Skilled Nursing Facilities

Skilled Nursing Facilities

Nursing Homes

Nursing homes (also known as nursing facilities and skilled nursing homes) provide shelter and care for seniors (9 out of every 10 nursing home residents) who have more serious health problems, functional impairments, or cognitive deficits and who often require 24-hour skilled nursing care. On average, their residents need at least some assistance with an average of 3.8 ADLs-notably bathing, dressing, toileting, and transferring. More than 56 percent of the residents will be cognitively impaired (for example, dementia as from a stroke or Alzheimer's disease), almost 50 percent will be wheelchair bound, and 6 percent will be bedfast. Residents admitted to nursing homes typically have more than one health problem, most frequently a combination of cardiovascular disease, mental and cognitive disorders, and disorders of the endocrine system, usually diabetes or hypothyroidism (American Health Care Association, 2001).

The nursing home population has become older and sicker (Sahyoun, Pratt, Lentzner, Dey & Robinson, 2001). The average age of admission is now 82.6 years. More than 51 percent of the residents are age 85 and over. They need help with a higher average number of ADLs and have multiple health problems. Nursing homes have responded by adding specialized wings and levels of care to accommodate residents with Alzheimer's disease and those in need of special types of rehabilitation therapies, subacute care, and hospice services. An increasing percentage of nursing home residents are minorities (7 percent), with African Americans now having a higher rate of nursing home admission than whites (American Health Care Association, 2001).

Elderly Americans have reduced their use of nursing home care because of the greater availability of noninstitutional group shelter and care options, their strong distaste for this option, and because they can cope with their frailty needs in their own homes (Bishop, 1999). It is, however, a more likely option for seniors who live alone, cannot depend on family, or cannot afford costly professional care. Home-based caregiving demands may simply become overwhelming if an older person requires the help of two persons when transferring between bed and toilet or needs continuous nursing care. Aging with choice may also be precluded when persons with Alzheimer's disease exhibit behaviors such as hitting, wandering, or putting themselves in danger, for example by touching a hot stove.

Just fewer than 5 percent of seniors now occupy nursing homes, ranging from 1.1 percent of 65 to 74-year-olds to just over 18 percent of the 85-plus group. On average, women enter a nursing home around age 80 and men around age 75. The average length of stay is about 2.4 years. About half of the older women will stay for less than a year, while 31 percent wills stay for 1 to 5 years and 15 percent will stay from 5 to 10 years. From a more realistic lifetime risk perspective, the proportion of age 65-plus elders who will eventually be nursing home occupants ranges from 39 percent to 49 percent. Importantly, the nursing home stay may not be permanent. Nursing home discharge data reveal that 30 percent recuperated and went back to the community (short-term rehabilitation after a hospital stay), a 36 percent moved to a hospital or another nursing home, 25 percent died, and 9 percent left for destinations unknown (American Health Care Association, 2001).

For-profit companies now own the majority (67 percent) of nursing homes, and well over half are owned or operated by a national multifacility chain. About 1 in 10 is operated by a hospital. Though the average nursing facility has 108 beds, the numbers can vary dramatically. Twenty-five percent have fewer than 100 beds, 52 percent have 100 to 199 beds, and 19 percent have 200 beds or more.

Nursing home care is expensive. In the United States in 2003, the average daily rate for a private nursing home bed was just more than $ 181, or more than $ 66,000 a year. For a semiprivate room the daily rate was just more than $ 158, or almost $ 58,000 a year. These charges vary dramatically across cities and states, however, and the most expensive nursing homes charge more than $ 600 a day-more than $20,000 a year (MetLife Mature Market Institute, 2003b).

Because of their high costs, it becomes crucial whether nursing home beds are eligible to be filled by recipients of Medicare and Medicaid. About 45 percent of the beds are certified for both the Medicaid and the Medicare programs, jsut over 3 percent are certified for Medicare only, 46 percent are certified for Medicaid only, and 6 percent are uncertified for either federal program. As testimony to the importance of the Medicaid program as financing source, mroe than two-thirds of the residents in nursing homes now receive Medicaid, only 9 percent are Mediciare beneficiaries, and 24 percent pay through private or other payer sources (for example, private insurance plans (American Health Care Association, 2001).

Even though nursing homes are the most regulated of all shelter and care options available to American seniors, and their overall quality has improved, evidence of lax enforcement and poor quality care persists. Nursing homes have suffered from lower Medicaid reimbursement rates, under staffing (Especially among nurses), high staff turnover, and in some states, such as Florida, from high insurance liability costs. Evidence suggests that for-profit homes, especially chain-owned homes, and those with more Medicaid residents have lower registered nurse and licensed practical nurse staffing levels and overall deliver a lower quality of care than nonprofit facilities (Centers for Medicare & Medicaid Services, 2004; Harrington, Woolhandler, Mullan, Carrillo & Himmelstein, 2001).

Families and professionals can now readily obtain information on the Internet about the size and ownership, patient profiles, staffing characteristics, and quality of care indicators of specific nursing homes. Medline Plus, a service of the National Institutes of Health, compiles and furnishes that information.

Trends in Nursing Home Care

Use of nursing homes is declining. This trend is fueled by increasing availability of home and community-based services, assisted living, in-home technology that makes it easier for physically and cognitively impaired seniors to remain in their homes, and society's general preference that we remain in our own homes as we age.

Some nursing homes are attempting to change their appearance and philosophy of care. The most publicized effort is the Eden Alternative, developed by Dr. William Thomas. It aims to eliminate residents' feelings of loneliness, helplessness and boredom-"the three plagues." Along with changing the physical ambiance of nursing homes by including plants, animals, birds and visits from children, an Eden Alternative nursing home promotes a more flexible management style with greater staff empowerment (especially among nurses aides and housekeepers) and advocates less rigid scheduling of activities and care plans, which encourages a stronger atmosphere of spontaneity.

In the spirit of the Eden Alternative, new nursing home initiatives are springing up throughout the country. Most notably, in 1997 a group calling themselves "nursing home pioneers" started a movement called the Pioneer Network to change the culture of nursing homes. This group included nursing home reform leaders from around the United States such as Dr. Thomas.

The Pioneer Network envisions a culture of aging that is life-affirming, satisfying, humane, and meaningful wherever seniors live. This approach is called culture change, which expresses the move to change the way seniors are treated whether in nursing homes or other residences. It is a major step toward providing comfortable living and humane care for seniors, particularly frail seniors.

In its first seven years, the Pioneer Network has produced results throughout the country (Pioneer Network, 2004):

  • Nine states have started "culture change coalitions" composed of long-term care professionals and others working to change the way seniors are treated and care for. Many others are forming coalitions.
  • Several multifacility organizations have committed their homes to culture change. Among them are Apple Health Care, Pinon Management, AGE Institute Holdings, Inc., and The Evangelical Lutheran Good Samaritan Society.
  • The Center for MEdicare and Medicaid Services has produced a 2 1/2 hour video about the Pioneer Network values, principles, and practices.
  • Nursing home providers who are implementing cultural change are reporting lower turnover of direct care workers and are reporting positive outcomes in resident quality care and quality of life.

 The information above is reprinted from Working with Seniors: Health, Financial and Social Issues with permission from Society of Certified Senior Advisors® . Copyright © 2009. All rights reserved.