Nursing Homes Overview

child visiting grandparent in nursing home
It can be difficult for some children to visit a nursing home.

Have you ever seen a positive news story about nursing homes? Unless you live in a town that includes bingo results with the sports scores, it's unlikely. Nursing homes have a bit of a public image problem, and you're much more likely to see stories about skyrocketing costs, negligence and penny-pinching measures that make those entrance fees seem even more exorbitant. One of the most "lighthearted" stories to emerge about nursing homes in recent years involved a Providence, R.I., cat that could sense when residents were about to die. While family members appreciated the advance notice the cat's presence provided, it's hardly the kind of story that makes outsiders feel warm and fuzzy about nursing homes.

It's not just the news, though. Nursing homes are sad, scary places to most of us. They often inspire shame -- potential residents may be embarrassed by impairments or illnesses that render them unable to care for themselves, family members might feel guilty about their inability to take care of a loved one, and even grandchildren along for a visit may be uncomfortable about their youth in the midst of all this aging. It's the last resort, and sometimes, the last stop, in housing options.


­Shameful feelings about nursing homes were quite normal in their early days in the United States; in fact, state governments stigmatized the early poor farms and almshouses that were prototype nursing homes at the turn of the 20th century so that people would be too embarrassed to use them. By the 1950s, the country was more willing to care for the elderly because nursing homes were modeled after hospitals, making them more of a health issue as opposed to a welfare issue. Unfortunately, it wasn't until the 1980s that the government realized what poor shape some of these homes were in and began to institute reforms that improved the quality of care residents received. That revolution in care continues to this day in the form of the culture change movement, which aims to transform the way that nursing home patients are treated.

We'll address culture change later on in this article, but for now, let's deal with some basics about nursing homes. On the next page, we'll take a look at what exactly a nursing home is and who lives there.



Nursing Home Admission

male resident of nursing home with aide
Males are in the minority at most nursing homes.

Currently, more than 1.5 million people in the United States live in nursing homes [source: Pear]. The majority of nursing home residents are women, usually widowed, and nearly half of nursing home residents are 85 years or older [source: AGS Foundation]. But what really distinguishes these people from those living in, say, an assisted living facility, is the amount of nursing care and supervision they need.

When an elderly person and his or her family decide that this level of care is needed, they go through a process as lengthy as applying to college. First, potential residents and families should tour homes and consider priorities and needs. Would you rather live in a larger nursing home that has several cafes and the most state-of-the-art medical equipment, shared between hundreds of patients, or would you rather live in a smaller facility with fewer services and activities but more personal attention? What location is ideal? Do you want a private room or are you willing to share?


When you're considering nursing homes, ask for data about violations detailed in the home's inspection report (nursing homes are required to keep this on hand) but also feel free to trust your gut. If you walk in and don't get a sense that the place is a home or that residents are healthy and happy, then you're probably right. When you're ready to apply, there's a mountain of paperwork to complete, including personal, medical and financial records. If the nursing home is competitive with few beds available, this process will also mirror applying for college. And once accepted, prepare to pay even more than you would for four years of education. Nursing home costs average about $77,000 for one year [source: University of Illinois at Urbana-Champaign].

About a third of residents entering a nursing home are eligible for Medicaid, which covers nursing home care, upon their admission, and another third will qualify for assistance as their own funds are used up [source: AGS Foundation]. Because Medicaid pays for so many people's nursing home care (the rules differ by state, however), most facilities accept Medicaid, but they may only have a limited number of beds or rooms set aside for Medicaid patients. For that reason, if you think that Medicaid may become an option down the road, you should check into the facility's policies about switching payment sources.

On the next page, we'll consider what that chunk of change buys you.


Nusing Home Services and Staff

An elderly woman and her caregiver
An elderly woman and her caregiver

As we discussed on the previous page, nursing homes are designed to provide constant supervision and 24-hour nursing care. More than half of nursing home residents are incontinent, and more than half suffer from dementia [source: AGS Foundation]. Nearly all residents need help with the most basic activities of daily living, including getting out of bed, using the toilet and eating. Nursing homes may also house short-term patients recuperating from an injury or illness.

Most of this resident care is provided by personal care aides. It's important to consider the aide to resident ratio; the National Citizens' Coalition for Nursing Home Reform recommends that at least one aide should be present for every five residents during the day, though more may be needed at busy times of the day such as meals [source: Morris]. During the evenings and nighttimes, this ratio can drop to 1-to-10 or 1-to-15 [source: Morris].


­Personal care aides are unfortunately usually overworked and underpaid, and the position is marked by a high amount of turnover. Still, if you're a family member of a patient, it's important to get to know and work with these people as they provide so much direct care. It can be difficult to turn over care of a loved one to another person, especially when you think you know best how things should be done. You can help personal aides by sharing information that might help them with your loved one, but remember that it's their job now.

Also caring for a nursing home resident are nurse practitioners and physician assistants, who, under the supervision of a medical director, provide medical care. There will also likely be a rehabilitation therapist on staff, as well as a dietitian overseeing the meals. Social workers or counselors will be on hand to assist with the emotional changes a move to a nursing home elicits. In selecting a nursing home, it's important to consider how much interaction these people will have with the resident. Does the medical director just provide oversight, or does he or she see patients? Some nursing homes require residents to see the facility's physician, while others provide transportation to outside doctor's appointments if that doctor won't travel to the nursing home.

Nursing homes now offer far more medical services than they did in the past, including those that may have required a hospital visit before, like kidney dialysis or respiratory support. But do nursing home residents have any say in their care?


Nursing Home Patients' Rights

A patient consults with her doctor about medical care.
A patient consults with her doctor about medical care.

In 1986, a study commissioned by Congress revealed that nursing home residents were often abused and neglected. As a result, sweeping nursing home reforms were included in the 1987 Omnibus Budget Reconciliation Act (OBRA). One reform required nursing home staff to conduct an assessment of each patient's condition upon arrival, as well as to an updated assessment at regular intervals. This assessment is known as the Minimum Data Set (MDS), and it provides a protocol for how each patient should be treated. In this way, nursing home residents get a highly individualized method of care. The patient's family can be a part of creating this standard of treatment.

­OBRA strengthened patient care in other ways as well. The new laws limited the use of physical restraints and mood-altering medications as a way to control patients. In fact, because overmedication was such a problem in nursing homes, OBRA created a way to try to eliminate unnecessary medications. Regimens of more than nine medications must be justified in the MDS, and at each update of the assessment, doctors should consider whether certain medications are still needed.


OBRA also set forth a Resident's Bill of Rights in a nursing home, which in addition to requiring that patients be advised of their own medical plans, included mandates about a right to privacy and a right to dignity. Ideally, this means that patients are able to make their own decisions, but a 2008 Slate piece highlighted the ethical dilemmas that could arise from such a situation. In "An Affair to Remember," writer Melinda Henneberger recounts the tale of an 82-year-old woman and a 95-year-old man who fell in love in a nursing home, only to have the man's son break up the relationship when it became sexual. Despite wanting patients to live full lives, nursing homes still have to err on the side of caution in some issues, and there is the question of whether someone with dementia could provide informed consent. In other issues, such as smoking, however, nursing homes generally allow patients to do what they want.

Nursing homes must comply with OBRA regulations to receive Medicare and Medicaid funding. To ensure that the guidelines are being met, the homes are inspected regularly by state surveyors. What do these surveys find?


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

woman in wheelchair with nursing home orderly
Be sure to check into past complaints before entering a nursing home.

In order to receive funding from Medicare and Medicaid, nursing homes must be inspected annually by state surveyors. Unfortunately, more than 90 percent of nursing homes were cited for not meeting health and safety standards in 2007 [source: Pear]. And the kind of care you receive might boil down to who owns the nursing home.

Approximately two-thirds of nursing homes in the United States are operated by private, for-profit firms, while another 25 percent are owned by not-for-profits and 10 percent are operated by the government [source: AGS Foundation]. Nursing homes operated for a profit are linked with a decreased quality of care and a greater number of complaints and violations in their inspections [sources: Harrington et al., Pear]. Not-for-profit and governmental homes are by no means perfect; in 2007, not-for-profit nursing homes averaged 5.7 deficiencies per nursing home, while government homes racked up 6.3 per home. However, for-profit nursing homes were reported to have an average of 7.6 deficiencies per home in 2007 [source: Pear]. The deficiencies included instances of infected bedsores, medication mix-ups and the use of physical restraints.


­The thinking goes that in order to make money, the for-profit homes make cuts that affect the quality of care, such as reducing the number of nursing staff or skimping on the meals. As a result, patients suffer, making them more likely to suffer depression or lose skills related to autonomy and independence than residents in other homes [source: Duhigg]. What's more, for-profit nursing homes often have a confusing corporate setup that makes it difficult to tell who's really to blame for poor resident care, which becomes particularly important should the need for a lawsuit or a federal fine arise.

But it's not only for-profit nursing homes that may skimp on care. In fact, because for-profit homes depend upon customer satisfaction in order to get new residents, they may be very well-run. And just because a not-for-profit or governmental group has its name on the letterhead doesn't mean you'll get great care. These groups may lend their name to the nursing home, while actual day-to-day management is done by an outside company.

If you do suspect abuse or neglect in a nursing home, you could address the issue with staff or contact your state's long-term care ombudsman. The ombudsman is required by law to examine complaints and can work with nursing homes or other agencies to solve conflicts.

Festering bedsores, fighting patients -- this isn't the rosy home that we may want for ourselves in our old age. Find out about what's being done to make nursing homes a better place on the next page.


Nursing Home Culture Change

nursing home resident with dog
Eden Alternative homes provide animals for companionship.

Many of us believe that nursing homes are cold, institutional places. Often, sadly, this stereotype has proved to be true. But currently, many are working at instituting a shift in how nursing homes operate. This movement is called culture change, and it involves rethinking how people are cared for in a nursing home.

­Spearheaded by the Pioneer Network, culture change involves some concepts that seem fairly simple in concept. Rather than running a nursing home according to a task-based schedule, which may involve one worker going up and down the halls to administer baths or change sheets, nursing homes would operate according to an individualized approach. This approach puts the patient's needs front and center, allowing for the highest possible quality of life. Staff members would have more one-on-one time with a smaller group of patients, allowing them to know when a resident wants a bath, as opposed to just giving a bath at a certain time.


Just as care becomes more individual and less regimented, so too should the facility look less like an institution and more like a home. This might involve changes in layout and appearance. One notable example of this approach is the Eden Alternative. There are several hundred homes across the country that have been "Eden-ized," meaning they are full of plants, animals and children. Rather than surrounding the elderly with surroundings that remind them of the end of life, they are surrounded by life, and preliminary studies of the method show that residents and their families are happier.

However, as you might imagine, changing the look and feel of nursing homes doesn't come cheap, and since many people are already worried about how they'll afford a nursing home now, there's no telling how long it will take to fully implement these ideas.

For more on nursing homes and other forms of long term care, see the links on the next page.


Lots More Information

Related HowStuffWorks Articles

  • "A Consumer Guide to Choosing a Nursing Home." NCCNHR. May 2007. (March 9, 2009)
  • "A Guide for Families: Making the Transition to Nursing Facility Life." American Health Care Association; National Center for Assisted Living." (March 9, 2009)
  • "At Rhode Island nursing home, death comes purring." CBC News. July 26, 2007. (March 9, 2009)
  • Chapin, Meldrena. Lecture at Feb. 26, 2009.
  • Coleman, Mary Thoesen, Stephen Looney, James O'Brien, Craig Ziegler, Cynthia A. Pastorino and Carolyn Turner. "The Eden Alternative: Findings After 1 Year of Implementation." Journals of Gerontology. 2002. (March 9, 2009)
  • Cornell University. "Aggression Between Nursing-home Residents More Common Than Widely Believed." ScienceDaily. June 4, 2008. (March 9, 2009)­ /releases/2008/06/080602170924.htm
  • "Culture Change in Nursing Homes." National Citizens' Coalition for Nursing Home Reform. 2006. (March 9, 2009)
  • Dentzer, Susan. "A Nursing Home Alternative." PBS. Feb. 27, 2002. (March 9, 2009)
  • Duhigg, Charles. "At Many Homes, More Profit and Less Nursing." New York Times. Sept. 23, 2007. (March 9, 2009)
  • Emerzian, A.D. Joseph and Timothy Stampp. "Nursing Home Reform: Its Legislative History and Economic Impact Upon Nursing Homes." Benefits Quarterly. 1993.
  • Engber, Daniel. "Naughty Nursing Homes." Slate. Sept. 10, 2008. (March 9, 2009)
  • Harrington, Charlene, Steffie Woolhandler, Joseph Mullan, Helen Carrillo, David U. Himmelstein. "Does Investor Ownership of Nursing Homes Compromise the Quality of Care?" American Journal of Public Health. September 2001. (March 9, 2009)
  • Henneberger, Melinda. "An Affair to Remember." Slate. June 10, 2008. (March 9, 2009)
  • Klauber, Martin and Bernadette Wright. "The 1987 Nursing Home Reform Act Fact Sheet." AARP. February 2001. (March 9, 2009)
  • "Living in a Nursing Home: Myths and Realities." American Health Care Association, National Center for Assisted Living. (March 9, 2009)
  • Matthews, Joseph L. "Choose the Right Long-Term Care." Nolo. July 2002.
  • Morris, Virginia. "How to Care for Aging Parents." Workman Publishing. 2004.
  • "Nursing Home Care." The AGS Foundation for Health in Aging. March 15, 2005. (March 9, 2009)
  • Pear, Robert. "Violations Reported at 94% of Nursing Homes." New York Times. Sept. 30, 2008. (March 9, 2009)
  • Pioneer Network Web site. (March 9, 2009)
  • Rosher, Richard B. and Sherry Robinson. "Impact of the Eden Alternative on Family Satisfaction." Journal of the American Medical Directors Association. May 2005. (March 9, 2009)
  • "The Evolution of Nursing Home Care in the United States." PBS. (March 9, 2009)
  • University of Illinois at Urbana-Champaign. "Long-term Care Health Coverage a Hidden Casualty of Economic Slide." ScienceDaily. Dec. 4, 2008. (March 9, 2009)­ /releases/2008/12/081204133602.htm