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Types of Nursing Homes

Nursing homes are known by many names, such as skilled nursing facilities, long-term care facilities, and sub-acute facilities. Nursing homes can elect to participate in Medicare and/or Medicaid. Medicare certification allows for all or part of the facility to be certified, therefore, a resident may have to transfer or move when Medicare is no longer the source of payment. A nursing home may also elect to have "dually-certified" beds where there is no distinction or separation in beds that are Medicare or Medicaid certified. Medicare-only facilities are known as skilled nursing facilities (SNF) while Medicaid- only facilities are known as nursing facilities. Generally, there are certain characteristics that define the type of nursing home.

Quality Measurements

When analyzing nursing home quality, it is best to look at several quality measurements to make your decision. The following are some good sources of information to include in your evaluation.

Nursing Home Report Cards�

Ratings that compare nursing home performance are an important issue for health care consumers. Nursing Home Report Cards� provides up-to-date objective ratings for nursing homes across the U.S. using a blend of quality measurement data such as survey results, both current and past, and measurements of repeating deficiencies.

Licensing Surveys or Inspection Reports

Each nursing home is inspected by its state health department and undergoes an on-site survey to see if it is in compliance with nearly 150 different regulations. Survey performance is a key measurement of how a facility meets certain health and safety requirements, including Medicare and/or Medicaid certification.

Accreditation

Nursing homes may receive additional endorsements by voluntarily seeking accreditation with the Joint Commission on Accreditation of Health care Organizations (JCAHO). To receive JCAHO accreditation, a nursing home must meet certain health and safety requirements.

Nursing Staff

The number of nurses on staff in a nursing home in relation to the number of patients or to other nursing home staff is often an indicator of quality that affects patient care. There are two regulations related to staffing requirements. One regulation requires a minimum Registered Nurse (RN) staffing level of eight consecutive hours a day, seven days a week while the other regulation requires 24-hour-a-day licensed nursing staff sufficient to meet the needs of the residents. Some facilities may be given a waiver for either of these requirements. Waivers are granted under certain conditions where the safety of the residents is not jeopardized.

Nationally, Medicare/Medicaid and Medicaid only facilities have on average one RN to 34 patients, one Licensed Practical Nurse (LPN) to 34 patients and one nurse assistant to 11 patients. These ratios will vary depending upon the time of day and/or shift.

The qualifications of the Director of Nursing is also a key indicator of quality performance as she/he sets the tone for the facility. A Director of Nursing must be a RN and unless the facility meets certain conditions, cannot serve as a charge nurse. A high-quality Director of Nursing will know the residents and the nursing staff.

Although most nursing homes suffer from a high employee turnover, a good indicator of quality patient care is stability in the employment of nursing staff. How long has the Director of Nursing been at the facility? How long have some of the nursing assistants worked for the facility? Taking a look at the classified ads for several weeks may also be a way to gather
quality information on a nursing home that is constantly trying to hire nursing staff.

Quality of Care

Measuring quality of care in a nursing home is different from measuring quality of care in a hospital. Hospitals treat short-term illness, whereas nursing homes provide long-term care including attention to mental and social conditions. The quality of care in a nursing home is related to how well the residents are functioning in all of these areas, and how that level of functioning is maintained. It is important to remember that even though a high quality of care may be provided by a nursing home, a resident may still experience an unavoidable decline in their abilities due to the nature of their illness. Nursing homes are required to provide the necessary care and services for residents to reach their highest level of physical, mental and social well being.

Some quality standards to look for in a nursing home are:

• Care and treatment of mental and psychosocial adjustment difficulties.
• Nutritional care and treatment to prevent weight loss.
• Skin care and treatment to prevent pressure sores or to promote healing and prevent infections.
• Treatment and services to maintain mobility such as range of motion regardless of if the resident is mobile or bed bound.

Payment Considerations

There are five basic ways in which nursing home costs may be financed.

1. Personal Resources
   Approximately 25 percent of nursing home care is paid for out of personal resources. On average, a nursing home can cost $46,000 a year for basic room and board.
   
   
2. Private Insurance
   Long-term care insurance is on the rise with more insurance companies offering insurance plans that cover nursing home and home health care. Details of coverage depend on the insurance policy.
   
   
3. Medicaid
   Medicaid is funded by both state and federal sources and is health insurance for eligible low-income individuals. Medicaid will pay for basic room and board for those who qualify in nursing homes that are certified for Medicaid. Medicaid currently pays for approximately 67 percent of nursing home care.
   
   
4. Medicare
   Under certain conditions, Medicare (Part A) will pay for a fixed period of time in a skilled nursing facility. Again, the nursing home (or the bed the resident is in) must be certified for Medicare. There is a 100-day benefit period in a calendar year for nursing home coverage, however, there are requirements that a resident must meet daily in order to receive nursing home coverage. The nursing home will assess and re-assess the resident to ensure that the individual is qualified and meet or continue to meet the Medicare coverage requirements. Once a resident does not meet the requirements, notice of non-coverage and the effective date is given.
   
   
5. HMO or Managed Care
   HMOs and managed health care plans also cover nursing home care. A facility must be a designated provider of the plan for nursing home care will be covered. Also, since assignment the Part A Medicare benefits were assigned to the HMO or managed care plan, coverage of nursing home care generally follows the requirements listed above for Medicare. The difference is that the HMO or managed care plan, not the nursing home, will determine if the resident meets the requirements for admission and will also determine when the resident no longer meets requirements.

Referrals

The Long-Term Care Ombudsman is a very good source for information. The ombudsman program is a significant part of the long-term care system as Ombudsmen act as advocates for residents and receive information about complaints and deficiencies from the State Health Department. Each state area agency on aging is required to have an office of the long-term care ombudsman. Ombudsmen visit nursing homes on a regular basis. They receive and investigate complaints and can refer serious situations/violations to the state health department. They cannot advise consumers on any one nursing facility but can provide information about complaints, survey results, and signs of good patient care.

Other good sources of information are:

• Hospital discharge planners
• Physicians who serve seniors
• Geriatric case managers
• Clergy
• Friends and family of residents in nursing homes

Visit

Visiting the nursing home is essential to evaluating nursing home quality. It will give you the opportunity to meet with nursing home staff, chat with residents, view the condition of the facility, watch the staff in action, and feel the atmosphere. When you visit, ask for the admissions coordinator who will introduce you to the features of the facility and give you a formal tour. Afterwards, you may ask to return and view the facility at your own pace.

You may want to ask to see the latest survey results or ask questions about the survey from your review of Nursing Home Report Cards�. Keep in mind that viewing a facility through an inspector�s or surveyor�s eye is limited to only the regulations that a facility must meet. These regulations, at best, are minimal requirements for licensure. Evaluate other signs that make the nursing home a "home" such as plants, animals, smiling staff and low noise levels.

Questions to Ask When Choosing a Nursing Home

• Is the nursing home Medicare certified?
• Is the nursing home Medicaid certified?
• Is the nursing home accepting new patients?
• Is there a waiting period for admission?
• Is the licensing and certification for the nursing home current?
• Is the license of the nursing home administrator current?
• Does the nursing home have any specialty care units?
• Are residents able to make choices about their daily routine, such as when to go to bed and what to eat?
• How is the interaction between staff and resident?
• Does the nursing home meet your cultural, religious and/or language needs?
• Does the nursing home smell and look clean?
• Can residents have personal articles and furniture in their rooms?
• Are there a variety of activities to choose from?
• Does the nursing home have volunteer groups?
• Does the nursing home have outdoor areas for resident use?
• Did the facility correct any Quality of Care deficiencies that they received on their most current survey?
• Can residents continue to see their personal physicians?
• Are the residents clean, appropriately dressed and well groomed?
• How well does the administrator interact with staff and residents?
• Does the nursing home have a resident and family council that meets independently of the nursing home�s management?
• Are care plan meetings held at times that are convenient for residents and family members to attend?
• Are there enough staff to assist each resident who requires help eating?
• Does the food smell and look good?
• Are residents offered choices of food at mealtimes?
• Are nutritious snacks offered?
• Does the dining room environment encourage residents to relax, socialize and enjoy their food?
• Are there handrails in the hallways and grab bars in the bathrooms for safety?
• Are the exit doors clearly marked and clear of impediments?
• Does the nursing home have a disaster plan to move residents in emergencies?
• Are spills cleaned up quickly?
• Are the hallways free of clutter and well-lighted?