Nursing home
Encyclopedia
A nursing home, convalescent home, skilled nursing unit (SNU), care home, rest home, or old people's home provides a type of care of residents
Care of residents
Residential care refers to long-term care given to adults or children in a residential setting rather than the patient's home. People with disabilities, mental health problems, or learning difficulties are often cared for at home by paid or voluntary caregivers, such family and friends, with...

: it is a place of residence for people who require constant nursing
Nursing
Nursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from conception to death....

 care and have significant deficiencies with activities of daily living
Activities of daily living
Activities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...

 . Residents include the elderly and younger adults with physical or mental disabilities
Disability
A disability may be physical, cognitive, mental, sensory, emotional, developmental or some combination of these.Many people would rather be referred to as a person with a disability instead of handicapped...

. Residents in a skilled nursing facility may also receive physical, occupational, and other rehabilitative therapies following an accident or illness. Residents may have certain legal rights
Nursing home residents' rights
Nursing home residents' rights are the legal and moral rights of the residents of a nursing home. Legislation exists in various jurisdictions to protect such rights. An early example of a statute protecting such rights is Florida statute 400.022, enacted in 1980, and commonly known as the...

 depending on the location of the facility.

United States

In the United States, a "Skilled Nursing Facility" or "SNF" is a nursing home certified to participate in, and be reimbursed by Medicare. Medicare is the federal program primarily for the aged who contributed to Social Security and Medicare while they were employed. A "Nursing Facility" or "NF" is a nursing home certified to participate in, and be reimbursed by Medicaid. Medicaid is the federal program implemented with each State to provide health care and related services to those who are "poor." Each State defines poverty and; therefore, Medicaid eligibility. Those eligible for Medicaid may be aged, disabled or children (e.g. Children's Health Insurance Programs - CHIPs and Maternal-Child wellness and food programs).

Each state license
License
The verb license or grant licence means to give permission. The noun license or licence refers to that permission as well as to the document recording that permission.A license may be granted by a party to another party as an element of an agreement...

s its nursing homes, making them subject to the state's laws and regulations. Nursing homes may choose to participate in Medicare and/or Medicaid. If they pass a survey (inspection), they are "certified" and are also subject to federal laws and regulations. All or part of a nursing home may participate in Medicare and/or Medicaid.

In the United States, nursing homes which participate in Medicare and/or Medicaid are required to have licensed practical nurses (LPNs) (in some States designated "vocational nurses" or "LVNs") on duty 24 hours a day. For at least 8 hours per day, 7 days per week, there must be a registered nurse on duty. Nursing homes are managed by a Licensed Nursing Home Administrator. Unlike U.S. nursing there are no standardized training and licensing requirements for administrators, though most states require a Federal License, and many states such as California have their own licensure for administrators. On April 18, 2005 there were a total of 16,094 nursing homes in the United States, down from 16,516 on December 12, 2002.

There are states that have other levels of care offered to elderly and other adults who need assistance and are able to live in the community. For instance, Connecticut has Residential Care Homes or RCH that are licensed by the State Department of Public Health. These homes provide 24-hour supervision and typically offer a more "home-like" environment. Many are actually large homes that have been converted to dwellings that offer a residential community that promotes an independent lifestyle and fosters fellowship with others who need some form of assistance to live in the community.

Services

Services provided in nursing homes include services of nurses, nursing aides and assistants; physical, occupational and speech therapists; social workers and recreational assistants; and room and board. Nursing homes also provide transportation. Most care in nursing facilities is provided by certified nursing assistants, not by skilled personnel. In 2004, there were, on average, 40 certified nursing assistants per 100 resident beds. The number of registered nurses and licensed practical nurses were significantly lower at 7 per 100 resident beds and 13 per 100 resident beds, respectively.

Nursing homes that participate in the Medicare and Medicaid programs are subject to federal requirements regarding staffing and quality of care for residents. In 2004, 98.5% of the 16,100 nursing facilities nationwide were certified to participate in Medicare, Medicaid, or both.

Medicare covers nursing home services for up to 100 days for beneficiaries who require skilled nursing care or rehabilitation services following a hospitalization of at least three consecutive days. The program does not cover nursing care if only custodial care is needed — for example, when a person needs assistance with bathing, walking, or transferring from a bed to a chair. To be eligible for Medicare-covered skilled nursing facility (SNF) care, a physician must certify that the beneficiary needs daily skilled nursing care or other skilled rehabilitation services that are related to the hospitalization, and that these services, as a practical matter, can be provided only on an inpatient basis. For example, a beneficiary released from the hospital after a stroke and in need of physical therapy, or a beneficiary in need of skilled nursing care for wound treatment following a surgical procedure, might be eligible for Medicare-covered SNF care.

SNF services may be offered in a free-standing or hospital-based facility. A freestanding facility is generally part of a nursing home that covers Medicare SNF services as well as long-term care services for people who pay out-of-pocket, through Medicaid, or through a long-term care insurance policy. Generally, Medicare SNF patients make up just a small portion of the total resident population of a free-standing nursing home.

Medicaid also covers nursing home care for certain persons who require custodial care, meet a state's means-tested income and asset tests, and require the level-of-care offered in a nursing home. Nursing home residents have physical or cognitive impairments and require 24-hour care.

The cost of staying in a nursing home can be equal to several thousand per month or more. In fact, cheaper nursing homes cost about $45,000 a year, whereas the most expensive ones can cost up to $200,000 per year. Some deplete their resources on the often high cost of care. If eligible, Medicaid will cover continued stays in nursing home for these individuals for life. However, they require that the patient be "spent down" to a low asset level first by either depleting their life savings or asset-protecting them, often using an elder law attorney.

U.S. Government regulations and oversight

All nursing homes in the United States that receive Medicare and/or Medicaid funding are subject to federal regulations. People who inspect nursing homes are called surveyors or, most commonly, state surveyors. State surveyors may inspect for compliance with licensure (State regulations) and/or certification (Medicare and Medicaid regulations).

The "Mininimum Data Set" assessment (MDS) is part of the U.S. federally mandated process for comprehensive assessment of all residents in Medicare or Medicaid certified nursing homes. The MDS assessment is a screening assessment that forms the basis of a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify and help residents meet or cope with health and other needs. The MDS also yields "Resource Utilization Groups" (RUGS) which are used for all Medicare reimbursement to SNFs, and is used in many States to set reimbursement for NFs.

For United States SNFs and NFs, the Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...

 has a website which allows users to see how well facilities perform in certain metrics (see "Nursing Home Compare Tool" in the external link section below). CMS also publishes a list of Special Focus Facilities - nursing homes with "a history of serious quality issues." The US Government Accountability Office
Government Accountability Office
The Government Accountability Office is the audit, evaluation, and investigative arm of the United States Congress. It is located in the legislative branch of the United States government.-History:...

 (GAO), however, has found that state nursing home inspections understate the number of serious nursing home problems that present a danger to residents. The GAO concluded that while CMS oversight has improved, there are still weaknesses in its oversight of nursing homes. A report issued in September 2008 found that over 90% of nursing homes were cited for federal health or safety violations in 2007, with about 17% of nursing homes having deficiencies causing "actual harm or immediate jeopardy" to patients.

SNFs and NFs are subject to federal regulations and also strict state regulations. The nursing home industry is considered one of the two most heavily regulated industries in the United States (the other being the nuclear power industry).

Medicare and Medicaid surveys

Federal regulation and inspection (surveying) of SNFs and NFs applies a model of health care quality created for research by Avedis Donabedian in 1965. The model uses the concepts of structure, process and outcome.
Structure

For surveying, structure is the nursing home's resources. That includes staff, their knowledge and skills, policies, procedures, records, equipment, buildings, etc. Structure surveying looks at the instrumentalities of care and their organization.
Process

Process is the nursing home's resources in action. Process surveying looks at the appropriateness, timeliness and quality of care and services in relation to each resident's needs. Process can be organized into 5 kinds of intellectual and physical activities: assessing, planning, implementing (acting), evaluating, and communicating. These activities must be integrated and often occur together. Unfortunately these processes can be task or resident-centered. A task nurse implements a physician ordered-dressing change, perhaps assessing the wound while it is uncovered. A resident-centered nurse would already know if the treatment causes the resident pain and pre-medicated the resident. During the care, she (or he) will talk with the resident about topics they have both shared before, distracting the resident from discomfort and addressing social needs. Communication is heightened when residents feel comfortable discussing various issues with someone who is experienced with their particular case. In this particular situation nurses are also better able to do longitudinal follow up, which insures the implementation of more lasting results.
Outcome

In Donabedian's model, outcome is assumed to result from processes and processes are assumed to require structures. An outcome may be a facility outcome which indirectly supports direct resident care. An example of an indirect or facility outcome would be supervising and correcting or training staff That changes staff knowledge and skills. Staff applying those new skills is a process which should yield better resident outcomes. Resident outcomes may be classified as physical (death, disease, disability or dysfunction) and psychosocial (discomfort, dissatisfaction). Resident outcomes are usually specified in terms of health, well-being, patient satisfaction, etc. Resident outcomes are usually improved when staff provide and residents experience resident oriented care.

Consumer choices

Current trends are to provide people with significant needs for long term supports and services with a variety of living arrangements. Indeed, research in the U.S. as a result of the Real Choice Systems Change Grants, shows that many people are able to return to their own homes in the community. Private nursing agencies
Nursing agency
A Nursing Registry as defined in Florida Statutes 400.462: "Nurse registry" means any person that procures, offers, promises, or attempts to secure health-care-related contracts for registered nurses, licensed practical nurses, certified nursing assistants, home health aides, companions, or...

 may be able to provide live-in nurses to stay and work with patients in their own homes.

When considering living arrangements for those who are unable to live by themselves, potential customers consider it to be important to carefully look at many nursing homes and assisted living
Assisted living
Assisted living residences or assisted living facilities provide supervision or assistance with activities of daily living ; coordination of services by outside health care providers; and monitoring of resident activities to help to ensure their health, safety, and well-being.Assistance may...

 facilities as well as retirement home
Retirement home
A retirement home is a multi-residence housing facility intended for senior citizens. Typically each person or couple in the home has an apartment-style room or suite of rooms. Additional facilities are provided within the building, including facilities for meals, gathering, recreation, and some...

s, keeping in mind the person's abilities to take care of themselves independently. While certainly not a residential option, many families choose to have their elderly loved one spend several hours per day at an adult daycare center
Adult Daycare Center
An adult day care center, also commonly known as adult day services, is a non-residential facility providing activities for elderly and/or handicapped individuals. Most centers operate 10 – 12 hours per day and provide meals, social/recreational outings, and general supervision...

.

Beginning in 2002, Medicare began hosting an online comparison site intended to foster quality improving competition between nursing homes.

Trends

In the U.S. a few nursing homes are beginning to change the way they are managed and organized to create a more resident-centered environment, so they are more "home-like" and less institutional or "hospital-like." In these homes, units are replaced with a small set of rooms surrounding a common kitchen and living room. The staff giving care is assigned to one of these "households." Residents have far more choices about when they awake, when they eat and what they want to do during the day. They also have access to more companionship such as pets. Many of the facilities utilizing these models refer to such changes as the "Culture Shift" or "Culture Change" occurring in the Long Term Care, or LTC, industry. Sometimes this kind of nursing home is called a "greenhouse."

User Reviews

In addition to the Medicare Ratings, after the advent of social internet, websites have made it possible for families and seniors to submit user reviews about nursing homes. The largest such a repository of user reviews in the United States can be found in the external links section.

Task-oriented care

Task oriented care is where nurses are assigned specific tasks to perform for numerous residents on a specific ward. Residents in this particular situation are exposed to multiple nurses at any given time. Because of the random disbursement of tasks, nurses are declined the ability to develop more in depth relations with any particular resident. Licensed (vocational) nurse training in the United States is task oriented. The primary care giver in a certified nursing home is a "Certified Nurses Aide" (CNA). CNAs receive a minimum of 75 hours of didactic and practical task-oriented training and must pass an oral or written test. Thus, in U.S. nursing homes, the training of the majority of direct care-givers in nursing homes is task oriented.

Resident-oriented care

Resident oriented care is where nurses are assigned to particular patients and have the ability to develop relationships with individual patients. Patients are treated more as family, as opposed to random patients in an institution. Using resident-oriented care, nurses are able to become familiar with each patient and cater more to their specific needs, whether they be emotional or medical. In contrast, institutional care is institution-centered. The focus is staff convenience and efficiency. Staff perform tasks rather than interact with residents to achieve desirable resident outcomes. Where resident-centered staff know residents by name, institutional staff identify residents by room number, diagnosis, or a task like "feeders" for residents who need help to eat.
Scientific findings


According to various findings residents who receive resident-oriented care experience a higher quality of life, in respect to attention and time spent with patients and the number of fault reports after the introduction of Primary Nursing. Once they experience it, nurses often prefer resident-oriented settings, too. Although resident-oriented nursing does not lengthen life, nursing home residents are able to connect with someone, which allows them to dispel many feelings of loneliness and discontent.

"Resident assignment" refers to the extent to which residents are allocated to the same nurse. With this particular system one person is responsible for the entire admission period of the resident. However, this system can cause difficulties for the nurse or care-giver should one of the residents they are assigned to pass away or move to a different facility, as the nurse/caregiver may become attached to the resident(s) they are caring for.

Various findings suggest that task-oriented care produces less satisfied residents. In many cases, residents are disoriented and unsure of whom to disclose information to and as a result decide not to share information at all. Patients usually complain of loneliness and feelings of displacement.

"Resident assignment" is allocated to numerous nurses as opposed to one person carrying the responsibility of one resident. Because the load on one nurse can become so great, various nurses are unable to identify with gradual emotional and physical changes experienced by one particular resident. Resident information has the ability to get misplaced or undocumented because of the numerous amounts of nurses that deal with one resident.

Emergency management

Dealing with an emergency in nursing home is always a formidable task which involves the damage control and mitigation of the event. Not many written plans or standard operating procedures are available publicly, except for a few. However, there are published academic reviews about the topic written by many authors , ,.

United Kingdom

In 2002 nursing homes became known as care homes with nursing, and residential homes became known as care homes.

In the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...

 care homes and care homes with nursing are regulated by different organisations in England
England
England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...

, Scotland
Scotland
Scotland is a country that is part of the United Kingdom. Occupying the northern third of the island of Great Britain, it shares a border with England to the south and is bounded by the North Sea to the east, the Atlantic Ocean to the north and west, and the North Channel and Irish Sea to the...

, Wales
Wales
Wales is a country that is part of the United Kingdom and the island of Great Britain, bordered by England to its east and the Atlantic Ocean and Irish Sea to its west. It has a population of three million, and a total area of 20,779 km²...

 and Northern Ireland
Northern Ireland
Northern Ireland is one of the four countries of the United Kingdom. Situated in the north-east of the island of Ireland, it shares a border with the Republic of Ireland to the south and west...

. To enter a care home, you need an assessment of needs and of your financial condition from your local council. You may also have an assessment by a nurse, should you require nursing care. The cost of a care home is means tested in England.

As of April 2009 in England, the lower capital limit is £13,500. At this level, all income from pension
Pension
In general, a pension is an arrangement to provide people with an income when they are no longer earning a regular income from employment. Pensions should not be confused with severance pay; the former is paid in regular installments, while the latter is paid in one lump sum.The terms retirement...

s, savings, benefits and other sources, except a "personal expenses allowance" (currently £21.90), will go to paying the care home fees. The local council
Local government in the United Kingdom
The pattern of local government in England is complex, with the distribution of functions varying according to the local arrangements. Legislation concerning local government in England is decided by the Parliament and Government of the United Kingdom, because England does not have a devolved...

 pays the remaining contribution provided the room occupied is not more expensive than the local council's normal rate, currently £364.48 for Hampshire for example. If the resident is paying more than this the council will not pay anything and contributions from a third party or charity must be found or the resident move to a cheaper care home. Between the lower and the upper capital limits, the resident pays their income less personal expenses allowance + £1/week for every £250 capital between lower and higher limit. The council pays the rest, subject to the same conditions as before. It is therefore preferable to find a home within the council's limit if council funding is likely to be required to avoid a forced move later. Patients with capital over more than £23,000 pay the full cost of the care home, until the total value of their assets fall below the threshold. Patients who require additional nursing care are assessed for this (Hampshire nursing limit 2009 £483pw) and receive additional financial support (£103.80pw) through the National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...

 (NHS); this is known as Funded Nursing Care.

The NHS has full responsibility for funding the whole placement if the resident in a care home with nursing meets the criteria for NHS continuing Health Care. This is identified by a multi-disciplinary assessment process as detailed on the DOH website.

Care homes for adults in England are regulated by Care Quality Commission
Care Quality Commission
The Care Quality Commission is a non-departmental public body of the United Kingdom government established in 2009 to regulate and inspect health and social care services in England. This includes services provided by the NHS, local authorities, private companies and voluntary organisations -...

, which replaced the Commission for Social Care Inspection
Commission for Social Care Inspection
The Commission for Social Care Inspection was a non-departmental public body and the single, independent inspectorate for social care in England. Its sponsor department was the Department of Health of the United Kingdom...

, and each care home is inspected at least every three years. In Wales the Care Standards Inspectorate for Wales has responsibility for oversight, In Scotland the Scottish Commission for the Regulation of Care and in Northern Ireland the Regulation and Quality Improvement Authority in Northern Ireland.

In May 2010, the Coalition Government announced the formation of an independent commission on the funding of long-term care, which is due to report within a 12-month timeframe on the financing of care for an Ageing population. The Care Quality Commission
Care Quality Commission
The Care Quality Commission is a non-departmental public body of the United Kingdom government established in 2009 to regulate and inspect health and social care services in England. This includes services provided by the NHS, local authorities, private companies and voluntary organisations -...

 have themselves implemented a re-registration process, completed in October 2010, which will result in a new form of regulation being outlined in April 2011.

See also

  • American Geriatrics Society
    American Geriatrics Society
    The American Geriatrics Society : a professional society founded on June 11, 1942 for doctors practicing geriatric medicine. Among the founding physicians were Dr. Ignatz Leo Nascher, who coined the term "geriatrics," Dr. Malford W. Thewlis, who was named the first executive secretary of the...

  • American Health Care Association
    American Health Care Association
    The American Health Care Association is non-profit federation of affiliated state health organizations, together representing more than 10,000 non-profit and for-profit assisted living, nursing facility, developmentally-disabled, and subacute care providers that care for more than 1.5 million...

  • American Society of Consultant Pharmacists
    American Society of Consultant Pharmacists
    The American Society of Consultant Pharmacists is an international professional association that provides education, advocacy, and resources to advance the practice of senior care pharmacy, and that represents the interests of consultant pharmacists who work with elderly patients.The organization...

  • Care Quality Commission
    Care Quality Commission
    The Care Quality Commission is a non-departmental public body of the United Kingdom government established in 2009 to regulate and inspect health and social care services in England. This includes services provided by the NHS, local authorities, private companies and voluntary organisations -...

     previously known as Commission for Social Care Inspection
    Commission for Social Care Inspection
    The Commission for Social Care Inspection was a non-departmental public body and the single, independent inspectorate for social care in England. Its sponsor department was the Department of Health of the United Kingdom...

  • Eldercare
  • Home care
    Home care
    Home Care, , is health care or supportive care provided in the patient's home by healthcare professionals Home Care, (also referred to as domiciliary care or social care), is health care or supportive care provided in the patient's home by healthcare professionals Home Care, (also referred to as...

  • International Association for Homes and Services for the Aging
    Iahsa
    The International Association for Homes and Services for the Aging is an international, not-for-profit educational and charitable organization founded in 1994...

  • Retirement village

External links

United States
  • Nursing Home Compare ToolMedicare's
    Medicare (United States)
    Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...

    past performance results of every certified nursing home in the USA
  • Search Engine with User Reviews — OurParents Search Engine which allows looking at user reviews in addition to Medicare data


United Kingdom

Australia
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