Long-Term Care and Nursing Home Basics

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Surely, moving permanently to a nursing home is at the bottom of most people's wish list. Most people have other long-term care options for care at home and in the community. Short-term nursing home rehab programs are a frequent transition period from hospital to home.

But for some people, particularly those with advanced dementia or complex medical needs for whom available family care and home- and community-based services are insufficient, a nursing home may be the most appropriate option for a long stay. If that choice becomes necessary, the decision should be based on good information and realistic expectations, not guilt or fear.

Just to be clear: A nursing home is a long-term care facility that offers 24-hour room and board and health care services, including nursing care, rehabilitation therapies, and a range of other treatments, and programs. People who live in nursing homes are referred to as residents, not patients. Nursing homes increasingly have two types of services: short-term rehabilitation programs and long-stay units.

By choosing a nursing home for a long stay, you are not abandoning your parent or other relative. You will need to remain involved at many levels to ensure that your parent receives the most appropriate care, is respected as an individual, and is able to maintain the highest level of function possible and enjoy a good quality of life. Starting with that premise, here are some basic facts about nursing homes today.

Defining nursing homes

Nursing homes are, in bureaucratic language, skilled nursing facilities (abbreviated as SNFs, and pronounced sniffs). Nursing homes, unlike assisted living or other community settings, offer skilled care by professionals such as nurses, doctors, and therapists.

For instance, a nurse administers intravenous (IV) injections, and a physical therapist helps a person regain or maintain function, Nevertheless, the amount of time nurses spend with patients is limited. The facility may have a medical director onsite or a doctor may be on call.

The need for skilled care is not clear-cut for persons with dementia. Sometimes people with dementia, even advanced cases, do not have easily identified needs for skilled care (as the Centers for Medicare & Medicaid Services defines it). The facility gets a lower reimbursement rate from Medicaid for these individuals, assuming it will accept them in the first place.

The majority of nursing-home services are provided by aides (called certified nursing assistants or CNAs) who do personal care and assist with activities of daily living (ADLs), such as bathing and dressing. Federal law requires CNAs to have a minimum of 75 hours of training, although some states have increased the training requirement.

These are the people with whom you or your parent will have the most contact. Getting to know them as individuals is important.

Nursing home residence on the decline

Although it may seem counterintuitive in an era in which the population is aging rapidly, the number of people living in nursing homes is actually declining. In 1995, 1.4 million Americans eligible for Medicaid (the prime payer of nursing home care) lived in nursing homes, but by 2010 that number had fallen to just over 1 million.

Some of this decline can be attributed to states’ efforts to provide more home- and community-based services as an alternative to more-expensive nursing homes. Some people who might have gone from home to nursing home are able to manage with help in an assisted-living facility.

Another factor is probably nursing homes’ own restructuring, as they focus more on sub-acute or post-hospital care and rehabilitation programs, paid for by Medicare at a higher rate than long-term care paid for by Medicaid.

Nursing homes vary by type of ownership:

  • Voluntary homes are run by nonprofit organizations, which may be sponsored by religious, fraternal, or community organizations.

  • Public or municipal homes are owned and operated by local governments.

  • Proprietary homes are run by for-profit corporations, which may have only a few facilities or be national in scope. This sector now constitutes 69% of all nursing homes.

The type of ownership of a nursing home provides no guarantee of quality, which has to be assessed individually. There is some evidence to suggest that nonprofit nursing homes offer better quality care.

Some nursing homes are large, and some are very small. According to the CMS Nursing Home Data Compendium of 2012, however, the majority of nursing homes have between 50 and 200 residents. But again, size is not the key determinant of quality. Small homes may offer a more intimate environment, but large homes may have more specialized staff and more activities.

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