Skilled nursing facilities (SNFs—also referred to as nursing homes) are licensed and certified by each state according to federal Medicare criteria. Skilled nursing facilities typically provide a broad range of health-related services for people ≥ 65 years (and for younger disabled people—see table ). Services include
Skilled nursing care (ie, care that is ordered by a physician and can be given only by a registered or licensed vocational nurse)
Rehabilitation services (eg, physical, speech, and occupational therapy)
Custodial care (ie, meals, assistance with personal care activities)
Medically related social services
Dietary services appropriate to each person's needs
Nursing homes may differ in the types of care that they provide. Many provide short-term postacute care (including intensive physical, occupational, respiratory, and speech therapy or intensive nursing care) after an injury or illness (eg, hip fracture, myocardial infarction, 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. Almost all nursing homes provide long-term care services to some degree, and many nursing homes also provide additional community-based services (eg, day care, respite care Respite Care Family caregivers play a key role in delaying and possibly preventing institutionalization of chronically ill older people. However, depending on the home situation and the needs of the older... read more ).
Placement in a nursing home may be unnecessary if community-based long-term residential care Residential Care In addition to nursing homes, there are a variety of facilities and programs to help people who can no longer live independently without support. Three examples are Board-and-care facilities... read more (eg, independent housing for older adults, board-and-care facilities, assisted living, life-care communities) is available, accessible, and affordable. Placement completely depends on the amount of nursing or supportive care the patient needs and the capacity of the specific facility, which varies widely.
The percentage of people in long-stay nursing homes has declined, partly because assisted-living facilities and home health care, which depend substantially on informal caregiving, are being used more.
A great number of people ≥ 65 will spend at least some time in a nursing home; however, only 5 to 10% of older adults live (ie, spend at least several years) in a nursing home (1 General reference Skilled nursing facilities (SNFs—also referred to as nursing homes) are licensed and certified by each state according to federal Medicare criteria. Skilled nursing facilities typically provide... read more ). The risk of nursing home placement increases significantly with age. The probability of nursing home placement within a person’s lifetime is closely related to the number of chronic diseases, mobility status, cognitive status, and age (eg, people aged 65 to 74, the probability is 17%, but for those > 85, it is 60%).
However, twice as many functionally dependent older adults live in the community as in nursing homes. About 25% of all community-dwelling older adults have no family members to help with their care. Special attention to health and health care needs of community-dwelling older adults could add quality and years to their life and limit costs by preventing institutionalization.
(See also Overview of Geriatric Care Overview of Geriatric Care Every 4 years, the US Department of Health and Human Services (HHS) updates its strategic plan and defines its mission and goals. The HHS strategic plan for 2022 to 2026 includes the following... read more .)
Effects of the COVID-19 pandemic on nursing home care
COVID-19 disproportionately impacted older adults in nursing homes in the US. As of August 2022, there have been 1,163,417 confirmed cases of COVID-19 and 154,578 deaths among nursing home residents. In addition, there are 1,250,427 confirmed cases and 2,564 deaths among nursing home staff (1 COVID-19 pandemic and nursing homes reference Skilled nursing facilities (SNFs—also referred to as nursing homes) are licensed and certified by each state according to federal Medicare criteria. Skilled nursing facilities typically provide... read more ). These numbers highlight the disproportionate death rate resulting from COVID-19 in older adults in nursing homes. In response, many family members took their loved one out of the nursing home. Large numbers of nursing home staff suffered from moral distress and burnout during the pandemic and left the nursing home and, in some cases, the profession. Additionally, about 300 nursing homes closed during the COVID-19 pandemic, and more are expected to close in the future. Fortunately, there have been fewer deaths of both residents and staff in nursing homes since the COVID-19 vaccines became available. The Centers for Medicare and Medicaid Services (CMS) reports that about 87% of nursing home residents have received primary vaccination, and almost 88% have received boosters (1 COVID-19 pandemic and nursing homes reference Skilled nursing facilities (SNFs—also referred to as nursing homes) are licensed and certified by each state according to federal Medicare criteria. Skilled nursing facilities typically provide... read more ).
COVID-19 pandemic and nursing homes reference
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 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; however, some states require a minimum of one visit every 30 days. For long-term care patients, nurse practitioners may provide independent care of the residents (patients) depending on whether their state allows independent practice.
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, nurse practitioners, and physician assistants limit their practice to nursing homes. They are available to participate in team activities and staff education 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 when appropriate and monitoring IV lines, suctioning equipment, and sometimes ventilators, nurse practitioners may help prevent patients from being hospitalized. Many physicians work closely with a nurse practitioner or a physician assistant to provide team-based care.
Detecting and preventing abuse Elder Abuse Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of older adults. Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial... read more is also a function of physicians, nurses, and other health care practitioners. All practitioners involved in care of older adults should be familiar with signs of abuse or neglect and be ready to intervene if 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.
The COVID-19 pandemic has highlighted a number of problems with quality of care in nursing homes and has caused government regulators to look more carefully at care in nursing homes. In response, regulators have provided enhanced training for nursing home staff about infection control and in some states require nursing homes to have full-time staff with expertise in infection prevention. In 2022, the National Academies of Sciences, Engineering, and Medicine (NAM) formed the Committee on the Quality of Care in Nursing Homes to study the state of nursing home care in the US. This committee issued recommendations for improving nursing home care (1 Supervision of care reference Skilled nursing facilities (SNFs—also referred to as nursing homes) are licensed and certified by each state according to federal Medicare criteria. Skilled nursing facilities typically provide... read more ):
Deliver comprehensive, person-centered, equitable care that ensures the health, quality of life, and safety of nursing home residents; promote resident autonomy; and manage risks
Ensure a well-prepared, empowered, and appropriately compensated workforce
Increase transparency and accountability of finances, operations, and ownership
Create a more rational and robust financing system
Design a more effective and responsive system of quality assurance
Expand and enhance quality measurement and continuous quality improvement
Adopt health information technology in all nursing homes
In the upcoming years, efforts must be focused on implementing these recommendations to ensure that vulnerable older adults receive the high quality and safe care they deserve.
Supervision of care reference
1. National Academies of Sciences, Engineering, and Medicine: The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC, The National Academies Press, 2022. doi: 10.17226/26526
If hospitalization becomes necessary, 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 Hospitalization A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more is avoided whenever possible because of its risks, such as health care–associated infections.
When patients are transferred to a hospital, their medical records, as well as their advance directives Advance Directives Advance directives are legal documents that extend a person's control over health care decisions in the event that the person becomes incapacitated. They are called advance directives because... read more and Medical (or Physician) Orders for Life-Sustaining Treatment (MOLST or POLST Physician Orders for Life-Sustaining Treatment (POLST) The do-not-resuscitate (DNR) order placed in a patient’s medical record by a physician informs the medical staff that CPR should not be done in the event of cardiac arrest. This order has been... read more 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. Many nursing homes use an SBAR (Situation-Background-Assessment-Recommendation) form for all transfers to ensure that relevant information is provided to the hospital (see the SBAR toolkit at Institute for Healthcare Improvement).
Nursing home care is expensive, averaging about $95,000 per year in 2021 (1 Costs reference Skilled nursing facilities (SNFs—also referred to as nursing homes) are licensed and certified by each state according to federal Medicare criteria. Skilled nursing facilities typically provide... read more ). In the US, nursing home care cost $21 billion in 1980, $70 billion in 2000, $121.9 billion in 2005, and > $157 billion in 2015. Federal and state governments pay almost 75% of the cost through Medicare, Medicaid, and the U.S. Department of Veterans Affairs (VA).
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.
In October 2019, Medicare changed its skilled nursing facilities reimbursement method from the Resource Utilization Groups (RUGS) model to the Patient Driven Payment Model (PDPM). RUGS primarily used the volume of therapy services provided as the basis for payment classification, which created an incentive for skilled nursing facilities to provide services to patients regardless of the patient’s needs. PDPM measures services provided to patients versus volume of services provided by the nursing home overall. PDPM includes 5 case-mix adjusted components (physical, occupational, and speech therapies, and nursing and non-therapy ancillary care) and one non-case-mix adjusted component to address resources used that do not vary by patient.
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. 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 (see table ). Older adults are the primary users of long-term care services and comprise (1 Reference Skilled nursing facilities (SNFs—also referred to as nursing homes) are licensed and certified by each state according to federal Medicare criteria. Skilled nursing facilities typically provide... read more )
84% of nursing home residents
95% of hospice patients
93% of residential care residents
82% of home health patients
63% of participants in adult day services
Selection of nursing home
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, nurse practitioners, and physician assistants should help families select a nursing home that matches the needs of the patient with the services of a nursing home. Practitioners 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, acute rehabilitation, 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
What services are available at the nursing home (eg, physical, occupational, and speech therapy)
What appropriate recreational activities are available
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Nursing Home Compare: Provides detailed information about every Medicare- and Medicaid-certified nursing home
LongTermCare.gov: The Administration for Community Living combined information from the Administration on Aging, the Administration on Intellectual and Developmental Disabilities, and the Department of Health and Human Services Office on Disability to provide information on long-term care access and cost
Kaiser Family Foundation: Providers and Service Use Indicators: Nursing Facilities: A resource providing data about health care facilities, including hospitals, nursing homes, and community health centers and the health care workforce, such as physicians, nurse practitioners, and physician assistants
American Action Forum: The Ballooning Costs of Long-Term Care