When it comes time for families to consider placing a loved one in a nursing home or assisted living facility, there are a lot of factors to consider. Where is it? How is it run? What sorts of activities does a particular nursing home offer? You’ll need to investigate these and many other questions to find the right fit for your loved one.
And there are a lot of options out there. According to data from the National Center for Health Statistics, as of 2016, in the U.S. there were an estimated:
— 4,600 adult day services centers.
— 12,200 home health agencies.
— 4,300 hospices.
— 15.600 nursing homes.
— 28,900 residential care communities.
That’s a lot of potential sources of care for your loved one, and digging a little deeper into the facts and statistics surrounding nursing home care could help you make a more informed decision.
In doing so, it may help to have a little more background information about nursing homes in general to inform your understanding of where a particular facility fits into the overall scheme of health care for an older adult or for someone who needs rehabilitation assistance or another type of long-term care at some other stage of life.
How Many and Who?
The Centers for Disease Control and Prevention reports that as of 2016, there were 1.7 million beds in licensed nursing homes in the United States. Many people who reside in nursing homes need assistance with one or more activities of daily living such as:
— Eating or preparing meals.
— Bathing and dressing.
— Going to the toilet.
— Managing medications.
— Moving around in the residence or getting to other locations.
As we age, these activities tend to become more challenging, especially if chronic health issues such as diabetes, arthritis, eye diseases or cognitive impairment are also present. Many of these problems occur simultaneously.
“There’s a complex set of issues why some people need a nursing home,” says Dr. Tanya Gure, section chief of geriatrics and associate professor in internal medicine at the Ohio State University Wexner Medical Center in Columbus. “Depending on what resources are available to them in retirement and their current network of support, they may move to a nursing home as they have increasing limitations in their basic functions.”
Some people need more help than others. Assistance feeding and bathing or medical care might be top priority for some, while others may have issues with mobility function or being able to transfer from sitting to standing on their own. All of these needs could mean that an individual will need the type of care that a nursing home can provide.
However, despite the fact that nursing homes, also called skilled nursing facilities, care for a lot of older adults, it’s a common misconception that nursing homes are only for the elderly. Skilled nursing facilities actually look after a wide range of people, and some are well younger than 65. Still, it’s true that older adults do make up a large proportion of the people who reside in nursing homes.
The National Center for Health Statistics reports that in 2015-2016, the most recent year for which data is available, the majority of long-term care service users were aged 65 or older, with 83.5% of nursing home residents being in that older age bracket. That means 16.5% of residents were younger than age 65 — a sizable minority.
Those younger residents (and some of the older residents too) may not be planning to stay there for the duration of their lives, but rather need rehabilitative care after a surgical procedure or injury. Some younger people with certain disabilities that require constant care, such as severe developmental disabilities, may also live in a skilled nursing facility.
This means that inside every nursing home, “some patients can be quite sick,” while others may need less intensive care, Gure says. Some patients may be nearing the end of their lives, while others won’t be there long term, but are residing there temporarily after a hospital stay to get better and stronger before they can go home.
Gure says this potential variation in the population and the many reasons why they may be living in a nursing home isn’t always discussed. “There is some misperception about nursing homes. Some of it is based on an antiquated image” of what a nursing home is and how it helps people. “I just want to emphasize that these facilities serve a huge variety of patients and can be a critically important resource.”
In addition, Gure notes that aging in America can be a socially isolating experience. As such, she routinely talks with her patients about their plans for the future, especially if they’re about to undergo an elective surgical procedure or foresee that they might need some extra care at some point. “This is a resource they can utilize so that when they go back home, they are more capable of facing what they find there.”
Gender and Ethnicity
More women reside in nursing homes than men — 60.3% of short-stay residents and 67.9% of long-stay residents were women. Additionally, non-Hispanic white people accounted for 75.1% of nursing home residents, the National Center for Health Statistics reports.
Gure says the lower percentage of minority residents is sometimes related to culture, but that these figures are changing. “The racial/ethnic mix depends on the community. More urban areas have a more racial and ethnic mix. You didn’t used to see a lot of Latino or Asian residents in nursing homes.”
She says some of that is due to a lack of cultural concordance and in not having providers who speak the language or who can cook the cuisine, so some of these individuals are cared for by family members. However, she adds, “that’s been changing over the years, and now more different types of patients are moving into nursing homes.”
Residents in nursing homes typically have at least one chronic condition for which they need some ongoing medical care, and some have experienced falls or other injuries that have necessitated more intensive care. However, the Centers for Medicare and Medicaid Services reports that just 5.3% of nursing home residents in 2014 (the most recent year for which data are available) had recently experienced an “injurious” fall. Another 11% had fallen recently but weren’t injured.
While some people may assume that nursing home residents all have cognitive difficulties such as Alzheimer’s disease or other forms of dementia, that’s not the case. Nearly 20% of residents have no impairment to their activities of daily living and “more than one-third (38.7%) had no more than mild cognitive impairment; a further 11.1% had no ADL (activity of daily living) impairment and little or no cognitive impairment,” the CMS reports.
Those with significant cognitive impairment, meaning they had difficulty with five or more activities of daily living, represented just shy of 15% of the nursing home population.
However, because some nursing home residents do have cognitive impairments, “that’s an important condition to consider and provide appropriate resources and care for,” Gure says.
It’s also a big reason why some people move into a nursing home at all. “Safety becomes a big factor” for seniors aging in place at home, and that may mean it’s time to move from home care to a nursing home.
Costs and Paying for a Nursing Home
Another popular misconception is that Medicare pays for a person’s residency in a long-term care facility. Andrew Shea, senior vice president for eHealth, Inc., a private, online health insurance exchange based in Santa Clara, California, says that “many seniors are unpleasantly surprised to discover that Medicare doesn’t pay for long-term care.”
While Medicare does cover the cost of skilled nursing home care in the shorter term, it only does so immediately following a hospitalization that lasts for at least three days, Shea says. “In those circumstances, Medicare may pay for up to 100 days.”
When you get to day 101, other forms of payment need to be in place. (The coverage rules for Medicare Advantage plans are different, so check your specific coverage plan for details.)
Finding a way to pay for long-term care can be a big problem for many people. “Depending on where you live, nursing homes can cost as much as $80,000 per year,” Shea notes, or more in some cases.
In fact, Genworth Financial, a financial advisory firm, reports in its 2019 Cost of Care survey, the most recent data available, that the median monthly cost of skilled nursing in a private room at a nursing home will set you back $102,200 per year. Prices can vary a lot depending on where in the coun try the community is located and which services a senior is using.
For example, Genworth reports that Alaska, Connecticut and Hawaii have the highest daily costs for private nursing homes at $994, $458 and $440 per day, respectively, adding up to a whopping $362,628 per year in Alaska and $160,418 in Hawaii. At the other end of the spectrum, Oklahoma, Louisiana and Missouri are the least expensive areas, with per day costs of $185, $187 and $187, respectively, which brings the annual total to around $68,000 per year in those states.
Long-term care insurance policies may be another option to pay for nursing home care, though Shea says that these policies can be prohibitively costly for many. “In the end, most people pay out of pocket until their own resources are used up,” Shea says. “Then Medicaid often steps in. In fact, Medicaid pays for the majority of nursing home care in the United States. That said, rules can vary significantly from one state to another, so it’s important to talk with someone to help you understand your options,” he says.
How COVID-19 Has Impacted Nursing Home
Over the past several months, the coronavirus pandemic has severely impacted nursing homes, and not in a good way. CMS reports that as of late October 2020, there have been more than 260,000 confirmed COVID-19 cases within nursing homes and more than 147,000 additional suspected cases.
The death toll so far exceeds 60,000. Data curated by the New York Times notes that the death toll among residents and staff at these facilities exceeds 84,000, accounting for 38% of all COVID-19-related deaths in the United States.
In an effort to curb transmission, many facilities have severely restricted visitation by loved ones, which creates its own series of added complications and increased feelings of isolation for individuals residing in nursing homes. This has presented an enormous challenge to nursing homes and other long-term care facilities, says Cal Stein, a partner in Troutman Pepper’s nursing home practice located in Boston.
“One of the biggest challenges facing nursing homes and long-term care facilities is harmonizing the regulations and guidance that focuses on prevention, with the practical capabilities of the facility, the staff and the residents. Although the rules and guidance may represent the ideal practice, it may not be practically possible for a facility to fully comply, or fully comply within the time period proscribed. And because the rules and guidance exist, any deviation from them — justified or unjustified — can serve to expose a nursing home to civil liability if a resident becomes sick with COVID,” he explains.
While the data is still emerging about how these pandemic-related changes to operations are going to impact nursing home residents long term, one study of the COVID-19 outbreak and response in Connecticut found that the prevalence of symptoms of depression increased by 15% among residents right after the peak of the COVID-19 outbreak.
Another potential consideration, Stein says, is legal action that could occur down the road. “One large challenge that nursing homes will face in the next 12 to 14 months will be actual and threatened lawsuits from residents and the families of residents who contracted COVID at the facility, particularly those who suffered long-lasting consequences or died as a result,” he says.
This challenge will almost certainly impact nursing homes at a disproportionate rate, he continues, in large part because nursing home residents as a population are particularly susceptible to COVID, typically because of age or pre-existing health conditions.
Also, because they typically reside on-site and infrequently leave, it’s harder to argue that an infection occurred outside of the facility’s walls. Whistleblower lawsuits brought by employees who may have been terminated for cause but speak out about any unsafe practices could also pose a threat to nursing home facilities in the coming months. All of these potential situations could make selecting the right nursing home for your loved one more complex in a post-pandemic world.
[RATINGS: Best Nursing Homes.]
Therefore, if you’re looking for a nursing home or a long-term care facility for a loved one now or if you will be in the near future, take care to do some extra diligence to ask about their procedures and policies regarding COVID and how staff are working to keep residents safe.
Since early May 2020, all nursing homes have been required to report any and all confirmed COVID-19 cases to the CDC. CMS also requires that these facilities alert residents and their families or representatives within 12 hours of confirmation of even a single case. These reporting requirements are designed to help families make informed care decisions for loved ones in a timely fashion. You can access information about a particular nursing home’s reported and suspected COVID-19 infections via the CMS’ COVID-19 Nursing Home Data site.
More from U.S. News
Update 11/02/20: This article was previously published and has been updated with new information.