Selecting a Nursing Home
In his compelling book, Being Mortal: Medicine and What Matters In the End, Harvard Medical School professor and surgeon Atul Gawande argues that old age is not a disease, although medicine has long treated it as one. This attitude has reinforced the perception of nursing homes as a less than welcome later life option.
However, the fear, like the term “nursing home” itself, stems from these outdated beliefs and behaviors. Today, skilled nursing facilities (SNF) and post-acute rehab facilities are stringently regulated and regularly inspected in order to maintain the highest standards of cleanliness and care.
The Department of Health conducts annual surveys to ensureresidents are safe, well cared for, and living with the dignity they deserve. Inspectors take note of everything from staffing levels to the number and cause of bedsores. Each state’s Department of Health can also be notified when a family or patient suspects any lapse on the part of the facility.
Although making the decision to place a loved one in a skilled nursing facility is obviously difficult, this guide will provide you with the information to help make both the choice and transition a little easier.
Who’s Who On The SNF Team
There are several key players in a skilled nursing facility. A federally licensed administrator oversees the day-to-day operations of the facility, while a director of nursing oversees the clinical team. A medical director is responsible for quality assurance on the clinical level. Attending physicians follow their patients’ care at the facility, and refer to specialists such as psychiatrists and podiatrists for interdisciplinary care when necessary.
Social services is another integral department within a SNF. The social service team ensures the wellbeing of the residents, and helps determine appropriate discharge plans. They are often the first to be consulted for any patient-related issues that arise.
The rehabilitation team is vital in helping patients maintain their highest level of functionality. Most facilities offer physical, occupational and speech therapies. Some will also have certified recreational therapists available.
There is also an admissions or intake coordinator who helps facilitate the transition from the hospital or home to the SNF. This person generally works closely with outside agencies and families to ensure the person in question meets nursing home placement criteria, and can offer tours and information regarding the facility’s services.
Most of today’s skilled nursing facilities provide various levels of care, from short-term rehab to long-term care.
Those needing long-term care generally require 24-hour nursing supervision and assistance with most or all of their activities of daily living (ADL). Often, the resident has tried to remain as independent as possible for as long as possible by utilizing caregivers or residing in an assisted living facility or residential care home. The transfer to a skilled nursing facility is usually a permanent placement, and the facility becomes their new (and final) home.
When you have made the decision to place your loved one in a SNF for long-term care, consider the following four factors carefully when selecting a facility:
- Home-like Environment
The best way to assess a facility is to take a personal tour. Most facilities will encourage you to tour in order to help dispel any preconceived notions regarding skilled nursing homes. Pay attention to:
- How are residents dressed? Are they still in their pajamas late in the day, or are they properly dressed? Residents, unless too infirm to leave their beds, should be encouraged to be dressed on a daily basis.
- Do you notice any odors? Most facilities today are vigilant in keeping the residence odor-free. There are always going to times of the day when odors are more prevalent, such as during morning bathing/dressing times, but otherwise the SNF not have any noticeable smell.
- Are the hallways clean and free of clutter?
- Are the rooms clean and free of clutter?
- Are the rooms decorated with personal belongings, or are they barren and hospital-like?
- Does the staff address the residents respectfully?
- What types of bedrooms are available: private, semi-private, triples, or quadruple occupancy?
- Are there areas for the family to gather for visits or special occasions?
- Nursing Capabilities
Since many patients residing in long-term care settings require more intense nursing care, be sure to ask:
- Does the facility provide 24-hour RN coverage? Even though it is federally mandated that all facilities have 24-hour LPN coverage, there are some duties that only an RN is qualified to perform, such as IV administration.
- Are the nursing assistants certified?
- Can the nursing staff handle advanced care needs such as wound therapy?
- Can the nursing staff handle the needs of patients with dementia?
- Does the facility use contract agencies?
- Does it appear as if the nursing staff is enjoying their work? Is morale high throughout the building?
- Does each patient have individualized plans of care?
- Dining Services
Dining is not only an opportunity for patients to eat, but an important opportunity for socialization and camaraderie. Considerations when choosing a facility include:
- What type of dining program is offered? Some facilities offer restaurant-like dining, while others serve all residents the same meal with limited opportunity for alternatives.
- Are residents encouraged to eat in the dining room?
- Are residents who are unable to feed themselves assisted by facility staff?
- Can the kitchen accommodate special dietary needs?
- How is the food? Ask for a sample menu, and enjoy a meal so you can see for yourself what your loved one will be eating. Keep in mind, however, that many facilities will limit the amount of salt and seasonings to accommodate dietary restrictions.
Planned activities are vital in the long-term care setting. They provide opportunity for socialization as well as cognitive stimulation. Some questions to consider:
- Are there activities my loved one would enjoy?
- Is there diversity amongst the activities?
- Are there activities they can do in independently?
- Are there outside activities?
- Are there activities that will take them off premises?
- Do the residents participate and enjoy the planned activities?
The need for SNF placement can also be temporary. After surgery or a lengthy illness, someone may need a place to recuperate where they can receive specialized nursing care and rehabilitation. Many skilled nursing facilities offer short-term stays to help patients return to their prior level of functioning. Those who utilize short-term rehabilitation are often not “typical” nursing home patients; many are younger, more independent and generally in better health — although people in their 80s and 90s have utilized post-acute rehab to recover from an event such as a broken hip, before returning home with a caregiver.
While the same criteria should be used when choosing a facility for post-acute care as for long-term care, there are some additional factors to be considered. They include:
Physical, occupational and speech therapy play an integral role in recovery from an illness, accident, or surgery. Some patients may need the services of all three disciplines, while others may only need one or two. A patient’s insurance company may also dictate how often therapy must be provided per the person’s coverage. Some questions to consider when choosing a facility include:
- Is the therapy team employed by the facility, or contracted?
- Are the therapists certified or otherwise credentialed?
- Do therapist use advanced techniques to aid results?
- Will the therapists evaluate the patient’s home environment prior to discharge?
- Will the therapists help educate caregivers about therapy techniques prior to discharge?
- Is there a track record of successful rehabilitation?
Be sure there are activities that align with your loved one’s needs. Non-traditional nursing home residents may not want to participate in activities typically geared towards long-term residents, such as Bingo or crafts. It is important, however, for them to be able to socialize and make the effort to engage with others, which can facilitate healing.
- Pre-Surgery Registration
If surgery is imminent and you are uncertain as to the reality of recuperating at home, speak with the doctor to see if a post-acute rehab stay would be a good option. Many facilities now offer the opportunity to pre-register for a short-term stay. For example, if you or your loved one is scheduled for a hip replacement, and know you have a flight of stairs to climb to get to the bathroom, it may be wise to consider a short-term rehab stay. You can tour potential facilities, ask appropriate questions, meet the staff who will be caring for you, and make an informed decision about where you would like to recuperate. In addition, many facilities will allow you to do the admissions paperwork in advance, making the transition from the hospital to the facility smoother.
When the clinical, therapeutic, and social service teams all agree you are ready to be discharged, you’ll either be referred for additional therapy, or sent home, possibly with home health services or non-medical assistance as needed.
While the initial goal upon admission for many patients is to return to their prior level of functioning, the reality is sometimes different. For some, their disease state, advanced age, or social situation works against them. For these individuals, discharge to the safest possible environment is paramount. Some may be able to go to a residential care home or assisted living, while others may learn the SNF has become their permanent residence.
The facility’s social service department can help determine the appropriate plan of action for discharge.
With over 5 million Americans suffering from Alzheimer’s disease and other forms of dementia, the task of caring for them often falls squarely on the shoulders of a relative. While for some, at-home care is sufficient; others require 24/7 supervision for many reasons, including personal safety.
Some dementia patients are not oriented to time, place or person and can no longer care for themselves. When the task for caring for a loved one with dementia becomes overwhelming for a family, it’s time to consider alternative placement options. Many skilled nursing facilities offer specialized dementia units with staff trained in caring for adults with the disease. If you are looking to place your loved one in a SNF because of cognitive impairments, here are some questions to consider:
- Does the facility have a secured unit to prevent the resident from wandering away?
- Does the facility offer any security devices to alert staff if the resident attempts to leave the building?
- Does the facility offer programming designed specifically for residents with dementia?
- If the facility has a specific dementia unit, does it have a dedicated staff?
It is often harder on families making this decision than on the resident with dementia. This is normal, and should be expected. It is difficult to accept that a physically “healthy” individual is no longer able to care for themselves due to cognitive impairment.
Learn more about dementia, Alzheimer’s and Memory Care in the following resources:
- Complete Guide to Memory Care
- The Caregivers Guide to Alzheimer’s Disease: 20 Memory Care Experts on Caring for Alzheimer’s and Dementia Patients
For many caregivers, the opportunity to go on vacation or take a break from caring for a loved one is very limited. Many facilities will offer respite care for short durations to allow such a reprieve. This is a useful way to get a “taste” of what the facility has to offer without permanent placement. Unfortunately, most respite stays are not covered by insurance and will require private pay. Learn more about respite care in our Respite Care 101 Guide.
Nursing Homes vs. Skilled Nursing Facilities
The terms “nursing home” and “skilled nursing facility” are not completely interchangeable. Skilled nursing facilities (SNFs) are sometimes part of larger nursing homes or even part of an acute care facility (i.e., hospital). The term “skilled nursing” refers to the level of medical care required. Skilled care includes physical, occupational, and speech therapies, or skilled nursing services such as intravenous therapy.
Skilled nursing staff consists of the following professionals:
- Registered nurses (RNs) and licensed practical nurses (LPNs)
- Physical and occupational therapists
- Speech-language pathologists
Skilled nursing care can be understood as care that must be provided by a skilled or licensed professional, and it must be certified as medically necessary by a licensed physician. Medicare certifies skilled nursing facilities if they have the staff and equipment needed to provide this type of skilled care. But skilled care is typically only covered for a short time following a three-day qualifying hospital stay (not counting the day of discharge), and for one of the following reasons:
- To maintain a patient’s current functional status and prevent a condition from getting worse.
- To help improve a patient’s condition over a specified period of time.
The goal of skilled nursing care is to help an individual learn to live more independently. The individual must continue to benefit from the skilled services being provided in order to maintain Medicare or private insurance coverage for those services.
If an individual’s condition cannot be improved or maintained through skilled nursing care, or the condition ceases to improve despite the treatments provided, the person typically only qualifies for custodial care. In contrast to skilled nursing care, patients usually require custodial care for much longer periods of time, months or even years.
Custodial care is provided by nursing homes. The confusion between the two terms is due to the fact that skilled nursing care and custodial care are often provided within the same facility. But a nursing home stay won’t be covered by Medicare if the resident requires only custodial care, or care which can safely and reasonably be provided by staff who are not skilled or licensed professionals.
This type of care includes non-skilled services and assistance with activities of daily living (ADLs), such as bathing and dressing. Custodial care can also include oxygen or caring for a colostomy or bladder catheter, or other tasks that most people are able to do for themselves, such as diabetes monitoring. Skilled nursing facility care is generally considered short-term care, while the custodial care offered by nursing homes is considered long-term care.
Skilled nursing care is the most expensive level of care available. The national average is around $6700 per month for a semi-private room, but this varies depending on location as well as services needed.
There are several ways to help cover the cost of nursing home care.
- Medicare: For some patients, Medicare A can help with the cost of nursing home placement. For those who are eligible, Medicare can help pay for up to 100 days per calendar year. However, certain criteria need to be met for Medicare A to pay. The patient must have a 3-night hospital admission and require skilled services (i.e.: intensive nursing services, 5-day a week therapy, etc.). Long-term patients may regenerate their Medicare A benefits if they are re-hospitalized for three days. Medicare part B can also help pay for in-patient rehabilitation services for long-term residents. For more information on what Medicare covers in a nursing home, visit Medicare.gov.
- Medicaid: Medicaid can help cover the cost of skilled nursing care in Medicaid-certified nursing homes, for patients who qualify. Depending on a person’s assets and income, Medicaid can be used to cover the Medicare co-pays or for long-term care. For more information, visit Medicaid.gov.
- Medicare Replacement Plans: Some insurance companies provide Medicare replacement plans, which, as the name implies, replaces a person’s federal Medicare benefits. Such plans provide patients with primary insurance coverage. Each plan offers different benefits, but most provide some type of skilled nursing coverage.
- Medicare Supplemental Plans: As the name implies, these plans are used in addition to Medicare and will often help cover any co-pays that a patient may incur. Each plan is unique, and you should verify benefits rather than assuming coverage. Visit Medicare Advantage for more information.
- Long-term Care Insurance: Many companies provide long-term care insurance, which are policies that may help cover nursing home care. However, they are expensive, and must be purchased well in advance of potential need. Because each company’s coverage varies, read the policy carefully and speak with a knowledgeable representative about coverage.
Protecting Your Assets
What if you have too much money to qualify for Medicaid, yet not nearly enough to cover ongoing custodial care in a SNF? This situation confronts many older couples and individuals, who do not want to forfeit their remaining assets in order to be eligible for coverage — yet also want their loved one to have the best possible nursing care.
For those who do not qualify for Medicaid or have supplemental insurance with skilled nursing benefits, costs incurred in a SNF, including co-pays, room and board, medications, specialized care and rehabilitation, are the responsibility of the individual receiving care. Seek the advice of an elder law attorney if your loved one has any substantial assets including cash, stock, bonds and real estate.
One possible strategy involves converting your assets to income via an annuity, which is a contractual agreement whereby an individual pays a lump sum in order to receive a future income stream. While buying an annuity reduces someone’s savings substantially, it provides the nursing home resident’s spouse with recurring income. Caution: annuity conversion strategies and Medicaid laws are complex, and you should always consult an elder law attorney in your state prior to making any purchase, as it is easy to make a costly mistake. Done correctly, however, you may be able to protect a considerable amount of your savings from being spent on long-term care.
Most people are hesitant about choosing a skilled nursing facility for a loved one, but there are times when the option of caring for them at home or allowing them to remain independent is no longer in their best interest. SNFs can offer a wide range of services to meet the needs of many older, and some younger adults, but the process is often overwhelming. We hope this guide has helped make the process a little easier for you.
Other Nursing Home Information Resources: