Nursing Home

September 17, 2011

Nursing homes serve as residence for individuals who are too frail, too sick, or too disabled to live in their homes. It is estimated that nearly 12 million individuals are disabled enough to require long-term care. As of 1999, 1.5 million resided in nursing homes and over one third of nursing home residents were 85 years of age or older. Residence in a nursing home can be temporary, during a recovery period in which the patient requires skilled nursing care, or permanent, in the presence of severe and irreversible decline of functional and cognitive abilities. Most individuals prefer to reside in their homes, especially when a network of friends, family members, and professional individuals is available to provide help. The decision to reside in a nursing home is postponed both for financial and psychological reasons. Psychologically, the impact of placement in a nursing home suggests this is the final move and represents a loss of function and familiarity. Placement is postponed while the caregiver tries to provide as much care as possible for as long as possible; it is materialized when the caregiver is physically and psychologically exhausted because care for physical and/or behavioral problems is required 24 hours a day. Also, when resources in the community are not predictably and promptly accessible, the individual may be no longer safe in the community and a move to a nursing home becomes warranted. Despite the number of services available to support long-term care to communitydwelling residents, long-term care has remained fragmented and care management or care coordination among various agencies to promote individual choice and control has been less than optimal.

Nursing home care is very costly, amounting to $90 billion in 1998. Out-of-pocket expenditures by consumers have accounted for nearly one third of the total costs. Nearly 50% of all nursing home residents pay for their care out of their own savings. Medicare provides coverage for such services only on a temporary basis. Individuals with low incomes/resources can qualify for Medicaid to obtain coverage for care in nursing homes. Most individuals “spend down” to levels of income/resource that are low enough to qualify for Medicaid, a mechanism that often leads to spousal impoverishment. It is important to note that Medicare and Medicaid programs will reimburse only to nursing homes that are certified by the government to provide service to Medicare and Medicaid beneficiaries.

Nursing home residents have certain protections under the law, and, similar to all patients, they have the right to be treated with respect and dignity; to be informed about their medical condition and medications, to see their own doctor; to be informed in writing about the services and associated fees before being admitted to the nursing home; and to manage their own resources or choose an individual whom they trust to do so. On the other hand, nursing homes are not required to admit a patient if he or she cannot show how they will pay for services and may legally discharge a resident for nonpayment. Although a patient’s family is not liable to reimburse for services received in a nursing home, the patient’s estate is. Families get pursued by nursing homes for debt collection after the patient’s death. Some are able to pay, and others not, especially in the event that they are financially devastated by the lengthy episode of illness. Families can seek financial advice through the legal services of the Area Agency on Aging.

There have been concerns about the quality of care rendered in nursing homes, following a report by the United States General Accounting Office in 1997 noting the presence of “serious or potentially life-threatening problems associated with nursing home care.” Issues such as the qualification and level of staffing have been central to such concerns. Several indicators of quality of care have improved over time, including the lower use of antipsychotic drugs and a decrease in the inappropriate use of each of physical restraint, indwelling urinary catheters, and the increase in the number of nursing home residents receiving hearing aids. Many areas still need improvement, however. For example, a number of patients continue to suffer unnecessarily from pressure ulcer, malnutrition, and dehydration. Furthermore, many elderly continue to experience verbal abuse and neglect.

The Center for Medicare and Medicaid Services proposes a checklist of items to inquire about when selecting a nursing home. This checklist is available through their website, cited below. Briefly, the person inquiring about a nursing home must check that the institution is Medicare and Medicaid certified; can provide the level of care and special services needed for the patient, if the patient has dementia, is on a ventilator, or needs rehabilitative services; the residents are dressed appropriately for the season of the year and time of the day; the facilities are clean and odor-free; the temperature and the lighting are adequate; the noise level is comfortable; the furnishings are sturdy; and the facility is located at a reasonable distance from family and friends. With respect to the staff, the person inquiring about the nursing home must ensure that staff members are warm, polite, and respectful to patients; there is a full-time RN in the nursing home at all times, in addition to the Director of Nursing; the same team of nurses and Certified Nursing Assistants (CNAs) work with the same resident 4-5 days a week; that the ratio of CNAs to residents is reasonable; that there is a full-time social worker; and that a licensed physician affiliated with the facility can be easily accessible. Serious quality problems can be reported to the Ombudsman of the Area Agency of Aging if matters are not resolved through discussions with the nursing home staff.

Parallel to the increase in life expectancy, the size of the elderly population is projected to grow substantially in the next decades. For example, the population 85 years of age or older, the frailest group of the elderly, and comprised of 4.2 million individuals in 1999, is expected to double in 2030, and more than quadruple by 2050. Such changes in population demographics are bound to strain the existing system for providing long-term care to elderly Americans. Given the disproportionate representation of women among nursing home residents, women are encouraged to be active participants in debates shaping relevant public policies.

SEE ALSO: Activities of daily living, Long-term care, Medicaid, Medicare, Patients’ rights

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