What to Look for in a Skilled Nursing Facility
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A skilled nursing facility, also known as a nursing home, is a residence for those who need short-term care following a hospital stay or for therapies following an illness or injury. Long-term nursing supervision may also be needed because of major declines in health status or health issues or disabilities that keep the patient from returning home.
Choosing a skilled nursing facility and navigating the medical, legal and insurance hurdles required can be more than a little stressful. Here are some tips for making the transition to a nursing facility as smooth and easy as possible.
Selecting a facility
The majority of skilled nursing facility residents have been transferred from a hospital. If you or a loved one are hospitalized, your hospital's social worker will help you select a facility that can best meet your needs. If you think you or a family member may need a skilled nursing facility in the future, you can get names, addresses and phone numbers of facilities in your area from the care coordination department of your hospital. Additional resources can be found at your local home health association or department on aging. (In Kentucky, call 502-564-6930.)
Here are some things to note:
Location. The degree of care you may not make it practical to choose a skilled nursing facility in or close to your community. However, if circumstances permit, consider choosing a skilled nursing facility that will allow family and friends to visit often and look out for your welfare.
Level of care. Not all facilities accept residents with complex medical problems. To select a facility that is best for your needs, it's important to know and accurately describe the services you or your family members require. For example, does the facility care for residents who are ventilator-dependent (on a breathing machine), use a feeding tube or have a tracheostomy? Can it meet special dietary requirements or care for a patient with dementia who might wander? Your physician or hospital case manager will help you with these decisions.
Payment sources. Does the facility accept all forms of payment, including private pay, health or long-term care insurance, Medicare and Medicaid? Does the facility have both Medicare and Medicaid beds so you can switch from one to the other if needed instead of moving to another facility?
Unscheduled visits. Visit the facilities interest you or ask a trusted friend or family member to do it for you. Make unscheduled visits at different times to observe as many interactions as possible. Is the property clean and odor-free? Are residents clean, dressed and active? Do they appear happy? Speak with the staff and observe how they engage with residents.
Physician affiliation. State and guidelines require all skilled nursing facility residents to be under the care of a physician who evaluates their plan of care and medications at least every 30 days. Is your physician affiliated with the facility or does the facility have a physician who cares for many of its patients?
Availability. Is a bed available and if not, will it be long before one becomes available? Can you add your name to a waiting list?
Staffing. How many nurses are on staff and how many come from agencies that supply temporary nursing staff? The majority of nurses at the facility should be staff members who are familiar with the residents' ongoing care needs. To find the ratio of staff to residents at each facility, visit
www.medicare.gov and select "Compare Nursing Homes in Your Area" from the list of search tools.
Activities. Check to see if the nursing provides interesting daily activities for residents to engage in. Are religious services included?
Communication. How often will staff your family with an update on your loved one's condition?
Contract and fee schedule. Get a copy of nursing facility's admission or contract agreement and fee schedule. Use the fee schedule to compare charges at different nursing facilities. Keep in mind, however, that the fee schedule does not include the cost of medications, laundry, special services such as beauty shop visits or visits from a barber, or expenses incurred for illness or injury. You are responsible for any additional expenses not covered by your insurance. If you plan to rely on a long-term care policy to cover skilled-nursing expenses, review the policy and terms now to acquaint yourself with its covered services.
Facilities. Take a close look at the outside of the building, the grounds and the parking lot. There is often a direct correlation between the condition of the exterior and the condition inside.
- How large are the common areas and how many does the facility have? If it is a multistory facility, are there common areas on each floor? Do the common areas have enough amenities to entice the residents to get out of their room? Are there TVs, game tables, numerous seating areas? Is the common area bright and cheerfully decorated?
- Does the facility have an enclosed courtyard so the residents can enjoy the outdoors when the weather is nice?
- Is the nursing home adjacent to an independent living facility so the healthy spouse can live nearby and not be dependent on transportation to see their spouse daily?
Services that may help with your decision:
Nursing Home Compare. The U.S. of Health and Human Services Medicare Web site offers an invaluable tool for comparing nursing homes in a particular geographic area. To locate the tool, visit
www.medicare.gov and choose Compare Nursing Homes in Your Area from the list of search tools. Or type Nursing Home Compare into a search engine such as
www.google.com. You can use Nursing Home Compare to find an information summary for a specific facility. Click on 'View all information' to find all categories of data available on that facility. Select 'Inspection Results' to find the date of the last state inspection, the number of deficiencies for which the facility was cited, the nature of those deficiencies and how many residents were affected. Select Nursing Home Staffing to find how much time the combined nursing staff has allotted to residents each day and how this number compares to the state average.
If you need help understanding the data, call the division of health systems regulation at your state department of public health (in Kentucky, call 502-564-7398) and ask for a nurse consultant for assistance.
Long-term care ombudsman. There are than 600 long-term care ombudsman or 'patient advocate' programs nationwide. Ombudsman volunteers visit nursing facilities regularly and are familiar with their strengths and weaknesses. An ombudsman cannot recommend a nursing facility but can provide the results of the latest state inspection and information about the facility's complaint history. (In Kentucky, call 1-800-372-2991 or TTY 1-800-627-4702.)
State inspection report. You can also the results of a state inspection report from the skilled nursing facility you are considering by searching Nursing Home Compare, or calling Medicare toll free at 1-800-633-4227. Nursing homes must provide a copy of their inspection upon request.
Family council meetings. Family council facilities have very active family councils, groups of family members who meet regularly to discuss issues of concern and generally act as patient advocates. Members can be informative and reassuring to someone just entering the decision-making process. Ask when the family council meets at the facility that interests you and if you can attend a meeting.
Continuity of care. You may feel comfortable if your own physician or another physician from your hospital continues your health care after your move to a skilled nursing facility. UK HealthCare Geriatric Services has an agreement with several nursing facilities to continue providing care to patients who have been discharged. To ask about this service, call 859-323-4836.
Paying for a skilled nursing facility
Skilled nursing facility care is generally estimated to cost $5,000 to $6,000 a month. Most insurance plans will cover room and board as well as medical expenses such as any medical and nursing care you may need, either for required, routine physician's care, injury or illness, or for medical services such as dressing changes, blood sugar testing or feeding tubes. The patient or patient's family is responsible for medical expenses not covered by Medicare or by secondary insurance.
Many of those entering skilled nursing facilities rely on their own financial resources or use long- term care insurance for their expenses. Traditional Medicare pays fully only for the first 20 days of care. From day 21 through day 100, the Medicare patient must share the cost of care by paying a daily coinsurance rate, which changes each year. A patient must meet certain conditions before Medicare will pay for skilled nursing care:
- Spend at least three consecutive nights in a hospital.
- Be admitted to the nursing facility within 30 days after discharge from the hospital following the three-night stay.
- Have a physician certify that skilled nursing services are needed for the same illness for which the person was hospitalized.
- If you have a Medicare replacement policy, you will need to look at your benefits plan to determine the insurance's share of costs.
- When Medicare benefits are exhausted, a nursing facility resident may either pay privately or qualify for coverage under Medicaid but may have to reduce personal assets first to meet income qualifications.
Under the 'spousal impoverishment' rule, the person entering a skilled nursing facility is allowed to protect a certain amount of assets and income for a spouse who remains at home. More information is available from the following agencies:
- Centers for Medicare & Medicaid Services. For information about Medicare or Medicaid coverage and qualifications. In Kentucky, call 859-219-1366.
- State Health Insurance Assistance Program(SHIP). Free health insurance 1 counseling and assistance for people with Medicare. 1-877-293-7447 (toll-free).
- State Medical Assistance Office. Information about Medicaid or programs to help with medical bills for low-income residents. Help with prescription drug coverage. Contact the Department for Community Based Services (DCBS) Office for your county.
Bring personal belongings that have special meaning to you such as family photos or a favorite quilt. Transfer subscriptions to newspapers or magazines to keep current with the news. Participate in as many activities as you can, including the facility's resident council, similar to the family council described above.
Don't assume you can't go anywhere. Nursing facility residents are encouraged to go out with family and friends whenever they can or to invite them to the facility for meals. Overnight or weekend visits outside the facility may also be permitted, depending on your insurance.
Knowing your rights may relieve anxiety or misconceptions you may have about living in a nursing facility. The skilled nursing facility must provide you with a written description of these rights. They include the right to be treated with dignity; freedom from restraints, abuse and involuntary seclusion from others; the right to privacy, including private time with visitors; and the right to be involved in regularly scheduled planning meetings where your condition and care are discussed.
Finally, if you decide that the facility is not the right place for you, you can move to another facility with an available bed. Follow your current facility's rules for leaving to avoid paying extra fees.
Tips for family members
- A scheduled visit and tour of the nursing home is the most efficient way to gather the facts. Call and make an appointment with the admissions director.
- Keep a camera with you on each visit. Photograph anything out the ordinary as well as good times. It may be useful to demonstrate that your loved one does have a good quality of life within their limitations. Remember that HIPAA (the Health Insurance Portability and Accountability Act) does not allow you to take pictures of other patients without their permission.
- The facility must develop a care plan enabling your loved one to achieve the highest practical level of functioning. It is very important for you to be at the initial and follow-up care plan meetings, as regularly scheduled. The meeting should include the dietitian, physical therapist, nursing director, social director and activities director.
- Request to see charts regularly to ensure that proper documentation of activities of daily living (ADLs) are noted as well as any reports you requested to be included such as new bruises, bedsores, etc. Changes in behavior, fever and falls should automatically be included in the chart, as this is required.
- Have a routine of frequently reviewing the nurses notes contained in the charts. The facility may require you to designate one person who is allowed to review the chart.
- Become familiar with the facility staff and names of staff, shifts worked, etc. Also learn the rules and regulations.
- Get to know family members of other residents who visit regularly. Sharing information and concerns is important.
- Get involved with family councils. These councils meet to discuss issues and concerns of the residents.
Resources for Kentuckians
Kentuckians for Nursing Home Reform
1530 Nicholasville Road
Lexington KY 40503
Kentucky Office of the Attorney General
1024 Capital Center Drive, Suite 200
Frankfort KY 40601
Office of the Inspector General
Adult Protective Services
Office of the State Long Term Care Ombudsman
National Adult Protective Services Association (NAPSA)
National Alzheimer's Association
225 N. Michigan Ave., Fl. 17
Chicago IL 60601-7633
National Center on Elder Abuse
National Citizens' Coalition for Nursing Home Reform
1828 L Street, NW
Washington DC 20036