It is upsetting to think about a relative going into a nursing home–and such arrangements may never even be necessary. But it’s wise to know your options before a crisis strikes.
Many people in their 70s, 80s, and 90s live full, rich lives and are able to run their own households with little–if any–assistance. But others who have debilitating physical or emotional conditions or who are extremely feeble often require the kind of care that can’t be provided by family or professional home care aides. They need the 24-hour attention that is available in a nursing home. While it’s difficult to think of a family member going into a nursing home, it is important to start planning when that person is able and healthy rather than making a pressured and less ideal choice in the event of an emergency. Here are some tips that will help you select a nursing home based on objective criteria and personal preferences.
Nursing homes serve as permanent residences for elderly people who are too sick or frail to live at home or as temporary facilities during a recovery period. However, many people who need some level of medical care or help with activities like shopping and preparing food, are able to remain in their own homes with the help of family and community and professional home care agencies. Find out about the range of services available in your area for assisting senior residents to stay at home. Good sources for exploring home and day care options are your physician and your state’s Office on Aging.
Nursing homes are designed for people who are chronically ill or need around-the-clock medical care. Some patients go directly to one after being discharged from hospitals because they need intensive care from a licensed nurse or therapy to recover from an injury or a disabling illness. Other seniors are in nursing homes because they can no longer manage daily activities, such as bathing, eating, dressing, and going to the toilet. But all nursing homes are not alike. Certain facilities are equipped to provide different levels of attention while others specialize. Depending on the needs of the individual, here are three general types of care that may be available:
1) Skilled nursing care is needed for medical conditions that require care by medical personnel such as registered nurses or professional therapists. Some people need skilled care for a short time after an acute illness, while others require it for longer periods. The specific therapy is usually ordered by a patient’s personal physician who outlines and monitors a treatment plan, which is carried out in the nursing home.
2) Intermediate nursing care is needed for stable conditions that require daily care, but not 24-hour nursing supervision. Such care is also ordered by a patient’s personal physician and supervised by registered nurses. Intermediate nursing care is less specialized than skilled nursing care and often involves help in performing daily routine tasks, such as bathing and eating. It is generally needed for a long period of time.
3) Custodial care helps a person perform activities of daily living, which include assistance with bathing, eating, dressing, and other routine tasks. It is usually given by people without medical skills because it is less intensive or complicated than skilled or intermediate care.
In addition, nursing homes offer a variety of special services that cater to the individual requirements of different people, such as rehabilitative therapies or treatments necessitated by specific conditions like Alzheimer’s disease.
Besides medical attention, there’s another important factor to consider in assessing a nursing home-the social environment. Some factors to think about: Is the home close enough so that family and friends can visit frequently? Are religious services available? Is there an outdoor area for residents to enjoy? What different types of activities are provided for residents? Discuss what is important to your relative. If the person you are helping is not mentally or physically able to communicate, consult with other family members and your relative’s close friends. (For a comprehensive list of details to consider when choosing a facility, see our Nursing Home Checklist).
The average cost of nursing home care in the United States in 1995 was $37,000, but in some parts of the country, the cost can be over $50,000. All facilities accept residents who can pay bills outright, and many homes have contractual agreements with the Veterans Administration (VA), the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), private insurance companies, and HMOs. Medicare and Medicaid payments are also accepted if the facility has beds certified for those programs and the resident is admitted under the auspices of Medicare (the federal health insurance program for people 65 and older) or Medicaid (the federal-state program for low-income Americans). Forty-four percent of the total tab for nursing home care in the U.S. is paid by nursing home residents or their families. Most of the rest is financed by Medicaid.
Medicare covers only the first 20 days of approved skilled nursing care. If a patient enters a nursing home immediately after a hospital stay in a Medicare-approved facility, some of the cost for days 21-100 will be covered too if skilled nursing care is required on a daily basis (a $92/day co-payment is required). But if the patient recuperates enough within that 21-100-day time period and doesn’t need such a high level of care, Medicare payments will be discontinued even though the person may have to stay in the home longer (on average, most people improve within 30 days). Nursing home care beyond the 100-day period, is not covered by Medicare or by Medigap insurance (Medicare supplementary policies).
Financial considerations very often affect how families select nursing homes. Those who plan to pay the cost themselves need to figure out how much they can afford and then find homes in their price range. Even people with nursing home insurance might have to cover some of the expense themselves and should know exactly how much this amount will be. If you determine that personal funds will run out after a few years and you’ll eventually need to apply for Medicaid, check to see if the nursing homes you are looking into have Medicaid certified beds so you won’t have to switch facilities. The rates Medicaid pays nursing homes are lower than those paid by individuals, which is one reason not all nursing homes accept Medicaid patients. Currently, Medicaid-certified facilities must comply with federal regulations on quality of care, but these standards are in jeopardy.
In order to be eligible for Medicaid, nursing home residents cannot exceed a certain amount in assets (predetermined by your state). Generally this means no more than about $1,000 in assets in the person’s own name (if you will need financial assistance, find out what your state eligibility requirements are by calling your state Medicaid office). Any sources of income you have, including your Social Security check, will go toward the cost of the nursing facility, except for a personal needs allowance of approximately $30 a month. Although Medicaid is designed to aid low-income people, many nursing home residents who are not in this economic bracket become eligible for assistance by transferring assets to their children in the years prior to applying for Medicaid.
Under Medicare’s Spouse Impoverishment provisions, husbands and wives of Medicaid-supported nursing home residents are allowed to keep more resources to allow them to maintain their own lifestyle. The spouse who remains at home is allowed to keep the couple’s home, car, and at least $1,918 per month of income and $15,348 in other assets (these amounts increase every year).
People who have Medicaid assistance when they enter a nursing home may be placed in any facility within 50 miles of their residence (this is called home assignment). You are usually permitted one rejection; after that, you may not have a choice. Some people set aside enough money to pay their own nursing home costs for a year or so. After they have depleted those funds (referred to as “spending down”), they can then apply for Medicaid. This strategy often enables them to enter the home of their choice.
Regardless of how you plan to cover nursing home costs, be sure to meet with the nursing home administration to make sure all the regulations are clear to you before signing any documents.
In addition to figuring out your needs and how you will finance nursing home care, you need to find nursing homes that meet those needs. You can call state Department of Health and ask for the office that oversees nursing homes for a list of nursing homes near you. You can also check Health Pages’ local nursing home listings for detailed information on the services they provide.
Next, you should call the facilities that seem most appropriate and ask some preliminary questions (such as whether or not they have Medicaid certified beds, what the waiting period for a bed is, or if they accept Alzheimer’s patients), to make sure they really do meet your requirements.
When you are down to a couple of choices, make sure the nursing homes are properly licensed, and find out if they are being sanctioned or fined for any deficiencies. Call your state Department of Health and ask for the office that oversees nursing homes. They will tell you if the homes have passed state inspections and if any complaints have been lodged against the homes. In addition, most states allow you to go to the Department and look through their files on the nursing homes you are interested in. These will have specific information on the homes’ history of compliance with resident care regulations.
It is essential to visit the nursing homes you are considering and talk with the staff, residents, and, if possible, residents’ relatives. A simple listing of nursing homes, like the one you get from the state, cannot and should not substitute for a personal visit. Include the family member who is going into the nursing home in this decision-making process to the greatest extent possible.
1) Call in advance of your visit to arrange for someone to show you around and to answer your questions. At this time, discuss your needs with the facility’s staff. As you walk around, use all your senses. Are the rooms, lounges, and dining areas clean and well kept? Do you smell any bad odors indicating that the facility’s housekeeping and patient care standards are not up to par? Heavy air fresheners or deodorants may be substitutes for conscientious care and maintenance. Are the exchanges you hear between residents and staff pleasant and respectful? Be wary if patients are hesitant to speak freely to you about the facility in front of the staff.
2) Try to visit around lunch or dinnertime. Meals are very important to both the medical and social well-being of nursing home patients. Food should be attractive and well prepared, and staff members should assist those who need help eating. Ask patients if they enjoy the food, and observe whether they leave a lot of it uneaten.
3) It is often useful to have a list of questions so you won’t forget any important factors. You can use our Nursing Home Checklist for this purpose and add any personal issues that are important to you.
4) If the first visit goes well, plan to make a second trip to the facility unannounced. Go at a different time of day from your first visit so you get a sense of the daily operating routines and of the atmosphere when the staff turns over.
Here are some questions to think about as you research nursing homes. Bring a copy with you to each facility you visit and take notes so you can compare them later on.
1) General Levels of Service
- Talk to the staff members, especially those providing hands-on services to residents. Do they appear competent and content in their jobs? Are residents treated with respect? Can you picture your relative being cared for by these people?
- Are residents well groomed, dressed, out of bed?
- Are residents out of their rooms?
- Is there privacy during personal care or treatment?
- Are residents’ calls for assistance answered promptly?
- How many residents does a nurse care for during the day, evening or night? A nurse’s aide?
- Are rooms attractive, comfortable, clean, well kept?
- Have residents personalized their rooms?
3) Resident Lounge Areas
- Is there sufficient space and furniture for visitors, conversation, TV watching?
- Is there a variety of leisure equipment available? Are residents enjoying it?
- Is there a place for private visits?
4) Activity Programs
- Is a schedule of daily events posted?
- Do the activities cover a range of different interests?
- Do residents participate in planning activities? Is there a resident council?
- Are there activities for patients confined to their bedrooms?
- Does the home have volunteers?
5) Dining Area and Menu
- Is the mealtime atmosphere to your liking?
- Has the home served the same meal listed on the menu? Are hot foods hot and cold foods cold?
- Does the food appear appetizing?
- Are residents satisfied with the quality of the food?
- Can residents get substitute meals when they do not like the menu?
- Are residents who need assistance helped promptly?
- May visitors join residents for meals?
6) Bathrooms and Showers
- Are bathrooms, showers and tubs close to bedrooms? How many residents share each one?
- Is there a call button near the toilet?
7) Health Care
- If the resident needs hospitalization, which hospitals does the home have a contractual relationship with?
- Who is the facility’s pharmacist or pharmacy consultant? Can residents use their own pharmacy?
- Is there a variety of therapeutic equipment?
Your continued involvement will help your spouse, parent, or friend adjust to their new home. Many families arrange their schedules so that a different person visits each day for an hour or so and brings news of the family as well as items like writing paper, books, and toiletries. You will also need to keep in touch with your relative’s doctor to keep informed about any changes in health or treatment.
Try to schedule outings for an afternoon, a day, or a weekend. Remember, the nursing home is, indeed, a home. Residents are free to come and go within their own capabilities. If you feel the nursing home is violating the rights of someone you love, call your local Long Term Care Ombudsman.
The following resources offer useful information on looking for and living in a nursing home:
The Department of Health and Human Services publishes the booklet How to Select a Nursing Home. For a free copy, write to:
Health Care Financing Administration
7500 Security Blvd., RM. N1-26-25,
Baltimore, MD 21244-1850
The American Association of Retired Persons (AARP) offers a 52-page manual entitled Nursing Home Life: A Guide for Residents and Families (stock #D13063), which is intended to assist those who are searching for a nursing home and those who are trying to adjust to life in a nursing home. They also offer a guide for caregivers living far from their loved ones called Miles Away and Still Caring (stock #12748). For a free copy, write to or call:
601 E St., NW
Washington, DC 20049
The National Citizens’ Coalition for Nursing Home Reform is an organization comprised of individuals and agencies advocating for quality of life and care for nursing home residents.
1444 Eye Street, NW Suite 1100
Washington, DC 20005
The National Senior Citizens Law Center practices law in support of legal services programs and on behalf of elderly clients and client groups.
3660 Wilshire Boulevard, Suite 718
Los Angeles, CA 90010
1330 Broadway, Suite 525
Oakland, CA 94612