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
When to Get Professional Help
Talking to a healthcare provider
Your home health nurse, social worker, and/or other healthcare provider 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 that can also 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. Getting 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 geriatrics healthcare provider can help you decide on the appropriate type of care best suited for your loved one.
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 can tell you how to obtain copies of evaluations of nursing homes by licensing agencies. (The National Association of Area Agencies of Aging has more information.) The federal government’s Medicare website provides additional information, including recent evaluations of all nursing homes in your area.
Know answers to the following questions before requesting help
- What problems are you having with caregiving?
- 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.
What You Can Do to Help
Start gathering information early
It is wise to begin the search for a suitable nursing home well in advance of seeking admission. Often, the best homes have no space available and long waiting lists.
Determine what the older person and the family want and need
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 nursing homes
Friends and acquaintances who have had family members in a nursing home are good sources of information. Healthcare providers, social service agencies, and some religious organizations are also potential sources of information.
Call nursing homes
Call the nursing homes on your list and ask key questions. By calling nursing homes and 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 doctor on call at all times?
- How far away is the hospital from the nursing home?
- Can a resident bring their 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
You can ask the director of nursing to show you around. This person has overall responsibility for the day-to-day nursing care provided. Ask about the philosophy of care at the facility and whether there are 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 and notice how they react and respond.
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 members 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 aides and observe them with residents
Aides 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 have occurred at the nursing 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 the person you care for in a facility where they 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 Medicare.gov.
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 about nursing homes 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 provides information on the ombudsman program and provides a link to state ombudsman programs. 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 website 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 hints, 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 they will need financial help from Medicaid, call your local county’s Department of Children and Family Services office to get a Medicaid application for long-term care. Information to help you understand and begin the application process is also available through the Centers for Medicare & Medicaid Services. Be sure that the nursing homes you are considering are Medicaid-certified.
Carrying Out Your Plan
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 making such a big decision for someone. You might also feel grief for the loss of the older person’s former self. The older person might say things that bring up these feelings. They 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/or clergy.
Even when you have excellent plans, there are obstacles or problems that may prevent you from carrying out your plans. You or the older person may have some beliefs that might get in the way of carrying out your plan. Here are some ways to challenge those beliefs.
Think carefully about what is bothering you about this decision. The guilt could be about no longer being able to provide the care, or worry that the nursing home is not good enough or that it is not the most expensive. You might feel guilty that you can’t visit often enough. Talk about these feelings with someone you trust who can provide an objective view or balanced perspective. Remember that you provided the best care you possibly could prior to the nursing home placement and that you are now in the role of an advocate who can visit and observe the care in the nursing home.
“Some people do die in nursing homes, but it is also a place to live. This home will be able to provide for your 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, looking 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.”
“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. If you come upon a care situation with the older adult, listen and observe what is occurring prior to speaking. Talk with the director of nursing about your concerns
“Tell me what you liked and didn’t like; I’ll talk with the dietitian about your preferences.” Participate in the nursing home care planning conferences for the older person. Bring in a favorite meal to share with the older person (call ahead to alert the staff). If the older person 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?
Checking on Progress
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 care for the older person most frequently 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 the older person.
State and federal laws ensure 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, and 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 office of aging. You can also call The National Consumer Voice for Quality Long-Term Care (202.332.2275).
If you decide to look for a new nursing home, repeat the steps listed earlier. 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.
Nursing Home Checklist
Here are some questions to guide you in making a decision about a nursing home. Bring 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.
Medicare also provides a helpful guideon how to choose a nursing home.
- 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 designee available by phone 24 hours 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?
Updated July 2015