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The Michigan Long
Term Care Companion Chapter 16 Nursing Homes The ABCs of Nursing Homes More than half of seriously ill hospital patients say that if they had to live permanently in a nursing home, they would be very unwilling to do so or would rather die, according to a 1997 study by the University of California at Los Angeles. This finding comes as no surprise. Many people feel that nursing homes are impersonal institutions that offer little hope to people suffering from late-life illnesses. Anxiety about nursing home life sometimes has little to do with the nursing home itself. Rather it may be fear of the variety of health problems and losses people often experience in late life that lead to nursing home care. It is natural to associate nursing homes with poor health and the end of life. Yet it is also easy to understand that we should not blame nursing homes for our fears about aging and illness. It is unfair to judge individual facilities sight unseen. Some facilities offer excellent care and virtually all have some dedicated, devoted employees who truly care about the residents. Better facilities focus just as much on quality of life as care, recognizing that all people need daily meaning in their life. Some nursing homes are finding ways to diminish institutional characteristics, creating more opportunities for resident autonomy, privacy and dignity. Nursing homes play a vital caregiving role for many people. Although only about five percent of older adults live in nursing homes at any given time, it is estimated that over 40 percent of older persons will need nursing home care at some point. The chance an older woman will need nursing home care during her life is about fifty percent. As medical advances enable us to survive serious illnesses and our mobile society pulls families apart, we are increasingly dependent on health businesses like nursing homes to deliver needed care. Whatever feelings you might have about nursing homes, there is no denying that they are an important part of our long term care system. Over 1.5 million people reside in U.S. nursing homes, including about 50,000 Michigan residents. Nursing homes dominate national use of public and private long term care funds, receiving about 75 percent of the more than $100 billion spent on long term care each year. It is best to keep an open mind about nursing homes. Consider them seriously when your needs and their services form a good fit. Some local nursing homes may offer care and services that compare favorably with help available in other settings. The name “nursing home” neither indicates quality or the lack of it. Judge each facility on its own merits. Resident Characteristics Nursing homes serve an increasingly fragile population. As home, community and assisted living options grow in popularity, nursing homes are left with little choice but to aim their services at the most dependent. This fact is reflected by resident needs:
Personal care needs are just part of the story. Many residents have complex health problems requiring sophisticated medical and nursing treatments. A growing number of residents need tube feedings, respiratory care, special skin treatments, IV therapy, ostomy or tracheostomy care, injections, or specialized rehabilitative services. Most receive multiple medications that require careful monitoring. Perhaps the greatest common problem nursing home residents face is depression and mental disorders. Almost two-thirds of nursing home residents have some form of mental impairment, most often Alzheimer’s disease or another type of dementia. More than 40 percent of people living in nursing homes suffer from mood disorders such as depression and anxiety. Distress and related behaviors associated with these conditions affect all people living in a home. About 70 percent of residents are women, two-thirds of whom are over the age of 80. More than 40 percent of people living in nursing homes are age 85 or older. Only one in 7 residents has a living spouse. The nursing home does not have to be your final destination. Nursing homes are often used for short-term convalescent or rehabilitative care. As hospitals rarely allow people to stay long enough to fully recover from accidents and illnesses, some nursing homes focus heavily on short-term therapeutic care that picks up where the hospital left off. Facilities with good therapy programs discharge many residents back to their homes or other more independent living settings. For many people, though, the nursing home is their final home. If you are not discharged within the first several weeks of your stay, the chance that you will ever return home decreases dramatically. Length of stays are increasing for long term residents. One study found that the average length of stay is about six months, but that one in five residents needs at least five years of care. Types of Nursing Homes Nursing homes are not all alike. They vary widely in mission, ownership, customer needs, quality, services, methods, environment and cost. Most of the approximately 450 nursing homes in Michigan are for-profit businesses. Although some of these are owned by individuals, the majority are owned by Michigan or national corporations. Less than a quarter of Michigan nursing homes are operated by non-profit businesses or government. Most of the non-profit homes are owned by church- or hospital-affiliated organizations. About three dozen nursing homes, known as county medical care facilities, are owned and operated by Michigan counties. There is a widespread perception that non-profit and county-owned facilities offer better care. While this is sometimes true, you cannot rely on ownership status as an indicator of quality of care. Where non-profit and county operators offer superior care, it is usually because there is strong local pride and involvement in their facilities. Not all non-profit and county homes have strong connections to their communities, however. Many hospitals operate nursing homes. In rural areas of Michigan, some hospitals offer nursing home care in a unit within the hospital called a hospital long term care unit. Licensed as hospitals, these hospital-based units do not have to meet Michigan nursing home rules and standards. But if they are certified by Medicare and Medicaid, they must meet all federal nursing home standards. For More Information The American Association of Homes and Services for the Aging publishes two guidebooks on continuing care retirement communities:
For information or to order, call AAHSA at (800) 508-9442. Or contact AAHSA’s web site at www.aahsa.org. Some nursing homes are part of a retirement community offering a variety of living options. These retirement communities often assure residents that they will be offered care in whatever setting is most appropriate to their needs, and that they can move among various living settings within the community as needed. They may be called life care centers or continuing care retirement communities. Life care centers and continuing care retirement communities generally charge a large entrance fee plus monthly rates that vary based on resident care needs and living settings. A life care center is registered with the Michigan Department of Consumer and Industry Services, which regulates life care contracts and monitors the centers’ financial arrangements with residents. Continuing care retirement community is a name used by a variety of retirement complexes, some that are registered as life care centers, some not. Some continuing care retirement communities are accredited by the Continuing Care Accreditation Commission, a private organization that sets standards for these communities. If you are considering moving into a life care center or continuing care retirement community, evaluate the financial arrangements carefully, determine how the center is regulated, and make sure that it offers all of the types of services you may need, at a price you can afford. Most nursing homes offer skilled and basic care. Skilled care means health services that can only be performed by, or under the direct supervision of, licensed health professionals like nurses, doctors and therapists. Examples of skilled care are tube feedings, treatment of severe bed sores and therapy. Basic care is help with routine health services, supervision, and assistance with personal care, like bathing, dressing and eating. These terms are sometimes defined differently by private insurance companies than by Medicare and Medicaid. Medicare covers only skilled care. Medicaid covers both skilled and basic care. Some nursing homes now promote subacute care, a marketing term used to describe care for people who are very ill or need unusual, specialized health services such as ventilator care. Providers offering this care claim that they are offering more intense health services to people who otherwise would remain in hospitals at far greater expense. These providers seek greater reimbursement from insurance companies and Medicare and Medicaid for this care. Some advocates and studies suggest that many people receiving subacute care are receiving the same type of care that skilled nursing facilities deliver, and that increased rates are not justified. Medicare and Medicaid do not formally recognize subacute care, although both programs pay higher rates to certain nursing homes offering specialized services. For example, Michigan’s Medicaid program pays increased payment rates to approved nursing homes that deliver ventilator care. Licensing, Regulation and Standards Nursing homes are regulated and monitored by both the state and federal governments. In Michigan, all nursing homes are licensed and inspected by the Michigan Department of Consumer and Industry Services (MDCIS). MDCIS evaluates whether nursing homes meet Michigan Public Health Code standards, primarily set in 1978. The federal government is involved in regulating nursing homes because it pays for much of the care through the Medicare and Medicaid programs. Current federal nursing home standards were set in 1987 when Congress passed the nursing home reform amendments. This law is sometimes referred to as OBRA ‘87 (Omnibus Budget Reconciliation Act of 1987),the broader act that contains the nursing home reform amendments. The federal law applies to nursing homes that participate in the Medicare or Medicaid programs. All but a few Michigan facilities participate in at least one of these programs. Most nursing homes participate in both. The federal government does not usually inspect nursing homes directly. The Health Care Financing Administration (HCFA), a federal agency that manages the Medicare and Medicaid programs, has contracted with the State of Michigan to evaluate nursing home compliance with federal law. Under this arrangement, the Michigan Department of Consumer and Industry Services inspects nursing homes to determine whether they are meeting both Michigan and federal standards. There are many similarities between Michigan and federal nursing home standards. Each contains extensive resident rights, staffing and care requirements, and inspection procedures. The federal standards set somewhat higher expectations than Michigan requirements, mandating that nursing homes “provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.” Chapters 18 to 23 give detailed information about nursing home care standards and resident rights. Most Michigan nursing homes are inspected about once a year. Chapter 26 gives more information about nursing home inspections and complaint procedures.
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Long
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