Nursing Homes:

You never think it will happen to you. When we're in our prime, in the peak of health, it's hard to imagine needing Skilled Nursing care. Yet with life expectancy rising and a record number of people approaching their senior years, it's inevitable that some of us will require Nursing Home care as our circumstances change.

What is a Nursing Home (Skilled Nursing Facility)?

A Nursing Home, also known as a Skilled Nursing Facility or SNF, has Registered Nurses who help provide 24-hour care to people who can no longer care for themselves due to physical, emotional, or mental conditions. A licensed physician supervises each patient’s care and a nurse or other medical professional is almost always on the premises.  Most nursing homes have two basic types of services: skilled medical care and custodial care.

Skilled medical care includes services of trained professionals that are needed for a limited period of time following an injury or illness:

• An R.N. doing wound care and changing dressings after a major surgery, or administering and monitoring I.V. antibiotics for a severe infection.
• A physical therapist helping to correct strength and balance problems that have made it difficult for a patient to walk or get on and off the bed, toilet or furniture.
• A speech therapist helping a person regain the ability to communicate after a stroke.
• An occupational therapist helping a person relearn independent self-care in areas such as dressing, grooming and eating.

Skilled care may also be needed on a long term basis if a resident requires injections, ventilation or other treatment of that nature.

Custodial or personal care includes assistance with what are known as the activities of daily living, such as:

• bathing
• dressing
• eating
• grooming
• getting in and out of bed, or walking around
• toileting (incontinence care)

People who are able to recover from a disabling injury or illness, may temporarily need the custodial care as they are getting back the strength and balance to be independent again.  For people who are losing their ability to function independently due to chronic disease and increasing frailty, custodial care may be a long-term need.  In the most severe cases where a person is bed-bound, ongoing supervision by an RN is necessary along with the custodial care, to ensure proper hydration and nutrition and to prevent skin breakdown. If a custodial care resident becomes ill or injured, they may spend a period of time in skilled care, and then return to custodial care.  Whether a resident is under skilled or custodial care is important in terms of who provides the care and who pays for the services provided.

Is Nursing Home care covered by Medicare, Medicaid and private insurance?

Most medical insurance coverage follows Medicare guidelines.  Private insurance and Medicare pay for nursing home care only for limited time periods following a hospitalization:

• You must have been hospitalized for at least 3 days.
• You must enter the nursing home within 30 days of the hospitalization.
• Only the first 20 days are 100% covered; then there is a daily deductible.
• There’s a 100-day maximum related to any one hospitalization and diagnosis.
• You must be making regular progress as documented by medical professionals.  If progress toward independence is no longer occurring, insurance coverage ends.

While you are receiving skilled care, or rehabilitation, the nursing home will provide any needed custodial care along with the professional services, and Medicare pays.  If you have Medigap insurance, it may cover deductibles and some other charges.  However if you reach a point where you no longer have “rehab potential,” but still need daily services of an RN in addition to the custodial care, you must bear the cost of the care.  For many people this means drawing down savings, sometimes to the point where your assets are mostly depleted, and then you may qualify for Medicaid (called Medi-Cal in California).  Medicaid will then start paying for the long-term care in a Nursing Home.

How does a Nursing Home differ from an Assisted Living Facility or a Continuing Care Retirement Community?

Some residents spend only a short time in a Nursing Home; others spend the rest of their lives there. However, the Nursing Home population has been declining in recent years as more choices become available for seniors who need help. With the rise of Assisted Living Facilities, for example, people who might formerly have gone into a Nursing Home yet are able to manage with more limited care, now have an additional option.

Assisted Living Facilities offer help with activities of daily living (personal or custodial care), but no, or very limited, medical care. An Assisted Living Facility also places greater emphasis on personal privacy and autonomy than does a Nursing Home. Nursing Homes have RN’s onsite and MD’s on call, 24 hours a day; while assisted living facilities provide only personal assistance that can be performed by someone with little or no medical training.

Continuing Care Retirement Communities provide independent living, housing-with-services, and Nursing Home care in one location, enabling seniors to remain in a familiar setting as they grow older. Many seniors enter a Continuing Care Community while they are healthy and active, knowing they will be able to stay in the same community and receive Nursing Home care should this become necessary. If a senior requires Nursing Home care for a while and then becomes well enough to again live independently, they can move back to an Independent Living arrangement without leaving the Continuing Care Community.

Appropriate candidates for a Nursing Home or Skilled Nursing Facility

Each senior's need for care or assistance is unique. Some individuals may have a short-term need, perhaps caused by a fall and a broken hip, that necessitates a brief hospitalization followed by rehabilitation. After a one- or two-month Nursing Home stay, the senior may be able to return home and continue receiving some services such as physical therapy from a home health care agency, if necessary.

Other people have more long-term needs, possibly due to Alzheimer's, extreme frailty, or a stroke. In this case, care is necessary on an ongoing basis.

A Skilled Nursing Facility is for an individual who meets one or more of the following criteria:

• Cannot take care of themselves because of physical, emotional, or mental problems;
• Can no longer care for their own personal needs, such as eating, bathing, using the toilet, moving around, or taking medications (custodial care);
• Requires more care than can be provided by their caregiver, and cannot live alone;
• Might wander away if unsupervised;
• Has extensive medical needs requiring daily attention or monitoring by an RN supervised by an MD;
• Is going to be discharged from the hospital and requires temporary Skilled Nursing care or rehabilitation before returning home or to a residential facility;
• Has been recommended for a Nursing Home by a physician.

Living arrangements offered in Skilled Nursing Facilities

Skilled Nursing Facilities provide a private or shared room with a private or shared bathroom. Some Nursing Homes allow couples to stay together, and some may even allow pets. With the emphasis on patient care, however, the general ambiance has precluded much privacy or a sense of "home".

Increasingly, however, creative architectural design has made some Nursing Home living arrangements more homelike. Through the use of natural fibers and lighting, for example, many spaces throughout the Nursing Home feel friendly and warm. Many resident rooms and hallways may be carpeted, with new carpet material that can be easily cleaned on a daily basis. In addition, outdoor courtyards and indoor plants enhance livability and personal comfort in some of today's Nursing Homes.

Another major design change that’s beginning to appear is in nurse's stations. Formerly centralized for efficiency, a Skilled Nursing Facility nurse’s station can now be more like a reception area where residents and staff can easily interact.

Services provided by a Nursing Home/Skilled Nursing Facility

Nursing Homes/Skilled Nursing Facilities offer an array of services, in addition to the basic skilled nursing care and the custodial care.  They provide a room, all meals, some social activities, personal care, 24-hour nursing supervision and access to medical services when needed.

Basic Nursing Home Services generally include:

• A clean, furnished room (private or shared)
• Dietary services: nutritious meals and snacks, in accordance with medical requirements
• Housekeeping and linen service
• Personal (custodial) care (including incontinence care)
• Therapeutic recreation and activities
• Transportation (some)
• 24-hour onsite medical staff: registered nurses (RNs), licensed practical nurses/licensed vocational nurses (LPNs/LVNs), and nurses' aides
• Supervision by physicians, some of whom are on call to consult with staff and visit patients as needed
• Resident evaluation and care planning

For an additional fee, many Nursing Homes provide:

• Rehabilitation services: occupational, physical, respiratory and speech therapy
• Pharmacy, laboratory and radiology services
• Dental services
• Special care units (see next section)
• Personal care items
• Laundry service

The key characteristics of Skilled Nursing Facilities include:

Key Characteristics of Skilled Nursing Facilities
Activities of Daily Living (dressing, personal care)	comprehensive assistance provided
Community Activities (social events, outings, golf, etc.)	a few activities offered
Community Services (laundry, cleaning, etc.)	many services provided
Health Services (medications, nursing care)	skilled nursing provided
Environment (personal freedom)	residents have limited independence
Overall Health (physical, emotional)	residents are in generally poor health

Adapted from SeniorHousingNet®

Special needs handled in a Skilled Nursing Facility

Some Skilled Nursing Facilities can handle the following special needs:

• Kidney dialysis treatment
• Alzheimer's and dementia care
• Respiratory care
• Parkinson's care
• Terminal illnesses (Hospice Care) in cooperation with a separate Hospice agency that visits the facility to provide specialized care
• Chronic psychiatric care

In addition, most Nursing Homes provide:

• Respite Care (care so that caregivers can take a break)
• Interim medical care (after a hospital stay)

Costs of a Nursing Home / Skilled Nursing Facility

Skilled Nursing Facility care is expensive, and the cost continues to rise. The average daily cost of a private room in a Nursing Home was $192/day or $70,080 a year, according to the 2004 MetLife Market Survey of Nursing Home and Home Care Costs. This is a more than $4,000 annual increase over the prior year. The cost of a shared Nursing Home room averaged $169 a day, or $61,685 a year.

In addition to a private or semi-private room and the care options you choose, where you live also affects how much you'll spend for Nursing Home care. Alaska reported the highest rates for a private room in a Skilled Nursing Facility, at $204,765 a year or $561 a day on average. The lowest rates were found in Shreveport, Louisiana, at $36,135 a year or $99 a day.

Payment options for Skilled Nursing Facilities include:

• Private pay
• Long-term care insurance
• Medicaid (called “MediCal” in California)
• Medicare

References and resources for Nursing Homes / Skilled Nursing Facilities

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)

Nursing Home Checklist (PDF) – Detailed list from the U.S. government that you can print out, then write in answers to a series of questions about any facilities you are considering. (Medicare.gov)

Planning Ahead: A Consumer's Guide to Nursing Facilities – Detailed information on issues when selecting a nursing home, with a good summary of the services to evaluate in each facility you are considering. (National Center for Assisted Living and American Health Care Assoc.)

Nursing Home Compare – Searchable database that helps you compare Medicare- and Medicaid-certified nursing homes in the U.S. that also explains how the government evaluates facilities and has links to information on nutrition/hydration care. (Medicare.gov)

Living In A Nursing Home: Myths and Realities – 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)

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

A Guide for Families: Making the Transition to Nursing Facility Life – Helps family members to ease the adjustment to Nursing Home living for their senior relative. (American Health Care Association)

Nursing Home Guide – Several articles on the steps to locating and adjusting to life in a nursing home with a searchable database that helps you find, evaluate and compare Nursing Homes across the U.S. (MyZiva.net)

Medicare Coverage of Skilled Nursing Facility Care is a consumer-oriented booklet on the coverage that Medicare provides for Skilled Nursing Facilities.

Amara Rose, Tina de Benedictis, Ph.D., Doug Russell, L.C.S.W., and Monika White, Ph.D. contributed to this article. Last modified on: 1/22/08.