The Nursing Home

      Individuals enter into long-term care facilities when in a state of health that renders them unable to care for themselves.  America is an aging society and it is common for individuals to face an acute or a chronic, progressive illness that will test their ability or a loved one’s ability to safely provide care.  This often occurs after a hospitalization where an individual has a decline in physical function.  Older individuals are at increased risk for nursing home placement partly because the incidence of chronic disease increases with age.  Chronic disease, which afflicts many nursing home patients, often leads to disability and impairs the ability to safely and effectively live independently.

When does one need nursing home placement?

     There are three classifications of nursing home patients: short-term stay patients; respite stay patients and long-term care patients.

     Short-term stay patients are broken down into rehabilitation stay patients and those who require intensive nursing care.  Older individuals who fall at home and break a hip are likely to need therapy to regain their strength to live independently again.  Rehabilitation stays in the nursing home have a goal of maximizing function.

      In addition to the hip fractures, there are many other types of patients who need rehabilitative nursing home stays.  Examples included after any major surgery such as a joint replacement or open-heart surgery or after a major medical illness with a prolonged hospital stay such as a stroke, heart attack or prolonged bout of pneumonia.  In addition to the acute medical problem these patients are going through, they are usually afflicted with multiple chronic medical problems or an overall poor level of functioning. 

     Some individuals are in need of intensive nursing care for a specific medical concern.  An infected wound in need of frequent dressing changes and intravenous antibiotics is a common reason for this type of nursing home stay.  These patients are usually admitted to a nursing home after a hospitalization with specific orders to treat his or her medical illness.  Doctors can also directly admit a patient from home if the doctor feels that treatment at home will be ineffective or unsafe but not serious enough to require hospitalization. 

     Respite stays are a short-term stays for patients.   When caregivers need a break, they place the resident in a nursing facility for a short period of time.  The typical scenario involves a demented patient being cared for at home. The family caring for the patient goes on a vacation and they need a place for their loved one to stay.   Since the demented patient is unable to live independently, they are placed in a nursing facility until the family returns from vacation.

     Some individuals are unable to be cared for at home and need long-term placement in the nursing home.  Long-term placement is needed when catastrophic medical issues occur or multiple chronic medical conditions add up and a patient is no longer able to live independently.  This can include someone who has had a catastrophic stroke and is in need of 24-hour nursing care.  It could include the patient with dementia and frequent wandering who is unsafe at home because of the risk of wandering away from home. 

     After an acute illness it is often easy to see the need for nursing home placement, but there are times it is more challenging.   For the patient living at home it is often a difficult decision to place them in a nursing home but at some point the safety of an older individual is compromised.  Here are some signs that a person living in the community needs long term care:

• Taking medicine incorrectly such as taking too many pills or missing doses.
• Inattention to activities of daily living such as grooming, eating, decreased hygiene or an unclean house.
• Changes in spending habits or not paying bills.
• Increased confusion, which may present as forgetting how to use items, decreased ability to communicate, repeating questions and getting lost.
• Strange behaviors e.g. wandering down the street in the pajamas.
• Decreased cleanliness of the home.
• Smell of urine and/or feces in the home.

What to Look for in a Nursing Home 

     When the decision is made to go into a nursing home there are many important considerations.  When being discharged from the hospital there is often limited time to determine the best nursing home placement.  The hospital staff - including the physician, nurses and social workers - can help guide you in the decision.  One must use caution when taking advice from employees of the hospital as fancy sale pitches from the local nursing homes often sway staff members.  Hospital staff often base decisions on sales presentations versus what is in the best interest of the patient. 

     If there is time, determine a few local nursing homes and do some research.  Below are a number of steps one should make to assure the proper nursing home is selected for you or your loved one.

Preparation

1. List all the nursing homes that are convenient to your home.
2. Talk with people about nursing homes including nursing home staff, people who have had family members in nursing homes, doctors, the long-term care ombudsman, social workers and clergy.
3. Review the nursing home site at www.medicare.gov/NHcompare/home.asp.
4. Narrow the list down to a few nursing homes to visit.
5. Visit the nursing homes on your list and observe/do the following:

·         Do patients look happy?

·         Is the building clean and well maintained?

·         Do patients just sit around and look bored?

·         Does the food look good?

·         Are call lights responded to quickly?

·         Does the staff looked stressed out?

·         Are staff members responsive to family’s and patient’s needs and requests?

·         Are patients calling out for help?

·         Is there excessive noise?

·         Do patients smell clean? Are there any strong odors?

·         Ask to eat a meal.

Meet with the staff and ask:

·         Do they have special services such as transportation services, a store, and a beauty shop?

·         What do you like about this place?

·         What do you dislike about this place?

·         Do you ever work short staffed?

·         Do you like to eat here?

·         Are snacks available for patients?

Ask family members of other patients or patients who are able to communicate:

·         What do you like/dislike about this place?

·         Are you glad you chose this place?

·         Is staff helpful and caring?

·         Are you invited to plan of care meetings?

·         What happens when you have a problem?

·         Is the food good and do you get enough?

·         Does each shift have enough help?

·         How often do they check on you?

What to Expect in the Nursing Home

     Nursing homes are not like home but there are certain things that should be expected out of a nursing home.   Nursing homes should provide a home like environment where all of your activities of daily living are meet such as eating, bathing, and grooming.

What should happen in the nursing home

• Safety/good medical care – such as stairways being locked and giving you all of your medicine
• Interaction with staff
• Stimulation – such as activities and games
• Pleasant and safe environment
• Cleanliness and an odor free environment
• 24-hour nursing care by nurses and nurses aides
• Therapy services such as physical therapy, occupation therapy, and speech therapy
• Your nutritional needs being met including being evaluated by a registered dietitian
• Access to social workers
• Medical support – you have a doctor who is assigned as your primary doctor while you are at the nursing home.  The doctor will see the patient around the admission time and then one time a month.  If there are medical problems that arise the doctor is called and handles issues over the phone.  No doctor is on site at all times.  It is different than a hospital where a doctor sees the patient everyday.

The home is a “nursing” home.  It is run primarily by nurses who provide nursing care and use nursing judgment to care for the patients. 

Types of nursing home patients

Skilled patients

     Skilled patients are nursing home residents who have a special need and receive services that are paid for by insurance.  Usually these services are some form of therapy or intensive nursing care such as wound management or intravenous therapy.  When you are maximized on your therapy or no longer require intensive skilled nursing care your skilled time will be over and insurance will not pay.

     At this point patients and their families have to make a decision – Where do I go next?  Many people will go home with some nursing care and therapy.  Others will go to an assisted living, where they still get some nursing care but are more independent.  Some people need to stay in the nursing home on a long-term basis.

Long-term placement

     Some individuals are not able to live out in the community by themselves or have significant disability that does not allow them to live with minimal care in an assisted living facility.  They are debilitated to a point where the only safe way to live is with 24-hour nursing support.   The nursing home becomes the new home. 

The Nursing Home Experience 

     The nursing home can be a scary place and having an understanding of what happens during a stay reduces trepidation.  Nursing homes are not as comfortable as home but they do not have to be unpleasant. 

     Many factors influence day-to-day experiences including ethnic background, economic circumstances, and staff ideals varying from patient’s ideals.  Serious neglect or mistreatment is rare because there are many built in mechanisms to prevent neglect. 

     Admission to the nursing home is stressful and confusing.  This is going to be the resident’s new home over the next few weeks to months or maybe even permanently.  Having some knowledge about the nursing home procedure can cut down on some of the anxiety. 

Admission procedure

Below is a general listing of what happens when you are admitted to a nursing home. 

• Orders are sent by your doctor to the nursing home. 
• The nursing staff reviews these orders and a complete nursing assessment is done on the patient.
• The nursing staff adds orders, after the patient is evaluated, based on nursing home protocols.
• The doctor then approves these orders.
• Your doctor at the nursing home may not be your primary care doctor.
• Your nursing home doctor will visit soon after admission, and then every 30-60 days.   Your doctor is not on-site at all times and most doctors do not make special trips to the nursing to see sick patients. Nursing homes can handle many medical conditions including common urinary tract infections, pneumonias, dehydration and minor traumas. If you are sick enough to be seen by a doctor you are sent to the emergency room. 
• Most patients are evaluated by physical therapy, occupational therapy and speech therapy.  If the patient qualifies, they will be picked up by the different therapy services.
• A dietitian will evaluate your diet. Three meals a day and snacks will be provided.
• You will be cared for on a day-to-day basis by a team of nurses and nurse aides.
• You will not be provided with one-on-one care.  The nurse and nurse aide who are assigned to you will be caring for many other patients.
• There is a nursing support team who will evaluate all of your needs to help assure you are getting optimal care.
• Social workers are available to assure your social needs are cared for such as discharge planning. 
• If you have to go out to doctor appointments the nursing home can arrange transportation for you through a local ambulance company.
• Most nursing homes have a variety of doctors that can see you in the nursing home.  This includes a psychiatrist, psychologist, podiatrist, dentist, eye doctor and sometimes an ear/nose/throat doctor.
• Many nursing homes hire nurse practitioners or physician assistants who are on site 40 hours a week to address medical issues that arise during your stay.  These advanced practitioners have higher-level skills and are able to diagnoses and treat common medical problems. 

The Plan: What happens after you settle in?

     The nursing home is a structured facility and each patient has a specific plan of care with individual goals.  The nursing home has multiple team members to help the patient meet his or her goals. 

     The nursing staff is the most prevalent member of your care team with the director of nursing overseeing all aspects of nursing care.  Bigger nursing homes have assistant directors of nursing to help with the daunting task of overseeing nursing care.  A nurse, who is directly responsible for all the patients on the nursing unit, oversees each unit.  Staff nurses supervise multiple nursing aides who are assigned to each unit and are responsible for most of the day-to-day care, such as bathing, hygiene and feeding.

     In addition to the direct care nurses, there are review nurses who spend their days making sure the patients are hitting their goals.   These review nurses examine the patient; review the medical record; and talk with families, nurses and therapists to help assure the patient is getting optimal care.  These nurses help assure that they are getting appropriate exercise, nutrition, laboratory follow-up and medications. 

     Administrators oversee the facility.  They are responsible for managing the finances, setting and enforcing policy and for the personal.  Large nursing homes have an assistant administrator to help the head administrator with his or her multiple duties. 

     The dietary staff is responsible for getting food to the patient.  The dietitian is responsible for assuring all patients get the proper diet.  The dietary manager oversees the kitchen while cooks are in charge of preparing the food.  Typically the floor staff, including the nursing aids and nurses, are accountable for assuring that patients get his or her food. 

     Social workers are a vital part of the nursing home staff.  They help with discharge to make sure all the services are set up for home including therapies, nursing care and any other services that are needed.  Social workers are responsible for setting up family meetings with long-term residents and coordinating services. 

     The activities department keeps the patients active.  They help set up games, organize spiritual activities and plan day trips. 

     Therapy is a vital component to the skilled nursing home success.  Therapists help get the patient back on their feet.  Physical therapists restore physical function and help with locomotion.  Occupational therapists help individuals regain their ability to perform activities of daily living such as eating, grooming and dressing.   Speech therapists help individuals with swallowing and cognitive function. 

     The attending physician is one of the least involved members of the team but is responsible for the overall care of the patient.  Attending physicians are not on site all the time and many only come into the facility when they have new admissions or performing their regulatory visits (which need to occur every 30-60 days). 

     The nursing home is very organized.  Each patient has meetings scheduled on a regular basis to assure that they are on track with their goals.  These are called care conferences and the patient’s strengths, weakness, diagnoses, goals and treatments are discussed.  Families and patients are invited to attend these meetings.  The first of these conferences is scheduled shortly after admission and then at least every three months. 

     Discharge planning is done at a meeting with the nursing home team.  At these meetings it is decided if the patient met his or her goals and more importantly will the resident function safely in the home environment. 

     Another important question is where should the patient be discharged.  Common places include home, home with another family member, assisted living or staying long-term in the nursing home.  Sometimes, prior to discharge the occupational therapist does a home evaluation to assure that the home is set up safely for the patient.  Social workers are very involved in the nursing home discharge as they set up home health nursing, therapy services if needed, and medications.  Follow up with the primary care medial provider is another task that is scheduled upon discharge from the nursing home. 

How to Make the Most of you Nursing Home Stay and Practice Health Care Responsibility

     Nursing homes are not like home and patient expectations are often not in line with reality.  Patients and/or families come in for their preadmission tour, which is essential a sales pitch, and nursing homes put their best foot forward and make things look better than they are.  When patients arrive at the nursing home things are not as they expected. 

     Nursing homes are not like hospitals.  Many patients and families expect many things to be the same as the hospital when entering the nursing home.  While patients are sick in the nursing home, they are not as acutely ill as they are in the hospital.  

     Hospitals are staffed much more intensively than nursing homes and consequently care is different.  Hospitals are reimbursed much better than nursing homes.  Nursing home nurses are assigned to approximately 20 patients while hospital nurses are assigned one nurse to 1-5 patients.  The ratio of nursing aides to patients is lower in the hospital so when a call light goes off in the hospital the response time is very rapid, but in the nursing home it takes much longer for a call light to be answered.   On the positive side for the nursing home, nursing homes are usually more “homey” than the hospital.

     Nursing home placement is a stressful time.  Patients and family members of nursing home patients want their loved ones to get better and this is often a slow process.  Frustration is common because progress is not made quickly.  Nursing home patients are usually older patients with multiple medical problems and do not have the physical reserve to bounce back from an illness that someone in their twenties does. 

     Nursing homes are not staffed to care for patients like an attentive family member could in the home.  When nursing home residents ring the call light there is usually a delay until the staff can get into the patient’s room.

     If nursing homes do not provide attentive care, than why go.  Nursing homes offer the advantage of 24-hour care with specialty equipment and specialty staff that is not available at home.  

     Nursing homes are not home. Most people would prefer to be in their home, but due to a medical condition are unable to care for themselves.  Here is a list of things that patients and families can do to make the most of their experience.

• Have a power of attorney.  This allows someone can make legal decisions if the patient is not competent to make decisions.  It also helps to decrease or avoid family conflicts.   The social worker in the nursing home can point you in the right direction to getting a power of attorney set up. It usually requires that you go through an attorney’s office.
• Learn about your or your family member’s medical conditions, treatments and progression of disease. Nursing home patients are typically chronically ill and it is essential that you have a complete understanding of their health and overall prognosis.  Nursing home staff, especially an advanced practice nurse or the doctor, can help you understand your medical condition and overall prognosis. 
• Know your health care provider’s schedule; talk with him/her about your condition.  Know when he/she visits.
• Be nice to nursing staff.  Staff has to care for a number of patients, they will not care for you or your family member like you would.  If there is a problem voice it right away – don’t be hypercritical no one wants to deal with a finicky family.  Complement the staff at every opportunity.
• Learn Medicare/Medicaid rules; know the appeal process and how to challenge the nursing homes decision regarding limitations to therapies and skilled time (which is paid for by insurance).
• Bringing in snacks for the nursing home staff, such as cookies or candy, can go along way in getting your loved one great care. 
• Your family member may have a change in mood or behaviors upon being placed in a nursing home.  Give the patient time to adjust.
• If you have a loved one in the nursing home; take time for yourself.  Trust the nursing home.  If you don’t trust the home then you should find a new home.
• Don’t expect perfection from staff, they will make mistakes.  Expect your family members to have needs met in a timely matter.
• Keep up to date on your care.  Know how you are progressing in therapy and when you may be discharged.  Understand your medical conditions and treatments.  Make sure you are getting proper testing, medication and medical follow up.  The key component to health care responsibility in the nursing home is using the nursing home record described below. 

Nursing Home Record

     The nursing home record is a way to record and monitor care.  Those who practice health care responsibility track these changes.  The skilled nursing home benefit is nursing care or rehabilitation services that are paid for by insurance.  This type of care is very goal directed and when it is over the patient will have to make a decision: stay at the nursing home, return home or go to some other living arrangement. 

     Tracking your care while under the skilled benefit will empower you to partner with the nursing home assuring that you will be discharged in a timely fashion.  Some nursing homes keep patients at the facility as long as they can in order to maximize reimbursement. 

    The personal nursing home record allows you to track your nursing home care to prevent staying in the nursing home any longer than necessary.  The record requires you to fill out information on your health care providers so you know how to contact them. 

     Key personal in the nursing home who you need to know include: the nurse in charge of your unit, the director of nursing, the physical, occupational and speech therapist who are caring for you and the doctor overseeing your care. 

     It is also important you have a basic understanding of the plan of care for the therapy services that you are receiving including the estimated length of time on that service.  Therapists are required to develop a plan of care and an estimated time you will be in the therapy.  Make sure you discuss with each therapist their plans and goals so it can be recorded on the form. 

     Nursing and medical care is another key component to nursing home care.  If you are receiving skilled nursing care, make sure you understand your goals.  For example, if you are receiving intravenous antibiotics for a wound infection you should know for how long and when you are to follow up with the doctor.  While those who are placed in a nursing home under therapy services are discharged when therapy is maximized, those who are under a skilled nursing benefit are discharged when the doctor feels skilled nursing care is no longer needed.  Understanding the plan and when you are to see the doctor is vital for assuming health care responsibility for the nursing home patient. 

     Other medical issues often arise while in the nursing home.  Keeping track of these changes is a practice of health care responsibility.  When there is a change in the medical condition of a patient, the nurse will notify the patient’s doctor.   The doctor will order a diagnostic intervention or new treatment.  The nursing staff is required to communicate these changes with the patient and family.  Recording any testing or new treatments on the nursing home record will help you monitor your medical care. 

     New treatments are often started in the nursing home and when the patient leaves the nursing home the primary doctor (who often does not care for the patient in the nursing home) is clueless about why the treatment was started.  The nursing home record provides a written statement that will be placed in the personal health care record so all health care providers have an understanding of why the treatment was started.  This will allow health care providers to determine if the medicine is still needed and greatly improve health care. 

     Ask your primary care provider, nurse and therapists what is your anticipated discharge date.  The exact date will likely not be known, but this will give you an idea what to expect.  Record this date on the nursing home record. 

Health Care Responsibility

1. Find a good nursing home
2. Bring your personal health record
3. Fill out and record your nursing home record.