A large part of my job includes helping families find a nursing home for their loved ones. Families often find caring for their loved ones to be too much physically and financially, and they end up looking to the solution of last resort. Many spouses and children promise their aging loved one that they will never put them in a "home." Sometimes, though, the reality of caregiving makes that promise impossible to keep. (Why people resort to nursing homes and the lack of viable community options are different topics to be covered later.)
When talking about nursing homes, I usually start the conversation with the basics: there are two ways to get into a nursing home. The first, and most preferred method, is to be admitted to a nursing home for rehab after a qualifying 3-day hospital stay. This is what triggers Medicare to pay the bill (for up to 100 days of rehab). The other way to be admitted to a nursing home is from home or an assisted living community for long-term care. Long-term care, unlike rehab care, is not paid for by Medicare and must be subsidized by private funds, VA benefits, long-term care insurance, and/or Medicaid.
At this point my families are usually still with me. "Okay, well Mom is not in the hospital, so we just need to find a long-term care bed." And this is where the conversation gets difficult. Finding a long-term care bed is difficult. And it is difficult because of money. Nursing homes receive two types of revenue: room and board payment for long-term care residents and rehab payments for short-term rehab residents. The difference between these two revenue streams is not small; the results of a 2009 national survey showed that the average reimbursement per resident per day for rehab was $441.44 and only $171.50 for long-term care residents (assuming the payor-source is Medicaid, which it is for 70% of long-term care residents in nursing homes). Nursing homes have an incentive to favor short-term rehab residents over long-term care residents, and often the motivation is not only profit but organizational viability. The nursing home industry reports that for each long-term care resident, the nursing home loses an average of $19.55 per resident per day. That's a (-14.0%) shortfall. So, how do nursing homes stay afloat? Luckily, the average profit for short-term rehab residents is 18.1%, which helps balance out the long-term care losses. For the families that are looking for a long-term care bed at a nursing home, this is bad news.
Most families seem to believe that once they make the painful decision to move their loved one to a nursing home, they will find the best facility closest to their home and schedule an appointment for the move. We can go over tools to do the search, things to look for, questions to ask (see www.ahrq.gov for some great guides); but most families will likely have to settle for less than their ideal nursing home. The very best of the nursing homes are able to attract short-term rehab residents and turn down long-term care residents. Finding a long-term care bed seems to come down to who is desperate enough to take the long-term care payment over $0 for an empty bed. Furthermore, the decision to take a long-term care resident over an empty bed is made on a daily basis, so there is no planning ahead or scheduling the move. Families must respond immediately to a bed offer and make the move within 1-2 days. That part is also hard for families. Moving into a nursing home is not like moving into an apartment or even an assisted living community. I'm not sure what else in life it is like. These issues continue to affect residents after admission, too. Consider a resident who may be well enough to go home or go to an assisted living facility from a nursing home. The resident will be taking a risk by giving up their nursing home bed. If their move is not successful and they need to return to a nursing home, will they be able to get back in that nursing home? Will they be able to find any nursing home that will offer them a bed? These questions must be taken into account when considering leaving a nursing home.
The decision to move a loved one to a nursing home is often painful for families. Like adding salt to a wound, the nursing homes families get to chose from are often not their first choices, and families have to make painful compromises on either location or quality. I feel for families facing this situation, and I do my best to empower them with information to hopefully lessen the sting of reality and to reassure them they are doing the best they can.