Choosing a Nursing Home |Assessing theNeeds for Elder Care. What's the Best Answer?

Choosing a Nursing Home should be a last resort based on objective assessment of the needs of the potential resident and the advice and referral of a physician. Look at all the possible options before making a life changing decision until it is necessary. The Merck Manual of Geriatrics- Third Edition, and The Merck Manual of Health and Aging are excellent references to assist in the decision process. AARP also offers helpful publications on nursing homes.

The probability of an individual relocating to a nursing home (Skilled Nursing Facility) is approximately 17% from the ages of 65 - 74. It increases to 60% for those over the age of 85. The risks noted by the Merck Manual of Geriatrics are living alone, loss of ability for self-care, impaired mental status,lack of social or informal support, poverty, and generally female.

Assessment tests have been developed by a number of doctors, medical programs and academic centers for the medical community. A list of those tests and typical questions and visual observations from those tests can be found in the manuals. These tests may be offered by professionals, most often your own observations will lead you to seek the level of care necessary to suit the situation.

Assessment is based on functional abilities,such as:
1. Acts of Daily Living relating to self-care, maneuverability and stability, toilet use and bladder and bowel control.
2. Independent Acts of Daily Living relating to meal preparation, performing housework, taking medicines, running errands,managing finances, and using the telephone.
3. Physical Health
4. Cognitive and Mental Health

Observations noted in the manual:
1. Eating- unexplained weight loss, clothing is food stained.
2. Physical- ability to rise or sit in a chair or on a bed, rock back and forth before rising, using nearby furniture for support, sitting by falling backward.
3. Toileting- clothes wet or soiled.
4. Bathing- skin or hair dirty.
5. Grooming- rumpled or disheveled appearance.
6. Walking- unsteady gait, falls.
7. Medicines- taking on time or not taking at all, taking too many for the dosage cycle.
8.Telephone-understand conversation, phone is answered, returning phone to the "off" position.
9. Money- bills paid on time, checking account not overdrawn, checks not being deposited, unusual accounts being paid.
10. Food Preparation- food kept past expiration dates, food in refrigerator fresh, pots and pans show scalding or food residues. Stove turned off.
11. Laundry- Clothes are Clean.
12. Housekeeping- home unkempt, different than normal, able to find things when and where needed.
13. Transportation- lost in familiar activity areas.
14. Shopping- kitchen and pantry stocked at reasonable levels and normal variety of food items.

If you are familiar with the individual, any behavioral change should seem obvious to you. Changes from the norm usually indicate it's time for a change requiring oversight and assistance. Home health care and a caregiver for 12 to 24 hours/day may be the immediate answer or an Assisted-Living Facility. A Skilled Nursing Facility also known as a Nursing Home is usually the answer when more serious conditions occur in physical and/or mental health.

In some instances the need for a Skilled Nursing Facility can be temporary for situations that involve ordinary incontinence, impaired daily activities such as recovery from surgery and necessary rehabilitation, mild dementia, and in cases of caregiver burnout. If the problem can be solved the patient can return home or to another residence.

Depending on the level of care necessary:
1. Board and Care Communities, sometimes referred to as "Rest Homes" are similar to Assisted-Living Facilities. These are for people who need minimal help with personal care. They provide room and board and help with daily activities, occasionally with health care. Rooms are similar to college dorms with a certain level of home atmosphere. The facilities are not closely regulated and close observation by frequent visits protects against neglect or elder abuse.
2. Assisted-Living Facilities are for people who can somewhat care for themselves with some help with their daily activities. They help people with memory problems, those that get confused or with physical problems. Some ALF's also have special units for dementia residents. These facilities vary from small to large, homey to elaborate. Residents have their own apartments with private bath, and sometimes small kitchenettes. The facility provides meals and helps with daily personal care where needed; they usually offer some social and recreational activities. Residents choose the activities and services they want to participate in. Some health care is usually provided, including 24 hour supervision. Doctors, nurses, as well as therapists may be available. Services and activities vary from facility to facility. Regulations for ALF's vary from state to state. Assisted-Living Centers are not a substitute for a Nursing Home. Medicare and Medicaid do NOT pay for Assisted-Living Centers.
3. Retirement and Life-care Communities are for older people who want independent living, but want or need help with caring for their home. Residences in these communities are usually made up of a group of apartments, townhouses, or detached homes. The community provides some social activities, transportation, entertainment facilities, some on-site nursing services, community meals, laundry services, house cleaning and maintenance. Many arrange group activities, trips, game nights, or lectures. Recreational facilities are often provided as swimming pools, tennis courts, and golf courses. Many of these communities are part of a Life-Care Community. Things to ask when considering: a)Is there an entrance fee in addition to monthly fees? Which services, activities and amenities are included? Are these fees tied to personal assets? b)What amenities, services and activities are available at what cost? Banks, Beauty Parlors, Post Office, General Store? Transportation available to local shopping centers, grocery stores, doctor offices, health care centers? What social and physical activities are available? c)Is there a minimum age to live in the community and any restrictions for visitors and family? d)Facility well maintained? Living units and setting pleasant? Adequate parking? e)Service personnel available to help? Cost? f)Meals provided with fees or at what charge? Available for guests at what charge?
Life-Care Communities are often referred to as "Continuing Care Retirement Centers." These are usually part of a Retirement Community where older people only want to move once with care available and provided for the rest of their life. It guarantees residents are cared for within the community regardless of health condition. May begin living in an apartment then move to the ALF program progressing to the Nursing Home. These communities are EXPENSIVE. They regularly charge a deposit plus monthly fees for additional services. Some have upper cap limits for monthly fees, but usually costs increase when level of service increases. Acceptance into these communities are usually tied to your assets. Medicare and Medicaid do Not usually pay for service in a Life-Care Community. Sometimes they may help pay for a Skilled Nursing Facility Services when needed, but usually only for a limited time.
4. Skilled Nursing Facilities are also referred to as Nursing Homes and are for people who need help with health care for chronic conditions but do not need to be hospitalized. These are long-term care facilities and provide continued health care by trained health care professionals. "Nursing" indicates nurses provide most of the care. They dispense medications, monitor disorders and progress, supervise treatments, consult with doctors about resident care and organize most of the activities in the center. Staff includes a registered nurse, licensed practical nurses, nursing assistants, and a director of nursing who oversees nursing care in the center. A medical director, a doctor, oversees medical care is also part of the staff. Residents must be seen by a doctor once a month, as they tend to develop additional disorders, infections, or confusion. Nurses may call them to discuss changes in care and treatment. Many Nursing Homes provide health care services such as oxygen treatments and drugs or fluids given by vein (intravenous therapy). Almost all provide rehabilitation, including physical, occupational, respiratory, and speech therapy.
Almost all Nursing Homes have a Social Worker on staff to help a resident adjust. They identify residents who are lonely and withdrawn and help resident, staff members and family to communicate with each other. They are able to assist in making reviewing insurances and making financial arrangements and how to apply for any Medicare and Medicaid benefits.
Some centers provide a minimum of services in an institutional, impersonal environment. Many resemble hospitals more than a home. Many are trying to change to a more home-like environment that gives the resident more control over their care. Some allow pets, encourage hobbies and work to develop friendly relationships with area residents. Nursing homes are highly regulated by the government. State agencies conduct surveys and inspections to monitor quality of care. A copy of the evaluation report is kept at the center and can be viewed by resident or their family. Even though these centers a monitored and regulated, they vary considerably in quality, personality and care. Anyone interested should try to get as much information as possible, ask to see the state evaluation. Are they certified for Medicare and do they provide for Medicaid residents, and is the family included in review of personal care of resident?

A comparison of nursing homes is available from Medicare at http://medicare.gov/NHCompare.home.asp. You can check by the state.

Choosing a Nursing Home:
1. Environment should be attractive and friendly, homelike and relaxed. Any unpleasant odors, and is it clean and well maintained? Are the dining room and other common areas bright and cheerful, pleasant atmosphere, livable noise level? Are paths around the grounds safe and accessible, a garden or patio? Is a safety plan in effect in case of fire or other emergency?
2. Residents reasonably happy and active, or wandering aimlessly and sitting doing nothing? Are they clean and properly dressed? Are restraints used and when and why?
3. Staff Members- do they treat the residents with respect, patience and friendliness. Is the staff experienced and qualified? High turnover rate? Respond to call in a reasonable amount of time? What is the staff to patient ratio?
4. Rooms - is there storage for personal items and can rooms be decorated with personal items? Is it bright and cheery, heating and air conditioning? Private rooms available? How are roommates selected? Is water available, snacks offered? Meals served hot, tasty and nutritious, special diets offered, time of meals? Is staff available to help feed residents?
5. Health Care- can resident keep own doctor? Is a hospital nearby? If resident goes to the hospital, will bed be available upon return? What services provided by Nursing Home? Are prescriptions and other medicines monitored? Help with dental care?
6. Services-Personal laundry by home or can it be done by family? (If the family can do the personal laundry, do it. Loss and theft are high and personal items disappear.) Telephones in rooms or can resident have own phone? Personal televisions?
Visiting- Nursing Center located for frequent visits by family members and friends? Specific visiting hours or open?
Activities- offered to encourage participation. How are residents informed of activities. Is there additional cost? Is there a television and game room? Religious services held on premises?
Costs - are all services resident needs covered in basic charge? Services for hair salon and laundry- how much?
Rights and Privacy- are residents allowed to come and go as they please? Are restraints used, when and why? Locks on private rooms? Does staff knock before entering? Are married couples allowed to live together? Sexual needs respected? Bathes and showers in a warm area, how many times a week? Are pets allowed? Is food or alcohol allowed in the rooms? What about lost or missing items, how handled? Who contacts the family?

Entry into a nursing home is typically ordered by a physician based on health condition and after a 3 day stay in a hospital. You will be referred to consult with the Social Worker at the hospital who will assist in the arrangements for the transfer and offer the options for which Nursing Center has available beds. You do not always have a lot of choices, but when given the possibilities prior to the transfer, check out the centers for suitability and location. All nursing centers are not alike.
Medicare does not pay for continued care at a skilled nursing facility but for 20 days, then up to 80% for the maximum of 100 days and then you are on your own or you have long-term care insurance or Medicaid. Medicaid must be applied for and the resident must meet certain criteria. Benefits and qualifications vary from state to state. Not all Nursing Homes accept Medicaid patients. Don't assume what someone else will pay for, the resident and his/her estate is financially responsible above and beyond any benefits, and limits exist as to asset transfers and ownership of any properties. The Social Worker can assist in any applications to Medicare, Medicaid or other insurance available and making financial arrangements. If the resident is a Hospice patient, check to understand how that program works.

Nursing Homes are highly regulated and inspections are made as to performance of the facility to maintain their certification. The best way to assure that a patient is well cared for is by frequent visits and different times of the day to see how it functions. A book written by Dennis Steele and Edward C. Watters III, M.D. entitled "Danger Zone is a good resource on how to evaluate care in Nursing Homes, the dangers, and what you can do about it. It is available on Amazon.com and is worth the purchase if you have someone in a center. Elder abuse and neglect does exist and the only way to stop it is observation and reporting it to the Ombudsman Program. The names and phone numbers are always posted on the wall in these centers. Use it if you suspect abuse in the facility. In Florida, they react very quickly investigating incidences and they have the authority to shut down a facility, so the centers are very cooperative when a representative arrives.

Elder Care is a major commitment made by a Caregiver who is usually a family member or close friend. Weigh all the options and do what's best for the elder to allow them to stay vital and happy and with the best quality of life possible. Placing a loved one in a nursing home can be a heart-wrenching experience so be prepared and informed. When it's time, it won't be easy, but sometimes it is best, and if it is, visit often and continue to care until the end of their life cycle.

There is a a comparison chart available from the Medicare website for Nursing Homes in your area.

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