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A Guide to Nursing Homes

Skilled Nursing Facilities and Convalescent Homes

A Guide to Nursing Homes

As the population ages, more of us are faced with the prospect of moving either ourselves or an older family member into a nursing or convalescent home. It may be a decision that arrives suddenly following hospitalization, or gradually as needs become more difficult to meet in other types of housing.

Deciding to move can be stressful, often due to misconceptions about these facilities. To make a decision that’s right for you or a loved one, it’s important to learn all you can about nursing homes.

What is a nursing home (skilled nursing facility)?

A nursing home is normally the highest level of care for older adults outside of a hospital. Nursing homes provide what is called custodial care, including getting in and out of bed, and providing assistance with feeding, bathing, and dressing. However, nursing homes differ from other senior housing facilities in that they also provide a high level of medical care. A licensed physician supervises each patient’s care and a nurse or other medical professional is almost always on the premises. Skilled nursing care is available on site, usually 24 hours a day. Other medical professionals, such as occupational or physical therapists, are also available. This allows the delivery of medical procedures and therapies on site that would not be possible in other housing.

The label “nursing home” has negative connotations for many people. Yet nursing homes provide an important component of senior housing options. It's important to separate nursing home myths from facts.

Myths about nursing homes

If I can’t take care of myself at home, a nursing home is the only option. Today, there are many options to help older adults stay at home, ranging from help with shopping and laundry to caregiving and visiting home health services. If home care options are no longer possible, other options, such as assisted living, may be a better fit if the primary need is custodial care rather than skilled medical care. Even if hospice care is being considered, home care is also often a possibility.

Nursing homes are for people whose families don’t care about them. Many cultures have strong beliefs that it is a family's duty to care for elders. However, in today’s world of smaller families living farther apart, work conflicts, and people living longer with more chronic illness, it simply may not be possible. Considering a nursing home does not mean you don’t care about your family. If you cannot provide the necessary care, it is the responsible decision to find a place where your family member’s needs will be met.

Nursing homes are poorly run, and I or my family member will get awful care. While it is key to research homes thoroughly and visit frequently, it is not true that all nursing homes provide poor care. There are more and more safeguards in place, and a facility’s staffing information and any previous violations are available to the public to help you make your decision.

Once I’m in a nursing home, I’ll never leave. Some illnesses or injuries have progressed to the point where both ongoing medical and custodial care may be necessary through the end of life. However, many people encounter a nursing home for the first time after a sudden hospitalization, such as from a fall or stroke. After rehabilitative care, either returning home or to another housing option may be a better fit.

Living arrangements in a nursing home

The ambience and layout varies from nursing home to nursing home. For example, some rooms may be private and others shared. Rooms may have their own bathroom, or bathrooms may be shared in the hallway. Some meals may be provided in the room, while others may be in a centralized dining area.

While nursing homes have traditionally been set up in a medically oriented design, with ease of patient care being the primary goal, some homes are now moving to a newer design model with smaller communities of 10 to 30 people within a home, private kitchens, communal areas, and continuity of staff.

When should I or a loved one consider a nursing home?

Whether you and your family are facing a quick decision about a nursing home due to a recent event, or have been coping with a worsening progressive disease such as Alzheimer’s or Parkinson’s, considering a nursing home is not an easy decision. Emotions such as guilt, sadness, frustration, and anger are normal. Working through the possibilities of housing, finances, and medical needs can help you and your family make an informed decision.

Here are some questions to ask when considering a nursing home:

  • Has the senior been assessed recently? If a nursing home is being considered as the next step after hospitalization, this probably has already been done. However, if a senior is considering a move from home or another facility, a more formal assessment by a medical team can help clarify the senior’s needs and see if other housing options may be a possibility.
  • Can the senior’s needs be met safely in other housing situations? The risk of falls may be too great, or the senior’s medical needs may no longer be able to be met at home or in another facility. If the senior needs 24-hour supervision, or is in danger of wandering off or forgetting about a hot stove, for example, a skilled nursing facility may be the best option. If the senior’s needs are solely custodial, though, an assisted living facility may be a better fit.
  • Can the primary caregiver meet the senior’s needs? Caregivers are often juggling the needs of work, their own family responsibilities, and their own health. It’s not possible for one person to be awake and responsive 24 hours a day. Sometimes other family members can help fill in the gap. Day programs, home care services, and respite care, where a senior temporarily stays in a nursing home, may also provide the support a caregiver needs. However, there may come a point where medical needs become too great and home care services are unable to bridge the gap or become too expensive.
  • Would the need for a nursing home be temporary or permanent? Sometimes, a temporary situation may be covered through home care, or family members might be able to rotate care on a short-term basis. However, if the level of care is expected to be permanent, this may be too expensive or coverage might not be enough.

Nursing home vs. other types of senior housing

Nursing homes provide some of the highest levels of care, both medical and custodial. If you’re not sure that you or your loved one needs that level of care for the long term, learn more about other types of senior housing, including home care, to see what will best fit your needs.

Choosing a nursing home

Finding a nursing home

Finding the right nursing home is not easy, and you may be under pressure to move fast due to a recent hospitalization or deterioration in a health condition. The more information you have, the greater your chances of finding the right fit for you or a loved one. Here are some tips on narrowing down your options:

  • Start with referrals. Does your family physician or specialist have any recommendations? Or do you know any friends who have used different homes? Knowing someone with first-hand experience of a nursing home can help you narrow your choices. However, remember your needs may differ; one size does not fit all.
  • Educate yourself. Online resources for nursing homes include ranking sites that utilize existing state data to rate nursing homes. In the U.S., every state has what is called a long-term care ombudsman, which can be a valuable resource about the current condition of a nursing home. Advocacy groups can also provide hints on searching for the right facility. See the Resources section below for more information.
  • Consider your medical needs. Different nursing homes may have more expertise in different areas. Are they experienced in handling your condition, such as for Alzheimer’s or a stroke? Or are you looking for more short-term rehabilitation?
  • Factor in distance. In general, the more convenient the home, the easier it is for family and friends to visit.

Planning a visit to a nursing home

Once you’ve narrowed down your list of homes, it’s time to plan a visit. Visiting is key to understanding if a home is right for you. As with other senior housing options, it’s the people that make the place, both the residents and staff. In a nursing home, you’ll also need to make sure that the medical care is delivered appropriately and promptly.

What to look for in a nursing home staff:

  • How frequently does the staff turnover? What is the staffing level on weekdays, weekends, and evenings?
  • Do they have time to speak with you, or does it feel rushed?
  • How would they manage your health condition? How are medications and procedures arranged? And how do they handle emergencies or accidents such as falls?
  • Do they appear genuinely interested in you, and do you see them interacting warmly with current residents?

What to look for in current residents and their families:

  • Do the residents appear happy, engaged? Or excessively groggy and overmedicated? Do they seem clean and well groomed? Do they seem like people you’d enjoy getting to know? How do they respond to you? Try to observe social gatherings such as meals or other activities. If needed, are residents getting timely help to eat, and with getting to and from the gathering areas?
  • If you see a family visiting, you can ask them about their impressions of the home and how their loved one has been treated. Ask if there is a family council and if you could attend.

What to look for in the nursing home facility:

  • Cleanliness. Does the facility appear clean? Do you smell urine or strong deodorizers that may be covering up the smell of urine?
  • Food. What kinds of meals are normally served? Does it look nutritious and appetizing? How are special diets handled? What kind of help is available with meals, and do they have to be eaten at the same time or in a common area? 
  • Arrangement. Traditionally, nursing homes have been run like a medical facility, including a centralized nursing station with set medication and mealtimes. Some nursing homes, however, are now moving to a different model, with smaller communities and communal areas. If this type is available in your area, it may provide a more homely feel.
  • Activities. What quality of life activities are available for residents? Are outside activities also arranged, health permitting?
  • Experience with your condition. If a loved one has Alzheimer’s, for example, is there a special care unit or specialized staff and activities? How does staff handle behavioral problems like agitation or wandering?

Understanding nursing home/skilled nursing facility costs

In the U.S. nursing home costs are a big part of nursing home care and can vary widely depending on the state you live in. Average costs are around $70,000 per year, so you need to know how you’re going to pay for nursing home care. It’s important to understand the limitations of insurance in covering costs:

  • Medicare only covers limited stays in nursing homes. Skilled nursing or rehabilitation services are covered for a period of about 100 days after a hospitalization. Medicare does not cover custodial care (such as assistance with feeding, bathing, and dressing), if that is the only care needed.
  • If your income and assets are limited, you may qualify for Medicaid, which does cover most of the costs of nursing home care. However, not all nursing homes accept Medicaid. If you suspect that you may need extended nursing home care in the future, you may want to contact an elder law attorney to learn more about which assets are protected, and to what extent. For example, if you have a spouse living at home, your home is normally not considered in eligibility for Medicaid for nursing home purposes, and some of your savings may be partially protected as well.
  • If you have long-term care insurance, check the provisions of your plan to see what portion of nursing home coverage is protected.

The Resources section below provides more information on managing and planning for nursing home costs.

Handling the emotions of moving to a nursing home

Moving is a stressful transition, even at the best of times, and moving to a nursing home brings on a whole host of different emotions.

If you are the one moving, you are leaving behind a familiar place and memories. If the nursing home move was due to a hospitalization, the transition may have been abrupt and you may not have had time to even process what has happened. Add to that the increased medical needs and decreased mobility, and it’s no wonder moving to a nursing home can be so stressful. You may even feel angry and abandoned by family members, even if you realize they can’t provide the level of care you need. Anger and grief are perfectly normal emotions.

If a loved one is moving, you may feel guilty for being unable to provide care, or sad that your loved one has to go through this transition. You may feel relief that your loved one is getting the care they need, tempered with guilt if caregiving has been particularly intense. Family members may have been arguing about whether a nursing home is necessary, where it should be located, and who should be the point of contact.

Easing the transition

Everyone needs time. Both the older adult and his or her loved ones need time to adjust to this transition and come to terms with their own their feelings. Trying to sweep anger and grief under the rug—or refusing to acknowledge the difficulties of the transition—will only intensify these feelings.

The older adult takes the lead. As much as possible, the older adult should be the one making the decisions about which nursing home is best. Whenever possible, he or she should come along on visits when making a nursing home decision, and make the choices about what to take along and how to personalize the room. If the older adult is unable, loved ones should try to think about what his or her wishes might have been. A familiar blanket or favorite music, for example, may provide comfort even if the older adult is unable to verbalize it.

Tips for loved ones

Keep in regular contact. Even if you live far away, know that frequent calls, letters, and emails make a big difference. Regular visits by family and friends help ease the transition. Keep your loved one in the loop about family events as much as possible.

Stay involved. Regular contact not only reassures your loved one, but allows you to serve as an advocate for your loved one’s needs. Even if you’ve chosen the finest facility, you want to make sure your loved one’s care continues to be of the highest standard, so visit at irregular hours to make spot checks, and get to know the staff. The more engaged they feel you are, the more attentive they are likely to be towards your loved one. If the nursing home has a family council—a group of relatives and friends who meet on a regular basis to discuss concerns and issues—consider joining.

More help for choosing nursing homes

Resources and references

Overviews

Guide to Choosing a Nursing Home – Provides information to help individuals, family members, caregivers, and those who assist them find and compare nursing homes, and make informed decisions about nursing home care. (Medicare.gov)

How to Choose the Right Nursing Home, Step by Step – Overview on whether a nursing home is necessary, doing the legwork to find the right home, and a checklist of questions to ask. (US News)

Skilled Nursing Care: Fact vs. Myth – Explodes 14 misconceptions about Nursing Home/Skilled Nursing Facility living on the basis that the quality of nursing home care has improved in recent decades. (American Health Care Association)

Evaluating nursing homes

Nursing Home Compare – Searchable database that helps you compare and rate Medicare- and Medicaid-certified nursing homes in the U.S., including staffing, health inspections and quality measures. (Medicare.gov)

Search Senior Housing Facilities – US News and World Report provides a searchable database of nursing homes, organizing data provided by Medicare. (US News and World Report)

Citizen Advocacy Groups – Provides information about citizen advocacy groups in your area, as well as contact information for all state ombudsmen. (National Citizens' Coalition for Nursing Home Reform).

Choosing a Nursing Home – Tips on finding and evaluating facilities, and details on financing this type of care. (The Health Pages)

Checklists for visiting a nursing home

Nursing Home Checklist – A comprehensive list of issues to consider while selecting an appropriate facility, under categories: First Impression, Living Area and Accommodations, Moving In/Contracts/Finances, Health/Personal Care/Services, Social & Recreational, Staff, Food, Licensure & Certification. (CarePathways.com)

Making the transition

Helping Your Loved One Transition to Skilled Nursing Care – Helps both residents and family members ease the adjustment to Nursing Home living. (American Health Care Association)

Nursing home costs

Medicare Coverage of Skilled Nursing Facility Care – Detailed information about Medicare coverage of skilled nursing care, including examples, as well as ways to get help paying for skilled care. (Centers for Medicare and Medicaid services)

Guide to Long Term Care Insurance – Information about policies, how to evaluate them, and questions to ask. (America’s Health Insurance Plans)

Medicaid Rules – A general overview of what assets are considered in qualification for Medicaid, and what protections there are for a spouse. (ElderLaw)

Authors: Joanna Saison M.A., Doug Russell, L.C.S.W., and Monika White, Ph.D. Last updated: December 2014.