Choosing a Nursing Home — hard on many levels


If you are choosing a nursing home it means a parent or close relative is not doing well.  It is a time of anxiety and concern.  You think about the fact the average stay in a nursing home is 2 years — bluntly meaning 50% of people who go into a nursing home (ICF) are dead within 2 years.   But, a big question is “which is the right one”?

In years past there were just “nursing homes”.  But, just like a growing tree there are now many branches.   So what are the branches of care in 2014?

  • Family care in the home
  • Family care supplemented with visiting aids and nurses
  • Full time home care (very expensive)
  • Independent living with services (senior apartments)
  • Assisted living — apartment  but with lots of services and meals
  • Residential care facility (RCF) (like assisted living but care includes medical oversight, like with a few nurses)
  • Intermediate care facility (ICF) for people who can not care for themselves.  People who are demented or severely disabled who need 24 hour per day supervision and medical oversight.  There are some reasons for short term stays like severe injuries that take a long time to heal.  But, generally, patients stay there until they die.  The next level is skilled nursing which leads to the concern that ICF is “unskilled” nursing which is not correct.
  • Skilled nursing facility (SNF).  High level of care, nearly like a hospital.  A strong component of therapy with the expectation of improvement and a switch to a lower level of care within a few weeks or few months.  If a patient is a hospital inpatient for at least 3 days they may qualify for 100 days of Medicare payment.
  • In recent years many ICF facilities have chosen to upgraded services to qualify as SNF facilities (at least for some beds) — they still provide long term care but have the option of billing Medicare for those patients who come out of the hospital.  It’s now hard to tell the difference between ICF and SNF in many locations.
  • Rehabilitation Facilities.  Not for long term care and usually paid for by insurance or Medicare.  Qualified patients might need rehab (intensive physical  and occupational therapy) following  joint surgery or following a stroke.  Some long term care facilities are connected to rehab facilities and only offer the long term care if the patient fails to go home after rehab.

Hospice is not a level of care or even home care.  It is medical supervision oriented solely toward comfort and death with dignity.  It is  mainly staffed by nurses plus a supervising physician.  The services are for dying patients.  The average time a person spends under hospice supervision is 2 weeks.  A doctor must certify a life expectancy of less than 6 months to qualify.  Hospice can supervise care in many locations (but not SNF).  Service at home and in the ICF are very common.

In many respects ICF is the last step and often the hardest.  Patients have usually been through several other levels of care and are failing.  Cost is always an issue.  ICF is expensive ($200 -$300 per day) and it is not uncommon to exhaust personal funds and end up requiring State financial assistance (Medicaid).  Because of the expense, patients and families usually see ICF as a last resort.  It is such a difficult step  patients are sometimes hospitalized before the decision to go to ICF is finally made (not good).

OK you need to select an ICF facility.  There are often several choices.  How do you pick one?  What are the main deciding factors:

  • Medicare rating — the higher the better (top is 5 stars)
  • Cost and whether the care center will keep the patient if they do not have money or will run out of money
  • Recommendations from families with relatives in the facility
  • The general appearance of the facility and the smell (smell of urine is a bad sign).
  • The care the facility delivers is vastly more important than the age of the facility or the size of the rooms.   One very highly rated care facility is 40 years old and has rooms holding 3 people each!

The facility needs to answer questions before choosing that facility.  Some questions are intended to set expectations.  Some questions are intended to find issues that might make the facility unacceptable.

  • What is the Medicare quality rating? (avoid less than 3 stars)
  • What is the price per day and what are the options?
  • What expenses are not covered by the room rate?
  • How is pharmacy involved with medications?
  • Can mail-order medications be used in the facility?
  • What are the findings from State inspections for the past 3 years?
  • What is the process to be admitted?  What is required?
  • What is the ratio of care givers (RN, LPN and CNA) per patient — during the day, at night and on weekends.  1 RN + 1LPN + 1 CNA per every 10 patients is good.
  • What is the waiting time for a bed?
  • Is there a house doctor, nurse practitioner or physician assistant that rounds regularly?  (under contract with the facility to make rounds — very nice service)
  • Can an outside primary care doctor also write orders?
  • How does the facility deal with a “do not resuscitate” order?
  • How often can a family call and obtain up to date information?
  • If a doctor or assistant rounds will the care center nurse inform the family of the recommendations?
  • What is the general daily schedule?
  • Is exercise & mental stimulation included every day?
  • What is the menu and how is it rotated
  • Are the rooms treated as just bedrooms or as the place where patients spend the day (the former is better)
  • What is the expectation for frequency of nursing checks at night (in order to prevent falls a check every 15 to 30 minutes is good)
  • How does the facility prevent loss of glasses or hearing aids?
  • Can special meals be served.  Is there a way to limit salt in the diet?
  • What is the average length of employment for staff (5 years is good)
  • Are SNF beds available in case of a short-term problem (like recovery from hospitalization)
  • What is the ratio of private pay to Medicaid pay patients.  (a ratio of 3 to 1 is OK but a care facility with all Medicaid operates with less money and less staff.
  • Does the staff have special training for dementia care?
  • What is the expense for oxygen therapy?
  • Can family bring food for the patient?
  • What are the statistics for falls in the facility for the past few years?  (falls are often a reflection of infrequent patient checks — checks that lead to helping the patient go to the bathroom)
  • Is there a psychiatrist that can assist the other doctors with adjustment of medications for agitation and depression?
  • What sort of alarm systems are present should a patient walk out a door?  (important for demented patients).

It is interesting to note that older care facilities often have better quality ratings than new facilities.   Older facilities can’t suddenly be new so they may opt to  meet strict quality measures.  It differentiates the facilities that otherwise might be squeezed out of the market.  But, any facility that has failed to make renovations over time suggests poor management or excessive profit taking.

Many people have selected nursing homes for loved ones.  Your comments would be appreciated.   Any other questions you think are important?

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