An Overview of Nursing Homes

Positive news about nursing homes is rare. Unless your local news includes bingo results alongside sports updates, such stories are seldom heard. Nursing homes often struggle with a negative public perception, with headlines frequently highlighting rising costs, neglect, and cost-cutting measures that make their fees seem even more unreasonable. A somewhat lighter story from recent years involved a cat in Providence, R.I., that could predict when residents were nearing death. While families appreciated the cat's eerie ability, it’s not the kind of tale that fosters warm feelings about nursing homes.

Beyond the news, nursing homes evoke feelings of sadness and fear for many. They can be sources of shame—residents may feel embarrassed by conditions that limit their independence, families might grapple with guilt over not being able to care for loved ones, and even young visitors can feel uneasy surrounded by aging residents. For many, nursing homes represent a last resort, and sometimes, the final chapter in housing choices.

In the early days of nursing homes in the United States, feelings of shame were common. State governments even stigmatized poor farms and almshouses, the precursors to modern nursing homes, to discourage their use. By the 1950s, attitudes shifted as nursing homes adopted a hospital-like model, framing elder care as a health issue rather than a welfare concern. However, it wasn’t until the 1980s that the government recognized the poor conditions in many facilities and initiated reforms to improve care quality. These efforts continue today through the culture change movement, which seeks to revolutionize how nursing home residents are treated.

We’ll explore culture change later in this article, but first, let’s cover the basics of nursing homes. On the next page, we’ll define what a nursing home is and discuss who typically resides there.

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Nursing Home Admission

Over 1.5 million individuals in the U.S. currently reside in nursing homes [source: Pear]. The majority of these residents are women, often widowed, with nearly half aged 85 or older [source: AGS Foundation]. What sets them apart from those in assisted living facilities is the higher level of nursing care and supervision they require.

Deciding on nursing home care involves a process as detailed as applying to college. Families and potential residents should visit facilities, evaluate priorities, and assess needs. Would a larger home with advanced medical equipment and multiple amenities suit you, or would a smaller, more intimate setting with personalized care be preferable? Location, room type, and services offered are also key considerations.

When evaluating nursing homes, review inspection reports for violations but also trust your instincts. If the environment feels unwelcoming or residents appear unhappy, it’s likely not the right fit. The application process involves extensive paperwork, including medical, financial, and personal records. For competitive facilities with limited beds, the process can resemble college admissions. Be prepared for high costs, with annual expenses averaging around $77,000 [source: University of Illinois at Urbana-Champaign].

Approximately one-third of nursing home residents qualify for Medicaid upon admission, with another third becoming eligible as their personal funds deplete [source: AGS Foundation]. While most facilities accept Medicaid, they may limit the number of beds or rooms for such patients. If Medicaid might be needed in the future, it’s crucial to understand the facility’s policies on transitioning payment sources.

On the next page, we’ll explore what that significant expense actually covers.

Nusing Home Services and Staff

As mentioned earlier, nursing homes are structured to offer round-the-clock nursing care and constant supervision. Over half of the residents struggle with incontinence, and a similar percentage suffer from dementia [source: AGS Foundation]. Almost all residents require assistance with basic daily activities, such as getting out of bed, using the restroom, and eating. Additionally, nursing homes may accommodate short-term patients recovering from injuries or illnesses.

The majority of resident care is handled by personal care aides. It’s crucial to evaluate the aide-to-resident ratio; the National Citizens' Coalition for Nursing Home Reform suggests a minimum of one aide for every five residents during daytime hours, with additional support needed during peak times like meals [source: Morris]. At night, this ratio can decrease to 1-to-10 or even 1-to-15 [source: Morris].

Personal care aides are often overburdened and undercompensated, leading to high turnover rates. However, as a family member of a resident, building a relationship with these caregivers is essential since they deliver the majority of direct care. Entrusting a loved one’s care to someone else can be challenging, especially when you feel you know what’s best. While sharing helpful insights with aides is beneficial, remember that the responsibility now lies with them.

In addition to personal care aides, nurse practitioners and physician assistants, supervised by a medical director, provide medical care. Rehabilitation therapists and dietitians are also part of the team, ensuring physical and nutritional needs are met. Social workers or counselors are available to help residents cope with the emotional impact of transitioning to a nursing home. When choosing a facility, consider the level of interaction these professionals have with residents. Does the medical director actively see patients, or is their role purely supervisory? Some facilities mandate the use of their in-house physician, while others facilitate visits to external doctors if necessary.

Modern nursing homes now provide a wider range of medical services than ever before, including treatments like kidney dialysis and respiratory support that once required hospitalization. But how much control do residents have over their own care?

Nursing Home Patients' Rights

In 1986, a congressional study exposed widespread abuse and neglect in nursing homes, leading to significant reforms under the 1987 Omnibus Budget Reconciliation Act (OBRA). One key reform mandated that nursing home staff assess each patient’s condition upon admission and update this evaluation regularly. Known as the Minimum Data Set (MDS), this assessment ensures a tailored care plan for each resident. Families are encouraged to participate in shaping these treatment standards.

OBRA also enhanced patient care by restricting the use of physical restraints and mood-altering drugs to control residents. Overmedication was a major issue, so OBRA introduced measures to reduce unnecessary medications. If a patient is prescribed more than nine medications, it must be justified in the MDS, and doctors are required to review the necessity of each drug during regular assessments.

OBRA established a Resident's Bill of Rights, ensuring patients are informed about their care plans and guaranteeing rights to privacy and dignity. While this empowers residents to make decisions, ethical challenges can arise. For example, a 2008 Slate article by Melinda Henneberger, "An Affair to Remember," described a romance between an 82-year-old woman and a 95-year-old man in a nursing home. Their relationship was halted by the man’s son when it turned intimate, raising questions about consent, especially for those with dementia. While nursing homes aim to support residents’ autonomy, they must balance this with caution in sensitive matters. However, in less contentious areas like smoking, residents are generally free to make their own choices.

To qualify for Medicare and Medicaid funding, nursing homes must adhere to OBRA regulations. State surveyors conduct regular inspections to ensure compliance. What do these evaluations typically uncover?

For-profit vs. Not-for-profit Nursing Homes

Nursing homes relying on Medicare and Medicaid funding undergo annual inspections by state surveyors. However, in 2007, over 90 percent of facilities were cited for failing to meet health and safety standards [source: Pear]. The quality of care often depends on whether the nursing home is for-profit or not-for-profit.

Around two-thirds of U.S. nursing homes are run by private, for-profit companies, with 25 percent managed by not-for-profits and 10 percent by government entities [source: AGS Foundation]. For-profit facilities are often associated with lower care quality and higher rates of complaints and violations during inspections [sources: Harrington et al., Pear]. While not-for-profit and government-run homes aren’t flawless—averaging 5.7 and 6.3 deficiencies per facility in 2007, respectively—for-profit homes had an average of 7.6 deficiencies. These issues included infected bedsores, medication errors, and improper use of physical restraints [source: Pear].

The assumption is that for-profit homes cut costs to maximize profits, often at the expense of care quality. This might involve reducing nursing staff or compromising meal quality, leading to poorer patient outcomes. Residents in these facilities are more prone to depression and loss of independence compared to those in non-profit or government homes [source: Duhigg]. Additionally, the complex corporate structures of for-profit homes can obscure accountability, complicating legal actions or federal penalties in cases of poor care.

However, not all for-profit nursing homes provide subpar care. In fact, their reliance on customer satisfaction for attracting residents can result in well-managed facilities. Conversely, not-for-profit or government-affiliated homes aren’t guaranteed to offer superior care, as their operations may be outsourced to external management companies despite their reputable branding.

If you suspect abuse or neglect in a nursing home, you can raise the issue with staff or contact your state’s long-term care ombudsman. Legally mandated to investigate complaints, the ombudsman can collaborate with nursing homes or other agencies to resolve issues.

Bedsores, patient conflicts—these are far from the ideal vision of aging. Discover what’s being done to improve nursing homes on the next page.

Nursing Home Culture Change

Many people view nursing homes as sterile, impersonal institutions, and unfortunately, this perception often holds true. However, a growing movement aims to transform how nursing homes function. Known as culture change, this initiative focuses on reimagining the way care is delivered in these facilities.

Led by the Pioneer Network, culture change introduces straightforward yet impactful ideas. Instead of adhering to rigid, task-based routines—like staff members performing baths or changing sheets on a fixed schedule—nursing homes adopt a personalized approach. This method prioritizes residents’ needs, enhancing their quality of life. Staff are assigned to smaller groups of residents, fostering deeper connections and allowing care to align with individual preferences, such as bathing when the resident desires rather than at a predetermined time.

As care becomes more personalized and less rigid, the facility itself should reflect a homely atmosphere rather than an institutional one. This transformation might include alterations in design and aesthetics. A prime example is the Eden Alternative, with hundreds of homes nationwide adopting this model. These "Eden-ized" facilities incorporate plants, animals, and children, creating a vibrant environment that contrasts with the typical end-of-life setting. Early studies suggest that both residents and their families experience greater happiness in such surroundings.

However, revamping the appearance and ambiance of nursing homes is a costly endeavor. Given the existing concerns about affordability, it’s uncertain how long it will take to fully adopt these innovative concepts.