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.