Nursing Homes

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Definition

A nursing home is a long-term care facility licensed by the state that offers 24-hour room and board and health care services, including basic and skilled nursing care, rehabilitation, and a full range of other therapies, treatments, and programs. People who live in nursing homes are referred to as residents.

Description

Slightly over 5% of people 65 years and older occupy nursing homes, congregate care, assisted living, and board-and-care homes. At any given time, approximately 4% of the population are in nursing homes with the rate of nursing home use increasing with age from 1.4% of the young-old to 24.5% of the oldest-old. Nearly 50% of those 95 years old and older live in nursing homes. Nursing homes must meet the physical, emotional, and social needs of its residents.

Required Care Plans

There are federal laws regarding the care given in a nursing home, and it is essential that staff members become aware of these regulations. It is required that staff conduct a thorough assessment of each new resident during the first two weeks following admission. The assessment includes the resident's ability to move, his or her rehabilitation needs, the status of the skin, any medical conditions that are present, nutritional state, and abilities regarding activities of daily living.

In some cases, the nursing home residents are unable to communicate their needs to the staff. Therefore, it is particularly important for nurses and other professionals to look for problems during their assessments. Signs of malnutrition and dehydration are especially important when assessing nursing home residents.

It is not normal for an elderly person to lose weight. However, some people lose their ability to taste and smell as they age and may lose interest in food. This can result in malnutrition, which can lead to confusion and impaired ability to fight off disease.

Older people are also more susceptible to dehydration. Their medications may lead to dehydration as a side effect, or they may limit fluids because they are too afraid of uncontrolled urination. It is very dangerous to be without adequate fluid, so the nurse and other staff must be able to recognize early signs of dehydration.

When the assessment is complete, a care plan is developed. This plan is subject to change as changes in the resident's condition occur.

Nursing homes are often the only alternative for patients who require nursing care over an extended period of time. They are too ill to remain at home, with families, or in less structured long-term facilities. These individuals are unable to live independently and need assistance with activities of daily living (ADL). Some nursing homes offer specialized care for certain medical conditions such as Alzheimer's disease.

Commonly, nursing home residents are no longer able to participate in the activities they once enjoyed. However, it is required by law that these facilities help residents achieve their highest possible quality of life. It is important for residents to have as much control as possible over their everyday lives. Laws and regulations exist to raise nursing home quality of life and care standards.

By law, nursing homes cannot use chemical or physical restraints unless they are essential for treating a medical problem. There are many dangers associated with the use of restraints, including the chance of a fall if a resident tries to walk while restrained. The devices may also lead to depression and decreased self-esteem. A doctor's order is necessary before restraints can be used in a nursing home.

Licensing

The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) offers accreditation to nursing homes through the Long Term Care Accreditation Program established in 1966. This group helps nursing homes improve their quality of care. The JCAHO periodically surveys nursing homes to check on quality issues.

A nursing home may be certified by Medicare or Medicaid if it meets the criteria of these organizations. Families should be informed of the certifications a nursing home holds. Medicare and Medicaid are the main sources of financial income for nursing homes in the United States.

The state where a nursing home is located conducts inspections every nine to 15 months. Fines and other penalties may be enforced if the inspection reveals areas where the nursing home does not meet requirements set by that state and the federal government. Problem areas are noted in terms of scope and severity. The scope of a problem is how widespread it is, and the severity is the seriousness of its impact on the residents. When a nursing home receives an inspection report, it must post it in a place where it can be easily seen by residents and their guests.

Contract

When a resident checks into a nursing home, a contract is drawn up between the patient and the facility. This document includes information regarding the rights of the residents. It also provides details regarding services provided and discharge policies.

Resident Decision-Making

Decisions are made by each nursing home resident unless he or she has signed an advanced directive giving this authority to someone else. In order for health care decisions to be made by another person, the resident must have signed a document called a durable power of attorney for health care.

Costs

Nursing home care is costly. The rate normally includes room and board, housekeeping, bedding, nursing care, activities, and some personal items. Additional fees may be charged for haircuts, telephones, and other personal items.

Medicare covers the cost of some nursing home services, such as skilled nursing or rehabilitative care. This payment may be activated when the nursing home care is provided after a Medicare qualifying stay in the hospital for at least three days. It is common for nursing homes to have only a few beds available for Medicare or Medicaid residents. Residents relying solely on these types of coverage must wait for a Medicare or Medicaid bed to become available.

Medicare supplemental insurance, such as Medigap, assists with the payment of nursing home expenses that are not covered by Medicare.

Medicaid qualifications vary in each state. Families of potential residents should check with their state government to determine coverage options. According to a federal law, a nursing home that drops out of the Medicaid program cannot evict current residents whose care is supported by Medicaid.

Private insurance, such as long-term insurance, may cover costs associated with a nursing home. People may enroll in these plans through their employers or other group insurance policies.

In many cases, nursing homes are paid for by the residents' personal funds. When these funds are exhausted, the residents sometimes become eligible for Medicaid assistance.

Patients' Rights

It is important for the professionals working in nursing homes to be aware of the residents' rights. Residents are informed of their rights when they are admitted. Residents have the right to:

• manage their finances
• privacy (for themselves and their belongings)
• make decisions (unless advanced directives or durable power of attorney exist)
• see visitors in private
• receive information regarding their medical care and treatments
• have social services
• leave the nursing home after giving the required amount of notice (A stay in a nursing home is normally considered voluntary; however, the facility will consider a variety of factors before discharging a resident. These factors include the resident's health, safety and potential danger to self or others, as well as the resident's payment for services. The contract will state how much notice is required before a resident may transfer to another facility, return home, or move in with a family member.)

Family Involvement

In some cases, a nursing home is chosen after the family has only a short time to prepare for the change. For example, when a patient is unable to care for himself or herself due to a sudden illness or injury, the family must turn to nursing home care without having the luxury of researching this option over time. The nursing home's costs must be explained to the resident or family prior to admission. It is important for the nursing home staff to be willing to answer the family's questions and reassure them about the care their loved one will receive.

Nursing home professionals have an opportunity to continue to work closely with the resident's family and loved ones over the course of a resident's stay. In these facilities, concerned family members and friends of the resident are involved in his or her care, and may have guardianship or other decision-making responsibility. These individuals may voice their concerns through meetings between staff and family members. Those with legal guardianship are entitled to see a resident's medical records, care plans, and other related material.

Communication

As in other health care settings, communication among nursing home staff is very important. In nursing homes, the care is based on a team approach. Physicians, nurses, and allied health professionals work together to make sure the resident is able to experience the highest quality of life possible.

In many cases, physicians who have had a long-term relationship with a patient continue treatment after the patient has been admitted to a nursing home. It is important for the nursing home staff to leave blocks of time open in the schedule for physician visits. It is also the staff's duty to keep the personal physicians apprised of a resident's medical condition.

The resident, physician, and resident's legal guardian and family must be told immediately if any of the following situations arise: an accident involving the resident, the need for a major treatment change, and a decision regarding discharge or transfer. Unless an emergency arises, the nursing home must give 30 days written notice of discharge or transfer. The family may appeal the decision.

Results

The quality of care in nursing homes is an important issue. Quality issues include:

• Ratios of staff to patients. Advocacy groups are pushing for increased staff-to-patient ratios in nursing homes. The National Citizens' Coalition for Nursing Home Reform recommends one direct care staff (R.N., L.V.N., or C.N.A.) per five residents during the day shift, 10 residents during the evening shift, and 15 residents during the night shift.
• Elder abuse. It is important for nursing home personnel to look for signs of abuse or neglect when a resident checks in and during a resident's stay. Signs of abuse include bodily injuries that appear suspicious, visible harm to the wrist or ankles that may indicate the use of restraints, skin ulcers that seem neglected, poor hygiene, inadequate nutrition, unexplained dehydration, untreated medical problems, or personality disorders such as excessive nervousness or withdrawal. The nurse or allied health professional is to report any signs of abuse to the supervisor or physician.
• Reimbursement. Nursing home administrators report that reimbursements do not cover the expenses, while nursing home advocates would like a higher portion of revenues to be allocated for direct patient care.

Resources

Books

Birkett, D. Peter, M.D., ed. Psychiatry in the Nursing Home. 2nd Edition. Binghamton, NY: Haworth Press Inc, 2001.

Hosley, Julie B. and Elizabeth A. Molle-Matthews (Editor). Lippincott's Textbook of Clinical Medical Assisting Philadelphia, PA: Lippincott, Williams & Wilkins, 1999.

Rhoades, Jeffrey A. The Nursing Home Market: Supply andDemand for the Elderly (Garland Studies on the Elderly in America). New York, NY: Garland Publishers, 1998.

Organizations

American Nurses Association. 600 Maryland Ave. SW, Ste. 100 West, Washington, DC 20024. (800) 274-4ANA. http://www.nursingworld.org.

Centers for Medicare & Medicaid Services. 7500 Security Boulevard, Baltimore, MD 21244-1850. (410) 786-3000. (877) 267-2323. http://www.medicare.gov.

e-Healthcare Solutions, Inc., 953 Route 202 North, Branchburg, N.J. 08876. (908) 203-1350. Fax: (908) 203-1307. info@e-healthcaresolutions.com. http://www.digitalhealthcare.com/.

Joint Commission on Accreditation of Health Care Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. (630) 792-5000. http://www.jcaho.org.

The U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, D.C. 20201. (202) 619-0257. (877)-696-6775. http://www.hcfa.gov.

Other

Coates, Karen J. Senior Class. May 2002 [cited March 1, 2003]. http://www.nurseweek.com/news/features/02-05/senior.asp.

Domrose, Cathryn. Seasons of Change May 2002 [cited March 1, 2003]. http://www.nurseweek.com/news/features/02-05/longterm.asp.

— Rhonda Cloos, R.N.
Crystal H. Kaczkowski, M.Sc.

Nursing homes are residential health care facilities that provide nursing care and supervision twenty-four hours per day. In addition to skilled nursing services, physical, occupational, and speech therapy are usually offered. These therapies are designed to enable residents to recover and improve functional ability lost as a result of disease or injury. In addition, residents may receive social services and engage in recreational activities designed to improve physical and mental health. Residents also receive assistance with activities of daily living such as eating, dressing, walking, toileting, transferring between a bed and chair, and bathing. Typically, a nursing-home resident will need help in three or more of these activities of daily living.

Nursing homes form part of the continuum-of-care options available for persons with chronic or long-term health care needs. This continuum ranges from independent home care to care within intensive-care units of hospitals. Not all nursing homes are the same. Some nursing homes provide basic services, called "custodial services." Others, called "subacute" facilities provide highly skilled and technologically complex services that resemble medical units in hospitals. Many provide a mix of services.

Length of Stay

The average length of time that a person spends in a nursing home varies by the type of facility and the services rendered. For example, a person who resides in a nursing home in which he or she receives largely custodial services is likely to be there as long as several years. In fact, such a person will not usually return to an independent or community living environment. However, a person in a subacute facility is generally there only a matter of weeks. Such a person often receives intensive nursing or rehabilitation services and returns home or goes to an independent community environment.

Nursing-home residents generally have long-term health care needs that have resulted from one or more chronic illnesses, disabilities, or injuries. These conditions are rarely completely cured. Such conditions include, but are not limited to, strokes, fractured hips, arthritis, and mental confusion. These conditions often place a substantial burden on the health and economic status of individuals, affecting their quality of life and contributing to the decline of the person's overall ability to live independently.

Regulation

The nursing-home industry is the second most regulated industry in the United States, second only to the nuclear industry. Nursing homes are required to be licensed by state health departments. They are inspected at least annually to determine compliance with approximately 150 different state and federal regulations, and results of these inspections are available to the public. In addition, nursing homes are regularly inspected or reviewed by other state and local organizations including, but not limited to, fire marshals, sanitarians, and patient-advocate organizations. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) may accredit nursing homes that voluntarily meet certain health and safety requirements.

Financing

There are four basic ways to pay for nursing-home care. These include private funds, insurance, Medi-care and managed-care plans, and Medicaid. In general, people pay for approximately 25 percent of nursing-home care from their own personal financial resources. Basic room and board in a nursing home averages approximately $46,000 per year. Because of the costs, long-term care insurance is on the rise, and the extent of coverage varies greatly depending upon the insurance carrier and the individual policy. The American Association of Retired Persons (AARP) provides an analysis of the major insurance companies and their types of coverage. This information can be easily accessed through the Association's web site. Medicare and Medicaid are important governmental programs that provide coverage for nursing-home care.

Medicare. Medicare is a federal medical-insurance program that generally provides coverage to persons who are sixty-five years of age or older, persons of any age with permanent kidney failure, or those receiving Social Security benefits. Medicare coverage for nursing-home care is limited. Nursing homes that receive reimbursement from the federal Medicare program must be certified. All, or only part, of a facility may be designated as Medicare certified. A nursing home must meet the federal conditions of participation in order to be certified and maintain certification. During the annual state inspection or survey, compliance with the conditions of participation is assessed.

As of January 1, 2001, a person who is admitted to a skilled nursing facility within thirty days of a three-day hospital stay, and who is receiving care for the condition for which he or she was in the hospital, may receive up to one hundred days of either total or partial coverage from Medicare. The hundred days of coverage are not automatic. In order to qualify for Medicare benefits, the person must receive daily skilled nursing care or therapy services, and be certified for those services by a group of professionals, known as a utilization review committee, who reviews the case. If the person meets all of these requirements, he or she will receive coverage as follows:

• Full coverage for a semi-private room, meals, nursing care, rehabilitation therapy, drugs prescribed by the physician, medical supplies and equipment for the first twenty days
• Partial coverage for up to an additional eighty days if the physician and the reviewing professionals certify continued need for skilled services

Government statistics show that patients receive an average of twenty-four days of coverage under Medicare.

Medicaid. Medicaid is a program of health insurance for eligible low-income persons. Both the federal and state governments fund Medicaid. The program was not initially established to provide long-term coverage for persons in nursing homes; however, it has become the primary method of payment for low-income individuals in these facilities. While it varies from state to state, Medicaid pays for approximately 65 to 75 percent of nursing-home care. In order to receive payment from Medicaid, nursing homes must also be certified.

Individuals applying for Medicaid must do so through the county office of the U.S. Department of Human Services in their state. Medicaid applicants must meet both financial and medical eligibility criteria. In order to meet the financial criteria, an individual's assets must be less than $2,000; or $3,000 for a couple in the nursing home at the same time. Assets include cash, real and personal property (excluding the primary residence), cars, stocks, bonds, and the cash value of life-insurance policies, investments, and trusts—if the trust provides for the person's care.

Many people have too many assets at the time of admission to a nursing home to qualify for Medicaid. They must typically "spend down" their assets to meet the financial eligibility requirement. In the past, these spend-down requirements have often left the community-living spouse destitute. As a result, more liberal laws now provide for the financial protection of such spouses. As of January 2001, most states allow the spouse of a nursing-home resident to retain half of the couple's assets and the family home and furnishings, so long as these assets don't exceed a state established minimum. These laws are subject to review both at the state and federal level.

(SEE ALSO: Aging of Population; Geriatrics; Gerontology; Medicaid; Medicare)

Bibliography

American Geriatrics Society (1993). "Regulation and Quality of Care Standards in Nursing Facilities." Journal of the American Geriatrics Society 48(1): 1519–1520.

Besdine, R. W.; Rubenstein, L. W.; and Snyder, L., eds. (1996). Medical Care of the Nursing Home Resident: What Physicians Need to Know. Philadelphia, PA: American College of Physicians.

—— (1997). Unrealized Prevention Opportunities: Reducing the Health and Economic Burden of Chronic Disease. Atlanta, GA: Author.

Franklin, M. B. (2000). "Paying Today for Tomorrow's Care." Kiplinger's Personal Finance Magazine 54(1):114–116.

Hoffman, E. (2000). "Nursing Homes Don't Have to Break You." Business Week (November 20):169–170.

Schick, F. L., and Scick, R., eds. (1994). Statistical Handbook on Aging Americans. Phoenix, AZ: Onyx Press.

U.S. Department of Health and Human Services (1994). National Health Interview Survey on Disability (Phase 1). Hyattsville, MD: Author.

— MARIA R. SCHIMER