What is a Nursing Home ?

A nursing home, or skilled nursing facility provides round the clock care by licensed staff. The facilities, or SNFs as they are referred to in the industry provide care and rehabilitation services to people who need assistance with the activities of daily living: bathing, eating dressing and grooming.

A team of licensed medical professionals is responsible for the care in a SNF. A physician medical director provides the medical oversight for the facility. In most states the medical director is required to visit each resident at least once a month. A Director or Nursing is in charge of all clinical services and is the one person who is most likely to know the care plans and status of each resident. Other members of the interdisciplinary team responsible for patient care include: occupational therapists, respiratory therapists, speech therapists, and activities experts.

The role of SNF's has evolved dramatically over the past 20 years. Once considered a rest home where residents with relatively minor physical ailments recuperated from long illnesses, the modern SNF can be thought of as an extension of hospital care. In fact, many hospitals have set aside beds or wings and now provide SNF care within the four walls of the hospital. These units are called transitional care or distinct part units. Similarly, operators of SNF's often create a sub-acute unit within the facility. In general, the distinctions between care in a SNF and care in a hospital setting have been blurred.

Currently the most frequent diagnosis for SNF residents are health concerns related to orthopedic issues, neurological issues and cardiovascular health issues.

In the past, length of stay at a SNF could be measured in years, currently the average length of stay is probably closer to 90 days. With the length of stay going down, and the intensity of services going up, the cost of staying in a SNF has escalated dramatically. (See Financial considerations)

SNF's are owned singly and in groups (called 'chains" in the industry). Various types of entities own SNF's including individuals, hospitals, for profit chains, not for profit chains, managed care organizations, religious organizations, and governmental entities. Notwithstanding the various ownership alternatives all SNF's provide similar services and are regulated in a similar fashion. The quality of care at an individual SNF is mostly dependent on the experience, skill and training of the management and clinical team. Variations in ownership, differences in for profit versus not for profit status of operators, and other considerations do not generally affect the quality of care of a SNF.

Regulations governing Nursing Homes

Due to some well-publicized problems in the past and the increasing intensity of the care they provide, SNF's are increasingly subject to extensive regulations. A summary of the regulations effecting SNF's can help consumers understand the safeguards that are in place to insure a minimum level of acceptable care.

From a federal regulation standpoint, HCFA (a division the Department of Health and Human Services) promulgates and regulates operations of SNF's in conjunction with State and County Regulations. States have their own regulations effecting SNF's. In California for example, Title XXII regulates some aspects of SNF's operations. County government offices are often the first line of contact and engagement with SNF's providing inspection and oversight of SNF's in their jurisdiction based on the federal and state laws.

While state governmental authorities generally issue all licenses for SNF operations, county officials provide periodic inspections of the facilities, issue citations for non-compliance with regulations, and suspend or revoke a facilities license for failure to conform to regulations. Facilities are inspected at least once a year at irregular intervals to induce an element of surprise. In addition, inspections can be initiated due to complaints. Inspectors have a wide range of latitude in issuing citations.

The local Fire Marshall typically inspects the building once a year. In the past the SNF business has been subject to fires, which have had catastrophic consequences on residents who are typically non-ambulatory.

A special license is required to manage a SNF. Regulations vary by State, but typically a bachelor's degree is required along with up to 1000 hours of training. A licensed nursing manger is required in each building. Both the administrator and the nursing manager are required to complete continuing education course work to keep their licenses current.

Choosing a SNF

While most lay people will have a difficult time evaluating the quality of clinical care in a SNF, there are many indicators that can help you chose a quality facility. Use the information provided below.

There are checklists available for doing comparative shopping between facilities but choosing the right facility for you can often come down to intangibles. First, as a long time SNF operator states: What is the "feeling" in the building? Do the residents look cared for? Do they appear attentive and groomed? How do the people in the building react to each other? Is there positive attentive communication between residents, between caregivers and residents, and between caregivers and caregivers? Are things organized, and clean? Is there a clean and fresh odor in the building?

The overall feeling one should come away with is that there is a positive spirit in the building, that the staff and the residents are communicating in a positive way and that the facility itself is clean and orderly and that there is a sense of pride and engagement that permeates the building.

SNF's are required to have resident councils which meet periodically to discuss any resident issues. In addition, many SNFs have family councils who meet periodically to discuss their concerns. If possible meet with members of the family council or resident council and discuss their impression of the operations and staff of the facility.

If possible meet with the Director of Nursing. He or she is the day-to-day leader of the clinical team and should exhibit good leadership and communication abilities.

Beware of "home like features" that may have been installed by the marketing department which appeal to the families but provide no benefit to the residents.

If you require services for individuals suffering from Alzheimer's or other dementias pay careful attention to the care of these residents. In the past, SNF's often physically restrained these individuals with physical restraints or through medication. It is now known that special care units that allow a fair amount of autonomy in a safe environment are best for these type residents. If the residents do not require high level clinical care, it may be that a less intensive environment such as a specialized assisted living center is a superior alternative.

Evaluating Quality

There are a variety of third party evaluations of facilities that may be helpful in making a choice of a SNF for your loved one.

As mentioned elsewhere, various federal, state, and county inspectors periodically "survey" all SNF's and provide reports. These reports are part of the public record but are often easy to find. The best place to find these reports is to ask a representative of the facility for the results of the most recent survey. By law SNF's must keep a copy of this information on hand and provide it to anyone making a request.

When you obtain a copy of this material you will find that often it contains either citations, deficiencies or comments about other shortcomings found by the inspectors. Often the deficiencies are categorized as major or minor. If a major deficiency is found, a plan of correction is required which is also available for your review. Please note that given differences in interpretation of regulations, changes in rules, changes of inspectors, history etc. it is not uncommon for a facility to have deficiencies. What you as a consumer should note is multiple serious deficiencies. Ask the administrator or the Director of Nursing for an explanation of any deficiencies that concern you. If you cannot get comfortable with their answers, you may want to find another facility.

In addition to written reports, there is usually an ombudsman employed by the County whose job is to aid families, SNF operators and residents achieve their mutual goals. If possible, contact the local ombudsman in your community to discuss the status of SNF's in our community. Note, because of their role, ombudsmen are as a rule reluctant to recommend any individual facility.

In various locations there are often advocacy groups which are organized to represent consumer's interests in relation to the nursing home industry. By all means seek out information from these sources but beware that their role is that of an advocate and that the information that they gather is to support their roles as advocates rather than to give a balanced picture.

Finally, there are Senior Referral Agencies that advertise their ability to assess quality and match families with an appropriate facility. These agencies often require families to pay a fee for their services. In addition, some agencies collect a fee from nursing homes to appear on an "approved" list of providers. Beware of using these resources, generally any relevant information to making a decision is part of the public record or subject to a families due diligence. More troubling is the potential for a conflict of interest created by accepting monies in exchange for referrals.

Paying for Nursing Home Care

Payment for SNF services comes from one of a combination of Medicaid, Medicare, Private Insurance including managed care programs and private resources of individuals. Cost for SNF care can range from $4,200 per month to $7,000 per month. Currently the vast majority of SNF residents rely on entitlement programs or insurance to pay for skilled care.

Medicaid is a needs based entitlement program funded by a combination of federal and state funds. SNF's are not required to admit Medicaid recipients but most do. It is not unusual for an individual to be admitted as a Medicare patient, to spend there resources down to a minimal level and then apply for Medicaid benefits to allow them to stay in the facility. In SNF parlance this is a Medi/Medi resident. In order to qualify for Medicaid, some families hide assets; this practice is unethical and not to be encouraged.

Because of the limited reimbursement available through Medicaid, SNF's that rely on a large number of Medicaid recipients can be expected to have fewer amenities and services than those facilities which rely on Medicare or private pay services. Some SNF's will actively screen out and deny admission to Medicaid recipients who are viewed as medically challenging.

The Medicare program provides a limited amount of health services to people over 65 years old. Part A covers hospital care, Part B covers ancillary and outpatient care. In the past SNF's actively sought Medicare patients because of the opportunity for increased reimbursement. Currently with the PPS system, SNF operators are learning to live with fixed reimbursement for a variety of medical conditions but in general SNF operators still welcome Medicare recipients.

SNF operators welcome private insurance and private funds as the highest source of reimbursement.

Current Status

With the increasing intensity of services provided and an industry wide heightened sensitivity to escalating health costs has come a new financial environment for SNF's.

Factors in the new financial environment include, decreasing volume of private pay residents, the introduction of the PPS system for Medicare patients and an increase in patient volume who are part of managed care.

The upshot is that the SNF industry has been in a dramatic financial downturn over the past 3 years. It is estimated that over half of the owners of SNF beds around the country are having some kind of financial difficulty.

As a consumer this means that you should be aware of the financial strains of the industry and inquire as to the financial status of the nursing homes you are considering.