What should you worry about?
For some individuals, nursing homes are their only option because they aren’t able to take care of themselves anymore. However, before selecting one to live at, there are several things you should consider. What are these? How do you know if you should transfer to another nursing home?
Nursing homes, or skilled nursing facilities, offer a wide range of health and personal care services. Many places offer rehabilitation services, such as physical, occupational, and speech therapy, which is why some people stay at a nursing home for a short time after being in the hospital. However, most nursing home residents live there permanently because they have ongoing physical or mental conditions that require constant care and supervision. The services available to handle this scenario include nursing care, 24-hour supervision, three meals a day, and assistance with everyday activities. There are variations of this depending on the need of the individual. Subacute nursing units provide services that require more intense therapy or monitoring than is normally provided in a nursing home, such as the ability to administer complex IV therapy or the use of ventilators. On the opposite end of the spectrum are assisted living facilities, which are residential facilities that provide individual rooms, three daily meals, and activities for older people who can no longer live alone but don’t require 24-hour nursing care. These facilities do provide 24-hour on-site support and assistance, including help with medicines and personal hygiene. Continuing care retirement communities (CCRCs) usually have all levels of living arrangements, ranging from independent living to nursing home care.
The main reason families look for alternate living situations for a loved one is their inability to care for themselves. Signs of this are when an older person is inattentive to toileting/bathing needs, wanders frequently, sleeps poorly at night, or is frequently agitated. Other times, there’s a sudden change in the individual’s mental or physical health that requires immediate placement in a facility. Given that resources vary between communities and all the different levels of care, finding the best place challenging. To select the facility that meets your family’s needs, the number one thing you need to do is not rush your decision and do your homework. You can start by asking friends and family if they’ve got experience with any local nursing homes. Another good resource is your loved one’s doctor. Not only should they be able to recommend good facilities, but they should guide you toward what level of care your loved one currently needs. If your loved one can still make choices or discuss their wishes clearly, include them in the process. Moving to a nursing home is a scary time for most individuals because they feel like they’re giving up their freedom. During the discussion, it’s key to consider what they/you want. What’s important to them/you concerning services and amenities? Is there hospice care or special units for dementia patients available? Is the place close to family and friends so they can easily visit?
There are many different ways to research the best facility for your loved one. With everything being online now, you can use government or nonprofit sites to narrow down possibilities. One of the best-known is Medicare’s Nursing Home Compare. It uses star ratings from 1 to 5 and posts recent inspection documents. The Centers for Medicare and Medicaid Services (CMS) require each state to inspect any nursing home that gets money from the government. If a facility doesn’t pass the inspection, they’re not certified. ProPublica’s Nursing Home Inspect is a project of the nonprofit investigative news outlet and offers more detailed data, such as unredacted portions of government reports, which puts rankings in perspective. Each state has at least one Agency on Aging and federal law requires them to have an Office of Long-Term Care Ombudsman. Ombudsmen visit nursing homes regularly, so they often know about what occurs in local facilities. They also investigate complaints about nursing homes and work to resolve the problems. If they can’t, the complaints get referred to the state health department. There are more than 500 local ombudsman programs nationwide. You can obtain the number for your local ombudsman by calling your county or state office of aging. Another option is using Eldercare Locator, a service of the US Administration on Aging, and provides links to local Agencies on Aging. A Place for Mom is the nation’s largest senior-care adviser service with a directory of about 19,000 senior-care properties, including facilities specializing in dementia care. Its advisers provide free assistance in finding care options. The senior-care properties in the network cover the fee. The referral fee is a percentage of the first month’s rent and is paid after a senior moves into the facility. All properties pay the same percentage. Some other possible resources are the American Association of Retired Persons (AARP) or a hospital social worker (if your loved one is hospitalized). If you’re feeling overwhelmed by all the information, you might want to hire a professional geriatric care manager. They can help you evaluate care options and select the best residence for your loved one. The National Association of Professional Geriatric Care Managers’ member directory can help you find one in your area. On average, they charge $100 per hour.
The only way to know for sure which facility is best suited to meet your loved one’s needs is to visit it. No amount of research can replace visiting homes and observing what it’s actually like. It would be best if you aimed to inspect at least three and during your visit, don’t be afraid to ask questions. One of the first is whether or not the facility is accredited with The Joint Commission. While this is voluntary, it shows that the facility has taken extra steps to comply with its rigorous requirements. Another thing to ask about is the patient’s “Bill of Rights.” State and federal laws ensure that nursing home residents have certain rights, including, but aren’t limited to, the right to privacy, confidentiality, respect, freedom from restraints, freedom to express grievances without retaliation, and freedom to have visitors. This should be posted at the entrance to the nursing home. An additional thing to inquire about is the facility’s philosophy of care. One aspect of this is the facility’s policy on using antipsychotic medications and its non-pharmacological approaches to care. There are dangers to using antipsychotic medications to treat dementia patients’ behavioral symptoms. Find out how the facility approaches end-of-life situations. Do these align with your family’s values? Ask about visiting hours. You should be able to visit whenever you’d like within in reason. To provide the best environment for their residents, most facilities will request that you don’t come in the middle of the night.
Make plans to meet with the director and director of nursing. Find out how long the director and heads of nursing, food, and social services departments have worked at the facility. Ask whether the properties have recently had a change of ownership or management turnover. If key members of the staff change often, that could mean there’s something wrong. The administrator will play a major role in your loved one’s care and serve as your primary contact. If you have trouble getting in touch with them, it can indicate that you should look somewhere else. After meeting with the administration team, tour the facility and talk to staff members because they’re going to be the ones ensuring your loved one’s safety, so their attitude, expertise, and professionalism are critical. The staff should possess the skills necessary to take good care of the residents and have a polite, warm, and respectful relationship with them. Do staff members know the residents’ names? Do they respond promptly? Ensure that there is a licensed nurse at the facility at all hours of every day and a registered nurse (RN) there at least 8 hours daily. To help the staff stay current, they should have easy access to continuing education and training programs. Confirm with the administrators that they don’t hire people with any record of mistreatment or neglect in the nurse aide registry. If the staff seem or say they are stressed or overworked, it’s a red flag. If they talk more to each other than residents, that’s also a concern. Ask what the ratio of caregivers to residents is. It should be no less than 1 to 15 for assisted living and 1 to 8 for memory care.
During the tour, look at the physical setup of the residence. It should look like a home, not a hospital, which means residents should be allowed to bring their own furniture or other belongings to make their rooms feel more like home. Make sure that the property is secure so that residents can’t wander off. However, it should have a secure, accessible outdoor space that residents can use whenever they desire. While in the hallways, listen and ask yourself, ‘Is the center calm and quiet or chaotic and noisy? Typically, the higher-functioning organizations are calmer. Does the facility offer quiet areas and activity spaces so that residents can decide what they want to do at any given time? Another important factor is the size of the facility. Smaller facilities are usually quieter and depending on your loved one’s personality; it can make a difference in how comfortable they’ll be. One way to look at it is, are they more introverted or social and outgoing? If there are any strong odors, ask about them. Bad smells can indicate a problem, while good ones might hide a problem. Also, look at the hair, clothing, teeth, and fingernails of the residents. These should be cleaned and well-groomed. Residents should be able to wear what they want and go to sleep and wake up on their own schedule. Try to stop by during mealtime. The dining room should be clean and the food should look tempting. Residents should have choices about what and when they eat. If your loved one has special dietary needs, make sure the facility will accommodate them. Also, if your loved one needs help drinking and eating during mealtime, a staff member should be able to assist them. Besides mealtime, there should be other activities that can make the residents’ experience better. There should be a list of daily programs posted. Check to see if they’re actually occurring. The best nursing homes allow their residents to play a role in planning and selecting these activities. It’s a good idea to talk to residents, too. Ask them what they like about the facility and what changes they would suggest. Find out what they think of the staff. Residents can give you valuable insights.
A special consideration that many don’t think of is if your loved one’s doctor has privileges at the facility. Most people receive better care when they’re able to remain with their primary doctor. Part of this is also assessing the reputation of the nursing home’s medical director. Regulations require that a doctor or their designee routinely visit an individual living in a nursing home, assess their health status, and monitor the plan of care. Keep in mind that there are no requirements for healthcare providers to visit an individual residing in an assisted living facility. These individuals would still need to be taken to their primary doctor. In relation to this, determine what conditions would cause a resident to need to move to another level of care.
Before selecting a facility, revisit them. This time don’t call ahead and go on a different day at a different time. Typically, late morning on a Saturday or Sunday is the weakest point in regards to staffing. This will also allow you to meet other staff members and see different activities. After you select a nursing home, carefully read the contract. If you don’t understand anything, question the director. Part of understanding the contract is learning in advance how much the nursing home will charge. Nursing home care is expensive. You need to find out what the basic monthly cost is and are there added costs if a family member needs extra help with medications or incontinence. Also, is there a community fee (a one-time payment covering the cost of moving someone into the facility and refurbishing a room)? If so, is it refundable if your loved one doesn’t want to stay?
According to the 2019 Genworth Cost of Care Survey (they’ve sold long-term care insurance for more than 40 years), the national median monthly nursing home costs was $7,513 for a shared room and $8,517 for a private room; assisted living costs $3,600; and memory care is about $4,700. If an older person has long-term care insurance, this can be used to pay nursing home expenses under certain circumstances. If you are considering purchasing long-term care insurance for possible future use, check the costs carefully, read the small print, and review the company’s background/track record. Typically, long-term care insurance should be purchased around the age of fifty since premiums increase as one gets older. Besides, the cost varies depending on the number of chronic conditions you have and the type of coverage you desire.
For some individuals, Medicare pays for nursing home care costs, but you have to meet specific criteria. Medicare Part A provides coverage for only short-term stays in skilled nursing facilities. For the coverage to be applied, it starts with a doctor’s order for specialized nursing care and rehabilitation after a hospital stay for something, such as a stroke or serious injury. Usually, in such instances, Medicare can pay a portion of the cost for up to 100 days. To have this happen, the person must be admitted to the skilled nursing facility within 30 days of leaving the hospital after being a hospital inpatient for at least three consecutive days. The nursing care must be for the same illness or injury or a condition related to it. To qualify again for new nursing home coverage, the person can’t be hospitalized or receiving skilled care for 60 days. Then a new three-day (or more) hospitalization as an inpatient can start another 100 days of partial coverage.
If your loved one doesn’t have Medicare, they’ll have to pay for the nursing home out of their own pockets. Once they’ve spent down their assets enough, they’ll qualify for Medicaid, which will help cover some of the costs. Medicaid is regulated by both federal and state laws, with eligibility for it varying by state. It’s provided only to persons in Medicaid-certified facilities. This means the nursing home must continue to provide care for a resident whose personal funds have been spent while residing there. If the nursing home doesn’t participate in the Medicaid program, they can discharge the resident if they run out of funds. It’s important to note that Medicaid does cover assisted living in more than half of the states if the cost is less expensive than a nursing home. However, the waiting list to get Medicaid coverage for assisted living is long.
There are certain things that you should look out for when investigating nursing homes. Per a 2018 report from the Office of Inspector General of the US Department of Health and Human Services, an estimated 21% of Medicare beneficiaries experienced adverse events during their nursing home stays. Medicare.gov has a search tool that provides reports on different nursing homes based on ZIP code. The facilities are rated on many factors, like staffing violations and health inspections. It’s important to understand the differences in severity of the violations because it’s not uncommon to find minor ones. If a nursing home you like has a few minor violations, ask the administrator what they’ve done to fix them. There shouldn’t be any reports of serious injuries resulting from neglect, abuse, or errors in medication management.
Abuse in nursing homes frequently goes unreported. One reason that abuse occurs is understaffing. Even though it’s unjustified, it can occur when staffers are under tremendous pressure due to their workload. This is why during your visit, you should ask what staff members’ anti-abuse training entails, how exactly abuse allegations are reported/investigated, how family members are notified of an incident, and what preventive measures the facility takes. Also, find out the facility’s policy for male staff members providing intimate care for female residents and the handling of these situations on short-staffed days. To help individuals more easily decipher if a facility has a recent abuse or neglect citation, CMS introduced a new alert icon on their online Nursing Home Compare tool in October 2019. The icon, a white hand within a red circle, is updated monthly. According to a report from The Wall Street Journal in December of the same year, 760 of the database’s 15,262 Medicaid- and Medicare-certified facilities, or almost 5%, had the icon. The change drew complaints from the American Health Care Association (AHCA) and LeadingAge, two nursing-home industry associations, because they feel that the icon gave the wrong impression. They feel that the new visual urges consumers to avoid a facility altogether rather than investigate it further. In addition, they point out that it doesn’t take into account the facilities that have taken corrective action after a citation.
Another important thing to investigate is the infection rate of different illnesses within the nursing home. The New York Times reported in September 2019 about drug-resistant infections that are spreading in nursing facilities. Often, new residents can bring infections with them, especially those coming straight from hospitals. One of the most concerning infections is Closterium difficile (C. diff) because it causes extreme diarrhea that can lead to death. According to the Centers for Disease Control and Prevention (CDC), one in 11 people over 65 who contracted healthcare-associated C. diff infection died within a month of diagnosis. Another illness that can quickly spread is influenza. One way to prevent spreading infection is if you’re sick, don’t visit a facility because you could be more dangerous to the residents than they are to you. Unfortunately, few states have sophisticated monitoring of infection problems. Many states rely on county public health departments to collect data, but this isn’t the same across the board, so the results vary significantly.
Once you decide on a nursing home, you might experience several different emotions, like anxiety, anger, guilt, depression, or fear. Many people feel grief for the loss of the older person’s former self. Often, your loved one might say things that bring up these feelings by saying certain things. Sometimes, they feel like they’ve been abandoned. Tension and disagreement can arise among family members making the situation even more challenging. While it’s natural and expected to feel this way, it’s still painful to go through. The best way to manage these feelings is to talk about them openly and directly with your loved one, other family members, close friends, medical professionals, and clergy. It’s also a good idea to consider the first month in the nursing home as a trial period to ease the transition. During this time, it’s important to visit frequently for short periods of time (this is better than staying for hours at a time). During these visits, get to know the staff and compliment them when they do a good job. Always be kind and courteous to the staff even when you may feel like responding negatively. Occasionally take a special treat to those who provide care for your loved one. Also, participate in care planning sessions and nursing home’s family council. A family council is an organization of family members who meet to make suggestions for how to positively influence the quality of residents’ care, treatment, and quality of life. If there isn’t a family council, consider starting one. Another option is to talk with the activities director and see if you can help in some of the activities and outings that are planned. If there are problems, try to work with the staff to resolve them. Don’t move to a new nursing home to get away from a problem, only to discover that the new location is no better or has worse problems.
The care of your loved one is a crucial matter that deserves time and attention. If you do it right, choosing a nursing home won’t be easy. Don’t be swayed by fancy décor or because the price is higher than other facilities nearby. Experts warn that doesn’t mean the care is better at these facilities. The right facility will make your loved one feel respected and comfortable, which comes down to the quality of the staff taking care of them. There are many different services available, which is why it’s crucial to find out which ones are offered by each facility. Remember that some are essential for meeting your loved one’s specific needs, but others are just as important for improving their quality of life. Also, start looking early since the best homes have no space available and long waiting lists. By doing everything that you can, your loved one will be in a facility that provides them with the care that they need and you’ll feel good knowing they’re safe.