Skilled Nursing Facilities
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: 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 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).
Placement in a nursing home may be unnecessary if community-based long-term residential care (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.
About 45% of people ≥ 65 spend some time in a nursing home; of these, ≥ 50% stay ≥ 1 year, and a minority of these die there. 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.
Nursing Homes at a Glance
(See also Overview of Geriatric 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 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.
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, such as health care–associated infections.
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. 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 over $100,000 per year in 2018. 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).
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.
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 ( Strategies for Avoiding Nursing Home Placement). Older adults are the primary users of long-term care services and comprise (1):
Strategies for Avoiding Nursing Home Placement
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 are some English-language resources that 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