20,788,749 allocated for small intermediate care facilities, primarily operated by the private sector.[28] The large institutional facilities at the time in the state also received federal intermediate care facilities (ICFs) funds totalling $63,462,458 with the private sector operating $18,453,062 "federal funds" for "not recommended" large ICF-MRs (over 16 in size).[29] In FY 2011, in Louisiana, federal intermediate care facility financing was at $341.4 million with home- and community-based services at $413.0 million.[30]

Administration

Administration of intermediate care facilities are the state offices of mental health or people with developmental disabilities through direct regional provision or local contracts, non-profit or profit. Administration of nursing homes are the state to local department of health direct to local contracts, generally for-profit.

Depending on size, staff may include those responsible for individual departments (i.e., accounting, human resources, etc.). Nursing home administrators are required to be licensed to run nursing facilities.[31]

Assisted living facilities

Assisted living residences or assisted living facilities (ALFs) are housing facilities primarily for elders and may also have services for people with disabilities.[32][33][34] These facilities provide supervision or assistance with activities of daily living (ADLs); ALFs are an eldercare alternative on the continuum of care for people, for whom independent living is not appropriate but who do not need the 24-hour medical care provided by a nursing home. Assisted living is a philosophy of care and services promoting independence and dignity which was promoted nationwide as a community support in the 1990s, not a new nursing facility movement.[35] While assisted living facilities may now offer a menu of different services, they often remain tied to nursing facilities, policies and practices which were the original source of national concern. In addition, these facilities were funded often instead of in-home services and supports for individuals and families in local communities which has been requested nationwide for over three decades.[36]

Skilled nursing facilities

A skilled nursing facility (SNF) is a nursing home certified to participate in, and be reimbursed by Medicare. Medicare is the federal program primarily for the aged (65+) who contributed to Social Security and Medicare while they were employed. Medicaid is the federal program implemented with each state to provide health care and related services to those who are below the poverty line. Each state defines poverty and, therefore, Medicaid eligibility. Those eligible for Medicaid may be low-income parents, children, including State Children's Health Insurance Programs (SCHIPs) and maternal-child wellness and food programs. seniors, and people with disabilities. However, Medicaid for individuals living at home, and for facilities as providers are two separate financing mechanisms (e.g., may have facility state supplements; facility payments for personnel, administration, and services) which are not separated for public review on their use.

Skilled nursing facilities are less "caretaking" (e.g., laundry, personal care at bed and bathing, meal assistance, housekeeping, medications, mobility, room in units, limited activities -as defined in approval applications). They offer services such as rehabilitation (physical therapy). Old style nursing homes (e.g., run by counties, and now being sold to for-profit enterprises) continue to receive federal funds.

Home health care

"Alternatives to facility care" of the 1970s included recommendations for home health and other community services. Home health typically refers to a nursing visit or aide visit to assist with daily living and are provided by certified home health care agencies. Barr (2007) reported Medicaid funds at $47.8 billion nationally in 2008, and Medicare, a different federal program at $20 billion in 2010. In the late 2000s, the annual cap on services was finally removed, and hospital care first was no longer a stated criterion.[37]

Young adults and many elders would prefer to obtain services at home. Those providing services are nurse's aides, personal assistance services, home health caregivers or home caregivers, "support aides", peer companions, and social day care in senior centers. They are somewhat reimbursed in insurance policies. Clients wish to retain their personal physician, and may wish to obtain therapies through private offices such as mental health counselors, chiropractors, home care agencies, medication management counselors, physical therapists, county aging workers, and rehabilitation counselors. Government may also offer directly or indirectly other services such as emergency assistance lines, social work visits, meals on wheels, respite or senior companions, transportation, appointments, money management, or in some instances, adult day programs, among others.

However, in some areas these services are available for a limited number of hours each week, and are therefore considered to be "underdeveloped community systems" for elders. Independent living (IL) services have made inroads in community services to support young adults with physical and medical needs to live in their own homes and apartments, including under the new self-directed care of Medicaid and Medicare.

In 2012 the American Association of Retired Persons, in its profiles on long term services and supports in the states, indicated that $5,495 per person is available for home health services, $11,142 for personal care services, $10,710 for aging waiver. The average for nursing facilities is $29,533 per person.[38] In part, this development may be traced to the arguments for "cost-effectiveness" and "cost benefits" made to shift institutional to community care.[39]

Intermediate care facilities

An intermediate care facility (ICF) is a health care facility for individuals who are disabled, elderly, or non-acutely ill, usually providing less intensive care than that offered at a hospital or skilled nursing facility. Typically an ICF is not privately paid by the individual or by the individual's family, but involves federal Medicaid financing with a state and federal share, and individual contribution. An individual's private health insurance and/or a third party service like a hospice company may cover part of the cost. ICFs in the community have been increasingly replaced financially by Home and community-based waiver services. (In FY 2011, only 8% ICFs compared to 65% HCBS waiver of $48.29 billion community spending in intellectual and developmental disabilities nationally).[40] For comparisons between intermediate care facilities large and small in intellectual disabilities, see Home and community-based services: Costs, utilization and outcomes in the state of Minnesota (Lakin et al., 2005).[41] The primary problem with these facilities today are their exorbitant cost (reported as average of $123,053 per person, likely institutions)compared to home and community-based Medicaid waiver services ($42,896 per person) which also far exceed the cost of nursing facilities (American Association of Retired Persons, 2012, p. 14).

Involuntary care as an administrative decision

Generally, involuntary care is involved in intermediate care facilities (ICFs) where a service demand has existed, and waiting lists occur for services for decades. Often these waiting lists will be for community services of other kinds including home and community-based Medicaid waiver services. These kinds of services have been involved with multiple lawsuits regarding equitable distribution, and are now subject to the US Supreme Court's Olmstead Decision on the "most integrated setting".

Regarding "nursing homes", hospitals may require placement for discharge, and decides also if the patient can stay in the hospital. This is called hospital administration. The hospital may call the ambulance, and may not inform relatives of the location of the patient. Once a patient has "been moved" (transported by ambulance) into the nursing home on the hospital's approved list, the nursing home claims all rights to decision making regarding the person' care, including relative contact.

By 2008, however, nursing home emancipation with elders back to homes in communities was undertaken with an extremely high success rate when conducted with independent living personnel.[42] Home health and long-term services and supports availability at the same extent as a facility nursing home has been "recommended" by community planners, professionals and academics since the 1970s, and aging personnel nationwide have been educated to that effect. Currently, a new effort to train personal care attendants and develop national standards is in place.[43]

Nurse at a nursing home in Norway

Staff

Intermediate care facility (ICF) staffing are direct service personnel and managerial personnel responsible for professional staff (including nurses and therapists), and for in house and community programming from transportation to grocery shopping, recreational activities, personal care and mobility, communication and home activities, and so forth. Almost all direct service staff are considered Direct Support Professionals.

Board and care homes

Board and care homes (residential care homes) are special facilities designed to provide those who require assisted living services both living quarters and proper care. These facilities can either be located in a small residential home or a large facility. A large majority of board and care homes are designed to room less than 6 people. Board and care homes are typically staffed by licensed professionals, including nurses, doctors and other medical professionals. These facilities are regulated. Board and care homes offer residents 24 hour assistance.

Medicaid and Medicare funding for community services

The Centers for Medicare and Medicaid Services is the component of the U.S. Department of Health and Human Services (DHHS) that oversees Medicare and Medicaid. A large portion of Medicare and Medicaid dollars is used each year to cover nursing home care and services for the elderly and disabled. State governments oversee the licensing of nursing homes. In addition, states have a contract with CMS to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries. Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid. These requirements are broadly outlined in the Social Security Act, which also entrusts the Secretary of Health and Human Services with the responsibility of monitoring and enforcing these requirements. CMS is also charged with the responsibility of working out the details of the law and how it will be implemented, which it does by writing regulations and manuals.[44]

Personnel

Direct staff

In most jurisdictions, nursing homes are required to provide enough staff to adequately care for residents. In the U.S., for instance, nursing homes must have at least one registered nurse available for at least 8 straight hours a day throughout the week, and at least a licensed practical nurse on duty 24 hours per day for up to 100 residents. The concern for decades is that the presentation of these sites as "medical" facilities is a misnomer, though medications are distributed, but other care such as for cancer may not be offered.

The federal government considers categories of direct service personnel to include staff and aides, and licensed and unlicensed personnel, to have similar needs and functions (See, classifications of mental health professionals for comparisons which are also available for hiring in facilities). The direct care staff have direct, daily contact with the patient in activities such as meals, personal care, daily activity (e.g., bingo), medications, and travel (often in wheelchairs) in the units. In a nursing home, the personnel may include registered nurses, licensed practical nurses and nursing assistants who are part of a "nursing world" not from a "medical school" (e.g., allied health personnel graduates) or a "professional trade" (e.g., mental health counselor certification), specializations (e.g., adaptive recreation), or "university graduates" (BA liberal arts, managerial). The new direct aides (e.g., psychiatric aides, nursing aides, support aides), are now considered to be professionals in the support fields as part of an effort to raise the standards, respect and expectations of these classes.

Indirect staff

Personnel may be hired in the "Buildings and grounds department". Custodians, maintenance staff, and groundskeepers, for example, keep the inside and outside of the building in clean, working order, though direct staff are responsible for areas of personal cleanliness.

Additional support personnel also include people who may have some contact with the patient in the nursing home. For example, nursing homes may have an activities director who is responsible for planning social activities, coordinating special visitors and religious services. Larger facilities may have multiple staff members, such as chaplains or activity assistants, who take on some of those roles. The government requires a minimal activity schedule for residents in order to obtain funds.

Ombudsmen

In the US, the American Red Cross may have an ombudsman in the nursing facilities.

Services

Nursing facilities offer (by county planning process) the most extensive care a person can get outside a hospital, if one discounts regional medical centers, alternative programs in the community (sometimes now, medical homes, and 24 hour care programs), and the newer assisted living facilities. Nursing homes offer help with custodial care—like bathing, getting dressed, and eating—as well as skilled care given by a registered nurse and includes medical monitoring and treatments. Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists.

The services nursing homes offer vary from facility to facility. Services can include:

The following fields of therapies are considered "related services" or "allied health or "ancillary services" which have distinct educational and certification paths from nursing personnel, and are educated in other than the Schools of Nursing and certified separately (standard CNAs, LPNs, RNs) now to BS and doctoral levels. The therapy groups, unlike the rehabilitation counseling and rehabilitation medicine (Master's and doctoral) groups, have been authorized to "practice independently" under the term "rehabilitation" and been given governmental payment rates. In many sites, the aide level ("nurse's aides", "psychiatric aides", "addictions aides"; originally, "support aides") performs many tasks, and new US Direct Support Workforce training are beginning to take in these personnel as needing to meet standards set by the Centers for Medicaid and Medicare.[45]

Occupational therapy

Rest home for seniors in Český Těšín, Czech Republic

Some individuals that are housed in a nursing home require ongoing occupational therapy. Occupational therapists "promote the health and participation of people, organizations, and populations through engagement in occupation".[46] These specialists provide intervention in areas of occupation such as: activities of daily living (such as bathing, dressing, grooming; instrumental activities of daily living (home and financial management, rest and sleep, education, work, play, leisure) and social participation.[46]

They also develop and implement health and wellness programs to prevent injuries, maintain function, and improve safety of residents. For example, Occupational Therapists can take a leadership role in developing and implementing programs to educate clients on compensatory techniques for low vision, customized exercise programs, or strategies to prevent falls. Occupational therapy practitioners may also consult with other staff within the facility or in the community on a variety of topics related to increasing safe engagement in activities. Occupational therapy practitioners can provide a variety of services to short- and long-term residents of a SNF. Based on a client-centered evaluation, the occupational therapist, the client, caregivers, and/or significant others develop collaborative goals to identify strengths and deficits and address barriers that hinder occupational performance in multiple areas. The intervention plan is designed to promote a client’s optimal function for transition to home, another facility, or long-term care.

Physical therapy

Some of the individuals that are housed in a nursing home need ongoing physical therapy. This can be for any number of reasons. Perhaps a person has motor skills that never fully developed or have stopped functioning for some reason. Perhaps an individual has undergone a surgery or medical procedure that requires some manner of physical restitution on a personal level. Nursing homes offer specialists that are well versed in the field of rebuilding muscle or helping one regain their confidence when it comes to doing something physical. This is one of the most common therapies that are done in these nursing homes.

Medical needs

Nearly all residents in a nursing home have some type of medical need, ranging from basic care requirements to more specialized needs. Most nursing facilities are equipped to deal with most general medical needs likely to emerge. Most of the staff will have ample training in how to deal with patients with specific needs. In fact, the staff that interact daily with the patients are normally registered nurses, who have spent years training for all contingent situations that they may encounter in a nursing home.

However, children and adults with medical and physical needs have been supported in families and community settings for decades, including through the early Katie Beckett waivers, serving children with technological needs. Personal assistance services in workplaces also may be Medicaid -funded and support individuals to live in the community, often throughout their adulthood. These are call community services, not necessarily nursing services.

Residential versus institutionalized care

In the US there are over 43 categories of residential care of the institutional variety in the US, including the modernized "assisted living facility" of the late 1990s.[47] These categories generally reflect the target of institutional reform to better quality supports in homes and communities.[48]

In various states, Medicaid Waiver programs have been developed to allow impoverished elders access to home-based care, instead of being forced into an institution.[49]

Though begun in New York in the 1970s, the legislative program was reported nationally together with other early community program development such as family support which grew to 950 programs serving younger adults and their families in New York alone.[50] In addition, in fields such as intellectual and developmental disabilities, [family support], small homes (no larger than 12, 2-4), small intermediate care facilities (ICF-DDs) and community supports (e.g., supported employment) were developed as new, integrated service systems.

References

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  38. ↑ Houser, A., Fox-Grage, W.and Ujvari, K. (2012). Across the States: Profiles of Long Term Services and Supports". Ninth Edition. (p.14) Washington, DC: Author.
  39. ↑ O'Day, B. "Independence and Transition to Community Living: The Role of the Independent Living Center". Austin, TX: Independent Living Research Utilization.
  40. ↑ Braddock, D., Hemp, R., Rizzollo, M., Tanis, E.S., Haffer, L, Lulinski, A., & Wu, J.(2013). "The State of the States in Developmental Disabilities, Ninth Edition." (p.39). Boulder, CO: University of Colorado, Coleman Institute on Developmental Disabilities.
  41. ↑ Lakin, K.C., Hewit,, A., Larson, S., & Stancliffe, R.J. (2004). Home and community-based services: Costs, utilization and outcomes. In: R. J. Stancliffe & K. C. Lakin, "Costs and Outcomes of Community Services for People with Intellectual Disabilities". Baltimore, MD: Paul H. Brookes.
  42. ↑ Seekins, T., Katz, M. & Ravesloot, C. (2008, March). Nursing home emancipation: Accomplishments of urban and rural centers for independent living. "Rural Disability and Rehabilitation. Research Progress Report #39". Missoula, MT: RRTC on Community Living, University of Montana.
  43. ↑ Seavey, D. & Marquand, A. (2013). "PCA Training Standards: Findings from a 50 State Study." San Diego, CA: Center for Personal Assistance Webinar.
  44. ↑ "Nursing Home Inspections". medicare.gov. Retrieved 2012-10-12.
  45. ↑ Larson, S., Sedlezky, L., Hewitt, A., & Blakeway, C. (2012, in press). The US direct community support workforce. In: J. Racino, "Public Administration and Disability: Community Services Administration in the US". Boca Raton, FL: CRC Press.
  46. 1 2 American Occupational Therapy Association [AOTA], 2008
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  48. ↑ Forthcoming, Public administration and disability: Community services administration in the US (Racino, in press, 2014)
  49. ↑ Nicole Dube; Associate Analyst. "NEW YORK'S LONG-TERM HOME HEALTH CARE PROGRAM". cga.ct.gov. Retrieved 2016-03-25.
  50. ↑ Tarky Lombardi, Jr., (1986–1988). Nursing Homes Without Walls. "Generations", 21-23.
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