4 http://staging.healthinaging.org/eldercare/cocoon/elder.xml The AGS Foundation for Health in Aging
The Empire State Building
350 Fifth Avenue, Suite 801
New York NY 10118 staff@healthinaging.org (212) 755-6810 www.healthinaging.org
Sections in this chapter:

Understanding the Problem
When To Get Professional Help
What You Can Do To Help
Possible Obstacles
Carrying Out And Adjusting Your Plan


Understanding the Problem
A nursing home becomes a valuable option when the amount of medical care and attention the older person needs cannot be provided at home. Problems such as frequent incontinence, dangerous wandering, inability to sleep at night (a disrupted sleepawake cycle), or agitation that is harmful can be very difficult to manage. If so, it may be time to consider placement in a nursing home so that the older person can have the care he or she needs.

Nursing homes are residential care facilities that provide a range of services. There are several types of nursing homes that you may want to consider, depending on the older person's needs:
  • Personal care homes - which provide personal care or assistance with activities of daily living (bathing, grooming, eating, etc.). These homes do not provide round-the- Clock nursing care.
  • Intermediate nursing facilities - which provide health related care to individuals who do not require skilled nursing care, but do need some help - such as help with medications or feeding including feeding tubes.
  • Skilled nursing facilities - which provide rehabilitation services and 24-hour licensed nurse coverage. These facilities are usually for short stays following hospitalization or a fracture.
You may also want to consider a "congregate care facility" where all three of these services are under one roof. One unit or area may be for adults with skilled nursing needs, such as hip surgery for two weeks. Then the resident goes back to a "personal care" area where there is less assistance.

To keep up with the increasing demand for elder care housing and services, "Assisted Living" has grown over the past several years. These are facilities that include several levels of care, including secured Alzheimer's units and residential independent living, as well as those listed above. Having levels of care available in the same facility is both convenient and reassuring.

It is very important to include the older person as much as possible in deciding whether to go to a nursing home and where to go. If the older person is mentally alert, he or she should be involved in the process every step of the way.

Moving from one's home to a nursing home is a big change in one's life and so it is likely that it will take time to become adjusted and comfortable there. Be patient and ask the older person to be patient as well. It can be helpful to give yourselves a time period such as a month to see if this nursing home is the right one. Thinking of the first month as a trial period may make it easier for the older person to make the move to a nursing home.

You can play an important role in making sure that the older person receives good care. You can do this by visiting often, expressing your concerns to the staff whenever they arise, and being active in the nursing home's family council (or helping to start a family council if the nursing home does not have one).

Paying for nursing home care can be a major concern. If persons enter a nursing home directly from a hospital, Medicare will often pay but usually for only a limited time. However, when persons enter from their own home, they usually pay out of their own savings. When their personal resources are spent, many nursing home residents become eligible for Medicaid. Medicaid is a state and federal program that will pay most nursing home costs for people with limited income and assets. Eligibility for Medicaid varies by state and is provided only to patients in Medicaid- Certified facilities. If the older person is medically in need of nursing home care, a nursing home that participates in Medicaid must continue to give him or her care even after changing to Medicaid. A nursing home that does not participate in Medicaid can discharge the resident. Some nursing homes try to avoid admitting residents who are currently or will soon become Medicaid recipients. This is because they can charge private paying residents more than they would receive under the Medicaid program.

If you will be relying on Medicaid from the beginning, find out if the nursing homes you are considering accept Medicaid residents. You should learn about eligibility for Medicaid in your state and how this applies to your situation. Your local Area Office on Aging or social workers in hospitals or nursing homes can give you this information. Medicare, which pays for health care of older Americans, will pay some nursing home expenses, but usually only for rehabilitation purposes, and only for a relatively brief period of time.

If the older person has "long term care insurance," this can, under certain circumstances, be used to pay nursing home expenses. If you are considering purchasing long term care insurance for possible future use by the older person, be sure to check the costs carefully. For older people with health problems, the premiums for long-term care insurance can be expensive.

Your goals are to:
  • Understand the different kinds of nursing home care that are available.
  • Review the older person's needs, your ability to provide care, and your own needs.
  • Learn about the nursing homes in your area and the services they provide.
  • Discuss the situation with the older person, family, friends, and health professionals.
  • If you do decide to use a nursing home, choose the one that best meets the older person's needs realizing that no place, even one's home, is perfect.
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When To Get Professional Help
A physician, home health nurse, and/or social worker can help you and your family with the decision about nursing home placement. Your local Area Office on Aging also has staff who can help evaluate your situation and your need for nursing home care. Call for help if:
  • You are having difficulty providing care. Call before the situation becomes a crisis. Many people wait too long and then wish they had acted sooner. You can learn about services that can help you keep the older person at home as well as the kinds of nursing homes available in your community. By getting this information early, you will be able to make the best use of the help that is available and give the best possible care to the older person.
  • You think placement in a nursing home is necessary. If you have already decided that a nursing home is necessary, professionals can help you decide which one best fits the older person's needs. Hospital social workers usually have experience with several nursing homes in an area and can make recommendations. Family doctors are often knowledgeable, as are geriatric doctors. An Area Agency on Aging can tell you how to obtain copies of evaluations of nursing homes by licensing agencies. If one professional cannot help, he or she will probably know another professional who can.
Know the answers to the following questions before calling for professional help.
  • What problems are you having with care giving?
  • Are you reaching your limit in being able to provide the care the older person needs?
  • Does the older person have a disability or behavior that is difficult to manage?
  • What type of care would the older person need? Round-the- Clock nursing supervision? Hospital-level care? Meals, laundry services, personal care, counseling, recreation, social services?
Here is an example of what you might say when calling

"Hello, I would like to speak with Dr. Troy about my father, James Woods. This is his daughter, Nancy. I am taking care of my Dad at home and it is becoming harder and harder to manage. He is very sick and demanding. I feel guilty about considering a nursing home, but right now I cannot provide the care that he needs."

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What You Can Do to Help
Gather information
  • Start gathering information early. It is wise to begin the search for a suitable nursing home well in advance of seeking admission. The best homes often have no vacancies and long waiting lists.
  • Determine your wants and needs. Different kinds of nursing homes provide different types of services and care, but all must provide certain basic services. Some people may want a safe and comfortable place to live among pleasant companions. Others may want a home that emphasizes special foods or foreign languages, or similarity in religious background. The older person may need specialized medical attention. Location may be an important factor if you, family, or friends want to visit often.
  • Ask people you know if they know of any good homes. Friends and acquaintances who have been in a situation similar to yours can be good sources of information. Other resources include your family doctor, nurses, social workers, and religious organizations.
Call nursing homes

Telephone the nursing homes on your list. By asking some key questions, you will be able to cut your list to those that are most likely to meet the older person's needs. Some suggested questions are:
  • What type of care does the home provide?
  • What are the arrangements for medical care?
  • Can residents use their personal doctors?
  • Is a physician on call at all times?
  • How far is the hospital from the nursing home?
Visit nursing homes

It is essential to visit the nursing home before the person you care for becomes a resident there. When you go, take with you a copy of the Nursing Home Checklist found at the end of this chapter.
  • Tour the facility with the director of nursing. This person usually has overall responsibility for day-to-day operations. Ask about the philosophy of care at the facility, and ask the director about problems they are having in carrying out that philosophy. Also ask how many nurses' aides there are compared to patients (aid/patient ratio).
  • Observe staff at work. Administrators should be courteous, helpful, and frank. They should treat residents and their requests with respect. Staff members should respond quickly to calls for assistance and treat residents with courtesy, respect, and affection. Warm, professional relationships between staff and residents are essential for quality care.
  • Visit more than once. Visit during different times of day, and make at least one unscheduled visit. Try to make one visit at night when the fewest staff are available.
  • Talk with the residents. Ask them what they like and what changes they would suggest. What do they like about the staff? By talking with the residents, you will gain valuable insights.
  • Talk with aides and observe them with residents. These are the people who do most of the hands-on care. Try to get a sense of how they feel and act toward residents. Sometimes observing what they do can tell you more than talking.
  • Ask to see the inspection report. This report will let you know the kind of care that is provided. The report will also show any violations including physical abuse that happened at the home.
  • Trust your gut feeling. If the grounds and rooms are beautiful, but the staff seems unhappy and mean to residents, don't put the older person there. You want the older person in a facility where he or she will feel respected and comfortable.
Talk to your local long-term care ombudsman. Federal law requires each State Agency on Aging to have an Office of Long-Term Care Ombudsman. Ombudsmen visit nursing homes on a regular basis and they often have knowledge of what goes on in facilities in their communities. In addition, they investigate complaints made by or on behalf of nursing home residents and work to resolve the problems. If they are unable to resolve problems, ombudsmen refer complaints to the State Health Department for action.

More than 500 local ombudsman programs now exist nationwide. Call your local Area Office on Aging (listed in your phone book) and ask how to contact a long term care ombudsman.

Ombudsmen cannot tell you which nursing home you should use, but they will provide current information about nursing homes in your area. Ask the local ombudsman about:
  1. Information from the latest survey report on the facility. (Your State Health Department produces a yearly report on the performance of all nursing homes certified for Medicare and/or Medicaid),
  2. any complaints against the nursing homes you are considering,
  3. the number and nature of complaints for the past year against the facility,
  4. the results and conclusion of the investigation into the complaint.
Keep in mind that ombudsmen are government employees. They cannot come out bluntly and say that a certain nursing home is unacceptable. So listen for subtle cues. For example, "Are you sure you would like Springmill?" "I think you should take a look at the Pine Barrens." "Be sure to include Green Acres in your list."

Plan how you will pay the nursing home bills

Be sure that you understand, ahead of time, how much the nursing home will charge. Then review the older person's financial resources. If he or she will need financial help from Medicaid, talk to your local Area Office on Aging or a hospital or nursing home social worker about the older person's eligibility and be sure that the nursing homes you are considering are Medicaid certified.

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Possible Obstacles
Once you decide that nursing home care is needed, you may experience painful emotions. You may become anxious, angry, guilty, depressed, or frightened by making such a big decision about someone you care very much about. You may also feel grief for the loss of the older person's former self. There may be tension and disagreement among family members. Such reactions are natural and to be expected. They should be faced directly by talking openly about the problems with other family members, close friends, medical professionals, and clergy.
  1. "I feel so guilty."

    Response: Think carefully about what is bothering you about this decision. What do you feel guilty about? Guilt about not doing enough for the older person? Guilt that the nursing home isn't the best or most expensive? Guilt that you can't visit more often? Then talk it over with family, your doctor, or others who have an objective, balanced perspective.

    Feeling guilty makes you think only about what you have done wrong, ignoring what others have done. You need to see the situation objectively in order to develop effective plans that solve the problem. And remember that there are positive benefits from being in a nursing home, including better care and more resources.
  2. "You're putting me in a nursing home to die."

    Response:     "A nursing home is not a place to die - it's a place to live and you will be able to live a much better life here than at home because of all the things staff can do to help you. I've visited the home and talked to the staff and the people staying there and I think you'll like it. You'll get the help you really need that I can't give at home. Let's give it a try. If you are not happy there, we will make some other arrangements. If this nursing home isn't what you need, we'll find one that is."
  3. "The staff are nasty and the food is bad."

    Response:     "Tell me exactly what the staff did that was nasty and I'll talk to them about it. Also tell me what food you liked and didn't like and I'll try to be sure you get food that you like. It takes a little time to get used to a new place to live - so let's give this place a try. If you still feel that things are not right in a month, we'll consider other places."
Think of other obstacles that could interfere with carrying out your plan

What additional roadblocks could get in the way of doing the things suggested in this chapter? For example, will the person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out the plan?

You need to develop plans for getting around these roadblocks. Use the six problem-solving steps in the chapter on "Using the Eldercare at Home book to solve caregiving problems."

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Carrying Out and Adjusting Your Plan
Carrying out your plan

Your goal is to find the best nursing home that fits the older person's needs and resources. Remember to include the older person as much as possible in all aspects of choosing a nursing home and to take his or her requests and feelings into consideration.

Checking on results

Once the older person is in a nursing home, you must monitor the care. If there are problems, you should work with the older person to resolve them. Get to know staff members who care for the older person the most and keep in contact with them. Ask questions and expect full answers.

State and Federal laws insure that nursing home residents have certain rights. These include the right to privacy, confidentiality, freedom from restraints, to express grievances without retaliation, to have visitors, etc. Check with your Area Office on Aging for a list of nursing home resident rights in your state. Contact your long-term care ombudsman if you feel the older person's rights are being violated.

If your plan doesn't work

If you have explained your concerns to the nursing home staff and you and the older person are still dissatisfied, you can call your state long-term care ombudsman. You can reach this person through your local Area Agency on Aging, which is listed in your local phone book. You can also call the National Citizens' Coalition for Nursing Home Reform (202-332-2275) about residents' rights, and the laws governing nursing homes.

If you decide to look for a new nursing home, repeat the steps listed earlier in this chapter. Be sure that the new location will meet the older person's needs better than the present one. Don't move just to get away from a problem and then discover that the new location has worse problems.

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Questions For Selecting A Nursing Home

Here are some questions to guide you in making a decision about a nursing home. You should carry this checklist with you when you visit a nursing home. Write down what you learn because, after you have visited a few homes, it will be hard remembering what happened at each visit.

Credentials
  • Does the nursing home have a current state license?
  • Does the nursing home administrator have a current license?
  • Is the home certified for Medicare and Medicaid?
Residents
  • Do residents seem well cared for?
  • Are most residents dressed for the season and time of day?
  • Do residents seem to enjoy being with staff?
  • Are residents involved in a variety of activities?
  • Can residents leave the nursing home for daytime trips or overnight stays at your house?
Facility
  • Is the atmosphere warm and pleasant?
  • Do rooms provide privacy?
  • Is there an activity room?
  • Is the home clean, orderly, and reasonably free of unpleasant odors?
  • Are grab bars, handrails, and emergency call buttons located in rooms and halls?
  • Does the building have smoke detectors, sprinkler systems, and emergency lighting?
  • Does the home have a security system to prevent confused residents from wandering out of the building?
  • Are there accessible outdoor areas for residents to use?
  • Is it easy for residents in wheelchairs to move around the home?
  • Is the lighting appropriate for what residents are doing?
  • Are there private areas for residents to visit with family visitors and physicians?
  • Are bedrooms furnished in a pleasant manner?
  • Can residents bring furniture and personal items from home?
Staff
  • Do staff show interest in and affection for individual residents?
  • Is staff courteous and respectful?
  • Do staff know residents by name?
  • Are enough nurses and aides on duty at all hours, including weekends?
  • Is the home sensitive to cultural and minority differences?
  • What is the average length of time staff have worked in the home?
Services
  • Is regular and emergency medical attention assured?
  • Do various staff and professional experts participate in evaluating each resident's needs and interests?
  • Does the resident or his or her family participate in developing the resident's care plan?
  • Is the plan reviewed regularly and is the family invited to participate?
  • Does the home have arrangements with a hospital for transfer of patients in an emergency?
  • Are pharmaceutical services available and supervised by a qualified pharmacist?
  • Does the home offer physical therapy and rehabilitative services?
  • Are interesting activities scheduled?
  • Are arrangements made for residents to participate in religious practices?
  • Are the dining room and kitchen clean?
  • Are meals nutritious, appetizing, and tasty? (Arrange to have a meal yourself.)
  • Does the staff assist residents who can't feed themselves?
  • Are special diets available for health needs, religious or ethnic preferences?
  • Is a weekly menu available? (Ask to see the menu for several weeks.)
  • When can the family visit? What activities involve the family?
  • Is there an organization for family members?
  • What services do volunteers provide?
Financial
  • How do monthly costs compare with the cost of other homes?
  • Are financial and other policies specified in a contract?
  • Do the resident's assets remain in his or her control or the family's?
  • Are all services covered by the basic daily charge?
  • Are advanced payments returned when the patient leaves the facility?
  • Will they "hold" the bed when a resident is admitted to a hospital?
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For additional information:

Your Area Office on Aging will have a supply of booklets and pamphlets to help in selecting a nursing home. You can find their telephone number in your local phone book.

"Nursing Home Life: A Guide for Residents and Families," (Revised 1997) developed by the American Association of Retired Persons (AARP). Write to: AARP, 601 E. Street NW, Washington, DC 20049 (202-434-2277). Internet Address: www.aarp.org.

"Choosing a Nursing Home: a Guide to Quality Care," (1986) Write to the American Association of Homes for the Aging, Suite 500, 901 E Street, NW, Washington, DC 2004-2037

"A Shopper's Guide to Long-Term Care Insurance," a free publication from the National Association of Insurance Commissioners, 120 W. 12th St., Suite 1100, Kansas City, MO 64105. 816-374-7259.

"Residential Care: A Guide for Choosing a New Home" (brochure # PF 1102), developed by the Alzheimer's Association, 919 N. Michigan Ave., Suite 1000, Chicago, IL 60611-1676. 1-800-272-3900.