Nursing Homes Health Article

NURSING HOMES

Nursing homes are residential health care facilities that provide nursing care and supervision twenty-four hours per day. In addition to skilled nursing services, physical, occupational, and speech therapy are usually offered. These therapies are designed to enable residents to recover and improve functional ability lost as a result of disease or injury. In addition, residents may receive social services and engage in recreational activities designed to improve physical and mental health. Residents also receive assistance with activities of daily living such as eating, dressing, walking, toileting, transferring between a bed and chair, and bathing. Typically, a nursing-home resident will need help in three or more of these activities of daily living.

Nursing homes form part of the continuum-of-care options available for persons with chronic or long-term health care needs. This continuum ranges from independent home care to care within intensive-care units of hospitals. Not all nursing homes are the same. Some nursing homes provide basic services, called "custodial services." Others, called "subacute" facilities provide highly skilled and technologically complex services that resemble medical units in hospitals. Many provide a mix of services.

LENGTH OF STAY

The average length of time that a person spends in a nursing home varies by the type of facility and the services rendered. For example, a person who resides in a nursing home in which he or she receives largely custodial services is likely to be there as long as several years. In fact, such a person will not usually return to an independent or community living environment. However, a person in a subacute facility is generally there only a matter of weeks. Such a person often receives intensive nursing or rehabilitation services and returns home or goes to an independent community environment.

Nursing-home residents generally have long-term health care needs that have resulted from one or more chronic illnesses, disabilities, or injuries. These conditions are rarely completely cured. Such conditions include, but are not limited to, strokes, fractured hips, arthritis, and mental confusion. These conditions often place a substantial burden on the health and economic status of individuals, affecting their quality of life and contributing to the decline of the person's overall ability to live independently.

REGULATION

The nursing-home industry is the second most regulated industry in the United States, second only to the nuclear industry. Nursing homes are required to be licensed by state health departments. They are inspected at least annually to determine compliance with approximately 150 different state and federal regulations, and results of these inspections are available to the public. In addition, nursing homes are regularly inspected or reviewed by other state and local organizations including, but not limited to, fire marshals, sanitarians, and patient-advocate organizations. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) may accredit nursing homes that voluntarily meet certain health and safety requirements.

FINANCING

There are four basic ways to pay for nursing-home care. These include private funds, insurance, Medi-care and managed-care plans, and Medicaid. In general, people pay for approximately 25 percent of nursing-home care from their own personal financial resources. Basic room and board in a nursing home averages approximately $46,000 per year. Because of the costs, long-term care insurance is on the rise, and the extent of coverage varies greatly depending upon the insurance carrier and the individual policy. The American Association of Retired Persons (AARP) provides an analysis of the major insurance companies and their types of coverage. This information can be easily accessed through the Association's web site. Medicare and Medicaid are important governmental programs that provide coverage for nursing-home care.

Medicare. Medicare is a federal medical-insurance program that generally provides coverage to persons who are sixty-five years of age or older, persons of any age with permanent kidney failure, or those receiving Social Security benefits. Medicare coverage for nursing-home care is limited. Nursing homes that receive reimbursement from the federal Medicare program must be certified. All, or only part, of a facility may be designated as Medicare certified. A nursing home must meet the federal conditions of participation in order to be certified and maintain certification. During the annual state inspection or survey, compliance with the conditions of participation is assessed.

As of January 1, 2001, a person who is admitted to a skilled nursing facility within thirty days of a three-day hospital stay, and who is receiving care for the condition for which he or she was in the hospital, may receive up to one hundred days of either total or partial coverage from Medicare. The hundred days of coverage are not automatic. In order to qualify for Medicare benefits, the person must receive daily skilled nursing care or therapy services, and be certified for those services by a group of professionals, known as a utilization review committee, who reviews the case. If the person meets all of these requirements, he or she will receive coverage as follows:

• Full coverage for a semi-private room, meals, nursing care, rehabilitation therapy, drugs prescribed by the physician, medical supplies and equipment for the first twenty days
• Partial coverage for up to an additional eighty days if the physician and the reviewing professionals certify continued need for skilled services

Government statistics show that patients receive an average of twenty-four days of coverage under Medicare.

Medicaid. Medicaid is a program of health insurance for eligible low-income persons. Both the federal and state governments fund Medicaid. The program was not initially established to provide long-term coverage for persons in nursing homes; however, it has become the primary method of payment for low-income individuals in these facilities. While it varies from state to state, Medicaid pays for approximately 65 to 75 percent of nursing-home care. In order to receive payment from Medicaid, nursing homes must also be certified.

Individuals applying for Medicaid must do so through the county office of the U.S. Department of Human Services in their state. Medicaid applicants must meet both financial and medical eligibility criteria. In order to meet the financial criteria, an individual's assets must be less than $2,000; or $3,000 for a couple in the nursing home at the same time. Assets include cash, real and personal property (excluding the primary residence), cars, stocks, bonds, and the cash value of life-insurance policies, investments, and trusts—if the trust provides for the person's care.

Many people have too many assets at the time of admission to a nursing home to qualify for Medicaid. They must typically "spend down" their assets to meet the financial eligibility requirement. In the past, these spend-down requirements have often left the community-living spouse destitute. As a result, more liberal laws now provide for the financial protection of such spouses. As of January 2001, most states allow the spouse of a nursing-home resident to retain half of the couple's assets and the family home and furnishings, so long as these assets don't exceed a state established minimum. These laws are subject to review both at the state and federal level.

MARIA R. SCHIMER

(SEE ALSO: Aging of Population; Geriatrics; Gerontology; Medicaid; Medicare)