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Skilled Nursing Facilities

(Nursing Homes)

by Barbara Resnick, PhD, CRNP

Skilled nursing facilities (SNFs) are licensed and certified by each state according to federal Medicare criteria. SNFs typically provide a broad range of health-related services for people 65 yr (and for younger disabled people— Nursing Homes at a Glance). Services include

  • Skilled nursing care (ie, care that is ordered by a physician and can be given only by a registered nurse)

  • Rehabilitation services (eg, physical, speech, and occupational therapy)

  • Custodial care (ie, meals, assistance with personal care activities)

  • Medically related social services

  • Pharmaceutical services

  • Dietary services appropriate to each person's needs

Many nursing homes also provide additional community-based services (eg, day care, respite care). Many provide short-term postacute care (including intensive physical, occupational, respiratory, and speech therapy) after an injury or illness (eg, hip fracture, MI, stroke). Hospitals (including rural hospitals with swing-beds) or freestanding facilities that may or may not be affiliated with a hospital may act as nursing homes.

Placement in a nursing home may be unnecessary if community-based long-term care services (eg, independent housing for the elderly, board-and-care facilities, assisted living, life-care communities) are available, accessible, and affordable.

The percentage of people in nursing homes has declined, partly because assisted-living facilities and home health care, which depend substantially on informal caregiving, are being used more.

About 45% of people 65 spend some time in a nursing home; of these, 50% stay 1 yr, and a minority of these die there. The probability of nursing home placement within a person’s lifetime is closely related to age; for people aged 65 to 74, the probability is 17%, but for those > 85, it is 60%.

However, twice as many functionally dependent elderly live in the community as in nursing homes. About 25% of all community-dwelling elderly have no family members to help with their care. Special attention to health and health care needs of the community-dwelling elderly could add quality and years to their life and limit costs by preventing institutionalization.

Nursing Homes at a Glance




Number of certified homes

About 16,000 (in 2011)

Number of beds

About 1.7 million (in 2011)

Occupancy rate

81.6% (in 2011)

Number of residents

1.39 million (in 2011)

Average monthly charge (varies significantly by state)

$6752 (in 2012)


Requirements for Medicare coverage

Must need daily skilled nursing care or daily rehabilitation therapy

Must be admitted to the nursing home or rehabilitation service within 30 days after a minimum 3-day hospital stay

Risk factors for nursing home placement

Older age

Living alone

Inability to care for self


Impaired mental status (eg, dementia)


Lack of social or informal support


Female sex

Potential benefits for residents

Increased structure

Opportunities for socialization

Nutritional encouragement

Exercise and activities

Access to nursing care

Help with adherence to the drug regimen

Potential problems for residents

Inability to leave the facility

Infrequent visitors

Complaints that may not be believed or taken seriously because residents are ill or old

Abuse, which may be subtle (eg, using drugs and physical restraints inappropriately to manage disruptive behavior) or not subtle (eg, pinching, slapping, yanking)

Decline in functional ability*

Undernutrition and weight loss*

Pressure ulcers*







Requirements for Medicare reimbursement

A licensed charge nurse on site 24 h/day

Certified nurse assistants

A full-time social worker if the facility has > 120 beds

A medical director and licensed nursing home administrator

A qualified recreational therapist to provide recreational programs

A rehabilitative therapist

A dietitian

Physicians, pharmacists, dentists, and pastoral services to be available as needed, but not required on site

Possible additional services

Medical specialty services (eg, ophthalmologic, otolaryngologic, neurologic, psychiatric, psychologic), which may require transport of patients to other facilities

IV therapy

Enteral nutrition through feeding tubes

Long-term O 2 treatment or ventilator support

Special care units (eg, for patients with Alzheimer disease or cancer)

Scheduled recreational events for groups

Choices of leisure-time activities for patients, especially those who are cognitively impaired or bedbound

Personal services (eg, hairdressing, makeup), usually paid for by the patient's personal funds

*These problems, which commonly develop or worsen among nursing home residents, can sometimes be prevented with attentive care.

Special care units must specify programs and admissions criteria, train staff specifically for the unit, meet regulations and reimbursement requirements, and have an identifiable area or discrete physical space.

Supervision of care

Physicians must complete the initial admission of residents to a nursing home. Then they may delegate routine follow-up of residents to a nurse practitioner or physician's assistant, who alternate with the physician in visiting residents. Visits must be done as often as medically necessary but not less than every 30 days for the first 90 days and at least once every 60 days thereafter.

During routine visits, patients should be examined, drug status assessed, and laboratory tests ordered as needed. Findings must be documented in the patient’s chart to keep other staff members informed. Some physicians limit their practice to nursing homes. They are available to participate in team activities and to consult with other staff members, thus promoting better care than that given in hurried visits every other month. Some nurse practitioners and physicians collaborate to manage patients’ disorders. By administering antibiotics and monitoring IV lines, suctioning equipment, and sometimes ventilators, nurse practitioners may help prevent patients from being hospitalized.

Detecting and preventing abuse is also a function of physicians, nurses, and other health care practitioners. All practitioners involved in care of the elderly should be familiar with signs of abuse or neglect and be ready to intervene if elder abuse is suspected. A public advocacy system exists, and nursing homes can be cited by regulatory agencies.

The federal and state governments are legally responsible for ensuring that a facility is providing good care; surveyors attempt to assess a facility’s performance and to detect deficiencies by monitoring outcome measures, observing care, interviewing patients and staff members, and reviewing clinical records.


If hospitalization becomes necessary and if possible, the physician who cares for a patient in the nursing home should coordinate with the treating physician for that patient in the hospital. However, hospitalization is avoided whenever possible because of its risks (see Hospitalization).

When patients are transferred to a hospital, their medical records, as well as their advance directives and Medical (or Physician) Orders for Life-Sustaining Treatment (MOLST or POLST) forms), should accompany them. A phone call from a nursing home nurse to a hospital nurse is useful to explain the diagnosis and reason for transfer and to describe the patient’s baseline functional and mental status, drugs, and advance directives. Similarly, when patients are returned to the nursing home from the hospital, a hospital nurse should call a nursing home nurse.


Nursing home care is expensive, averaging over $80,000 per year in 2012. In the US, nursing home care cost $21 billion in 1980, $70 billion in 2000, $121.9 billion in 2005, and > $140 billion in 2010. About 44% of the cost is paid by Medicaid, 26.5% by the patient, 16% by Medicare, 7.5% by private insurance, and about 4% by other private funds.

Problems related to reimbursement

Critics suggest the following:

  • The rate of reimbursement may be too low, limiting patient access to rehabilitation and services that enhance quality of life, especially for patients with dementia.

  • Financial incentives to provide restorative care and rehabilitation for patients with limited functioning may be insufficient.

  • Nursing homes may be motivated to foster dependence or to maintain the need for high-level care so that reimbursement is maximized.

Nursing home placement

A patient’s preferences and needs can be determined most effectively through comprehensive geriatric assessment, including identification and evaluation of all disorders and evaluation of the patient’s functional ability (see Comprehensive geriatric assessment). Disabling or burdensome disorders—most commonly dementia, incontinence, and immobility—may trigger consideration of nursing home placement. However, even modest amelioration of a disorder may forestall the need for a nursing home ( Strategies for Avoiding Nursing Home Placement).

Strategies for Avoiding Nursing Home Placement


Possible Solutions

Urinary incontinence

Treating the cause may enable patients to remain at home.


Family members or other caregivers can be taught strategies for managing frustrating or disruptive behavior. For example, using purchased or rented monitoring devices can help with behaviors such as nocturnal wandering.

Functional impairments

Physical and occupational therapists and home health nurses can

  • Assess patients in their homes

  • Help determine whether placement in a nursing home or in an assisted-living facility is necessary

  • Suggest ways to help patients function better

  • Teach patients to use adaptive devices

  • Encourage exercise

Durable medical equipment, if needed, can be provided.

Need for elaborate and detailed care

Support and respite services can help prevent family members or other caregivers from becoming resentful or worn out.

Physicians can help by listening when caregivers discuss their burdens and by providing them with information about community caregiving support groups and about options for paid respite care.


Nursing homes vary in the types of medical, nursing, and social services provided. Some states set minimum nurse-to-patient ratios that are more stringent than federal requirements; the ratio of other staff members to patients varies considerably.

Physicians should help families select a nursing home that matches the needs of the patient with the services of a nursing home. Physicians should consider the following:

  • Which clinical care practice model the nursing home uses (eg, private single-physician practices, large networks of primary care practitioners who routinely visit a certain set of nursing homes)

  • Which hospitals have transfer agreements with the nursing home

  • Which special therapeutic services, palliative care, hospice, and other services are available

  • Whether staff members are employed full-time or part-time

  • What the patient’s medical coverage is, particularly if it is a Medicare capitated program, which covers certain aspects of ongoing medical care but does not cover long-term custodial care

Resources In This Article

* This is a professional Version *