Eldercare at Home: Choosing a Nursing Home
Caregiving How Tos
Understanding the Problem
A nursing home becomes a valuable option when the amount of medical care and nursing attention the older person needs cannot be provided at home. Problems such as frequent incontinence, dangerous wandering, inability to sleep at night (a disrupted sleep - awake 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.
It is very important to include the older person as much as possible in deciding whether to go to a nursing home or other care setting. 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 life change. Adjusting to the move and becoming comfortable will take time. Both the family care giver and the older person will need patience during the adjustment period. Consider the first month in the nursing home as a trial period when you can help ease the transition for the older person. Visiting frequently for short time periods can be more helpful during the adjustment phase than staying for hours at a time.
You can play an important role in assuring that the older person receives good care by being involved during this transition by visiting often, speaking with the staff, and participating in both the care planning sessions and nursing home's family council. If there is no family council, consider starting one. Talk with the activities director and see if you can help in some of the activities and outings for the residents.
Finding suitable alternative living arrangements is becoming more complex since there are a number of community resources that provide various levels of care. The resources vary from community to community and, with the exception of nursing homes, standard definitions based on services provided are generally lacking. Moreover, terminology and regulation varies from state to state. Funding sources for the different care facilities vary also.
Nursing homes are residential care facilities that provide a range of services. Both federal and state regulations require that a doctor or his or her designee will routinely visit an individual living in a nursing home, assess the resident's health status, and monitor the plan of care. Licensed nursing staff are in the facility 24 hours a day. Some nursing homes provide secure units specifically for persons with dementia. There are several types of nursing home care that you might want to consider, depending on the person's needs.
Skilled nursing care provides 24-hour licensed nurse coverage and rehabilitation services. These facilities provide care for both short term and long-term stays. An example of a short-term stay would be one following hospitalization to repair a fractured hip which would require a stay of two to four weeks for physical therapy. An example of a long-term stay would be care for someone for whom care could no longer be safely provided in the home or for someone who is not expected to recover the ability to care for himself or herself.
Subacute nursing units provide services that require more intense therapy or monitoring than is normally provided in a nursing home. An example would be intense rehabilitation services and/or 24-hour licensed registered nurse coverage capable of managing more acute problems such as complex intravenous therapy or ventilator-dependent persons. These services are generally provided within a skilled nursing facility and are considered short-term needs.
Alternatives to Nursing Home Care:
Adult Day Care is used commonly for patients with dementia who need supervision and assistance with their activities of daily living (ADLs) such as toileting, bathing, eating etc., while primary caregivers work.
Assisted living facilities are residential facilities that provide individual rooms, two to three daily meals, and activities for senior citizens who can no longer live alone but do not require 24-hour nursing supervision. These facilities are sometimes referred to as congregate care or congregate living facilities and have grown in number recently. Assisted living facilities provide 24-hour on-site support and assistance including help with medicines and personal hygiene. Many assisted living facilities offer a secured Alzheimer's unit. These facilities are prohibited from providing skilled nursing services and are regulated under a different set of state regulations than those governing a nursing home. If skilled nursing services are required, these services can be provided by a separate home health agency as directed by a doctor or his or her designee. There is no doctor involvement in the plan of care for an individual residing in an assisted living facility nor are doctors required to visit, either by state or federal law. An older adult still should receive primary care from their community physician or from a physician who may have an office practice on site at an AL facility.
Board and care homes are generally smaller, more home-like residences for individuals who can no longer live independently. These facilities provide room, board, and assistance with some activities including managing medicines and help with personal hygiene. Fees and services vary from one site to another. The size of the residence determines whether or not it is regulated by a state agency and this varies from state to state.
Sheltered Housing is subsidized through Housing and Urban Development. Programs may be supplemented by social work services and activities coordinators. Personal care assistance, housekeeping services and meals are sometimes offered.
Continuing care retirement communities (CCRCs) usually have all levels of living arrangements, ranging from independent living to nursing home care. The financial requirements for a person to enter a CCRC will vary according to whether health care is included in the total cost or charged only if used. In general, CCRCs are reluctant to accept people directly into the assisted living or nursing home facilities.
Program of All-Inclusive Care for the Elderly (PACE) is available in some states. The goal of PACE is to keep frail elderly who meet requirements for nursing home placement out of the nursing home. This is accomplished by a government program that utilizes a medical – social model in an Adult Day Care Center. More information can be found at www.cms.hhs.gov/PACE
Paying for Nursing Homes:
Paying for nursing home care is a major concern for most individuals. If persons enter a nursing home directly from a hospital, Medicare will often pay, but only for a limited time. When persons enter from their own home, they usually pay for the nursing home stay. When personal financial resources are spent, many nursing home residents become eligible for Medicaid. Medicaid is regulated by both federal and state laws and provides funding 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 persons in Medicaid-certified facilities. A Medicaid-certified nursing home must continue to provide care for a resident whose personal funds are spent while residing there. A nursing home that does not participate in the Medicaid program can discharge the resident. Some nursing homes try to avoid admitting residents who are currently or will soon become Medicaid recipients as they can charge private paying residents a higher fee 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. To learn more about eligibility for Medicaid in your state, gather information from such reliable sources as the Centers for Medicare and Medicaid Services and your county Family and Child Services Department. The local Area Agency on Aging will have useful information also, and the AARP too, have a wealth of information about nursing homes, Medicare, and Medicaid. If your loved one is in the hospital when you are considering nursing home placement, the hospital social worker is another valuable resource.
Medicare, which pays for a number of health care services including hospitalization and limited nursing home stays for episodic illness, will not pay for long-term care in a nursing home. If the older person has long-term care insurance, this can, under certain circumstances, be used to pay nursing homes expenses. If you are considering purchasing long-term care insurance for possible future use, be sure to check the costs carefully, read the small print, and review the background and track record of the company involved. It is currently recommended that people consider purchasing long-term care insurance as they approach the age of fifty. Premiums for long-term care insurance increase as one ages and vary in cost with the number of chronic conditions present and type of coverage desired.
In summary, 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 health care needs and stamina.
- 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.
- Choose the nursing home that best meets the older person's needs, realizing that no place, even one's own home, is perfect.
The older person's doctor, home health nurse, or hospital social worker are among the people who can help you and your family with the decision about nursing home placement. Many counties have a council of aging, or an Area Agency on Aging, which can be helpful.
You should request help if:
- You are having difficulty providing care
Begin the discussion 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 keep the older person at home as well the kinds of nursing homes available in your community. Obtaining information early will enable you to make the best use of help that is available and help provide the best possible care for the older person.
A frank discussion with a geriatric health care provider can help you decide on the appropriate type of care best suited for your loved one.
- Home care with increased supervision
- Subsidized Senior Housing with supervision
- Adult Day Care
- Assisted Living Facility
- Continuing Care Retirement Community
- Respite Care
- Program for All-inclusive Care for the Elderly
- Nursing Home
- 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 home 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, geriatric nurse practitioners, and geriatric social workers. Your regional Area Agency on Aging (listed in your phone book) can tell you how to obtain copies of evaluations of nursing homes by licensing agencies. The federal government Medicare web site provides additional information and posts the most recent evaluations of all nursing homes in your area. The web site on line is located at www.medicare.gov.
Know the answers to the following questions before calling the doctor:
- 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? Choices include round-the-clock nursing supervision, acute hospital care, subacute care, personal care, meals, counseling, laundry services, recreation, and social services.
Here is an example of what you might say when calling for help:
"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 for me to manage. His care is demanding more of my time; I'm torn between his needs and my family's needs. I feel guilty about considering a nursing home, but right now I cannot provide the care he needs."
- 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 might want a safe and comfortable place to live among pleasant companions. Others might want a home that emphasizes special foods or foreign languages, or similarity in religious faith. The older person might need specialized medical attention. Location can be an important factor if you, your family, or friends want to visit often.
- Ask people you know if they know of any good homes.
Friends and acquaintances who have had loved ones in a nursing home are good sources of information. Health care providers, social service agencies, and some religious organizations are also potential sources of information.
Call nursing homes
- Telephone the nursing homes on your list
By asking some key questions, you will be able to select those that are most likely to meet the older person's needs. Some suggested questions to ask include the following:
- 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?
- Can a resident bring his/her own furniture?
- 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 section.
- Tour the facility with the director of nursing.
This person has overall responsibility for the day-to-day nursing care provided. Ask about the philosophy of care at the facility and whether she or he has problems maintaining that care philosophy. Ask how many nurses aides there are compared to residents ("aide-to-resident ratio"). Ask what the nursing staff turnover rate is. Observe how the director greets residents and staff, notice how they respond to her or him.
- Observe staff at work.
Personnel should be courteous, helpful, and honest. They should treat residents and their requests with respect. Staff members should respond quickly to calls for assistance with courtesy and respect. Warm, professional relationships between staff and residents are essential for quality care.
- Visit more than once.
Visit at different times of the day and make at least one unscheduled visit. Try to make one visit at night to see how many 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? Are interesting activities scheduled on a regular basis? Residents can give you valuable insights.
- Talk with nursing assistants and observe them with residents.
Nursing assistants are the ones who provide most of the hands-on care. Try to get a sense of how they feel and act toward the residents. Sometimes observing what they do can tell you more than talking with them.
- 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 has occurred at the home.
- Trust your instinctive feelings.
If the grounds are beautiful, but the staff seems unhappy and unkind to the residents, do not place the older person there. You want your loved one in a facility where he or she will feel respected and comfortable.
- Compare Nursing Homes.
Compare the quality of the nursing homes you are considering. Use the five star quality rating system produced by the Center for Medicare and Medicaid.Information on health inspections, nursing home staffing, and quality measures can be found at Nursing Home Compare at the Medicare.gov web site.
- 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 occurs 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. The Administration on Aging, a department of CMS, provides information on the ombudsman program and provides a link to state ombudsman programs. Go to www.aoa.gov, select Elder Rights Protection. Select "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 the following:
Information from the latest survey report on the facility (The Medicare web site at www.medicare.gov and your state Health Department have annual performance reports for all Medicare and Medicaid nursing homes.)
Any complaints against the nursing homes you are considering,
The number and nature of complaints for the past year against the facilities
The results and conclusion of the investigation into the complaint
Keep in mind that ombudsmen are government employees. They cannot state bluntly that a particular nursing home is unacceptable. Listen for subtle cues, such as, "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 in advance 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, be sure that the nursing homes you are considering are Medicaid-certified. Call your local county Department of Children and Family Services office to discuss obtaining and completing a Medicaid application for long-term care. Information to help you understand and begin the application process is also available at the official CMS web site http://cms.hhs.gov/.
Problems You Might Have Carrying Out Your Plan
Once you decide that nursing home care is needed, you might experience painful emotions. You might feel anxious, angry, guilty, depressed, or frightened by being part of such a big decision about someone for whom you care very much. You might also feel grief for the loss of the older person's former self. The older person might say things that evoke these feelings. He or she might feel abandoned. There can be tension and disagreement among family members. Although such reactions are natural and to be expected, they are painful when they occur. These problems need to be managed directly and openly by talking about them with the older person and other family members, close friends, medical professionals, and clergy.
"You're putting me in a nursing home to die."
"Some people do die in nursing homes, but it is also a place to live. This home will be able to provide for your care needs now that I am no longer capable of providing 24-hour care. I've visited the home and talked to the staff and some of the people staying there. I hope you will keep an open mind in the first few weeks and look for things to like about the facility. If you are not happy there, we will make some other arrangements. If this nursing home isn't what you need, we will find one that is."
"These people are nasty."
"Tell me exactly what the staff did that was nasty and I will talk to them about it." Visit the home unannounced at various times of the day. Listen and observe. If something you hear or see is not what you think it should be, talk with the director of nursing about your concerns.
"The food is awful."
"Tell me what you liked and didn't like and I'll talk with the dietitian about your preferences." Call ahead to alert the staff and bring in a favorite meal to eat together. If he or she is capable of traveling by car, consider going out for a meal together.
Think of Other Problems You Might Have Carrying Out Your Plan
What other problems could get in the way of doing the things suggested in this section? For example, will the older 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 this plan?
Once the older person is in a nursing home, you must monitor the care. If there are problems, you need to work with the older person and the nursing home staff to resolve them. Get to know the staff members who are most involved in caring for your family member and remain in contact with them. Ask questions and expect full answers. Compliment them when they do a good job. Be kind and courteous even when you may feel like responding negatively. Occasionally take a special treat to the nursing staff who provide care for your loved one.
State and federal laws insure that nursing home residents have certain rights. These rights include but are not limited to the right to privacy, confidentiality and respect, freedom from restraints, freedom to express grievances without retaliation, freedom to have visitors. The nursing home "Bill of Rights" is often posted at the entrance to nursing homes.
What to Do If Your Plan Isn't Working
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. The number for the regional ombudsman in your area is usually posted in the public areas of the nursing home. You can obtain the number for the ombudsman by calling your county or state Area Agency on Aging. You can also call the National Citizens' Coalition for Nursing Home Reform (202-332-2275) or visit the web site.
If you decide to look for a new nursing home, repeat the steps listed earlier in this section. Be sure that the new location will meet the older person's needs better than the present one. Do not move just to get away from a problem only to discover that the new location is no better or has worse problems.
Here are some questions to guide you in making a decision about a nursing home. Carry this checklist with you when you visit a nursing home. Write down what you learn at each facility. Once you are back home after visiting several facilities, review your notes as you make your decision. The following web site as a guide from Medicare on how to choose a Nursing Home: http://www.medicare.gov/Publications/Pubs/pdf/02174.pdf
- Is the current state license posted in a prominent location?
- Is the nursing home administrator's license current?
- Is the home certified for Medicare and Medicaid?
- Does the Medical Director participate in the American Medical Directors Association meetings and continuing education programs?
- 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?
- Is the atmosphere warm and pleasant?
- Do rooms provide privacy?
- Is there an activity director and a separate room for activities?
- Is the home clean, orderly, and reasonably free of unpleasant odors?
- Are grab bars, handrails, and emergency call buttons located in rooms and halls?
- Do you see 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, friends, and doctors?
- Are bedrooms furnished in a pleasant manner?
- Can residents bring furniture and personal items from home?
- Are there pet animals in the facility, or a program where owners bring their pets to visit the residents at regular intervals?
- Are there plants the residents can care for if they wish?
- Do staff show interest in and affection for individual residents?
- Is staff courteous and respectful? Do they smile?
- Do staff call the residents by name?
- Are enough nurses and nursing assistants on duty at all hours, including weekends?
- What is the average length of time staff have worked in the home?
- Is the home sensitive to cultural and minority differences?
- Is there a social worker on staff?
- Are resident assessments completed in a timely manner upon admission and throughout the year?
- Are routine and emergency medical attention assured?
- Is the Medical Director or his or her designee available by phone 24 hour a day?
- Do various staff and professional experts participate in evaluating each resident's needs and interests?
- Does the resident and/or his or her family participate in developing the resident's care plan?
- Are there capable nursing staff members always available to assess a resident's changing health status and to act efficiently in an emergency situation?
- Who provides the pharmaceutical services? Are these services supervised by a qualified pharmacist?
- Does the home offer physical therapy and other rehabilitative services?
- Are interesting activities scheduled?
- Are arrangements made for residents to participate in religious practices?
- Are the dining room and kitchen clean?
- Are the meals nutritious, appetizing, and tasty? If possible, arrange to have a meal.
- Does the staff use a pleasant, caring manner to assist residents who can't feed themselves?
- Are special diets available for health needs, religious, or ethnic preferences?
- Is a weekly menu available? Does the menu cycle have enough variety?
- What are the visiting hours and what activities involve the family?
- Is there a resident council? Is there an organization for family members?
- What services do volunteers provide?
- Is the facility a for-profit or non-profit organization
- Where is the company headquarters located?
- Is the administration amenable to family members contacting the company CEO?
- 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?