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Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? (1996)
Chapter: 3 Evolving Health Care Scene
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Suggested Citation:"3 Evolving Health Care Scene." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
Evolving Health Care Scene
The nation's health care system is in a historic transformation driven by rising prices, pressures on public and private budgets, and scientific and technological change. These forces are prompting major changes in the structure, organization, financing, and delivery of health care. The health care delivery system today is not what it was yesterday, and not what it will be tomorrow. Hospitals are changing in ways not considered possible a few years ago. A combination of changes in payment policies and technological and scientific advances has permitted shifts from the traditional inpatient hospital setting to ambulatory care settings, the community, home, and nursing homes. Hospitals increasingly are offering nontraditional services including hospital-based ambulatory care, home health care, and skilled nursing services units (AHA, 1994a). Shortell and coauthors have aptly likened the turbulence in the health care system to ''an earthquake in its relative unpredictability, lack of a sense of control, and resulting anxiety. At the epicenter of this earthquake is the American hospital" (Shortell et al., 1995, p. 131).
The boundaries between hospitals and nursing facilities are beginning to blur, and the walls around them are moving outward into the community where community-based home health services and other alternatives to nursing facilities are developing (Shortell et al., 1995). The typical nursing home of the past provided primarily custodial care for the elderly needing assistance; persons with acute conditions were treated in hospitals. Today, the demand for nursing home care is shifting from the traditional custodial care model toward one that often has
a rehabilitative component (Johnson et al., Part II of this report1). Nursing facilities are beginning to provide a wide array of services to individuals who are disabled with an increasing number of unstable chronic conditions (Morrisey et al., 1988; Shaughnessey and Kramer, 1990). The type of care provided is also changing with the increasing severity of illness and disability of some of the residents; it includes rehabilitative care, ventilator assistance, care for residents with an emerging acute care crisis, and respite care. Special care beds in nursing facilities have expanded rapidly in recent years for patients with Alzheimer's disease or other dementia in general. Subacute care is offered in many nursing facilities for patients discharged from the hospital to the nursing facility (AHCA, 1995).
Impetus for Cost Containment
Enactment of Medicare and Medicaid in 1965 began a period of tremendous growth in health care services, especially hospital services. The combination of (a) increased demand for services stimulated by increased public and private insurance and (b) reimbursement on a retrospective basis has stimulated a rapid rise in use, costs, and expenditures. The need for cost containment policies became evident as the cost of health care reached unprecedented levels and comprised a steadily increasing share of the nation's output.
In 1993, personal health care expenditures (PHCE) reached $783 billion. Although the rate of growth in very recent years is slower than it has been in more than three decades, spending for health care continues to increase faster than the overall economy. While the share of private funds shows a slight decline, public funds as a share of the total PHCE continued to increase, accounting for 43 percent of the PHCE in 1993. Medicare and Medicaid accounted for one-third of all PHCE (Levit et al., 1994). Moreover, the federal government's share of health care costs has been steadily increasing.
Growing concerns about the continuing increases in health spending led to the development of a series of cost containment measures beginning in the mid-1970s. These included the Certificate of Need program (1974–1986); stimulation of competition through support of health maintenance organizations (HMO) starting in 1974; and various constraints on reimbursement in the 1980s. A key step was the enactment of the Tax Equity and Fiscal Responsibility Act (TEFRA) in 1982, which placed a cap on annual operating revenues per inpatient Medicare case at each hospital; it was followed in 1983 by Medicare's Prospective Payment System (PPS), under which hospitals are paid a predetermined amount per
The Institute of Medicine (IOM) committee commissioned this paper from Jean Johnson and colleagues. The committee appreciates their contributions. The full text of the paper can be found in Part II of this report.
FIGURE 3.1 Employment in hospitals, United States, 1969–1994. NOTE: Monthly employment through October 1995 is higher than comparable employment for 1994.
SOURCE: Bureau of Labor Statistics, Current Employment Statistics Program.
Medicare discharge using national rates based on flat rates per admission calculated for each of the approximately 470 (in 1995) diagnosis-related groups (DRG).
Both of these measures have led to major changes in the financing and delivery of health care and have forced hospitals to change the way they staff their facilities and to integrate vertically (with payers) and horizontally (with each other) (ProPAC, 1995). In the years immediately following TEFRA and PPS, the use of inpatient services and hospital employment declined briefly. However, hospital staffing levels began to rise again in 1986 (see Figure 3.1).
A possible explanation for the staffing increase is a combination of scientific and technological advances and an increasing proportion of hospitalized patients tending to be more critically ill requiring more intensive inpatient hospital care and skilled and specialty services, including nursing services (HRSA, 1993). This situation explains to some extent the continuing increases in registered nurse (RN) employment in hospitals even when other employment was declining (see Figure 3.2).
FIGURE 3.2 Nurses as a percent of total full-time-equivalent (FTE) personnel in community hospitals, United States, 1979–1993. NOTE: LPN = licensed practical nurse; RN = registered nurse. SOURCE: American Hospital Association, Annual Surveys, 1979–1993, special tabulations.
Managed care organizations2 such as HMOs and preferred provider organizations (PPO) developed rapidly, changing the nature of private health insurance and increasing price competition. These evolving payment systems have in turn affected the structure of the health care delivery system by limiting service and directing when and where patients receive their care.
Focus of the Chapter
This chapter presents a brief overview of the major changes occurring on the health care scene, with a focus on the hospital and nursing home sectors, and what these shifts mean for the organization and delivery of nursing services to
The term "managed care" as used in this report is broadly understood to encompass organized efforts by third parties, such as health plans, to influence the access, use, and cost of services provided to patients by care givers.
FIGURE 3.3 Sources of funds for medical care expenditures, United States, 1993. SOURCE: Levit et al., 1994.
patients.3 As stated in Chapter 1, hospitals and nursing homes represent two separate but related health care markets. Hospitals are a part of the basic acute health care system, and inpatient services are paid for largely by private insurance, Medicare, and Medicaid. The reimbursement for nursing home care, by contrast, is usually through Medicaid or out of pocket; almost no private insurance for long-term care is being purchased (see Figure 3.3). Also, hospitals historically have been not-for-profit institutions whereas nursing homes have been predominantly investor-owned companies. The committee believes that the issues resulting from the evolving health care environment that the nation is witnessing are related and yet different in many ways for the two sectors.
Private Insurance And Public Payers For Health Care
Health care in the United States is financed primarily through a combination of private health insurance and public coverage, and historically has been pro-
For a detailed discussion of the changing health care delivery environment and the evolution of managed care, see ProPAC (1994), Chapter 3; Shortell et al., 1995; Shortell and Hull, in press.
vided through a fee-for-service (FFS) system. Although public efforts at reforming health insurance have not progressed, the private health insurance sector continues to experience rapid change as it responds to cost pressures from employers. This has led to greater competition in the market and shifts by employers and other purchasers of health care from some insurance companies to other companies, leading to some instabilities in the market. These shifts are reflected in major changes in the organization of the health industry including rapid consolidation into larger corporations through mergers; consolidations and integrated networks; diversification of products; corporate restructuring; and changes in ownership. The most important of the changes is the growth of managed care organizations.
A combination of rising costs of care, dissatisfaction of payers, lackluster growth in personal income, and pressures on public and private budgets has led to the rapid growth of managed care. The emerging health care system is increasingly dominated by managed care organizations that are securing significant discounts from hospitals and physicians while attempting to reduce excess capacity and reduce the demand for high-cost services and procedures. Although HMOs have existed for half a century, their growth especially since 1980 has been phenomenal. The number of persons enrolled in HMOs has risen from about 6 million in 1970 to an estimated 50 million by the end of 1994 (see Figure 3.4). The 20 largest HMO companies have 59 percent of the total national enrollment. Nationally, the net increase in HMO enrollment rate from 1988 to 1993 was 38 percent; New England showed the highest regional level of penetration (26 percent). HMO penetration in Massachusetts reached 34 percent in 1993 and 40 percent by midyear 1994 (GHAA, 1995).
Compared to a typical FFS indemnity plan, HMOs reduce the use of health services. One Congressional Budget Office analysis (CBO, 1995) found that most of the reduction in use of health services is generated by group- or staff-model HMOs, which reduced services by nearly 20 percent. On average, independent practice associations (IPA) do little better than indemnity plans, reducing the use of services by about 1 percent. When these findings are combined using 1992 year-end enrollment patterns for HMOs and IPAs, the estimated average effect of HMOs is to decrease the use of health services by about 8 percent compared to indemnity plans. Approximately 37 percent of HMO enrollment was in group- or staff-model HMOs compared to 63 percent in IPAs and network plans at the end of 1992.
Although cost control has been the dominant force behind the rapid growth of managed care, in recent years the demand for value and accountability has emerged. Purchasers of health care, especially employers, have sought more
FIGURE 3.4 Number of people receiving care in HMOs, United States, 1976–1995. SOURCE: Adapted from GHAA, 1995, p. 3.
hard evidence on the quality, effectiveness, and appropriateness of the care they are buying (Shortell and Hull, in press).
A literature analysis of several peer-reviewed studies (Miller and Luft, 1994) found that in comparison to FFS indemnity plans, HMOs had generally lower hospital admission rates, shorter lengths of hospital stay, and fewer uses of hospital services. The studies also showed an average of 22 percent lower use of expensive procedures, tests, and treatments for which less costly alternative interventions were available. For most health conditions, HMOs appear to provide health care roughly comparable to that available through indemnity plans. Compared to FFS indemnity plans, HMO enrollees were less satisfied with service and patient–physician interaction, but more satisfied with the financing aspects of the plans. The authors found that the evidence comparing costs in HMOs and FFS indemnity plans was limited, with inconclusive results. Moreover, not much information is available on the impact of managed care on lowering overall health spending, and there is no persuasive evidence of lower growth rates for costs under managed care. The authors caution against generalizing across all managed care plans because of the rapid growth and diversity of plans in recent years. They express the urgency of additional research on managed care perfor-
mance on outcomes that goes beyond reducing costs, before the nation moves much further in this direction. At present almost no research has been conducted on whether the savings come from increased efficiency or reduced access and/or quality.
Davis and colleagues (1995) found that FFS enrollees were more satisfied with their plan's access and quality of care; managed care enrollees were more satisfied with their plan's cost, paperwork, and coverage of preventive care. The survey also found a high rate of involuntary plan changing, limited choice of physicians, and low levels of satisfaction among low income managed care enrollees. These findings are based on a population-based survey conducted by the Commonwealth Fund in 1994 of about 3,000 adults insured in FFS plans and managed care organizations.
Critics of managed care contend that the cost containment incentives of managed care may result in underservice and less than optimal care, especially for patients with chronic illness and those of lower socioeconomic status. Little evidence is available with which to evaluate the quality of primary care delivered by managed care plans or to show that the successes of managed care in relatively healthy populations can be replicated among sicker patients (Safran et al., 1994). To help fill that gap, the Medical Outcomes Study (MOS), a longitudinal study of patients' health care use and health outcomes was begun in the mid-1980s.4 Safran and colleagues found that relative to patients in an FFS plan, those in prepaid plans rated several aspects of an outpatient medical visit less favorably. The investigators compared the extent to which each of the five indicators of primary care quality (accessibility, continuity, comprehensiveness, coordination, and accountability) was rated over a 2-year period by a cohort of chronically ill patients in each of the three insurance plans—FFS indemnity plan, prepaid care through IPA, and group- or staff-model HMO. The investigators found that financial access was highest in prepaid plans; organizational access, continuity, and accountability were highest in the FFS plans; and coordination and comprehensiveness was lowest in HMOs. The authors conclude that these results raise questions regarding the associated cost inefficiencies and outcomes of care. It is an open question whether the magnitude of cost savings will continue after managed care has saturated the health care market.
On the other hand, Lurie and colleagues (1992) in their study of Medicaid patients in Minnesota found no difference in quality of care of chronically mentally ill patients between capitation plans and fee-for-service plans.
For further information on the MOS and analyses of the data, see Stewart et al., 1989; Tarlov et al., 1989; Wells et al., 1989a,b; Greenfield et al., 1992; Kravitz et al., 1992; Rubin et al., 1993.
Several shifts are taking place in the ownership, control, and configuration of health care organizations. One shift is toward proprietary or investor-owned health organization chains (IOM, 1986a). Health organizations are often classified according to ownership because the corporate goals, tax status, and financing structures differ somewhat by ownership categories. Although nonprofit facilities generally have charitable goals, many facilities may seek to maximize revenues. Proprietary facilities generally are oriented to achieving profits, and an increasing number of these health organizations are publicly-traded corporations and multifacility organizations or chains.
The formation of not-for-profit independent hospitals predates that of investor-owned enterprises, although for-profit hospitals have been in existence for some time. For the past several years, a steady shift has been occurring from the traditional independent not-for-profit hospitals to for-profit consolidated enterprises and investor ownership, and not-for-profit hospitals have established for-profit subsidiaries and other arrangements (IOM, 1986a).
The largest proportion of new managed care organizations are proprietary; some traditionally nonprofit corporations are converting to proprietary status.
The majority of nursing facilities are proprietary, and facilities are increasingly owned by investors. Of the total nursing facilities in 1991, 71 percent were reported as proprietary, 24 percent were nonprofit, and 5 percent were government owned (NCHS, 1994). Nursing facilities, like other segments of the health industry, are consolidating into large health care organizations, with the largest chain reporting more than 90,000 beds in 1991.
Profit margins reported for the health care industry have generally been good (Burns, 1992; Abelson, 1993; Rudder, 1994). Forbes reported that in 1994, the all-industry median for return on equity was 12.6 percent for 1 year and 11.4 percent for 5 years (Kichen, 1995). The health care industry ranked first of 21 industry groups for its 5-year return on equity (HCIA and Arthur Andersen, 1994; Kichen, 1995).
Profit-making issues, however, are complex, and detailed discussion of the issues is beyond the scope of this study.5 The issues of profits on investment and excessive administrative and capital expenditures, however, need to be more fully understood. Few studies of the industry have been conducted, especially those that determine appropriate levels of expenditures for-profits, administrative costs, and capital.
For a more in-depth discussion of issues surrounding for-profit enterprises in health care, see IOM (1986a) and the literature cited there.
As indicated earlier, technology, reimbursement policies, and continuing concern over rising health care costs have combined to stimulate competition in the health care industry. This competition in turn is prompting fundamental restructuring of the organization, financing, and delivery of health care in hospitals.
Hospital care expenditures accounted for 42 percent of personal health care expenditures in 1993. Growth in hospital spending decreased in 1993 for the third consecutive year, mostly because of reduced admissions and lengths of stay. As shown in Figure 3.3, nearly all hospital care is financed by third parties, with only 3 percent paid out-of-pocket. Private health insurance accounted for 36 percent; public funding financed 56 percent of the total PHCE, with the primary payers, Medicare and Medicaid, accounting for more than 41 percent share. Medicare's share of funding for all hospital expenditures was 28 percent in 1993, the highest since the mid-1980s. In 1993, 61 percent of Medicare benefits were for hospital care (including inpatient, outpatient, and hospital-based home health care), reaching $92.7 billion in 1993, an increase of 10.1 percent in just 1 year (Levit et al., 1994).
Hospitals are responding in various ways to the need to reduce costs and to adapt to managed care and other payment arrangements that fix in advance the reimbursements received for patient care. Among the responses are efforts to reengineer care and staffing for that care in innovative ways. These actions and their implications for hospitals and inpatient care are discussed briefly below.
Restructuring of Hospital Services
In response to the emerging dominance of payers, providers have engaged in various forms of reorganization and reevaluation. Searching self-examination is part of the current transition in the medical care arena. Physicians are organizing in some communities to negotiate with payers so that they can contract with other providers for the delivery of services to patients. Physicians in this role compete with traditional insurers—HMOs and other managed care organizations. Hospitals are organizing integrated delivery systems in which they purchase physician practices. Thus, hospitals are now competing with physicians and insurance companies in some markets.
Hospitals are developing integrated systems of care through networks, mergers, and consolidations. These structures seek to incorporate the concept of continuum of care, providing services ranging from ambulatory to long-term care in a "seamless" care system for the consumer. Hospitals also are competing for physician referrals and physician loyalty by teaming up with physicians in vari-
ous types of integrative arrangements. These include physician–hospital organizations, IPAs, and management service organizations. The growth of managed care has largely contributed to this trend toward the development of integrated systems.
The increased number of integrated service delivery networks is one of the more significant structural changes occurring today (ProPAC, 1995). Financing and delivery systems are combining into provider networks and managed care entities. Hospitals are joining together to form systems in which multiple hospitals are owned, leased, managed, or sponsored by a central organization. Between 1984 and 1990, the number of multihospital systems increased from 250 to 311, declining somewhat to 283 systems by 1993, probably as a result of mergers among systems (Shortell and Hull, in press). Groups of hospitals, physicians, other providers, insurers, and/or community agencies are also integrating to form more comprehensive delivery systems to market jointly a comprehensive set of services to plans, insurers, or purchasers in their communities.
These changes are having a major influence on what services are offered and where they are provided and, consequently, on hospital capacity and use. Vertically integrated entities are growing in importance, with increasing emphasis being placed on outpatient and community care in place of heavy inpatient orientation. About 11 percent of community hospitals reported in 1993 that they were already participating in health networks, working together with other hospitals, physicians, and insurers to coordinate a wide range of services for the community (AHA, 1994c). Many others reported working toward such collaborative formations.
Closures and Mergers
Hospitals are closing and entering into mergers and joint ventures at an unprecedented pace in order to strengthen their market share and realize economies of scale (ProPAC, 1995). Hospital closures reduce excess beds and lead to cost savings by allowing the remaining hospitals to spread their costs over a wider patient base. The American Hospital Association (AHA) reported closures of 675 community hospitals between 1980 and 1993.6 Thirty-four of the closures occurred in 1993 (AHA, 1994b). As might be expected, rural community hospitals have been particularly vulnerable to closures, outnumbering closures of urban hospitals, while representing slightly less than half of the total number of hospitals (Bogue et al., 1995).
AHA defines community hospitals to include institutions that are non-federal, short term, and general or other special hospitals whose facilities are open to the public. Not included are hospital units of institutions, long-term hospitals, psychiatric hospitals, and alcoholism and chemical dependency facilities.
Mergers involve the dissolution of one or more similar organizations and their assimilation by another. Mergers are undertaken either to eliminate direct acute care competitors or to expand acute care networks. They frequently convert inpatient capacity to other functions; only rarely does the acquired hospital continue acute care services after a merger (Bogue et al., 1995). Between 1980 and 1992, AHA reported 215 mergers involving 445 hospitals or health care systems (AHA, 1992).7 The AHA recorded another 18 completed mergers in 1993 (AHA, 1994c). More than 650 hospitals were involved in mergers or acquisitions in 1994, affecting more than 10 percent of the nation's hospitals. This number includes 219 investor-owned hospitals that were merged into other investor-owned chains and 154 investor-owned hospitals whose mergers into other chains were expected to be completed in 1995. In addition, 301 other hospitals were involved in 176 such arrangements during 1994 (Lutz, 1994).
As a result of closures, mergers, networking, and acquisitions, the number of independent community hospitals has been declining since the late 1970s. After declining rapidly between 1985 and 1990, the rate of decline during the 1990s has slowed. The number of community hospitals declined from 6,193 in 1970 to 5,829 in 1980, and 5261 in 1993. Between 1983 and 1993, admissions to these hospitals declined 15 percent, from 36 million to nearly 31 million (AHA, 1994a). The magnitude of decline varies by region, hospital size, and metropolitan status. (See Table 2.1 in Part II of the report.)
Mergers and integration of institutions, in the context of increasing restructuring of the delivery of health services, may provide an opportunity to rethink the way services are offered in many institutions and offer an approach to structural change. The possibility exists for avoiding duplication and reducing costs. For example, in addition to collapsing centralized services such as human resources, financing, and information services, clinical programs may be consolidated, potentially shifting nursing and other health personnel from their accustomed site of work.
Inpatient Activities
In the years immediately following the establishment of the PPS, noticeable reductions were observed in hospital inpatient admissions and inpatient days of care. Although this trend continued in the 1990s, the rate of the decline has slowed. Declining hospital admissions combined with shorter lengths of stay resulted in a 21 percent decline in inpatient days between 1983 and 1993 (AHA, 1994a). This drop, in turn, has led to a reduction in the number of beds staffed for use (see Table 3.1).
The 1992 component of this total was derived from AHA summary of registered hospitals from annual survey data tapes.
TABLE 3.1 Inpatient Activity in Community Hospitals, Total Patients and Patients 65 Years of Age or Older, United States, Selected Years, 1983–1993
Inpatient Activity
Percent Change 1983–1993
Number (in millions)
Inpatient Days
Persons 65 years or older
SOURCE: American Hospital Association, Annual Surveys, 1983–1993, special tabulations.
For persons 65 years of age and older, however, after a decline of 5.4 percent in admissions and 18 percent in inpatient days between 1983 and 1986, inpatient hospital use has been increasing. The annual number of admissions for this age group grew by 7 percent between 1990 and 1993, whereas admissions for persons under 65 years of age declined by 5.5 percent (HRSA, 1993).
More recent data from the AHA indicate that inpatient admissions are increasing. A comparison of hospital data for the first quarter of 1995 and the first quarter of 1994 shows a 3.2 percent increase in total admissions. This rate of increase in admissions is the highest since 1976. The growth in admissions of persons 65 years and older accounts for a large part of this increase. While admissions show an increase, length of stay continues to decline, marked by a sharp decline of 7.8 percent among patients 65 years of age and older (AHA, 1995a). The drop in length of stay resulted in a decrease in inpatient days (see Table 3.2). Several factors in addition to cost containment influence inpatient length of stay, including reimbursement incentives, technological advances, and increased availability of home health care. The number of staffed beds in U.S. community hospitals has continued to decline since 1983. Between 1983 and 1993, the total number of staffed beds had dropped by more than 104,000 beds (AHA, 1995b (see Table 2.3 in Part II of this report). As seen in Table 3.2, this trend has continued in 1994 and 1995 (AHA, 1994c, 1995a).
Inpatient case mix also has changed in recent years, along with a strong trend toward higher levels of acuity (ProPAC, 1995). This increase in acuity can be attributed to several factors, including movement of less complex services out of
TABLE 3.2 Percent Change in Inpatient Community Hospital Utilization, United States, 1994–1995
Percent Change Quarter Ending March 1994–1995
Inpatient admissions
Patients ≥ 65 years
Adjusted admissions
SOURCE: American Hospital Association, National Hospital Panel Surveys, March Panel, 1994, 1995.
the hospital or into outpatient services, and the pressures to reduce the length of stay stimulated by changes in reimbursement. The increased acuity of patients and the consequent complexity of inpatient hospital care and services require more specialized and intense nursing care than before. This is reflected in the increased use of special care units such as the intensive care units (ICU) in hospitals. The number of staffed beds in ICUs in community hospitals increased by 29 percent between 1983 and 1993. The percentage of total staffed beds that are ICU beds also rose during this period from 7.5 percent to nearly 11 percent in 1993. During the same period acute care beds dropped from nearly 82 percent to 64 percent (see Table 2.4 in Part II of this report).
Historically, the primary function of hospitals has been to treat acute illness and injury; prevention of disease and promotion of health have been the domain of the public health system and individual care givers. In the emerging health care system there are incentives to merge these two roles and to organize the entire continuum of care (Shortell et al., 1995). In an effort to maintain patient base as well as to capture market share, hospitals have extended the scope and type of services offered beyond the traditional acute inpatient services. They now emphasize prevention, health promotion, and primary care to a much greater degree than previously.
In responding to the need to reduce costs, hospitals have to some extent shifted the site of care and consequently some of the costs (Table 3.3). Changes in payment policies, incentives to treat patients in less costly sites, and technological advances have contributed to the shift for a growing number of services to
TABLE 3.3 Trends in Outpatient Visits and Other Selected Services Offered in Community Hospitals, United States, Selected Years, 1983–1993
Total Number of hospitals offering:
Hospice Program
Outpatient visits (in millions)
ambulatory care settings, to post-acute service settings such as skilled nursing facilities, or to home health care and rehabilitation services. This shift has resulted in substantial growth in the use of, and spending on, those areas. Hospital outpatient spending rose 290 percent between 1984 and 1993, while hospital inpatient expenditures went up only 82 percent (ProPAC, 1995). Spending for home health care also has grown rapidly. By 1993 expenditures for hospital-based home health care had reached about $4 billion (Levit et al., 1994).
While inpatient hospital use has been declining over the past decade, outpatient care, in terms of both the number of visits and the number of outpatient departments, has risen dramatically (Table 3.4). In 1993, approximately 88 percent of community hospitals reported having an outpatient department, compared to 54 percent in 1985. Furthermore, in 1993, community hospitals reported 367 million outpatient visits, an increase of about 5 percent from 1992 and 75 percent from the number reported in the early 1980s. The increase of outpatient surgeries accounts for much of the growth in outpatient visits. In 1993, more than half of all surgical procedures in community hospitals were performed on an outpatient basis, compared to 24 percent 10 years earlier (AHA, 1994a). Technological advances and cost-cutting efforts by payers have contributed to this growth.
Recently released data from the AHA National Hospital Panel Survey show a substantial increase in outpatient visits (AHA, 1995a). The percentage increase between 1994 and 1995 was 13 percent, the highest rate since 1970. (See Table 2.7 in Part II of this report.)
TABLE 3.4 Percent Change in Outpatient Community Hospital Utilization, United States, 1994–1995
Emergency visits
Clinic visits
In addition to the growth in outpatient services delivered on hospital premises, many hospitals are developing more hospital-based services to care for patients beyond the acute inpatient hospital care. They are also expanding their long-term care services. The principal factors prompting these changes include the growing numbers of elderly persons, children, and disabled adults requiring long-term, post-acute care; the shift away from long stays in the hospital; technological advances; and payer pressures to reduce hospital stays and to gain market share of the services.
Hospital-sponsored Home Health Services
The number of hospitals providing hospital-sponsored home health services increased from 29.7 percent in 1985 to 38.0 percent in 1992 and 42.2 percent in 1993 (AHA, 1994a). The growth in home health agencies was spurred by the inclusion of these benefits in Medicare. Home health services prior to that time were provided predominantly by public health departments and not-for-profit visiting nurse associations. Since that time, the growth of investor-owned chains and of hospital-sponsored or joint venture agencies has been substantial.
In recent years, the growth in the development of high-technology services such as ventilator care, enteral and parenteral nutrition, antibiotic therapy, and chemotherapy has also been rapid. Increasing use of these high-technology services in home health care has been stimulated by changes in hospital reimbursement.
Hospital-Based Skilled Nursing Units
Unoccupied hospital beds are being converted in some hospitals into post-acute skilled nursing units, hospice units, and special care centers. Patients are
''discharged" from the acute care inpatient hospital bed and admitted to the skilled nursing care or hospice unit or to their homes with provision of hospital-sponsored home health services.
Between 1983 and 1993 the number of hospitals reporting use of hospital-based skilled nursing services units more than doubled from 600 to 1,350. Areas with high AIDS caseloads have established special AIDS units. Other special care centers include cancer centers, transplant centers, designated high-level trauma centers, and neonatal intensive care units.
Although the nursing home sector of the U.S. health care system is not undergoing the rapid and intense turbulence occurring in the hospital sector, it is the recipient of seismic fallout from the epicenter of the earthquake (to continue Shortell's [1995] analogy). Fallout from the evolving patterns of reimbursement and delivery of care in hospitals, and other economic and demographic factors, are changing the characteristics of persons entering nursing homes and, therefore, the demand for nursing home beds. At the same time, persons needing primarily custodial care increasingly are looking for alternative long-term care settings. Hence, the sicker patients tend to concentrate in nursing homes. The increased acuity and disability of individuals needing long-term care are placing new types of demands on providers of care. This situation is exacerbated by the aging of the population.
The capacity of nursing homes to meet the increasing demand for services has been strained during the past decade. The demand for nursing home services and other long-term care services is growing with the increasing number of persons who are aged and chronically ill. The total number of licensed nursing facilities was about 16,600 in 1994 (AHCA, 1995). These nursing facilities had 1.67 million beds in 1994. Overall, the supply of beds in nursing facilities has not kept pace with the demand, especially in relation to the growth in the oldest-old population, those persons age 85 years and older (see Table 3.5). This demand will increase in the years ahead as the elderly represent an increasing proportion of the total population.
Occupancy measures the demand for nursing facility services and is often used as an indicator of an undersupply of beds. The occupancy rate in nursing facilities has remained high. The median occupancy rate nationwide was 93 percent in 1994. Wide variations are observed among states, from a high of 98 percent in Georgia, to 79 percent in Texas, to a low of 52 percent in Alaska (AHCA, 1995). Thus, some areas and states may have shortages of nursing home services and others may have an adequate or oversupply of nursing home beds (Swan and Harrington, 1986; Wallace, 1986; Harrington et al., 1992a, 1994a; Swan et al., 1993a; DuNah et al., 1995). In some states, such as Oregon, occupancy is down even when the supply is ratcheted down. Areas with shortages are
TABLE 3.5 Number of Licensed Nursing Home Beds per 1,000 Population Aged 85 and Older, by Region, Selected Years, United States, 1978–1993
Beds per 1,000 Persons 85 and Older
Total U.S.
SOURCE: DuNah et al., 1995.
of concern because they may limit access for those in need of services. This overall high occupancy rate reflects both the shortage of beds discussed above and the increase in patients discharged from hospitals needing subacute care and rehabilitative care (HCIA and Arthur Andersen, 1994).
The likely consequence of this shortage is that nursing facilities can be somewhat selective in their admission practices, and some have limited the access of individuals who may have the greatest need for services (Nyman, 1989a).
Forces Affecting Demand for Nursing Home Services
As the population ages and develops multiple chronic conditions, the need for long-term care (LTC) services, including nursing home care, will increase. The demand for nursing facilities to provide more complex services is growing in response to several trends, including increased age and disability of residents, medical technology, cost containment pressures, and government policies (Hing, 1989; Shaughnessy et al., 1990; Kanda and Mezey, 1991; Schultz et al., 1994).
The magnitude of the potential growth in demand is illustrated by the projected growth of the older population discussed in the previous chapter. Medical technology, formerly used only in the hospital, is being transferred to nursing facilities. The use of intravenous feedings and medication, ventilators, oxygen, special prosthetic equipment and devices, and other complex technologies has made nursing home care more difficult and challenging (Harrington and Estes, 1989; Shaughnessy et al., 1990). The kinds of services that are increasingly being provided in some nursing facilities are also creating a greater need for skilled nursing care, in particular, greater professional nursing involvement in the direct care of patients and in supervision, more clinical evaluation, and more financial and human resources.
Several federal government policy changes in the 1980s have contributed to
an increase in nursing home demand and government expenditures for nursing home services. As noted earlier in the chapter, the adoption of PPS led to early discharges from acute care hospitals and more referrals and admissions to nursing facilities (Guterman et al., 1988; Neu and Harrison, 1988; Latta and Keene, 1989; U.S. House of Representatives, 1990). Legislation in 1988 established a minimum level of asset and income protection for spouses when determining Medicaid nursing home eligibility, and this too contributed to an increase in Medicaid program costs (Letsch et al., 1992). These policy changes have all encouraged the demand for nursing home services and, thereby, increased Medicaid and Medicare outlays for this type of care.
Some states have also adopted policies to control Medicaid nursing home demand, including Medicaid eligibility policies and preadmission screening programs (Ellwood and Burwell, 1990; HCFA, 1992a,b; Harrington et al., 1994c). These policies may have had a constraining effect on demand and, consequently, on the growth of nursing home capacity.
Expenditures and Payments Policies
Expenditures for nursing home care reached about $70 billion in 1993 (Levit et al., 1994). As seen in Figure 3.1, unlike the hospital market, nursing home care is financed mainly by the government (63 percent in 1993) and out-of-pocket payments (33 percent in 1993). The Medicaid program paid 52 percent of the total bill in 1993; only 9 percent of nursing home care was financed by Medicare and 2 percent by private insurance.
Nearly 69 percent of the residents of nursing homes are recipients of Medicaid for at least some of their costs (AHCA, 1995). The limited role of private insurance and Medicare in paying for LTC distinguishes the long-term care market from the hospital market. Individuals who need nursing home care generally must pay for their own care out-of-pocket. The high cost of long-term care in nursing homes (about $30,000 to $50,000 per year) leads many individuals and families to spend down their resources, often to poverty levels. Those who exhaust their own resources before dying usually become eligible for Medicaid, which will then pay for their care over and above their complete social security and other retirement incomes.
Recent analysis by Spillman and Kemper (1995) shows that 44 percent of persons who use nursing homes after age 65 start as private payers, 27 start and end as Medicaid recipients, and 14 percent spend down assets to become eligible for Medicaid benefits. Of all persons 65 years of age, 17 percent can expect to spend some time using a nursing home and receiving Medicaid benefits; 3 in 5 of this group will have entered the nursing home already eligible for Medicaid.
As a consequence, a number of states have developed initiatives to reduce the strain on the state's budget. These efforts vary from state to state.
Cost Containment Policies
State Medicaid programs have undertaken a number of policy initiatives to control supply and reduce spending on nursing home care. This process began in the early 1980s, when federal budget cuts to state Medicaid programs became standard features of the budget process (Bishop, 1988).
Certificate of Need The most important policy affecting the supply of long-term care beds is the state's certificate-of-need (CON) program. The health planning and CON program established in 1974 (P.L. 94-641) gave states considerable authority and discretion to plan and control the capital expenditures for nursing facilities and other health facilities (Kosciesza, 1987). The effectiveness of CON policies in controlling bed supply has been widely debated (Cohodes, 1982; Friedman, 1982; Swan and Harrington, 1990; Mendelson and Arnold, 1993).
These controversies resulted in the repeal of the program in 1986. Even so, 44 states continued to use CON and/or moratorium policies to regulate the growth in nursing facilities in 1993 (Harrington et al., 1994a). Because of the cost pressures on states, we can expect most states to continue their efforts to limit the supply of nursing home beds even though their bed supply is not keeping pace with the aging of the population.
Medicaid Because Medicaid dominates the LTC market, Medicaid eligibility policies and reimbursement rates are of critical importance to both consumers and providers of nursing home care. The rapidly rising cost of care in a nursing facility, which is consuming an increasingly larger portion of the state Medicaid budget, has been a major concern to state policymakers. States have considerable discretion in developing Medicaid reimbursement methods and rates. Many states have undertaken initiatives to control the growth in nursing home reimbursement rates (Holahan and Cohen, 1987; Bishop, 1988; Nyman, 1988a; Holahan et al., 1993; Swan et al., 1993a,b).
Until 1980, states were required to pay for Medicaid nursing home services on the basis of "reasonable costs"; many states used retrospective reimbursement systems to pay the costs of care (GAO, 1986). The Omnibus Budget Reconciliation Act of 1980 (OBRA 80) gave states greater flexibility in developing reimbursement systems. This provision, known as the Boren Amendment, allowed states to pay nursing facilities based upon what was "reasonable and adequate to meet the costs incurred by efficiently and economically operated nursing facilities in providing care."
Since 1980, there has been a pronounced shift away from retrospective reimbursement to prospective facility-specific methods (Swan et al., 1993a,b; 1994). In addition, the number of states with case-mix reimbursement has increased substantially (see Table 3.6). By 1996, about one-half of all state Medicaid
TABLE 3.6 Number of States by Medicaid Nursing Facility Reimbursement Method and by Number Using Case-Mix Reimbursement, United States, 1979 and 1993
Total number of statesa
Reimbursement methodb
Prospective, facility-specific
Prospective, class
Prospective, combination
States using case-mix reimbursement
Average Medicaid per diem rate
a The total number of states includes the District of Columbia.
b The total number of states for 1979 does not add up to 50 states as Arizona did not have a Medicaid program in 1979.
SOURCE: Swan et al., 1994.
programs are expected to be using case-mix reimbursement. Medicaid nursing home reimbursement methods are primarily prospective and vary substantially across states. These methods create wide variations in rates and have dramatic impact on nursing home expenditures and staffing (described in chapter 6).
Medicare Medicare accounts for 9 percent of nursing home expenditures. Medicare retrospective payment methods based on reasonable costs have been widely criticized as inflationary (Schieber et al., 1986; Holahan and Sulvetta, 1989). Because prospective reimbursement systems have been shown to reduce costs in the hospital sector, the Health Care Financing Administration (HCFA) is considering this approach. Congress in OBRA 93 has mandated that Medicare study prospective reimbursement as a means of controlling nursing facility costs. In response, HCFA is conducting a demonstration project to study prospective case-mix reimbursement for Medicare and for participating state Medicaid programs.
The challenge is for Medicare to control its share of the costs while ensuring access, appropriate care for resource-intensive residents, and high quality of care (Holahan and Sulvetta, 1989; Weissert and Musliner, 1992a,b).
Alternative Sites of LTC Care
Federal Medicare policies have dramatically expanded coverage for alternatives to care in nursing facilities during the past 5 years. This expanded coverage encouraged the rapid growth in home health care agencies and in the volume of such services (Letsch et al., 1992; NAHC, 1993). Federal and state policies have also expanded alternatives to institutional care under the Medicaid home and community-based waiver programs (Justice, 1988; Lipson and Laudicina, 1991; Gurny et al., 1992; HCFA, 1992b; Miller, 1992; Folkemer, 1994). The net effect of all these programs is not clear; these types of programs may be reducing the demand for nursing facility care in some areas or the programs themselves may be growing as a response to the limited supply of nursing home beds in some areas.8
As seen in Table 3.7, growth in the nursing home industry is slower than that observed in alternative types of LTC facilities. The total number of licensed nursing facilities in 1993 was 16,959 (DuNah et al., 1995). These facilities had 1.74 million beds. While the growth in licensed nursing facilities has hovered around 2 percent per year for the past several years, and only 1 percent between 1992 and 1993, the increase in residential care facilities, including board and care, personal care, foster care, and/or assisted living facilities, has been rapid. In 1993, there were 39,080 licensed residential care facilities for the aged with about 642,600 beds (Harrington et al., 1994b). According to the National Health Provider Inventory, in 1991, there were nearly 13,170 board and care facilities with 120,636 beds for the mentally retarded (NCHS, 1994). These facilities do not have skilled nursing care and are not eligible for Medicaid and Medicare payments. During the period 1983–1993, the growth in residential care beds for the aged has been about 11 to 12 percent annually (Harrington et al., 1994c).
In 1993, home health care was provided to about 1.4 million persons per day by 7,000 home health agencies (NCHS, 1993a). Three-quarters of home health patients were 65 years of age and over, and almost 20 percent were 85 years and older. Two-thirds of home health patients were women. Among the home health patients in 1993, about one-half of the admission diagnoses were for the following six conditions: diseases of the heart and hypertension (17 percent); injury and poisoning (9 percent); diabetes (7 percent); and cerebrovascular diseases, malignant neoplasms, and respiratory diseases (6 percent each).
The number of licensed home health care agencies increased by 24 percent just between 1992 and 1993, and licensed adult day care agencies increased by 41
A full discussion of the growth of alternative LTC facilities and services is beyond the scope of this study. The reader is referred to another IOM study that defines issues relating to quality of LTC services in home and community-based settings (IOM, 1996). A larger study currently is in the planning stages.
TABLE 3.7 Number of Licensed Long-Term Care Facilities, United States, 1992 and 1993
Intermediate care facilities for the mentally retarded
Residential care facilitiesa
Adult day care agencies
a Includes board and care, personal care, assisted living, and other categories of residential care for the aged that are licensed by states. Categories vary by state.
SOURCE: Harrington et al., in press.
percent in the same period. This growth can be expected to continue, but the growth in this sector generally does not involve skilled nursing personnel. In 1993, expenditures for home health care reached nearly $21 billion, (not including the $4 billion spent for care provided by hospital based home health care). Public financing accounted for nearly one-half of the expenditures for home health care (Levit et al., 1994).
Restructuring of the Nursing Home Industry
Nursing facilities, like other sectors of the health industry, are consolidating into larger health care organizations. Although not as rapidly and widespread as the hospital industry, the nursing homes are diversifying in the services they offer. HCIA and Arthur Andersen (1994) report that 23 of the 25 largest nursing home chains were involved in acquisitions in 1993. Nursing homes and chains are also forming integrated networks of services with hospitals, physicians, subacute care providers, home health care, and other relevant providers. Despite the recent movement toward consolidation within the industry, nursing home chains control only about 35 percent of the market and the 20 largest chains operate only 18 percent of the nursing home industry (HCIA and Arthur Andersen, 1994).
Many providers are developing their own home- and community-based divisions or affiliating with existing providers of those services. Approximately 4 percent of nursing facilities were offering these services in 1992. Nursing facilities are also expanding to cover services such as specialty care, rehabilitation, adult day care, assisted living, and respite care. Approximately 22 percent of all nursing facilities currently offer assisted living services. Some nursing homes are shifting from being primarily a place for custodial care to being facilities with
residents receiving short-term rehabilitative care and other complex care requiring high technology such as ventilator-dependent patients discharged from the hospital who need subacute care skilled nursing services (AHCA, 1995).
Special Care Units
In the 1980s, special care units (SCU) emerged as an important intervention for care of persons with special needs, ranging from care requiring high technology to care for dementia. Increasing numbers of nursing facilities are shifting from traditional custodial long-term care to a more specialized level of care (AHCA, 1995). Today more than 1 in 10 nursing facilities have a special unit or program for people with dementia, with more than 1,500 SCUs.
By 1994, nearly 90,000 beds were dedicated to special care. Most of these beds are dedicated to residents with Alzheimer's disease or those needing special rehabilitation services. The most dramatic increase has been in ventilator care beds, from 3,162 in 1993 to 13,291 in 1994. Beds dedicated to special rehabilitative patients increased by 2000 and beds dedicated to AIDS patients grew by 2,300 between 1993 and 1994. Although there is much diversity among SCUs, most incorporate some type of physical modification, including security measures to limit egress, specialized activity programming for residents, and special training for staff, who are often permanently assigned to the unit. These units do not focus only on older adults in the later stages of life, but their development is fueled by Medicare's hospital PPS and other payers of health care (Lyles, 1986; Ganroth, 1988; Swan et al., 1990; AHCA, 1995).
Subacute Care Units
Nursing homes are also expanding to cover subacute care. Subacute care is increasingly becoming acceptable as an alternative to cost-effective health care delivery model. Subacute care units of nursing facilities are emerging in response to the need to provide care to patients who suffer from medical conditions or are recovering from surgical procedures and require a broad range of medical and rehabilitative services. More than 50 percent of nursing home admissions today come from hospitals, and most patients need care for unstable medical conditions. The subacute care option is favored by payers because nursing facilities generally can provide such care at lower cost than hospitals. Many subacute care programs are clinically and therapeutically comparable to the medical, surgical, and rehabilitation units of an acute care hospital, yet the cost of care in a subacute care unit is about 40 to 60 percent less than comparable care in an acute care setting. The higher reimbursement rate for subacute care is also attractive to nursing facilities. Although hospitals are ahead of nursing facilities in establishing subacute care units, several major nursing home chains are rapidly moving into this area. At the present time, more than 10 percent of nursing facilities offer
some type of subacute care. Many more skilled nursing facilities and hospital-based skilled nursing units are developing and implementing subacute care programs. Today, more than 15,000 beds are dedicated for subacute care. Growth in subacute care is projected from $1 billion today to $10 billion by year 2000. (Stahl, 1995b).
Rules related to quality assessment and quality improvement, personnel requirements, and admissions practices have been set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which has recently incorporated subacute care into its survey process. Outcomes, physical plant, and physician credentials are three major areas addressed in JCAHO Accreditation Standards for Subacute Units (Stahl, 1995a).
Implications For Nursing Services
The above narration is a brief overview of the rapid and perhaps fundamental changes occurring in the health care system and the movement toward a continuum of care. Redesign and reengineering have become principal strategies of the 1990s for many health care organizations. Institutional care—hospitals and nursing homes—and the personnel who provide the care are particularly affected.
Although the issues affecting the nursing home industry are somewhat different in kind and intensity from those in hospitals, they have not escaped the effects of the health care transition. Under sustained cost pressures, most states are expected to continue their efforts to limit the supply of nursing home beds, even though the bed supply in many states may not be keeping pace with the aging population. The challenge is to match staffing levels and skills to the changing characteristics of the residents.
The focus of care is shifting. The emphasis is no longer on inpatient hospital care; rather, hospitalization is viewed as one event in a patient-based continuum of care. Health care providers, physicians, and nursing staff are increasingly called upon to change the way they deliver patient care. The model has changed to care delivered across a continuum, not focused on a particular episode of hospitalization, through the use of teams, case managers, and protocols. All these efforts have led to changes in the nursing delivery patterns developed mostly over the last two decades for organizing the delivery of nursing care in hospitals. Such a major transformation of the health care environment cannot be accomplished successfully without support of the nursing professions and without changes in management and governance structures (Shortell et al., 1995; VHA, 1995).
Changes that affect any single part of the health care sector will have implications for the work of nursing personnel and the outcomes expected from their respective contributions. Clearly, given that there are more than 3 million nursing personnel, the number of interactions they have with others in the system is potentially limitless and, therefore, of great relevance.
The transformation of hospitals, nursing homes, and other health care orga-
nizations will continue to grow as organizations expand their search for solutions to issues brought about by reform and change in an environment that is increasingly drawn toward delivery of less costly and noninstitutional care. Just as the hospital of the future will serve only very sick patients requiring highly complex care, the nursing home of tomorrow will also serve patients with serious disabilities and with rehabilitative and other subacute care needs. The rest of the population will increasingly receive care in outpatient units, home- and community-based settings, assisted living facilities, and similar settings.
Next: 4 Nursing Personnel in a Time of Change »
Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? Get This Book
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Hospitals and nursing homes are responding to changes in the health care system by modifying staffing levels and the mix of nursing personnel. But do these changes endanger the quality of patient care? Do nursing staff suffer increased rates of injury, illness, or stress because of changing workplace demands? These questions are addressed in Nursing Staff in Hospitals and Nursing Homes, a thorough and authoritative look at today's health care system that also takes a long-term view of staffing needs for nursing as the nation moves into the next century. The committee draws fundamental conclusions about the evolving role of nurses in hospitals and nursing homes and presents recommendations about staffing decisions, nursing training, measurement of quality, reimbursement, and other areas. The volume also discusses work-related injuries, violence toward and abuse of nursing staffs, and stress among nursing personnel--and examines whether these problems are related to staffing levels. Included is a readable overview of the underlying trends in health care that have given rise to urgent questions about nurse staffing: population changes, budget pressures, and the introduction of new technologies. Nursing Staff in Hospitals and Nursing Homes provides a straightforward examination of complex and sensitive issues surround the role and value of nursing on our health care system.
Front Matter i–xvi
2 Implications of Population Change 31–41
3 Evolving Health Care Scene 42–67
4 Nursing Personnel in a Time of Change 68–91
5 Staffing and Quality of Care in Hospitals 92–127
6 Staffing and Quality of Care in Nursing Homes 128–168
7 Staffing and Work-Related Injuries and Stress 169–188
Appendixes 193–194
Appendix A: Presentations Made to the Committee 195–196
Appendix B: Liaison Panel 197–198
Appendix C: Separate Statement and Responses 199–204
Appendix D: Acronyms 205–208
Biographical Sketches of Committee Members 230–238
Part II: Resources for the Study 239–240
1 Study Activities 241–276
2 Statistical Resources 277–305
3 Commissioned Papers 306–307
Quality of Care, Organizational Variables, and Nurse Staffing 308–332
Professional Nursing Education - Today and Tomorrow 333–360
Nursing Staff and Quality of Care in Nursing Homes 361–425
Quality of Care and Nursing Staff in Nursing Homes 426–452
Nursing Facility Quality, Staffing, and Economic Issues 453–502
Nursing Injury, Stress, and Nursing Care 503–532
Index 533–542


text:
Dallas mayor disavows 'key' presentation to Vick
DALLAS (AP) —The Mayor of Dallas says he did not sanction giving Philadelphia Eagles quarterback Michael Vick a "key to the city."
Vick won The Associated Press Comeback Player of the Year award this past season, his second in the NFL since serving 18 months in prison for operating a dogfighting operation.
Mayor Pro Tem Dwaine Caraway presented the key at a ceremony in Dallas last week. In a statement issued Monday, Mayor Tom Leppert distanced himself from the gift.
"The action taken was not sanctioned by my office and was not an official ceremonial honor on behalf of the city of Dallas," he said.
He said "official keys to the city" are presented by the mayor or an elected official designated by the mayor and are reserved for "an elected official of international status."
"Clearly, this was not the case in this situation and one without my knowledge or approval," he said.
In his own statement, Caraway said the key was "ceremonial."
"These ceremonial gifts are different from the official keys to the city presented by the mayor," he said.
As for honoring a convicted felon, Caraway said, "I care deeply about animals" and "am deeply sorry to offend anyone who loves animals."
He acknowledged Vick's past but noted that "since making some bad choices, Michael Vick has devoted time to speaking to children about staying in school staying away from drugs, making positive choices about picking friends and the importance of education. That was the focus of the event."
Leppert said he has asked the city manager to "propose guidelines to prevent this situation in the future. Caraway said he would "welcome a clarification of the guidelines."
Copyright 2011 The Associated Press.

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text:
Q: How do I connect installed module to python shell? I have downloaded 'numpy' by using
pip install numpy

and it says that my installation is successful. I have also installed python 3.7.3 on Windows, but everytime I try to import numpy on the python shell, I get the following error:
Traceback (most recent call last):
  File "<pyshell#1>", line 1, in <module>
    import numpy as np
ModuleNotFoundError: No module named 'numpy'

How do I 'connect' my already installed numpy to the actual python shell?

A: pip most likely belongs to Python 2. For Python 3, it would normally need to be pip3.
You should usually avoid calling these executables directly though, because it is not well defined which instance of Python they belong to if you have more than one version installed.
The recommended alternative is to call it as module with the exact interpreter you want:
python3 -m pip install numpy

A: numpy is connected automatically to the Python shell with import numpy as np if you install numpy from the default Ubuntu repositories. In all currently supported versions of Ubuntu open the terminal and type:
sudo apt install python3-numpy

redpajama_set_name: RedPajamaStackExchange


text:
Open Access Published by De Gruyter Open Access October 22, 2008
Young syncopal man and decision about permanent cardiac pacing
Malgorzata Lelonek , Adam Stanczyk and Jan Goch
From the journal Open Medicine
Download article (PDF)
A 20-year old man experienced recurrent syncope, that suggested a partially neutrally-mediated mechanism, but in some cases were without a prodrome. The tilt test was negative. The 12-lead ECG and electrophysiological study showed first-degree AV block. Syncope in bradyarrhythmia was suspected and an implantable loop recorder was indicated. In the first month after implantation the patient experienced one syncopal episode. In the stored ECG, AV junctional rhythm was detected. The patient received a pacemaker and symptoms improved.
Keywords: Syncope; Implantable loop recorder; Pacemaker
[1] Brignole M., Alboni P., Benditt D., Bergfeldt L., Blanc J.J., Thomsen P.E., et al., Guidelines on management (diagnosis and treatment) of syncope-update 2004. Executive summary, Eur. Heart J., 2004, 25, 2054–72 Search in Google Scholar
[2] Strickberger S.A., Benson D.W., Biaggioni I., Callans D.J., Cohen M.I., Ellenbogen K.A., et al., AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society, Circulation, 2006, 113, 316–27 http://dx.doi.org/10.1161/CIRCULATIONAHA.105.17027410.1161/CIRCULATIONAHA.105.170274Search in Google Scholar
[3] Assar M., Krahn A., Klein G., Yee R., Skanes A., Optimal duration of monitoring in patients with unexplained syncope. Am. J. Cardiol., 2003, 92, 1231–1233 http://dx.doi.org/10.1016/j.amjcard.2003.07.04210.1016/j.amjcard.2003.07.042Search in Google Scholar
[4] Krahn A., Klein G., Yee R., Hoch J., Skanes A., Cost implications of testing strategy in patients with syncope: randomized assessment of syncope trial, J. Am. Coll. Cardiol., 2003, 42, 495–501 http://dx.doi.org/10.1016/S0735-1097(03)00659-410.1016/S0735-1097(03)00659-4Search in Google Scholar
[5] Sagrista-Sauleda J., Romero-Ferrer B., Moya A., Permanyer-Miralda G., Soler-Soler J., Variations in diagnostic yield of head-up tilt test and electrophysiology in groups of patients with syncope of unknown origin, Eur. Heart J., 2001, 22, 857–865 http://dx.doi.org/10.1053/euhj.2000.239810.1053/euhj.2000.2398Search in Google Scholar PubMed
[6] Fujimura O., Yee R., Klein G., Sharma A., Boahene K, The diagnostic sensitivity of electrophysiologic testing in patients with syncope caused by transient bradycardia, N. Engl. J. Med., 1989, 321, 1703–1707 10.1056/NEJM198912213212503Search in Google Scholar PubMed
[7] Vardas P.E., Auricchio A., Blanc J.J., Daubert J.C., Drexler H., Ector H., et al., Guidelines for cardiac pacing and cardiac resynchronization therapy. The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in Collaboration with the European Heart Rhythm Association, Eur. Heart J., 2007, 28, 2256–2295 http://dx.doi.org/10.1093/eurheartj/ehm30510.1093/eurheartj/ehm305Search in Google Scholar PubMed
© 2008 Versita Warsaw
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
Lelonek, Malgorzata, Stanczyk, Adam and Goch, Jan. "Young syncopal man and decision about permanent cardiac pacing" Open Medicine, vol. 3, no. 4, 2008, pp. 505-509. https://doi.org/10.2478/s11536-008-0033-y
Lelonek, M., Stanczyk, A. & Goch, J. (2008). Young syncopal man and decision about permanent cardiac pacing. Open Medicine, 3(4), 505-509. https://doi.org/10.2478/s11536-008-0033-y
Lelonek, M., Stanczyk, A. and Goch, J. (2008) Young syncopal man and decision about permanent cardiac pacing. Open Medicine, Vol. 3 (Issue 4), pp. 505-509. https://doi.org/10.2478/s11536-008-0033-y
Lelonek, Malgorzata, Stanczyk, Adam and Goch, Jan. "Young syncopal man and decision about permanent cardiac pacing" Open Medicine 3, no. 4 (2008): 505-509. https://doi.org/10.2478/s11536-008-0033-y
Lelonek M, Stanczyk A, Goch J. Young syncopal man and decision about permanent cardiac pacing. Open Medicine. 2008;3(4): 505-509. https://doi.org/10.2478/s11536-008-0033-y
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text:
Endswell Pharmacy provides free medical care in four communities in UER
Bolgatanga,– Endswell Pharmacy, a private community pharmacy in the Bolgatanga Municipality has organized free medical screening exercise for four communities in Bolgatanga East District and neighboring communities near Nabdam district of the Upper East Region.
The beneficiary communities included; Kango, Zuarungu-Nyorkoko, Sakaribisi and Tangabisi.
Mr Lawrence Atongo, Proprietor of Endswell Pharmacy, in an interview with the Ghana News Agency (GNA) after the exercise, said the Pharmacy derived profit from services it rendered to members of the various communities and outside the Bolgatanga Municipality.
Therefore, as part of services it rendered to members of the public, the proprietor said management of the Pharmacy decided to organize the free screening to give back to the community as its corporate social responsibility.
"We thought it wise to galvanize the small resources we have, to give back to society through this free medical screening exercise, with the health professionals to screen the community members for various health conditions," he said.
Mr Atongo, who is also a Pharmacist, said it was the wish of management of Endswell Pharmacy to scale up the exercise to other communities across the Region, "This is just the beginning, we are hopeful that by the grace of God, we would be able to scale it up to other communities in the Region."
He said a healthy community is a collective responsibility, and called on members of the public, especially health professionals, benevolent individuals to support his outfit with needed expertise and that in a way will complement efforts of the Ghana Health Service to improve health care delivery in the Region.
The Pharmacist said management of Endswell Pharmacy also provided free medicines as part of the screening exercise to participants found with health problems, after which they took time to educate them on simple health conditions to ensure they lived healthy lifestyles.
Mr Desmond Yaani, an Ophthalmic Nurse who led the team of health professionals, told the GNA that 100 people from the beneficiary communities turned out for the screening exercise.
He said the team assessed among other conditions, Blood Pressure (BPs), Random Blood Sugar (RBS) levels, weight, and temperatures and ran Rapid Diagnostic Tests for malaria on all the participants.
He said the team also examined the eyes, ears, noses and throats of the participants to rule out any abnormalities and conditions of the vital organs as some people do not seek medical checkup, unless they had problems with those organs.
He disclosed that some of the beneficiaries screened had some eye conditions including; mature and immature cataracts, allergic conjunctivitis, while others had ear, nose and throat conditions such as otitis media, impacted wax, acute rhinosinusitis, Respiratory Tract Infections among others, and encouraged them to seek medical attention at health facilities.
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ABCA1 overexpression leads to hyperalphalipoproteinemia and increased biliary cholesterol excretion in transgenic mice.
Mild dyslipidemia in mice following targeted inactivation of the hepatic lipase gene.
Overexpression of human lecithin cholesterol acyltransferase leads to hyperalphalipoproteinemia in transgenic mice.
Overexpression of hepatic lipase in transgenic rabbits leads to a marked reduction of plasma high density lipoproteins and intermediate density lipoproteins.
Identification of apolipoprotein B-100 low density lipoproteins, apolipoprotein B-48 remnants, and apolipoprotein E-rich high density lipoproteins in the mouse.
Quantification of high-density-lipoprotein cholesterol by precipitation with phosphotungstic acid/MgCl2.
Rat plasma lipoproteins: re-evaluation of a lipoprotein system in an animal devoid of cholesteryl ester transfer activity.


Recently, Wabco has been releasing a lot of new and exciting news. As there is a growing number of vehicles equipped with Automated Manual Transmissions, Wabco is expanding its portfolio of repair kits and available Mercedes spare parts to meet the needs of the high-quality aftermarket Mercedes truck spare parts market. With two new repair kits for the 2-position cylinder, Wabco has closed the gap in the repair options for the Mercedes AMT 3rd generation. The kits have been available since August this year and include the 2 Mechanical kit and the 2 Sealing kit.
For Wabco customers this means repairs are effortless and straightforward as the AMT devices are located on the outer surface of the transmission. This also helps stop leaks into the Electronic Control Unit which can add up to some costly repairs.
Wabco is offering an air processing unit for European trucks. Of course, a braking system can't function without both brake valves and a compressor. There are many functions integrated into an APU (Air processing Unit) or E-APU (Electronic Air Processing Unit) to make sure air is dried and cleaned before passing to the brake values, and that the whole air system continues to function properly over the long term.
Wabco offers a comprehensive range of air dryers and APUs. If your air dryer is poorly maintained issues including moisture penetrating into reservoirs and valves can cause corrosion, which can remain undetected for a long time and cause the failure of connected devices in the form of flash rust. The moisture that stays in these reservoirs reduces the volume of storage and therefore the number of brake operations that are possible while the engine is at a standstill or when the compressor fails. Drivers rely on the function of the air dryer and rarely use the drain valves of the reservoirs Lubrication fin the compressor results in small amounts of oil entering the compressed air space and this oil burns when heat is generated A lot of this combustion can be filtered out by the range of replaceable cartridges from the Wabco high-quality aftermarket European truck parts portfolio.
Wabco has released compressors for Mercedes Benz, and it's possible to exchange Voith air compressors in Mercedes Benz trucks with the OM 457 engines with Wabco compressors. This is another addition to the high-quality aftermarket Mercedes Benz truck spares range.
Wabco is a specialist in compressed air braking systems and the major vehicle manufacturers use a comprehensive range of Wabco braking products. The new Volvo B5LH Bus chassis list has just been released. The new high-quality aftermarket Volvo parts supplied by Wabco include a directional control valve, safety valve, 2 filter cartridge, spring brake, sensor, pressure limiting valve and an overflow valve.


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ROCOR Chooses Memorial Church to Honor Reunion
admin | 21 June 2012
The Synodal Cathedral Hosts Namesday Celebrations for the First Hierarch of the Russian Church Abroad
PRAVMIR. June 18, 2012. The Synod of Bishops of the Russian Orthodox Church Outside of Russia has chosen the Russian Orthodox Church of St. Seraphim of Sarov in Sea Cliff, NY, to be the memorial church in honor of the reunification between the Russian Orthodox Church Outside of Russia and the Moscow Patriarchate. A corresponding gramota will be issued to the clergy and parishioners of the church on August 1, the feast day of St. Seraphim of Sarov.
The church's frescoes, from the narthex to the main cupola, will depict the thousand-year history of the Russian Orthodox Church from the Baptism of Rus' to the signing of the Act of Canonical Communion in Moscow. Work on the frescoes has not yet been completed. The frescoes will depict the Holy Apostle Andrew the First-Called; Saints Vladimir and Olga, the Equals-to-the-Apostles; saints of Kiev and Muscovite Rus'; saints of the Synodal period; His Holiness, Patriarch Tikhon; the New Martyrs and Confessors of Russia; and the patron saints of those who worked for the unity.
The Act of Canonical Communion between the two parts of the Russian Orthodox Church was signed on May 17, 2007, by the late Patriarch Alexy II of Moscow and All Russia and the late Metropolitan Laurus, First Hierarch of the Church Abroad
PRAVMIR. June 18, 2012. The Synod of Bishops of the Russian Orthodox Church Outside of Russia has chosen the Russian Orthodox Church of St. Seraphim of Sarov in Sea Cliff, NY, to be the memorial church in honor of the reunification between the Russian Orthodox Church Outside of Russia and the ...
Russian Church official: let's not dramatize the Pan-Orthodox Council situation
Russian Church official: let's not dramatize the Pan-Orthodox Council situation
Metropolitan Onuphrius Expressed His Condolences to the Family of the Killed Clergyman of the Horlivka Diocese
Today, dialogue is the only civilized solution to all problems and perplexities, excluding the escalation of evil and…
Elder Ephraim gave a lecture "Contemporary Man and the Spiritual Life"
On Thursday, 23 January 2014, over 600 people filled a room at Eleon Loft in Athens to hear…


PUBLIC LAW 103-337—OCT. 5, 1994 108 STAT. 2887 (e) LIMITATION.—Of the amount authorized to be appropriated by section 301 for Cooperative 'Hireat Reduction programs, $25,000,000 may not be obhgated until the President submits to Congress the first report required under subsection (c). SEC. 1208. COORDINATION OF CERTAIN COOPERATIVE THREAT Reports REDUCTION PROGRAMS. (a) MiLITARY-TO-MlLITARY CONTACT PROGRAMS.—(1) None of the funds authorized to be appropriated in section 301 for Cooperative Threat Reduction programs may be obligated for activities under a military-to-military contact program until the Secretary of Defense and the Secretary of State submit to Congress a joint report on the coordination of military-to-military contact programs and comparable activities carried out under their respective jurisdictions. (2) The report shall cover the following programs and activities: (A) Defense and military-to-military contact programs to be carried out using funds authorized to be appropriated in section 301 for Cooperative Threat Reduction programs. (B) Military-to-military contacts and comparable activities that are authorized by section 168 of title 10, United States Code, as added by section 1316. (C) Programs authorized under chapter 5 of part II of the Foreign Assistance Act of 1961 (22 U.S.C. 2347 et seq.). (3) The report shall include a discussion of how the programs and activities referred to in paragraph (2) are carried out to maximize— (A) the effect of such programs and activities in enhancing United States foreign policy objectives; and (B) cost-efficiency in the conduct of the programs and activities. (b) REPORT. —Section 1207 of the Cooperative Threat Reduction Act of 1993 (title XII of Public Law 103-160; 107 Stat. 1777; 22 U.S.C. 5956), is amended by adding at the end the following new paragraph: "(5) A description of how all of the activities carried out under the authority of this title and other laws providing authority for cooperative threat reduction are coordinated with similar activities that are carried out under any other authority, including activities relating to military-to-military contacts, environmental restoration, and housing.". SEC. 1209. SENSE OF CONGRESS CONCERNING SAFE AND SECURE DIS- MANTLEMENT OF SOVIET NUCLEAR ARSENAL. (a) FINDINGS. — Congress makes the following findings: (1) It is a pressing national security challenge for the United States to expedite the safe and secure dismantlement of the nuclear arsenal of the former Soviet Union. (2) In particular, it is essential to expedite the return of strategic nuclear warheads from Ukraine, Belarus, and Kazakhstan and to expedite the safe and secure dismantlement of the nuclear delivery vehicles of Ukraine, Belarus, and Kazakhstan. (3) Leakage of nuclear materials and technology, and the continuing threat of emigration of scientists and technicians from the former Soviet nuclear weapons complex, pose a grave threat to United States national security and to international stability.


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Национальный проект «Малое и среднее предпринимательство и поддержка индивидуальной предпринимательской инициативы» — один из национальных проектов в России на период с 2019 по 2024 годы. В феврале 2020 года куратором проекта назначен первый вице-премьер Андрей Белоусов. Руководителем стал министр экономического развития Максим Решетников.

Описание
Национальный проект «Малое и среднее предпринимательство и поддержка индивидуальной предпринимательской инициативы» ставит целью расширение доступа субъектов малого и среднего предпринимательства (далее — МСП) к финансовым ресурсам, в том числе к льготному финансированию.

Он должен достичь следующего целевого показателя: увеличение численности занятых в сфере малого и среднего предпринимательства, включая индивидуальных предпринимателей, до 25 млн человек.

Проект должен решить следующие задачи:
 улучшение условий ведения предпринимательской деятельности, включая упрощение налоговой отчётности для предпринимателей, применяющих контрольно-кассовую технику;
 создание цифровой платформы, ориентированной на поддержку производственной и сбытовой деятельности субъектов малого и среднего предпринимательства, включая индивидуальных предпринимателей;
 совершенствование системы закупок, осуществляемых крупнейшими заказчиками у субъектов малого и среднего предпринимательства, включая индивидуальных предпринимателей;
 упрощение доступа к льготному финансированию, в том числе ежегодное увеличение объёма льготных кредитов, выдаваемых субъектам малого и среднего предпринимательства, включая индивидуальных предпринимателей;
 создание системы акселерации субъектов малого и среднего предпринимательства, включая индивидуальных предпринимателей, в том числе инфраструктуры и сервисов поддержки, а также их ускоренное развитие в таких областях, как благоустройство городской среды, научно-технологическая сфера, социальная сфера и экология;
 модернизация системы поддержки экспортёров, являющихся субъектами малого и среднего предпринимательства, включая индивидуальных предпринимателей, увеличение доли таких экспортёров в общем объёме несырьевого экспорта не менее чем до 10 процентов;
 создание системы поддержки фермеров и развитие сельской кооперации;
 обеспечение благоприятных условий осуществления деятельности самозанятыми гражданами посредством создания нового режима налогообложения, предусматривающего передачу информации о продажах в налоговые органы Российской Федерации в автоматическом режиме, освобождение от обязанности представлять отчётность, а также уплату единого платежа с выручки, включающего в себя страховые взносы.

Согласно паспорту проекта на сайте Правительства РФ, общий бюджет реализации нацпроекта «Малое и среднее предпринимательство и поддержка индивидуальной предпринимательской инициативы» составит 481,5 млрд. рублей, из которых 416,2 будут направлены из федерального бюджета, еще 11,4 из региональных, а 53,9 будут привлечены из внебюджетных источников.

Федеральные проекты в составе национального проекта «Малое и среднее предпринимательство и поддержка индивидуальной предпринимательской инициативы»:

 «Акселерация субъектов малого и среднего предпринимательства»
 «Популяризация предпринимательства»
 «Расширение доступа субъектов МСП к финансовым ресурсам, в том числе к льготному финансированию»
 «Создание системы поддержки фермеров и развитие сельской кооперации»
 «Улучшение условий ведения предпринимательской деятельности»

Календарь планируемых событий

 2019 – Число индивидуальных предпринимателей в малых и средних компаниях составит 19,6 млн. Доля малого бизнеса в ВВП страны составит 22,9%, а доля этого сектора в общем объеме несырьевого экспорта — 8,8%. Число самозанятых к концу года должно увеличится до 200 тыс.человек.
 2020 – Год предпринимательства в России. Число индивидуальных предпринимателей в малых и средних компаниях составит не менее 20,5 млн человек, а доля этого сектора в ВВП достигнет 23,5%. Разработка механизмов доступа малого бизнеса к фондовому рынку, а также организация комплекса услуг господдержки для предпринимателей в 40 центрах «Мой бизнес», где помощь смогут получить 4% субъектов МСП. С 1 июля 2020 года от обязанности предоставлять налоговую декларацию будут освобождены не менее 800 тыс. малых и средних предпринимателей.
 2021 – Общий объем закупок крупнейших заказчиков у малого и среднего бизнеса в 2021 году составит 3,8 трлн руб., а число занятых в этом секторе составит 21,6 млн.человек. Доля малого и среднего бизнеса в ВВП достигнет 25%, а доля субъектов МСП в общем объеме несырьевого экспорта — 9,25%. Количество малых и средних компаний, вышедших на зарубежные рынки при помощи Центра поддержки экспорта, составит 9,1 тыс.
 2022 – На создание и развитие государственных микрофинансовых организаций из бюджета выделят почти 7,3 млрд руб. — почти столько же, сколько за предыдущие три года. При этом всего в сфере малого и среднего бизнеса будут работать 22,9 млн человек, а доля этого сектора в ВВП достигнет 27,5%. Количество самозанятых к концу 2022 года составит 1,8 млн человек.
 2023 – Почти треть ВВП будет приходиться на малый и средний бизнес. Малым и средним компаниям будет организована поддержка уже в 100 центрах «Мой бизнес», доля охваченных малых предприятий составит 9%. Количество субъектов МСП, выведенных на зарубежные рынки при помощи центров поддержки экспорта, составит 13,3 тыс. Доля малого и среднего бизнеса в ВВП России к 2023 году составит 30%, а в несырьевом экспорте приблизится к 10%.
 2024 – Реализация механизма снятия барьеров для малого бизнеса. Число занятых в сфере малого и среднего предпринимательства составит 25 млн человек. Сектор будет давать 32,5% ВВП страны и 10% несырьевого экспорта. Объем закупок крупнейших заказчиков у малых предпринимателей составит 5 трлн руб., а число самозанятых — 2,4 млн человек.

Реализация
С 1 января 2019 года стартовала программа по открытию центров поддержки предпринимательства «Мой бизнес», площадки по оказанию комплексных услуг, где предприниматели могут оперативно проконсультироваться по оформлению кредита, получению господдержки в рамках действующих программам. К 1 декабря открылось 60 таких центров, которыми было предоставлено свыше 487 тысяч услуг, проведено почти 22 тысячи мероприятий, в которых приняли участие более 247 тысяч человек. Также стартовал эксперимент по применению специального налогового режима — налога на профессиональный доход — в 4 пилотных регионах: в Москве, Московской и Калужской областях, а также в Республике Татарстан. По состоянию на 1 ноября 2019 года количество самозанятых составило 261 тысячу человек.
На 2020 год показатель по количеству самозанятых определен 800 тысяч человек, а сам эксперимент будет расширен на 19 регионов. Помимо этого, комплекс мер по поддержке МСП включил доступ к микрозаймам и кредит по льготной ставке, не превышающей 8,5% годовых. Для участия в реализации этой программы кредитования субъектов малого и среднего бизнеса Минэкономразвития в июле 2019 года выбрали 90 уполномоченных банков.

В сентябре 2020 года министр экономического развития Максим Решетников заявил о готовности снизить ставки для кредитования бизнеса в рамках льготной
государственной программы «8,5%». Так называемая программа «8,5%» предусматривает предоставление кредитов по льготной ставке на приобретение основных средств, финансирование оборотных средств, рефинансирование кредитов, факторинг, лизинг, микрозаймы.
За 2 года реализации нацпроекта были созданы институты поддержки бизнеса и на федеральном, и на региональном уровнях и были настроены под национальные цели. Центры «Мой бизнес» работают в 84 регионах страны. По программе льготного кредитования по ставке 8,5% в рамках нацпроекта МСП заключено соглашений на 1 трлн рублей. Министр экономического развития Максим Решетников подчеркнул, что с 2021 года планируется снижение ставки льготного кредитования с 8,5% до 7%. Это станет одним из изменений обновленного нацпроекта МСП, направленного на создание благоприятных условий для работы самозанятых и рост их числа; создание условий для легкого старта и комфортного ведения бизнеса, в том числе переход с ЕНВД на альтернативные налоговые режимы; акселерация субъектов МСП; создание цифровой платформы МСП.

Число самозанятых в 2020 году превысило целевой показатель, который заложен в нацпроект МСП. Вместо зафиксированных в паспорте нацпроекта показателя в 800 тысяч, количество вновь зарегистрированных самозанятых на октябрь составило больше миллиона – 1 248 299, а концу года превысило 1,5 млн человек.
По итогам 2020 года крупнейшие заказчики заключили более 300 тысяч договоров с предприятиями малого и среднего бизнеса, а объем закупок достиг 2,5 триллионов рублей.

На апрель 2021 года согласно результатам опроса, проведенного АНО «Национальные приоритеты» совместно с Mail.ru Group, узнаваемость национального проекта составила 81%.

Примечания

Ссылки

 Паспорт нацпроекта "Малое и среднее предпринимательство" на официальном информационном портале "Будущее России. Национальные проекты"
 Инфографика основных параметров реализации национального проекта "Малое и среднее предпринимательство"

2000-е годы в России

redpajama_set_name: RedPajamaWikipedia


7) Must appear in person or have a representative present.
8) 10 days prior to the WPC meeting, email all this information to the Chair of the Wheaton Planning Commission to be placed on the agenda. (Chair email: wheaton.plancommissione@gmail.com) If the information is not received 10 days prior to the meeting, you will be placed on the following month's agenda.


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Johannesburg Things to Do – Attractions & Must See
Cities Feb 24, 2017
See recent posts by Virtual Tourist
As one of the most thriving cities in Sub-Saharan Africa, Johannesburg stands out as a city full of culture, extravagance, and fun. There are endless options of tourist attractions to see in Johannesburg, but here are a few that you can't miss.
Built on a former gold mine, Gold Reef City is a combination of a theme park, museum, casino, and hotel, established as a massive entertainment complex for locals and tourists alike. You can enjoy a tour of the gold mines or head straight for the roller coasters.
Apartheid Museum
Johannesburg has a rich history and many cultural attractions to see, but one of the more solemn destinations is the Apartheid Museum, one of the few museums in the city. The museum allows visitors to experience the troubling past of the city by literally experiencing segregation at the museum entrance to the many interactive exhibits throughout the museum.
Montecasino
One of three casinos in Johannesburg, the Montecasino is certainly the most popular. The Tuscan themed casino is built in the form of a city walk with many shops, cafes, and of course, slots, blackjack tables, and more. Some of the most entertaining sights include jugglers, acrobats, and fire breathers that perform around the casino.
Constitution Hill
For a taste of the old and new Johannesburg, head to Constitution Hill where you can tour the newly fledged democratic country's main court, and then walk over to former apartheid-era prisons and the Johannesburg Fort. The juxtaposition of the city's current seat of power next to the famous prisons where Nelson Mandela and Mahatma Gandhi were once imprisoned provide a remarkable glimpse into the Afrikaner culture and the nation's rugged history.
Nicknamed Soweto, the South Western Township is a neighborhood filled with history. It contains Nelson Mandela's old home and the Hector Pietersen Museum, which was named after a 12-year-old boy killed in the famous Soweto uprisings during the apartheid. In addition to witnessing the site of many riots that changed the political landscape of South Africa, you can also go bungee jumping at the township's famous disused cooling towers.
Editor's Note: The information contained on this page was compiled using real traveler reviews about things to do in Johannesburg.
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