A nursing home is usually a permanent residence for people in need of 24/7 care that includes some medical assistance. Ninety percent of (about 15,600) nursing homes in the United States participate in Medicaid and Medicare. About two-thirds of them are for profit and one-quarter are nonprofit. Nursing homes may also be the site of delivery for rehabilitation post-surgery or hospitalization.
The terms ‘nursing home’ and ‘skilled nursing facility’ are sometimes used interchangeably. This is because they may offer similar services and may even be found under the same roof. However, the methods of payment and length of stay at each of these facilities can be quite different. Let us help you sort it out. Keep reading below to learn more about nursing homes. You can learn about skilled nursing facilities elsewhere on CaringInfo.
What Services Do Nursing Homes Provide?
Federal guidelines state that, at minimum, nursing homes must provide:
- 24-hour access to skilled nursing staff, with staff on-site for eight hours a day and on-call for remaining hours
- Medical treatment supervised by a licensed physician
- Services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of patients
Residents often have multiple medical conditions, and can require assistance with daily activities such as bathing and dressing. In 2016, nursing home staff spent a national average of 4.1 hours attending to each resident per day. (Source: Kaiser Family Foundation)
A nursing home may also offer skilled nursing care.
What Is the Difference Between Nursing Homes and Skilled Nursing Care?
Skilled nursing care refers to care or treatment that can only be performed by licensed nurses. This type of care may be offered in hospitals, assisted living communities, Continuing Care Communities, nursing homes, and other certified locations.
Skilled nursing care is not limited to a skilled nursing facility, so keep that in mind when discussing the services a nursing home may offer. Learn more about skilled nursing and skilled nursing facilities.
How Are Nursing Homes Regulated?
Nursing homes are regulated at the federal level by CMS, but enforcement of the regulations happens at the state level. Both federal and state governments share responsibility for quality assurance in nursing homes.
The performance criteria are federal, but the federal government has delegated responsibility to inspect nursing homes using these criteria and to certify eligibility to participate in the Medicaid program to states.
For the Medicare program, state governments inspect facilities on behalf of the federal government and make certification recommendations to the federal government; the certification decisions are made by CMS.
The federal government has authority in both Medicaid and Medicare programs to conduct independent inspections of certified nursing homes to audit the states’ certification activities. The federal government can also decertify substandard facilities.
State monitoring of nursing home performance now includes three types of activities:
- Nursing home inspections (called surveys) are conducted at least once a year by staff of the state health facilities licensure and certification agency.
- An “Inspection of Care” (IOC) is conducted either by the state Medicaid agency, the state health facilities licensure and certification agency, or a professional review organization. By law, inspection of the ‘care provided to every Medicaid recipient’ must be done annually.
- Investigation of ad hoc complaints submitted by residents, their families, or ombudsmen and other third parties. Complaints frequently concern possible violations of federal conditions and standards, or other regulatory requirements.
Monitoring the performance of thousands of nursing homes for quality assurance purposes has been difficult to carry out effectively and reliably. The quality criteria are inadequate, the surveys are not sufficiently discriminating, and state and federal agencies are understaffed and underfunded. This can lead to considerable variability from state to state.
Adapted from Improving the Quality of Care in Nursing Homes. Institute of Medicine (US) Committee on Nursing Home Regulation.Washington (DC): National Academies Press (US); 1986.
Have New Regulations Provided More Protections to Nursing Home Residents?
Regulators have been striving to put more control into the hands of residents. They now have:
- more say over when they see visitors,
- input on whom they share a room with
- input on what they eat
- more protection against theft and financial rip-off
- and more control over when they can be discharged
Residents with dementia also have more legal protection. The protections work to stop the practice of nursing homes sending such residents to hospitals and then refusing to readmit them. Justice in Aging has summarized many of the recent changes in pdf form and CMS has issued a fact sheet.
What to Consider When Selecting a Nursing Home
The National Institute on Aging has outlined a good way to consider different facilities:
- Consider what you want and what is important to you. Meals, physical therapy, or a religious connection, for example.
- Talk to friends, family, and healthcare providers, and ask for recommendations
- Talk to several facilities
- Visit the facility
- Come with a list of questions for the facility
- Visit the facility again without calling ahead
- Carefully, carefully read the contract you are given. We have summarized issues with contracts for you to consider.
Important Questions to Ask When Choosing a Nursing Home
Medicare has provided an excellent set of questions to ask when visiting a prospective nursing home.
Sample questions to ask include:
- Are there resident policies I must follow? Will I get a written copy of these policies?
- How many nurses, including Certified Nursing Assistants, will be available to help me during the day, at night, and on weekends? (The nursing home is required to post this information)
- Do staff knock on the door before entering a resident’s room?
- Do residents have a choice of food items at each meal? Do they serve food you like?
- Are there quiet areas where residents can visit with friends and family?
- Are residents clean, well groomed, and dressed appropriately for the season and time of day?
- Does the nursing home check to make sure they don’t hire staff members with a finding or history of abuse, neglect, or mistreatment of residents in the state nurse aid registry?
- Does the nursing home’s inspection report show quality of care problems or other citations (failure to meet one or more state or federal requirements)? (Note: The nursing home must have the report of the most recent state or federal survey of the facility available for you to look at. These reports tell you how well the nursing home meets federal health and safety regulations. Reports can also be found on most state survey agency websites.)
- Can residents still see their personal doctors? If needed, will the facility help arrange transportation?
- Is the nursing home for profit or not for profit?
Does It Make a Difference if a Nursing Home is For Profit or Not for Profit?
Yes, extensive research finds nursing home ownership and sponsorship affect the quality of care that facilities provide to their residents (Source: Center for Medicare Advocacy). For-profit facilities, particularly those owned by multistate chains, are more likely to reduce spending on care for residents and to divert spending to profits and corporate overhead. While the research findings do not necessarily apply to an individual nursing home – some for-profit nursing facilities give excellent care and some not-for-profit nursing facilities give poor care – the general rule is documented in study after study: not-for-profit nursing facilities generally provide better care to their residents. (Source: United States Government Accountability Office)
Do Nursing Homes Provide Hospice?
Some, if not most, nursing homes have relationships with local hospices. If there is a specific hospice that you want to work with, be sure to state this during your visit. If the nursing home does not currently have a relationship or contract with that hospice, they should be able to set one up.
You can use the Five-Star Quality Rating System tool created by CMS to compare skilled nursing care centers. Since 2008, the rating system measures results of Health Care Surveys (both standard and complaint), Health Inspections, Quality Measures and Staffing. The tool can help you create questions you want to ask facilities as you are starting your search for the right place for care. Just remember that quality metrics and online reviews are not the main guides to choosing a nursing home.
How is Nursing Home Care Paid For?
Nursing home care can be paid for privately, with Medicare resources for a limited time, or through long-term Medicaid. Although it is illegal for a certified nursing home to require a resident to pay privately for any set period of time, many nursing homes give preference to applicants who can pay privately. The longer you can pay the private rate, the more options you will have when looking for a facility.
What Does Long-Term Medicaid Cover?
In all states, Long Term Medicaid – also called LTC Medicaid or Institutional Medicaid – pays for care for individuals that reside in nursing homes. (Source: American Agency on Aging). Medicaid also offers Home and Community Based Services which allow individuals who live outside of nursing homes to receive services.
Every state sets its own rules for the Medicaid program, and there is great variability from state to state. If a person meets the requirements for long term care in one state, there is no assurance that they will meet the requirements in another.
What to Consider When Applying for Medicaid Coverage of Nursing Home Care
It is estimated that between 80% and 90% of nursing homes accept Medicaid. While this percentage sounds high, these percentages are very misleading. Nursing homes may accept Medicaid, but often have a limited number of “Medicaid beds.” “Medicaid beds” are rooms, or more likely shared rooms, that are available to persons whose care will be paid for by Medicaid.
Nursing homes prefer residents that are “private pay,” meaning the family pays the cost out-of-pocket. This is because private pay residents pay approximately 30% more for nursing home care than Medicaid pays. In 2023, the nationwide average private payer pays approximately $260 per day for nursing home care, while Medicaid pays approximately $182 per day.
For Medicaid to pay for nursing home care, the patient must qualify financially, need Nursing Home Level of Care (NFLOC), and meet the requirements of a state’s Functional Assessment Process.
Information on Qualifying Financially
- Evaluation includes both income and assets of patient and spouse if married.
- Varies by state—maximum asset limits for patients, with rare exceptions, is $2000. Maximum assets for spouse are usually about $148,620.
- Income limit for patients is usually under $3000 per month.
There are strict rules and ‘look back’ periods that must be observed as a person is spending down their assets to apply for Medicaid, so planning is very important. The American Council on Aging can help you find a qualified Medicaid planner in your area.
What is a Nursing Home Level of Care?
There is no formal, Federal definition of a nursing home’s level of care, so the definition varies from state to state. The state criteria must be met to receive long-term care from Medicaid. The requirements for each state are found on The American Council on Aging’s page about state specific Medicaid eligibilty.
What is the Functional Assessment Process?
The Functional Assessment is a thorough evaluation used to determine a resident’s physical health and need for assistance on a daily basis. Nursing homes complete this process when intaking a new resident to help plan for their care. Generally, the criteria include an assessment of:
- physical functional ability such as the ability to dress, bathe, manage medications and so forth;
- medical needs such as catheter care;
- cognitive impairment; and
- behavioral problems such as wandering. Most state use questionnaires; some require that a physician attest to the condition of the patient or require a face-to-face assessment.
The process differs from state to state and may vary by program but always requires the consent of the patient.
The American Council on Aging provides a comprehensive website explaining the Medicaid long-term care program and providing information on how to qualify for Medicaid assistance for long-term care. The process to qualify is complex and can take a long time, – easily 45 to 90 days. It is wise to plan ahead.
Once someone is approved for Medicaid to pay their nursing home costs, all their income, minus a monthly personal needs allowance of $30-$200 (varying by state), will go to the nursing home to pay for care.
Even if the patient doesn’t need or qualify for Medicaid at the beginning of the process, it is best to select a Medicaid certified facility. Uncertified facilities can evict you when your money and insurance run out. Choices of other facilities at that point may be very limited.
Medicaid certified facilities cannot evict residents who qualify for Medicaid during their stay and still need nursing home care. Often, a patient may enter a nursing home under Medicare following a hospitalization and later move to Medicaid as financial resources are used up.
Other Alternatives to In-Home Care
There are other care facility options to consider as well: