Nursing homes have changed dramatically over the past several decades. These changes have been driven by government regulations and consumer pressures. Today’s nursing homes are highly regulated, high-quality institutions for the care and treatment of older adults who have severe physical health and/or mental disabilities.
Almost half of all people who live in nursing homes are 85 years or older. Relatively few residents are younger than 65 years. Most are women (72%), many of whom are without a spouse (60% widowed) and with only a small group of family members and friends for support..
Some type of disability or impairment with activities of daily living (ADLs) is the most common reason that older people live in nursing homes. Not surprisingly, people living in nursing homes generally have more disability than people living at home. About one fourth (25%) of nursing-home residents need help with one or two ADLs (eg, walking and bathing), and three fourths (75%) need help with three or more. More than half of residents are incontinent (either bowel or bladder), and more than a third have difficulty with hearing or seeing.
In addition to physical problems, mental disturbances are common in nursing home residents. In fact, dementia remains the most common problem, and affects an estimated 50%-70% of residents. In addition, more than three fourths of nursing-home residents have difficulty making daily decisions, and two thirds have problems with memory or knowing where they are from time to time. Problematic behaviors are also common, shown by at least one third of nursing-home residents. These behaviors may include verbal and physical abuse, acting inappropriately in public, resisting necessary care, and wandering. Communication problems are also common—almost half of nursing home residents have difficulty both being understood and understanding others. Depression is diagnosed in 20% of nursing home residents.
Although disability is common among nursing home residents, the length of stay is really quite variable. Twenty-five percent of people admitted stay only a short time (3 months or less). Many of the people who stay for a short time are admitted for rehabilitation or for terminal (ie, end-of-life) care. About half of residents spend at least 1 year in the nursing home, and 21% live there for almost 5 years. Interestingly, function often improves in many of the residents who stay for longer times.
The number of people admitted to nursing homes in the United States has increased since 1994. Most people are admitted to nursing homes after being discharged from a hospital after surgery or a sudden illness. Unfortunately, nursing-home residents also often return to the hospital with sudden medical illness.
Without a breakthrough in the treatment of dementia, the number of people 65 and older living in nursing homes will likely double by the year 2020. Interestingly, the occupancy rates in nursing homes have gone down over the past several years, so that the average nursing home is less than 90% full. Generally, this is thought to be because there are other options for long-term care, such as assisted living facilities. Other social and financial causes are also likely. Surprisingly, the greater availability and use of home-care services allowed by Medicare have not consistently decreased admissions to nursing home.
There are several risk factors for admission to a nursing home, including the following:
On the other hand, certain factors do not seem to affect nursing-home admissions. These include the following:
Not surprisingly, older adults with positive attitudes toward nursing homes are more likely to use them.
Nursing Home Characteristics and Financing
Currently there are 17,000 nursing homes with a total of 1.8 million beds in the United States. These hold 1.6 million residents and discharge 2.4 million residents every year to home, hospital, or hospice care. Of these 17,000 facilities, 65% are for-profit, 25% are not-for-profit, and 10% are government nursing homes. The average nursing home operates 107 beds, with some having more than 200 beds. A little more than half of all nursing homes (56%) are part of a chain.
Nursing homes are increasingly offering medical services similar to those offered in hospitals after surgery, illness, or other sudden medical problems. Older adults need a higher level of care, and hospital stays are shorter than they used to be. Medical services vary a lot among nursing homes, but include kidney dialysis, orthopedic care (care for muscle, joint, and bone problems), respiratory support, support after surgery, rehabilitation, intravenous therapy and antibiotics, and wound care. Traditionally, these services have been available only in hospitals and rehabilitation centers.
Currently, $90 billion is spent annually on nursing home care in the United States. This figure is expected to increase to $150 billion by 2007. Where does this amount of money come from? (See table.)
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Sources and Amount of Nursing-home Spending |
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|
Public Programs |
Private Sector |
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|
Medicaid |
48% |
Out of pocket (paid by patient) |
31% |
|
12% |
Health insurance |
5% |
|
|
Other |
2% |
Other private funds |
2% |
|
Total |
62% |
Total |
38% |
Almost one third of residents are eligible for Medicaid when they are admitted to a nursing home. Another third eventually qualify as their financial resources are used up.
Under the Balanced Budget Act of 1997, Medicare payments to skilled nursing facilities are based on a patient’s skilled nursing needs and rehabilitative potential, rather than on cost. For example, nursing homes must keep written records of the patients’ progress to ensure reimbursement for rehabilitative therapy, which is needed by many nursing home residents. Nursing homes are also required to have careful and thorough admission policies for Medicare beneficiaries. (See also Insurance, Financing, and Costs of Health Care)
Your family doctor or other health care provider (eg, home health nurses and social workers) can provide recommendations for nursing homes. Older adults and/or family members should try to visit as many places as possible to get a sense of what the place is like, including the overall atmosphere and quality of care. Using a checklist can help you evaluate quality, the range of services, convenience, and costs. Your visit may last an hour or two so that you can meet and talk with the admissions officer, nursing home administrator, head nurse, and social worker. Remember that no nursing home is perfect, and all will likely be very different from the current living situation.
Nursing homes may often seem scary and depressing, and moving into one can fill people with a sense of betrayal and failure. Family involvement is important in helping the older person make the transition to a new living arrangement. Contrary to the stereotype, families do not abandon their loved ones by placing them in a nursing home. In fact, only a few nursing home residents are truly without any family. Family members are encouraged to visit residents regularly and to be involved in the total care of their older relative. Family members can offer companionship and assistance with the basic activities of daily living, and they may be better able to communicate the needs of the resident.
Healthcare Providers in Nursing Homes
Residents of nursing homes today are “sicker” and more disabled than nursing home residents were in the past. This emphasizes the importance of quality medical care within nursing homes. The healthcare team within nursing homes is made up of a variety of skilled professionals, including nurses, physicians, nurse practitioners, physician assistants, and medical directors.
Nurses are a key member of the medical staff within nursing homes. Nursing assistants are also very important, because they provide much of the routine care. The quality of care is linked to the following factors:
Although it would be ideal to increase nursing staff levels in nursing homes, this has not happened for a variety of reasons. Two of the major reasons are:
High staff turnover rates (over 50% every year for professional nurses) have also been linked to a greater number of nursing home residents being readmitted to a hospital.
The physician is a critical member of the medical team. He or she manages the overall healthcare of the residents. Ideally, the physician should be a permanent employee of the nursing home, preferably specializing in geriatric medicine (medicine for older patients). This type of permanent staffing arrangement is thought to deliver a better quality healthcare, because the physician is involved in all aspects of the nursing home. Usually, this improves both staff communication and treatment of residents. Some evidence also suggests that nursing home residents are hospitalized less often when the nursing home employs a limited number of dedicated physicians. The quality of medication administration within the nursing home also increases when nurses, physicians, and other members of the healthcare team regularly discuss patient care and treatment.
Nurse practitioners and physician assistants
Nurse practitioners and physician assistants have become more involved in the primary care of nursing home residents. These health professionals are typically nurses who received additional medical training, so that they can diagnose and treat routine illness with oversight by a physician. Studies suggest that nurse practitioners and physician assistants, acting together with the primary care physician, can achieve the following:
However, the nurse practitioner or physician assistant must always be supervised by a qualified physician. The physician provides advice and is available to manage and care for residents with more serious or complicated conditions.
In many ways, the quality of medical care in the nursing home is determined by the medical director. The medical director works closely with the entire staff. He or she must be aware of and up-to-date on the laws, regulations, and organizations that affect nursing homes and long-term care. The medical director, together with the medical staff, sets quality standards for the nursing home through specific policies and procedures. The medical director must make sure the nursing home meets and follows all relevant state and federal regulations and guidelines. He or she must also work with the nursing home administrator and director of nursing to keep the staff working as an efficient team. Certification for medical directors after completion of a formal course is now offered through the American Medical Directors Association.
Extensive nursing-home reforms were enacted as part of the Omnibus Budget Reconciliation Act of 1987. These regulatory changes established training guidelines and minimum staffing requirements for nursing homes, and also strengthened the rights of residents. For example, the new laws limit the use of restraints and medications as a way to control resident behaviors. These laws also required that all nursing home residents receive a comprehensive assessment at specific intervals or times. This comprehensive assessment is known as the Minimum Data Set (MDS).
How is the Minimum Data Set (MDS) used?
The MDS focuses specifically on clinical issues related to quality of care. If any problems or potential problems are identified, the healthcare team must review the protocols used in the care of the residents. These protocols outline standard diagnostic and treatment plans for the specific problem(s) in question. In other words, they are practice guidelines that the healthcare team is encouraged to use.
Measuring the overall impact on quality of care produced by these regulatory changes has been difficult. The government has put a new set of quality indicators in place (based on MDS items), in an effort to speed up improvements in quality. Using this system, nursing homes can compare their individual performance with regional and national averages. They can use this information to help guide their efforts to improve the quality of care (see www.cms.gov).
In addition to comprehensive assessments, the physician must also keep clear records that indicate the need for all medications, particularly those that affect behavior or mental function. If nine or more medications are being administered (to one resident), the state government flags the care for investigation. Unnecessary medications are prohibited. In this situation, unnecessary medications are defined as those that are given under any of the following conditions:
In addition, specific types of medications have been banned from use in nursing homes. If these banned drugs are administered without proper reasons written in the patient’s record, the state government will issue a citation.
Medical Care of Nursing-home Residents
The medical care of nursing home residents is demanding and challenging. Many nursing home patients are physically and psychologically frail, which makes treatment more complicated. The most common health conditions of older patients in nursing homes are dementia, heart disease, high blood pressure, arthritis, and stroke. Other common problems include infections, urinary incontinence, falls, fainting, depression, malnutrition, and pressure ulcers.
Often, nursing home residents have more than one medical condition. Multiple conditions often mean multiple medications. Unfortunately, multiple medications increase the chances of having a bad reaction to a medication as well as other medical complications. Family members often are not prepared for these things to happen. Instead, complications tend to make people resist any treatment, which may actually end up decreasing the quality of life and independence of the resident.
The overall clinical care and the way specific problems are managed must be individualized for each patient. The approach can vary enormously from one person to another, ranging from measures that increase the patient’s comfort to numerous diagnostic tests and treatment. Diagnostic issues are another complicating factor. Many older patients have symptoms that are subtle or not typical, making diagnosis difficult. In addition, many patients have mental impairment, and the strict regulatory (government) requirements in these situations further complicate medical decisions.
In addition to clinical care, health care providers must be sensitive to the complex legal and ethical issues that can arise. For example, think about a frail nursing home resident who requires tube feeding. Some of the many considerations include the following:
Regardless of these difficulties—or perhaps because of—the relationships that develop between patients, families, physicians, other health care providers, and staff in the nursing home are among the most rewarding.
Understanding what each nursing home resident prefers for care (based on his or her underlying value system) results in improved care and overall quality of life. Surprisingly, fewer than one in eight nursing home residents has discussed preferences with health care providers. In addition, there is often a lack of follow-up on “future directives,” such as living wills and do-not-resuscitate orders. These directives may change after the person has been living in the nursing home for a time. Some nursing homes have ethics committees that can help resolve any ethical dilemmas that arise. These committees should have several members who are experienced in different areas of healthcare. This ensures a broad opinion and insight that is critical for care of nursing home residents, and especially for end-of-life issues. (See also Legal and Ethical Issues.)
Certain care strategies have recently been developed that can further improve quality. Consultation with specialists (eg, cardiologists, urologists, etc) may improve care and treatment results. These specialist services should be part of the comprehensive, ongoing assessment for each patient. Continuing education programs for physicians and nursing staff may also improve care. However, special-care units, which have become common in nursing homes, have not been shown to necessarily improve quality of care.