Finding the Right Nursing Home

Nursing homes provide a cost-effective way to enable patients with injuries; acute illnesses or postoperative care needs to recover in an environment outside a hospital. Nursing homes also serve chronically impaired individuals who are not expected to recover and who will typically die in the nursing home. About 91% of the 1,650,000 US nursing home residents are over the age of 65.

Nursing homes serve two kinds of residents. The first are those who have been discharged from the hospital for rehabilitative care. Medicare pays for a limited time for this kind of nursing home care.

Second are residents who may suffer from chronic physical or mental disorders, or they may simply be feeble and unable to move about, bath themselves, or provide their own meals. Medicare does not pay for their type of care, but Medicaid typically will pay. These people are often referred to as "long term care" residents.

It is hard to determine the length of time a stay in a nursing home will be. It depends on if it is for temporary rehabilitation or long-term care for something like dementia. According to a recent survey, the average combined length of stay for both types of nursing home residents is 2.44 years. Since this is a combined statistic, it should be noted that short-term nursing stays for rehab generally last about 23 days and since the 2.44 years is an average, this means that long-term care stays would last on average much longer.

How Do You Select a Nursing Home for Long Term Care?

Choice Made by Hospital Discharge Planner
You may not need nursing home care until after an illness or injury has sent you to the hospital for treatment. All hospitals have a discharge planning service. One responsibility of this planning service is to assess and arrange for post-hospital care if necessary. If the discharge planner determines a need for nursing home care, then he or she usually recommends the appropriate facility with consent of the patient and family. Your doctor also has to have visiting arrangements with the nursing home where you will be. The planner also arranges for Medicare.

As a prospective purchaser, you do not have to agree with or accept the planner's decision, and you can offer an alternative location if you feel more comfortable. The facility, however, has to be a skilled nursing provider and a staff doctor must be available on a 24-hour emergency basis. The facility must also have access to a hospital with emergency room treatment.

Referral
Many nursing home admissions are not made directly from a hospital, so the potential resident, or more likely the family, must choose a facility among perhaps dozens in the local area. Selection of the appropriate home is important, especially in light of the proliferation of abuse and neglect problems. A valuable resource is a good referral from friends or relatives who have had someone close to them in a nursing home. Make sure they are familiar with the quality of care in the facility they are recommending.

Phone Survey
It's a good idea to call all the facilities in your area and ask for bed rates. Also ask about staff turnover; age of the facility; whether the rate includes extras such as diapers and personal items; whether it is a chain, locally owned or nonprofit, and whether they offer the level of care you need. You can eliminate a number of facilities before you take the next step of an inspection tour.

Amenities Are Nice, But...
The newness of a facility and the amenities say nothing about the quality of care. Nor is a high daily bed rate always an indicator of better care. Many older facilities have lower fixed costs, and they may be able to give quality care at lower rates even if the surroundings are not so spiffy. The staff is the key to a quality nursing home stay, not the physical surroundings. A good indicator of quality is how long staff members have been with the facility. Long tenures usually mean job satisfaction. These people probably enjoy working with residents and are likely to have a good rapport with their charges and dispense high quality care. Always ask about tenure and turnover rates.

Inspection Tour
When possible, make visits at various times during the day to the nursing home you are interested in to make personal observations of the staff and residents.

Checklists
There are numerous checklists and evaluation helps on the internet to assist you in the selection of a nursing home in your area.

Costs for Nursing Home Care

The cost of a nursing home depends a great deal on where it is located in the country and whether it charges more for private paying patients versus Medicaid and Medicare patients. The Internet is replete with nursing home search services and prices in any given area, with specific nursing homes, can easily be determined. It's hard to understand why nursing homes in some areas are so expensive and more reasonably priced in others. It may have to do with state laws regarding staffing levels. For example, nursing homes in rural areas in the Midwest may cost about $6,000 a month whereas a nursing home on Long Island in New York might cost $15,000 a month.

Nursing homes look very much like hospitals. Staff is housed in accessible nursing stations. Residents live in utilitarian, hospital-like rooms with little or no privacy, and they sleep on hospital beds and are usually referred to as "patients" by the staff. Hospital pricing models are also used. Residents are charged daily flat rates for semiprivate or private rooms just like a hospital. Extra services and supplies are added to the bill. This pricing model assumes that all residents require the same supervision and care. Of course, this is not true.

Medicare Nursing Home Coverage

Traditional Medicare will pay for 20 days of a skilled nursing care facility at full cost and the difference between $194.50 per day (2022 rate) and the actual cost for another 80 days. Private Medicare supplement insurance usually pays the 80 day deductible of $194.50 per day. However, Medicare often stops paying before reaching the full 100 days. When Medicare stops, so does the supplement coverage.

To qualify for Medicare nursing home coverage, the individual must spend at least 3 full days in a hospital and must have a skilled nursing need and have a doctor order it. The transfer from a hospital must occur within a certain time period. The new Medicare Advantage Plans generally cover nursing homes differently from traditional Medicare. Most plans require payment upfront as opposed to traditional Medicare that pays 100% first. Under a Medicare advantage plan, a nursing home stay for rehab would likely be approved on a day by day or week by week basis. These advantage plans do not provide the same coverage as traditional Medicare. On the other hand, advantage plans have done away with the traditional Medicare requirement for 3 days in the hospital before transitioning to nursing home rehab.

There is a misconception that Medicare automatically covers up to 100 days of all nursing home stays. In reality, 100 full days of Medicare coverage is not that likely. When the skilled nursing need is not required, then Medicare stops paying.

Not all nursing home admissions come from a hospital - a prerequisite for traditional Medicare. Less than half of all nursing home admissions are from the hospital. Also, a hospital stay resulting in nursing home care does not automatically qualify for Medicare coverage under traditional Medicare. The stay may have been less than 3 full days or it may not be skilled.

Medicaid

Medicaid is a welfare program, jointly funded by the federal government and the states and largely administered by the states. Medicaid pays for about half of all nursing home costs in the United States. To qualify for Medicaid - in most states - a person must spend down his or her liquid assets to less than $2,000 and his or her monthly income must be insufficient for care.

Long Term Care Insurance

Long term care insurance is an alternative source of funding for long term nursing home care. From virtually nothing in previous years, insurance paid 7.5% of nursing home receipts in 2002. This percentage is increasing every year.

The government is also sending a clear message it wants private insurance to play a larger role. This began with the recommendation of the Pepper Commission in 1992 and continued with the HIPAA legislation in 1996 and on to the offering in 2003 of long-term care insurance for federal workers, military, retirees and their families.