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Trends in Special Care: The 1995 National Nursing Census of Sub-Acute Units

Publication Date
Aug 31, 1997

U.S. Department of Health and Human Services

Trends in Special Care: The 1995 National Nursing Home Census of Sub-Acute Units

Executive Summary

Joel Leon, PhD, Michael Cheng, PhD, and Jennifer Dunbar, MHS

Project HOPE Center for Health Affairs

September 1997

This report was prepared under contract between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Project HOPE. The National Institute on Aging provided additional funding for this project. For additional information about this subject, you can visit the DALTCP home page at or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The e-mail address is: The Project Officer was Robert Clark

The objectives of this study were to establish a reliable baseline estimate of the number and distribution of sub-acute care units in licensed nursing homes; to estimate the bed capacity of these units in 1995; and to sketch the characteristics of the nursing homes where these units were located. This effort was part of a larger study on the development of specialty care programming in nursing homes.


The past decade has witnessed the emergence of sub-acute care units in nursing homes (Banaszak-Holl et at, 1996). This recent development arises from broad efforts to reduce the costs of providing health care and dynamics that are specific to the evolution of the nursing home industry.

Sub-acute units encompass a broad spectrum of programs diverse in patients, services, and settings (Lewin-VHI, 1995). Nursing homes operate these units for residents requiring short- term recovery after serious trauma or accident, providing specialized care such as complex medical/surgical interventions for cardiac, respiratory, oncology, neurology, postsurgical, and terminally ill patients (Glosner, 1994). The growth in numbers of sub-acute care units has been attributed to two major factors: efforts to slow health spending and the drive by nursing homes for more and more profitable customers.

Nursing homes that do not provide specialized care compete with less cost intensive alternatives such as home-based services and assisted living environments. As the number of hospital beds continues to shrink, the potential role of nursing homes as the major source of sub-acute care may be challenged by hospitals' use of their own space. Specialized sub-acute units are only one type of specialty service now being offered within nursing homes (Leon et at, 1997).

Data Sources and Methods

Data for this study come from the screener instrument used in the 1995 Trends in Special Care (TSC) Survey, a survey of a nationally representative sample of all licensed nursing homes. The survey examined the growth in specialty care being provided by nursing homes.

Data collection involved mail and telephone interviews. Using the sampling frame developed by the National Center for Health Statistics for its 1995 National Survey of Nursing Homes, a representative sample of 6,471 licensed nursing homes were contacted in two waves. The overall response rate to the survey was over 94 percent.

The screener instrument included questions about the size, ownership, and certification status of the facility, and availability and capacity of current and planned specialty programs and units within the nursing home.


Nationally, in 1995, about 2,165 or 13 percent of nursing homes reported special units for sub- acute care. Of these, 611 also reported having special rehabilitation units. Beyond the 2,165 with sub-acute units, an additional 1,101 facilities, or 7 percent of all nursing homes reported rehabilitation units. In total, about one-fifth of all nursing homes reported having either sub- acute units, rehabilitation units, or both (see Figure 1).

It is estimated that across the nation, total bed capacities among these 2,165 sub-acute units reached 62,406 beds. Distribution of units and beds varied across the states and regions. Nursing home facilities in the south accounted for about a third of the units and a third of the beds. Florida had the largest number of facilities with sub-acute units (202) and the highest number of beds (7,881) followed by California with 192 facilities and 5,305 beds, and Ohio with 139 facilities and 4,291 beds.

Additionally, in nine states, 20 percent or more of the facilities reported having sub-acute units (Arizona, Colorado, Florida, Maryland, Massachusetts, New Jersey, Nevada, Utah, and Washington).

Almost half of the facilities (48 percent) reporting sub-acute units were owned by for-profit companies that were part of a chain. Over 16 percent were part of independent, for-profit institutions, while nearly 21 percent were owned by non-profit, independent facilities. Less than 4 percent were government facilities. Among all sub-acute units, 80 percent were based within free-standing nursing homes. Nearly 20 percent were hospital based.

Growth in the development of sub-acute units in nursing also appears likely. In 1995, among the 2,165 facilities that reported having a sub-acute unit, 573 (26 percent) reported plans for expanding existing sub-acute care programs. Among the 14,663 facilities that reported not having a sub-acute unit in 1995, 1,932 (13 percent) reported plans to develop a sub-acute facility within the next five years.


If trends continue in the direction indicted by the 95/96 TSC Census, nursing homes will become more specialized in the future. It appears that the sub-acute market is particularly strong in the South, in major urban areas, and within nursing homes that have a larger than average bed capacity. These markets, combined with the large numbers of facilities planning to expand existing or develop new units, point to sub-acute care as a growing industry.