Caregiver Guide: Choosing a Nursing Home

Understanding the Problem

When the needs of an older person can no longer be met in the home setting, finding an alternate living arrangement can be challenging. 

The inability to care for oneself is a primary consideration for families when seeking alternate living situations. The primary caregiver and family members often begin to search for assistance when an older person:

  • is inattentive to toileting and bathing needs
  • wanders frequently
  • sleeps poorly at night
  • is frequently agitated

Finding suitable alternative living arrangements is becoming more complex as 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.  Additionally, terminology and regulation vary 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 their 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:

  • Intermediate nursing care provides health-related care to individuals who do not require nursing care, but do need some help, such as help with medicines or feeding.
  • 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 for 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 who could no longer safely receive care in the home or for someone who is not expected to recover the ability to care for themselves.
  • 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 IV therapy or use of ventilators.  These services are generally provided within a skilled nursing facility and are considered short-term needs.

Alternatives to Nursing Home Care

Assisted living facilities

Assisted living facilities are residential facilities that provide individual rooms, three daily meals, and activities for older people 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 the ones 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 other healthcare provider. There is no healthcare provider involvement in the plan of care for an individual residing in an assisted living facility and neither state nor federal law requires them to visit. The older person should still be taken from the facility to visit his or her primary care provider as needed.

Board and care homes

Board and care homes are generally smaller, more home-like residences for people 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 differs from state to state.

Continuing care retirement communities

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. 

Adjusting to moving to a nursing home

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, they 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.  It will take time to adjust to the move and become comfortable. Both the primary caregiver and the older person placed in the facility will require patience during the adjustment period. Consider the first month in the nursing home as a trial period to help ease the transition for the older person. During the adjustment phase, visiting frequently for short time periods can be more helpful 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. You can be 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. (A family council is an organization of family members who meet to make suggestions for how to have a positive influence on the quality of residents’ care, treatment, and quality of life.) 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.

Paying for nursing homes

Paying for nursing home care is a major concern for most people. If people enter a nursing home directly from a hospital, Medicare will often pay, but only for a limited time. When people enter from their own home, they usually pay for the nursing home stay themselves. After personal 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 have been 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 the older person 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 Center 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 American Association of Retired Persons (AARP) has a wealth of information about nursing homes, Medicare, and Medicaid. If the older adult is in the hospital at the time of consideration for nursing home placement, the hospital social worker is another valuable resource. 

Medicare, which pays for a number of healthcare 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 home expenses. If you are considering purchasing long-term care insurance for the older person’s 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 around the age of fifty. Premiums for long-term care insurance increase as one gets older, and the cost varies depending on the number of chronic conditions present and the type of coverage desired.

Your goals are to:

  • Understand the different kinds of nursing home care available
  • Review the older person’s needs, your ability to provide care, and your own healthcare 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 healthcare providers
  • Choose the nursing home that best meets the older person’s needs, accepting that no place, even one’s home, is perfect
Click on each of the topics below to read more.

Updated July 2015

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