Nursing Homes

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. Other names for nursing homes are skilled nursing facilities (SNFs) and skilled nursing units (SNUs). There were about 16,100 nursing homes in the United States as of 2005. 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 housing, assisted living communities, and board-and-care homes. At any given time, approximately 4% of the population of the United States is 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. Some SNFs accept younger adults (anyone over the age of 18) who need physical or occupational therapy following an accident or illness. 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. Staff members are required to 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. Such persons 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 (ADLs). 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 (formerly the Joint Commission on the Accreditation of Health Care Organizations) 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 commission 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; 98.5% of nursing homes in the United States were certified to participate in one or both programs as of 2005. 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.

KEY TERMS

Activities of daily living (ADLs) —Self-care activities performed during the course of a normal day such as eating, bathing, dressing, toileting, etc.

Assisted living —A type of facility for people who are not able to live independently but do not require the level of skilled nursing provided by a nursing home.

Congregate housing —A type of housing arrangement for seniors that offers independent living in separate apartments as well as opportunities to share activities of daily living with other residents. Congregate housing does not usually involve assisted living or skilled nursing care, however.

Culture change —A term that refers to a movement in the United States to make nursing homes more resident-centered and less like hospitals.

Long-term care —Residential care over a period of time. A nursing home is a type of long-term care facility that offers nursing care and assistance with daily living tasks.

Medicaid —The federally funded program in the United States for state-operated programs that provide medical assistance to permanently disabled patients and to low-income people. Medicaid is the medical assistance provided in Title XIX of the Social Security Act.

Medicare —The federally-funded national health insurance program, provided for by Title XVIII of the Social Security Act in the United States for all people over the age of 65.

Restraint —A physical device or a medication designed to restrict a person's movement.

Skilled nursing facility (SNF) —Another name for a nursing home.

The state in which 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 problemis 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. To help with choosing a nursing home, Medicare has set up a Nursing Home Compare website at http://www.medicare.gov/NHCompare/ that allows users to search by geography, proximity, the name of the nursing home, or special focus.

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.

Culture change

Culture change refers to a movement to transform nursing homes into more homelike and less hospital-like communities. Spearheaded by groups like LIFESPAN, the Eden Alternative, and the Green House Project, people involved in changing nursing homes formed the Pioneer Network in 2000. The network advocates giving elders as much choice and self-determination as possible, including more opportunities for human companionship and keeping pets. As of 2004, nine states (Colorado, Florida, Illinois, Michigan, New Jersey, North Carolina, Pennsylvania, South Carolina, and Washington) had formed culture change coalitions.

The Pioneer Network drew up a list of values and principles that has been adopted by the NCCNHR (formerly the National Citizens' Coalition for Nursing Home Reform and other groups:

• Know each person.
• Each person can and does make a difference.
• Relationship is the fundamental building block of a transformed culture.
• Respond to spirit, as well as mind and body.
• Risk taking is a normal part of life.
• Put person before task.
• All elders are entitled to self-determination wherever they live.
• Community is the antidote to institutionalization.
• Do unto others as you would have them do unto you—yes, the Golden Rule.
• Promote the growth and development of all.
• Shape and use the potential of the environment in all its aspects: physical, organizational, psycho/social/spiritual.
• Practice self-examination, searching for new creativity and opportunities for doing better.
• Recognize that culture change and transformation are not destinations but a journey, always a work in progress.

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 NCCNHR recommends one direct care staff member (R.N., L.V.N., or C.N.A.) per five residents during the day shift, per 10 residents during the evening shift, and per 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 such personality disorders 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

BOOK

Baker, Beth. Old Age in a New Age: The Promise of Transformative Nursing Homes. Nashville, TN: Vanderbilt University Press, 2007.

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

Chapman, Reynolds C. Nursing Homes from A to Z: A Guide Designed to Educate Residents and Family Members in Navigating the Complex Environment of a Nursing Home. New York: iUniverse, 2007.

Frolik, Lawrence A. Residence Options for Older and Disabled Clients. Chicago: American Bar Association, 2008.

Weiner, Audrey S., and Judah L. Ronch, eds. Culture Change in Long-Term Care. New York: Haworth Social Work Practice Press, 2003.

PERIODICALS

Feng, Z., D. C. Grabowski, O. Intrator, et al. “Medicaid Payment Rates, Case-Mix Reimbursement, and Nursing Home Staffing-1996-2004.” Medical Care 46 (January 2008): 33–40.

Labossiere, R., and M. A. Bernard. “Nutritional Considerations in Institutionalized Elders.” Current Opinion in Clinical Nutrition and Metabolic Care 11 (January 2008): 1–6.

Marx, T. L. “Partnering with Hospice to Improve Pain Management in the Nursing Home Setting.” Journal of the American Osteopathic Association 105 (March 2005): S22–S26.

Reuben, D. B. “Better Care for Older People with Chronic Diseases: An Emerging Vision.” Journal of the American Medical Association 298 (December 12, 2007):2673–2674.

Robinson, S. B., and R. B. Rosher. “Tangling with the Barriers to Culture Change: Creating a Resident Centered Nursing Home Environment.” Journal of Gerontological Nursing 32 (October 2006): 19–25.

Winningham, R. G., and N. L. Pike. “A Cognitive Intervention to Enhance Institutionalized Older Adults' Social Support Networks and Decrease Loneliness.”

Aging and Mental Health 11 (November 2007): 716–721.

ORGANIZATIONS

American Nurses Association. 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910-3492. (800) 274-4ANA or (301) 628-5000. http://www.nursingworld.org.

Centers for Medicare & Medicaid Services (CMS). 7500 Security Boulevard, Baltimore, MD 21244-1850. (800) 633-4227. http://www.cms.hhs.gov/.

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

Joint Commission. One Renaissance Blvd., Oakbrook Terrace, IL 60181. (630) 792-5000. http://www.jointcommission.org.

National Center for Health Statistics (NCHS). 3311 Toledo Road, Hyattsville, MD 20782. (800) 232-4636. http://www.cdc.gov/nchs/.

NCCNHR (formerly the National Citizens' Coalition for Nursing Home Reform). 1828 L Street, NW, Suite 801, Washington, DC 20036. (202) 332-2275. www.nccnhr.org.

Pioneer Network. P.O. Box 18648, Rochester, NY 14618. (585) 271-7570. http://www.pioneernetwork.net/.

U.S. Department of Health and Human Services. 200 Independence Avenue, S.W., Washington, DC 20201. (202) 619-0257. (877) 696-6775. http://www.dhhs.gov/.

OTHER

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

NCCNHR. A Consumer Guide to Choosing a Nursing Home. Washington, DC: NCCNHR, 2007. Available online in PDF format at http://nccnhr.newc.com/uploads/NhConsumerGuide.pdf.

Rhonda Cloos R.N.

Crystal H. Kaczkowski M.Sc.

Rebecca Frey Ph.D.

NURSING HOMES

Nursing facilities, commonly called nursing homes, serve a small percentage of older adults. These facilities continue to be in the public-policy spotlight because of efforts to redefine their position in the long-term care system and because of ongoing efforts to enhance the quality of care they provide to their residents. Nursing facilities are defined here as facilities with three or more beds that routinely provide twenty-four-hour nursing care services to sick or disabled individuals; they may be certified by Medicare or Medicaid or licensed by the state as a nursing facility, and they may be freestanding or part of a larger facility. There are four major characteristics of nursing facilities: (1) facility characteristics, (2) resident characteristics, (3) financial characteristics, and (4) administration and staffing characteristics.

Facility characteristics

A nursing facility (NF) is a facility that has met Medicaid certification requirements. A skilled nursing facility (SNF) is one that has met Medicare certification requirements. Facilities that are part of hospitals and intermediate-care facilities for the mentally retarded (ICF-MR) are not included in this discussion.

In 1998, there were about 17,000 nursing facilities containing approximately 1.8 million beds and 1.6 million elderly and disabled residents in the United States. Six states—California, Illinois, New York, Ohio, Pennsylvania, and Texas—accounted for 37 percent of all nursing-facility beds (over 640,000 beds). Texas had the most nursing-facility beds (122,365). The total number of nursing facilities (and the number of licensed beds) fell slightly between 1998 and 1999. Nationwide, there were 49.7 beds per 1,000 persons age sixty-five or older in 1999, a drop of 4.2 percent from 51.9 beds in 1998. The average size of a nursing facility in 1997 was 107 beds. For the thirty-three largest chain-owned facilities, the average number of beds per facility in 1999 was 109, which was a 5.1 percent drop from the average of 115 beds in 1998.

Data from the 1997 National Nursing Home Survey revealed that approximately 77 percent of all facilities and 84 percent of all beds are certified by both Medicare and Medicaid. In 1997 the occupancy rate in all nursing facilities was about 88 percent, which is 5 to 10 percent, less than during the early 1990s. According to Manton and Gu, "there was a large absolute decline (415,000 persons) in the institutional population 1994 to 1999" (p. 3). Over 66 percent of the facilities are located in the Midwest and southern regions of the nation, and about 61 percent of the facilities are located in metropolitan areas.

The majority of nursing-facility beds in 1997 were owned by for-profit organizations (67 percent), followed by not-for-profit organizations (26.1 percent), with government-owned homes accounting for about 8 percent of all facilities. The consolidation of the nursing-home industry is reflected by the fact that between 1998 and 1999 the number of licensed beds in the nation's thirty-three largest nursing facility chains increased by almost 2 percent. These chains owned approximately 27 percent of all beds nationwide in 2000 with about 56 percent of all nursing homes in the United States being part of a chain.

A significant change in nursing facilities has been the addition of what has been called specialcare or subacute care units within nursing facilities. These units "have emerged in an effort to meet the needs of subgroups of residents such as those with Alzheimer's disease or with relatively short-term post-acute needs" (Wunderlich and Kohler, p. 22). The number of dementia-specific special care units has also grown and "as of 1996, nearly one in four nursing homes had at least one organized dementia care unit, wing, or program" (NIA, p. 41). As a result of this growth, the Centers for Medicare and Medicaid Services (CMS) now track information on special units for residents with Alzheimer's disease. In addition, the Alzheimer's Association has developed specific guidelines for special care units (SCUs) and the Joint Commission of Accreditation of Healthcare Organizations has developed SCU standards. These types of units continue to be viewed by operators, staff, and family members as a better alternative to traditional nursing-facility care. Because of the lack of a standard definition for SCUs, the National Institute on Aging has supported a number of projects to examine the nature and effectiveness of these units. One of the significant outcomes of this research has been the development and testing of a method for classifying SCUs, which has allowed for a more effective comparison of the care provided across different types of SCUs.

Resident characteristics

One established fact about older adults is that in general they are living longer and healthier lives. There has also been an increasing availability of alternatives to nursing facilities (e.g., assisted living) and an increased use of community-based services (e.g., home health care), with the result that the profile of the "typical" nursing facility resident has changed in significant ways since 1985. There are now three older women for every older man in nursing facilities. This ratio has not changed since 1985, but the percentage of white residents declined from 93 percent in 1985 to 89 percent in 1997. It is very common for women to be widowed at the time of admission. Persons sixty-five years and older using a nursing facility in 1997 had an average age at admission of 82.6 compared to 81.1 in 1985. A common approach used by health care providers to measure functional ability in older adults is activities of daily living (ADLs). This method consists of measuring changes in the person's ability to perform six ADLs. ADLs include such functions as bathing, dressing, and eating. The mean number of ADLs that nursing facility residents experienced difficulty in increased from 3.8 in 1985 to 4.4 in 1997 (Sahyoun et al.; Wunderlich and Kohler). The four ADLs that nursing facility residents receive the most assistance with are bathing (96 percent of residents), dressing (87 percent), toileting (56 percent), and eating (45 percent). Approximately 50 percent of nursing facility residents are over the age of 85. Because of these increases in levels of disability (which have lead to much higher levels of frailty) and the trend towards entering the facility later, operational and clinical challenges have increased for administration and staff, who now must care for sicker, frailer residents with more complex medical problems. These changes have occurred in the context of an "increased use of preadmission screening, expanded role of Medicaid home and community-based waivers, the introduction of Medicare and Medicaid managed care programs, the general trend toward prospective payment, and more rapid discharges from hospitals" (Wunderlich and Kohler, p. 22). As a result, "the services that were once provided in the hospital setting are now more frequently available in the nursing home setting; assisted living environments are starting to provide nursing care; and home health agencies deliver services that were once available only in acute care environments or nursing homes" (Fairchild, Knebl, and Burgos, p. 84).

In 1997, approximately 58 percent of residents were admitted to a nursing facility from a hospital or another nursing facility. Another one-third were admitted from their homes, and 40 percent of this group had been living alone. The most common diagnoses at the time of admission were cardiovascular disease, mental and cognitive disorders, and disorders of the endocrine system (i.e., diabetes mellitus); and, almost without exception, residents had more than one diagnosis when they were admitted. These conditions often contribute to functional decline, which can impact ADLs and instrumental activities of daily living (IADLs) such as shopping and taking medication. When combined with other risk factors, such as living alone and low income, these conditions make it more and more difficult for a person to remain independent, increasing the risk for admission to an institutional environment such as a nursing facility.

Financial characteristics

The government's current expenditures for health care clearly favor nursing-facility care, which is costly—a conservative estimate put the cost of a nursing-home stay at $47,200 per year in 1999. Total nursing-facility care expenditures in 2000 were $92 billion, compared to $40 billion in 1988. The Congressional Budget Office (CBO) projects the nation's expenditures for long-term care services for the elderly will exceed $108 billion by the year 2010. The largest portion of these expenditures ($52 billion) will come from Medicaid; out-of-pocket expenditures will exceed $29.3 billion; Medicare will account for $16 billion; and private long-term providers will account for $11.2 billion. Medicare, which was designed to pay mostly for acute care or hospital costs, has historically paid for a very small portion of nursing facility care; this is expected to continue into the future, while long-term care insurance will likely play a more significant role. The growth in expenditures for nursing-facility care is projected to accelerate over this decade because of a number of factors, including rising provider costs in such areas as labor and liability rates. The CBO estimates that inflation-adjusted expenditures for long-term care for the elderly will grow annually by 2.6 percent between 2000 and 2040.

In 1997, average daily charges ranged from $136 for skilled care to $109 for intermediate care. For certified Medicaid beds, rates averaged $98, while Medicare rates were $216 per day. Across these rate categories, significant differences occurred based on such factors as ownership status and region of the country. For example, the rate for a skilled bed operated by a proprietary facility in 1997 was $139 per day, compared to $147 per day for a not-for-profit facility. The average daily rate for that same skilled bed in the northeast was $176, compared to a low of $115 in the South. Between 1990 and 2000, the desire of providers to fill a bed with a Medicare patient depended on the type and level of reimbursement and regulations. Currently, many providers are attracted to the Medicare program because of the relatively high reimbursement rates for these residents.

Administration and staffing

In 1997, it was estimated there were approximately 1.4 million full-time and part-time employees in nursing homes. The recruitment and retention of these employees, although a significant issue for all businesses today, pose some rather unique challenges for nursing-facility providers. The challenge of retention is critical in a nursing-facility environment because of the direct impact it has on quality-of-care issues. The administrative team, working with other staff in a facility, creates the culture of quality care. The ability to create and maintain a culture of quality is often hindered by high turnover of staff in many facilities. Singh and Schwab (1998) report that about 40 percent of nursing home administrators turn over each year, and the American Health Care Association (AHCA) reported in 1997 that the turnover rate for RNs and LPNs was 51 percent and that nurse's aides had a turnover rate of 93 percent. Registered nurses account for only 15 percent of the average nursing staff, while certified nurse's aides account for nearly 66 percent of staff. A number of factors contribute to staff turnover, including job stress, limited career opportunities, pay, and organizational culture. When looking at the clinical staff, the area that receives the most attention is pay. Based on 1997 data, the average RN was paid $16.88 per hour, LPN wages averaged $12.88, and nursing aide wages averaged $7.44. When these relatively low hourly rates are combined with a minimal benefit package, a strong economy, and the demands associated with caring for frail, medically complex persons, the challenge to retain quality employees can be easily appreciated.

The need to improve staffing standards and levels has received increased attention. In 1997, the staff-to-resident ratio for all direct-care staff was 89 per 100 residents and 59 nurse's aides per 100 residents. Certified nurse's aides spend the most time with residents, providing a significant portion of direct care, and yet they are often not well prepared to provide the level of care required by residents with increasingly complex medical problems. Based on the Medicare time studies that used the Online Survey, Certification, and Reporting (OSCAR) system, staffing hours for nurses averaged 3.5 hours per resident day (24 hours) for all nursing facilities in 1998. Registered nurses were found to spend 0.74 hours per resident day, LPNs spent 0.69 hours per resident-day, and nurse's aides averaged 2.09 hours. Because of the wide variation in resident care needs these numbers vary significantly across facilities. In contrast to the OSCAR finding of 3.5 hours per resident-day, a CMS time study came up with 4.17 hours, and a recently convened expert panel found the average to be 4.55 hours.

The recently released Institute of Medicine study on improving the quality of long-term care adds its support to this issue by recommending that CMS not only require RN presence twenty-four hours per day, but also that minimum staffing levels for direct care be developed.

Finally, the increasing role of the medical director has contributed to improving the quality of care. Each facility is required to have a medical director, who provides care to those residents who do not have a primary care provider. The medical director also plays a critical role in shaping clinical policies and procedures. The voluntary certification of physicians as Certified Medical Directors offered through the American Medical Directors Association has assisted physicians to better understand not only their clinical role within long-term care, but also to have a better appreciation of how to more effectively work within a nursing facility and as an active member of the administrative team.

Conclusion

Nursing facilities continue to serve a vital role within the long-term care system, even as they struggle to deal with a number of issues ranging from delivering quality care to adequate reimbursement. The frenetic pace of change is driven by the dynamic environment in which they operate, which seems destined to continue to bring more and more uncertainty to the role they will play in the long-term care system in the future. The recent Nursing Home Initiative by CMS has helped to continue focusing attention on addressing nursing-home quality and on minimum staffing ratios. Whatever the future holds for nursing facilities, one thing seems certain: if they are to survive and prosper, they will have to continue to evolve to meet the ever-changing needs of the residents they serve and to find funding mechanisms to adequately support the services they provide.

Thomas J. Fairchild Janice A. Knebl

See also Assisted Living; Long-Term Care; Medicaid; Medicare; Nursing Home Administration; Workforce Challenges.

BIBLIOGRAPHY

Aventis Pharmaceuticals, Inc. Institutional Highlights Digest. Managed Care Digest Series, 2000.

American Health Care Association. Facts and Trends 1999: The Nursing Facility Sourcebook. Washington, D.C.: ACHA, 1999.

Congressional Budget Office. Projections of Expenditures for Long-Term Care Services for the Elderly. CBO, 1999. Available at www.cbo.gov/

Fairchild, T. J.; Knebl, J. A.; and Burgos, D. "The Complex Long-Term Care Service System in Matching People with Services." In Long-Term Care. Edited by Zev Harel and Ruth Dunkle. New York: Springer Publishing Company, 1995.

Gabrel, C. S. An Overview of Nursing Home Facilities: Data from the 1997 National Nursing Home Survey. Hyattsville, Md.: U.S. National Center for Health Statistics, 2000.

Heffler, S.; Levit, K.; et al. "Health Spending Growth Up in 1999; Faster Growth Expected in the Future." Health Affairs 20, no. 3 (2001).

Manton, K. G., and Gu, X. "Changes in the Prevalence of Chronic Disability in the United States Black and Nonblack Population above Age 65 from 1982 to 1999." Proceedings of the National Academy of Sciences of the United States of America, Early Edition. 8 May 2001. Available at www.pnas.org

National Institute on Aging. Progress Report on Alzheimer's Disease 1999. Silver Spring, Md.: Alzheimer's Disease Education and Referral Center.

Sahyoun, N. R.; Pratt, L. A.; et.al. The Changing Profile of Nursing Home Residents: 1985–1997. National Center for Health Statistics, Centers for Disease Control and Prevention, 2001.

Singh, D. A., and Schwab, R. C. "Predicting Turnover and Retention in Nursing Home Administrators: Management and Policy Implications." The Gerontologist 40, no. 3 (2000): 310–319.

Wunderlich, G. S., and Kohler, P. O., eds. Improving the Quality of Long-Term Care. Washington, D.C.: National Academy Press,. 2001.

U.S. Census Bureau. "Nursing Home Residents 65 Years Old and Over by Selected Characteristics: 1997." In Statistical Abstracts of the United States, 2000. Washington, D.C.: Census Bureau.

Nursing Homes

Sections within this essay:

Background

With more people living longer and with the first of the Baby Boom generation reaching retirement age,, it is hardly surprising that the number of people requiring some sort of long-term nursing care is growing. According to the American Association of Homes and Services for the Aging (AAHSA), people who reach the age of 65 have a 40 percent likelihood of entering a nursing home; by 2020, approximately 12 million older Americans will need long-term care. The type of care available today fills a variety of needs; traditional nursing care for the infirm or incapacitated, assisted living for people who are still somewhat independent, adult day care for those who need supervision when the family is not available, and home health care for those who want or need to remain in their own homes.

Until the twentieth century, elderly people who could no longer take care of themselves were taken in by family members; those without money or family were placed in almshouses. Older Americans today have much better options and can expect a much better quality of life. With so many facilities (17,000 nursing homes alone), choosing the right one can be a challenge. Those who must reside in nursing homes—and their families—need to determine the best option based on quality of care, comfort level, location, and cost. The smart consumer will do enough research to know exactly what to look for in choosing a nursing facility.

History of Nursing Homes

The concept of a residence set aside solely for the elderly and infirm was unknown until the nineteenth century. Before that, it was understood that elderly people would be taken in by family once they were unable to care for themselves. Those who had no family could rely on servants if they had the financial resources, but for those who were alone and poor the only choice was the local almshouse.

As the Industrial Revolution brought more people to cities, families spread out and often people had no local extended family to fall back upon when they were in need. The result was a growing number of single and widowed people who had no one to take care of them in their old age. The first homes for the elderly were established by churches and women's groups, catering to widows and single women who had limited resources. Homes such as the Indigent Widows' and Single Women's Society in Philadelphia and the Home for Aged Women in Boston were a far better option than an almshouse. These early homes were not open to all. Many of them required entrance fees, and some asked for certificates of good character. Requirements like these shut out the neediest, who were still relegated to the almshouse.

By the beginning of the twentieth century, sensibilities about caring for the poor and incapacitated had begun to change. Specialized facilities were built for children, the mentally ill, and younger infirm individuals. But little was done for the elderly, and they merely became a larger percentage of the almshouse population. In 1880, one third of the residents of almshouses in the United States were elderly; by 1923, two thirds were elderly.

Social Security

It was not until the 1930s that things began to change for older people in need. The Social Security Act of 1935, part of President Franklin D. Roosevelt's New Deal, provided monthly payments to those over the age of 65. Although the payments were relatively small, they were an important step. Some older people were able to leave the almshouses and live on their own. Others were able to enter private facilities.

There was an unforeseen downside. Private facilities were unregulated, which meant that many were poorly run—dirty, overcrowded, unresponsive to residents' needs. Public facilities were at least regulated, but part of the Social Security legislation mandated that recipients were not eligible to live in them; only the truly indigent could stay in public homes.

By the 1950s, Congress realized that the situation needed to change. The Social Security Act was amended so that recipients could be eligible for public accommodations. The Medical Facilities Survey and Construction Act of 1954 mandated the construction of public facilities for the elderly.

Medicare and Medicaid

It was the creation of Medicare and Medicaid in 1965 that provided regulation for nursing homes. Congress set the first set of standards for nursing homes in 1967 and differentiated between "skilled nursing facilities" and "intermediate care facilities." (Skilled nursing facilities provide nursing and rehabilitation services; intermediate care facilities provide care to people who do not need immediate nursing care.) Congress periodically updated the standards, notably in 1987 as part of the Omnibus Budget Reconciliation Act (OBRA) and again as part of the 1990 OBRA.

The 1987 OBRA standards require that skilled nursing facilities and intermediate care facilities provide a level of care that will allow patients "to attain or maintain the highest practicable physical, mental, and psychosocial well-being." Among the specifics:

• Facilities must allow patients (or their proxies) to make their own choices in activities, schedules, and health care decisions.
• Facilities must have around-the-clock licensed practical nurse care and at least one registered on duty at least eight hours every day. Nurse's aides are required to receive specialized training.
• State agencies must create, monitor, and enforce both state and federal standards, in part through the establishment of investigatory units and ombudsman units.

The Patient Self Determination Act of 1990, part of OBRA 90, governs long-term facilities that participate in Medicare or Medicaid:

• Facilities must provide patients with information in writing that outlines their rights to participate in medical care decisions (including the right to accept or refuse treatment).
• Facilities must provide written statements outlining their policies.
• Patients have a right to issue advance directives, and facilities must document this in their records.
• Facilities must comply with state laws on advance directives and cannot discriminate against patients who have or have not issued them.
• Facilities must provide education for staff and the general community on advance directive issues.

Choosing A Nursing Home

Deciding to opt for nursing home care is a difficult experience for the patient and for the family. Ideally, a nursing home should be a place that combines the benefits of modern health care with the amenities of a home-like atmosphere. A nursing home that is sterile and hospital-like may suit some people but probably not most, likewise a nursing home whose staff is pleasant but whose facilities are in poor repair. Most experts in nursing care advise people to explore the options before the need arises, but few people plan ahead to the day when they may need long-term care.

The Medicare web site (www.medicare.gov) includes a useful comparison tool called Nursing Home Compare. This tool provides information on Medicare- and Medicaid-certified nursing homes throughout the United States. Visitors can get information on nursing homes by geographic region, community, or ZIP code. They can compare facilities, patient-to-staff ratio, various programs offered within each home, and so forth.

While tools such as Nursing Home Compare can break down general information about nursing homes, they cannot provide information such as whether a particular facility met only the minimum standards or exceeded all standards. Experts recommend that the patient (if possible) and the family members involved in the decision-making process visit several nursing homes before making a choice. This is important because nursing home care is usually long-term, and also because it is particularly traumatic for elderly, infirm people to have to move. Moving from one nursing home to another is physically and emotionally taxing for patients and families.

Often, the decision to move to a nursing home is one that must be made quickly—often, the patient is sent to a nursing home after a hospital stay and must be transferred immediately after being discharged from the hospital. In some cases it may be better to pay for a longer stay in the hospital or arrange for temporary home care instead of taking the first available nursing home even if it seems less than ideal.

Paying for Nursing Home Care

Few people can pay out-of-pocket for nursing home care; the specialized round-the-clock full-service costs can run up very quickly. People who have financial assets can pay on their own, but those assets get used up rapidly. For those who have limited assets (such as a small pension), there are a number of payment options.

Medicaid pays the expenses of nearly two thirds of all nursing home residents. It is distributed jointly by federal and state agencies Each state has a State Health Insurance Assistance Program (SHIP) that determines Medicaid payments. You can reach yor state's SHIP by visiting the Medicare web site (www.medicare.gov). Medicare does not usually pay much toward nursing care; it functions as health insurance for those over 65, but not as long-term insurance. Check www.medicare.gov or call 1-800-MEDICARE to get clarification.

Medicaid does not cover assisted living or continuing care retirement communities. However, 22 states do offer assistance for these services under a program called Program of All-Inclusive Care for the Elderly (PACE). An individual must be at least 55 years old and be screened by doctors and other medical professionals to determine whether such care is available. For a list of PACE organizations state-by-state, visit the web site www.cms.hhs.gov/pace/pacesite.asp.

Private health insurance may cover some long-term care, but often it has limits. Managed care plans are useful only if the nursing home in question is covered by the plan. An option worth exploring is long-term care insurance. The costs vary, but the national Association of Insurance Commissioners (www.naic.org) offers information on long-term care including a free Shopper's Guide.

Nursing Home Abuse

With some 17,000 nursing homes serving 1.6 million individuals, it is expected that standards will vary, even among homes ostensibly adhering to the same standards. Unfortunately, in some nursing homes, abuse exists. Homes that are overcrowded, or homes with staff shortages or minimally trained staff, are susceptible, but it would be wrong to say that any specific condition makes abuse more likely. Under no circumstances is abuse excusable or acceptable in any way.

The greatest danger of nursing home abuse is that its victims are often either too frightened or too disoriented to report it, or even to tell friends or family. Those with family members in a nursing home should be aware of what to look for when trying to determine whether abuse exists:

• The patient appears fearful or agitated, depressed or withdrawn.
• The patient is isolated with no justification.
• The staff is rude or makes humiliating or derogatory comments to patients.
• Patients are making complaints.
• Patients' rooms are not kept clean by staff.
• Common areas are unsanitary.
• Patients appear unkempt or dirty.
• Patients have bed sores or other untreated medical conditions.

• Patients have unexplained wounds, cuts, scrapes, sprains, or broken bones.
• Patients experience sudden unexplained weight loss.
• Patients are restrained without explanation as to why.
• Patient's personal property is missing.
• Money is missing from patient's accounts.
• Staff restricts or refuses visitors.
• Patient makes sudden changes in a will or other financial documents.

If you find abuse in a nursing home, you should report it at once. The U.S. Administration on Aging has a National Center on Elder Abuse web site (www.elderabusecenter.org) that links to individual state agencies. You can also call the Elder Care Locator at 1-800-677-1116. In an extreme emergency (if a patient's life is in danger, for example), dialing 911 may be the best idea.

Alternatives to Nursing Homes

Although good nursing homes provide comprehensive care in a comfortable setting, a skilled nursing facility may not be the right choice. It is important, both for the patient and the patient's family, to explore other options.

For those with adequate funds, of course, private nurses, cooks, housekeepers, and drivers are not difficult to obtain. Most elderly people, however, live on fixed incomes and have limited resources. For these people, alternatives to nursing home care, if covered by insurance or Medicare, may be less expensive than long-term care in a skilled nursing facility.

Home health care may be a better option, particularly for elderly people who are in reasonable health but who need assistance. A home health care worker can assist the patient with everything from shopping for groceries to physical therapy to bathing. For patients who are in reasonable health but for whom living at home is impractical (even with home health aides), assisted living facilities or continuing care retirement communities (CCRCs) may provide a good alternative. Some of these facilities are run like hotels; residents live in small apartments an are independent, but meals and housekeeping services are provided. While best-suited to people who are still independent, they can also accommodate people suffering from conditions such as Alzheimer's disease.

Adult day care services are often useful for those caring for elderly relatives who cannot be left alone during the day, (for example, Alzheimer's disease patients). The typical adult day care facility works much like a child day care center; the participants are dropped off and kept occupied during the day with a variety of activities. Along with those activities, the participants are fed and also given the opportunity to socialize with others. Adult day care provides caregivers (usually adult children) an opportunity to continue working or taking care of other matters during the day while being able to watch their loved one at home overnight.

Some elderly individuals may benefit simply from a medical transportation program, which provides door-to-door transportation to doctor's appointments and outpatient treatment, for example. This is helpful for people who can take care of their basic needs but who no longer drive.

Additional Resources

Guide to Choosing a Nursing Home, Centers for Medicare and Medicaid Services, 1994.

Old Age and the Search for Security, Carole Haber and Brian Gratton, Intiana University Press, 1994.

Social Froces and Aging, Robert C. acthley, Wadsworth, 1994.

Organizations

Centers for Medicare and Medicaid Services (CMS)

7500 Security Boulevard
Baltimore, MD 21244 USA
Phone: (877) 267-2323
URL: www.cms.hhs.gov
Primary Contact: Mark B. McClellan, Administrator

National Family Caregivers Association

10400 Connecticut Avenue, Suite 500
Kensington, MD 20895 USA
Phone: (301) 942-6430
Fax: (301) 942-2302
URL: www.nfcacares.org
Primary Contact: Suzanne Mintz, President

U/S/ Administration on Aging

One Massachusetts Avenue
Washington, DC 20201 USA
Phone: (202) 619-0724
Fax: (202) 357-3555
URL: www.aoa.gov.org
Primary Contact: Josefina G. Carbonell, Assistant Secretary on Aging

Nursing homes

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 and Demand 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. [email protected]. <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.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The nursing home staff may include an administrator, medical director, director of nursing, and directors for other allied health services. It is important for nursing home staff to understand the policies regarding care in these types of facilities.

The following professionals may provide care and treatments in nursing homes:

• physicians
• nurses
• nursing assistants
• dietitians
• physical, occupational, and speech therapists
• pharmacists
• social activities staff
• dentists
• social workers or psychological counselors
• other staff, such as custodians and office personnel

Nursing homes

Definition

A nursing home is a long-term care facility that offers 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

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). Nursing homes are largely populated by the elderly. 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 him or her 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.

KEY TERMS

Long-term care —Residential care over a period of time. A nursing home is a type of long-term care facility that offers nursing care and assistance with daily living tasks.

Restraint —A physical device or a medication designed to restrict a person's movement.

Viewpoints

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.
• Nurses' salaries. Salaries may be lower in long-term facilities than in acute care hospitals.
• 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.

Professional implications

Long-term care is a growing trend, making nursing homes a viable career alternative for nurses and allied health professionals. Approximately one out of twenty Americans over age 65 live in nursing homes, although younger adults may require the special services a nursing home offers. There are about 17,000 nursing homes in the United States caring for over 1.5 million people. Nursing homes have an average occupancy rate of 80 percent.

Nursing homes must meet the physical, emotional, and social needs of its residents. The leadership staff may include an administrator, medical director, director of nursing, and directors for other allied health services. It is important for nursing home staff to understand the policies regarding care in these types of facilities.

These professionals provide care and treatments in nursing homes:

• physicians
• nurses
• nursing assistants
• dietitians
• physical, occupational, and speech therapists
• pharmacists
• social activities staff
• dentists
• social workers or psychological counselors
• other staff, such as custodians and office personnel

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 and 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.

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.
• Have 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.

Resources

BOOKS

Hosley, Julie B. "Geriatric Patients." In Lippincott's Textbook for Medical Assistants, edited by Julie B. Hosley, ShirleyA. Jones, and Elizabeth A. Molle-Matthews. Philadelphia: Lippincott, 1997, pp.1021–22.

ORGANIZATIONS

Health Care Financing Administration. 7500 Security Boulevard, Baltimore, MD 21244. (410) 786-3000. <http://www.hcfa.gov>.

Joint Commission on the Accreditation of Health Care Organizations, 601 13th Street NW, Suite 1150N, Washington D.C. 20005. (202) 783-6655. <http://www.jcaho.org>.

OTHER

Federwisch, Anne. "A Good Home?" NurseWeek (September 6, 1999): <http://www.nurseweek.com/features/99-9/goodhome.html>.

"New law bars nursing homes from dumping patients." NurseWeek (March 29, 1999): <http://www.nurseweek.com/news/99-3/29f.html>.

"Your Guide to Choosing a Nursing Home." U.S. Department of Health and Human Services, Health Care Financing Administration. (August 2000): <http://www.medicare.gov/Publications/Pubs/pdf/nhguide.pdf>.

Rhonda Cloos, R.N.