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.