After reading such a "testimonial," we are relieved that neither we nor anyone we care about lives in a nursing home. Alternatively, if a friend or relative resides in a nursing home, we hope that "hers is different." But more and more Americans can expect to be admitted to a nursing home.

Why should independent, middle-aged adults worry about what goes on in nursing homes? Only 5% of Americans older than 65 years live in nursing homes, and only 10% are admitted in 1 year [2]. Some go home, some die, and some remain; that's not so bad. But a more detailed analysis is less comforting. Of persons who were 65 years of age in 1990, 43% will enter a nursing home in their lifetimes; 55% of these will stay at least 1 year, and 21% will stay 5 years or longer [3]. The remarkable yet continuing increases in life expectancy, even among the very old [4], strongly suggest that nursing home use will increase because use is strongly associated with age [2], even adjusted for disability. Currently, 1.5 million Americans live in nursing homes; by the year 2030, this number will increase to 5 million [5, 6]. In addition, the cost of nursing home care is a sleeping giant. It was $53 billion in 1990 and was the fastest growing component of major health care expense in the national budget [7]. It is estimated that the cost in the year 2000 will exceed $140 billion [8]; in the year 2030, costs may exceed $700 billion. Because the use and costs of nursing home care are booming, efforts to improve that care are especially important.

Although increased nursing home use by older Americans can confidently be predicted, the real problem is a disturbing shortage of physicians willing to provide care for nursing home residents. Only 1 in 10 primary care physicians spends more than 2 hours per week providing care in nursing homes [9]. Although 60% of physicians who visit nursing homes are internists, they spend less time in nursing home care than do family physicians (unpublished data). As with primary care providers, many of the physicians who do visit their patients when they are admitted to nursing homes are themselves older and therefore likely to stop practicing soon; the mismatch between a growing nursing home population and a shrinking pool of physicians willing to attend those patients is yet another maldistribution problem in physician resources. How we train physicians in nursing home care is a moot question until more physicians are recruited to provide care in nursing homes. But the knowledge base is an exciting one, and the challenge to master and apply it to patients in need is itself a recruiting strategy.

Our 84-year-old correspondent suggests that physician practice in the nursing home deserves attention. The American College of Physicians, through its Subcommittee on Aging, has decided to try to make a difference by highlighting the knowledge base in nursing home care, an effort primarily directed at the nongeriatrician. This issue of Annals contains one [10] in a group of articles on evaluation and management of common clinical problems in the nursing home. The series is to be published as a monograph by the College. Wide distribution to medical students and housestaff in internal medicine and family medicine is anticipated through an education grant from the Merck Foundation as part of its "Healthy Aging" Program, which is designed to help preserve vitality in older adults. These articles address only the component of clinical care that is specific to nursing home residents; attention is given to avoid duplicating general information on geriatrics and gerontology now available in many fine texts.

The professional satisfactions of nursing home care are substantial. Grateful patients, attentive and motivated staff, advanced pathologic conditions with classic physical findings, and the opportunities to make a difference in a patient's quality of life and sense of self-worth and to master intensive geriatric care are rewards available to physicians who are receptive to learning geriatrics and applying it to nursing home residents. The exclusion of geriatrics and principles of nursing home care from the medical education of most currently practicing physicians has led to ignorance of the nursing home, negative attitudes toward nursing homes and their residents, and unfamiliarity with the process of nursing home care.

Although the many disincentives for primary care physicians to continue caring for their patients who are admitted to nursing homes must be acknowledged and addressed, none is unique or insurmountable. Travel time and distraction from office- or hospital-based practice, low and slow reimbursement, volumes of paperwork, staff who appear less technically sophisticated than those in hospital or office settings, patients who usually do not get better and go home, and chronic clinical problems that are frustrating and difficult to manage make many good and caring clinicians reluctant to go to the nursing home. And yet those who do care for nursing home residents describe clinical and intellectual satisfactions from meeting human needs that would otherwise be neglected or mishandled. Further, many features of nursing home care are changing with implementation of the Omnibus Budget Reconciliation Act of 1987, which was begun in 1990. This legislation, directed at improving quality of care in nursing homes, mandated 1) a Minimum Data Set to objectively collect clinical information on nursing home residents; 2) standards for training nurses' aides; 3) a reduction in the use of physical and pharmacologic restraints; and 4) a redefinition of the measures used to assess quality. These regulations emphasize improving outcomes of care rather than the previous endless documentation of care; early evaluations indicate that nursing home residents are substantially better off.

There are several additional specific reasons to master and provide nursing home care. Many nursing home residents can and do go to the physician's office for ambulatory care, and nearly all are admitted at some time to a hospital for acute illnesses. It seems sensible for the physician providing office and hospital care to know about and direct care in the nursing home. It is commonly assumed that nursing home residents remain in that setting for life, but many of those admitted return to the community; of Medicaid admissions (best data available) in California, more than one third are discharged to their homes within 6 months [11]. The rate for all admissions is estimated to be one half [12]. The increasing use of nursing home beds for short-term rehabilitation or other "step-down" care to shorten hospital stay makes such nursing home admissions even more likely; most physicians would probably want to continue caring for their patients during limited nursing home stays. Nursing homes with academic affiliations for teaching and research are becoming more prevalent and increase the intellectual legitimacy of nursing home care. Management of chronic disease and continuity of care over time are the mainstream responsibilities of contemporary medicine, and nursing home residents typify patients who need informed and attentive primary and chronic care. For each nursing home resident, at least two community-dwelling older persons have the same disease and disability burdens but have support systems and care providers (usually unpaid family and friends) allowing them to stay at home. Accordingly, nursing home practice prepares physicians to manage similar, if less intense and less clustered, disorders in the community.

Functional impairment is the final common pathway of most chronic disease, especially in older persons with multiple advanced disorders [13]. Initial identification of lost function, proceeding then to traditional clinical evaluation and finally to therapeutic intervention, is a method well learned in the nursing home. Functional status, best determined by use of standardized brief clinical instruments [14], is a most sensitive clinical indicator with which to follow disease progression or response to therapy in the elderly. The Minimum Data Set, completed by nurses, also assesses functional status well. Recognizing that success is measured by improved function rather than cure is also a major source of physician satisfaction in providing nursing home care. The relevance of emphasizing functional capacity cannot be overstated for older patients, regardless of where they live. Patient satisfaction and preservation or restoration of independence are crucial and dominant themes for older persons. These patients, in or out of the nursing home, are best served by physicians who recognize these priorities and have learned the principles and practice of comprehensive geriatric assessment [15, 16].

In this issue of Annals, Ouslander and colleagues [10] discuss clinical management strategies related to admission evaluation, periodic screening, and efficient continuing care of the nursing home resident. Other crucial topics in nursing home care to be included in the monograph are principles of drug use; the resident with abnormal mental status; incontinence, including detection, evaluation, behavioral and pharmacologic treatment, and staff training; falls and mobility problems; ethics, including patient rights, advance directives, restricted treatment, ethics consultation teams, and legal issues; nutritional issues and approaches; pressure sores, including evaluation, management, and prevention; pain management; fever and infections; and psychiatric care.

More than 1.5 million Americans live in nursing homes; they consume a large amount of health care resources and their number may triple in the next generation. Otherwise good and caring physicians have been insecure and hesitant in delivering care in nursing homes or have been reluctant to visit them at all for many reasons, ranging from convenience to lack of information about or comfort with the common clinical problems encountered. But as hospital stays become shorter and shorter and more care is moved to ambulatory settings, the primary care of older adults increasingly will include the complex clinical issues of care for those who are severely functionally impaired. Less than half of that population resides in institutions; most are able to remain at home in the community with support. Generalist physicians now and in the future will be expected to provide primary care to adults of all ages. Specialist geriatricians are not the answer to the care of frail older patients in the community or the nursing home. The article by Ouslander and colleagues begins an accessible and thorough series on geriatric care for physicians willing to go to nursing homes. We applaud the effort and recommend it to you.