Stressful but Vital: Picking a Nursing Home

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The decision is one of the hardest you will ever make. Your spouse, parent or another loved one needs care that assisted living or home health care simply cannot provide. You need to choose a nursing home.

It’s a difficult and emotional task. The horror stories are well documented, and even in the best nursing homes the transition can be wrenching for the entire family.

Finding a good nursing home takes research and perseverance. You want a safe, engaging and pleasant environment with caring staff and solid medical practices.

“You can actually get all of that in a nursing home — if you know what to look for and how to search,” said Larry Minnix, chief executive of the American Association of Homes and Services for the Aging, a trade group for nonprofit nursing homes and other organizations for the elderly.

Unfortunately, the typical search for a nursing home is made under duress. More than 60 percent of admissions come from hospitals. The patient may have broken a hip or had a stroke and now needs rehabilitative care. The hospital is in a hurry to discharge and may move quickly to get the patient moved to an available nursing home bed, regardless of the operator’s quality or reputation.

“Hospitals ought to be more aware, but it often is just not on their radar screen whether they are sending a patient to a good nursing home or a bad one,” said Janet Wells, director of public policy at the NCCNHR (formerly the National Citizens' Coalition for Nursing Home Reform), an advocacy group.

In such situations, you have precious little time to do your research. What is more, these temporary stays often become permanent, depending on the individual case and sometimes on the quality of the temporary care received.

Paying for a nursing home is another huge source of stress. Medicare pays only for medically necessary care in a skilled nursing home, like physical therapy or intravenous medicine. It does not pay for what is called custodial care — help with walking, eating, bathing and other daily tasks. Instead, the majority of nursing home residents pay from personal money, long-term care insurance policies or, if they qualify, through Medicaid.

The average cost of nursing home care is $200 a day, and that does not include additional fees for specialized services like care for patients with Alzheimer’s or dementia.

To find a nursing home you can really feel good about, consider these important steps.


START WITH THE DATA

Every year the Centers for Medicare and Medicaid Services collect data on more than 15,000 nursing homes throughout the country. Health inspection data, staffing and quality measures are combined to come up with an overall ranking of one to five stars. To look up nursing homes in your area, go to medicare.gov and click on the “nursing home compare” tool.
http://www.medicare.gov/NHCompare/Include/DataSection/Questions/SearchCriteriaNEW.asp?version=default&browser=Firefox|3.5|MacOSX&language=English&defaultstatus=0&pagelist=Home&CookiesEnabledStatus=True#TabTop

In addition to the rankings, the site offers a useful brochure entitled Medicare’s Guide to Choosing a Nursing Home, as well as other resources.
http://www.medicare.gov/Publications/Pubs/pdf/02174.pdf

Keep in mind that government rankings have their limits, and they reflect the nursing home’s performance during only a short period.

“Health inspection data is only as good as the data itself,” Ms. Wells said. She points out that many studies show that state inspections tend to underreport nursing home deficiencies and the seriousness of those deficiencies. “The home could be even worse than it appears in the rankings,” she said. “Of course, it could also be better.”

There are other shortcomings. For example, under the grading curve Medicare uses, precisely 10 percent of nursing homes in any one state are permitted to get five stars.

That could mean a four-star-rated facility may be just as good as a top-rated home down the street but simply falls below the percentage cutoff, said David LaLumia, president of the Health Care Association of Michigan, which represents nursing homes and rehabilitation centers in the state. On the other hand, it could also mean that more homes would fall into lower rankings if the curve did not exist.


VISIT, THEN VISIT AGAIN

Nothing substitutes for what you see, hear and smell when you visit a nursing home, Mr. Minnix said. Be sure to visit more than once and at different times of the day and different days of the week. Take the checklist from the Nursing Home Compare Web site with you.
http://www.medicare.gov/nursing/checklist.pdf

“Trust your five senses,” advised Mr. Minnix. “Does it smell like cleaning fluid and urine when you walk in or fried chicken and apple pie? You also want to see an ant farm of activity. Are the staff friendly and interacting with the residents?”

Be sure to ask to speak with crucial leaders, including the executive director, lead physician and head nurse. If those people are not available, ask when you can meet with them. If you get the runaround, Mr. Minnix said, that could be a red flag.

When you do meet with the staff, ask them if you may attend a resident council or family council meeting. These groups are usually run by family members to address concerns and improve the quality of care. You will get a good inside view of what is really going on at the nursing home from these meetings.

After your visits, always ask your loved one’s doctor, clergy, friends and family what they know about the homes on your short list.


WHAT TO ASK

There are two big buzzword trends in nursing home management that can significantly increase the quality of care.

Ask the nursing homes you visit if they engage in “person-centered care,” as well as “consistent assignment,” suggests Carol Benner. She is the National Director of the Advancing Excellence Campaign, a coalition of industry, government and consumer groups working to improve nursing home quality.

Nursing homes that provide person-centered care allow residents to wake up when they want to, eat when they want to and generally set their own schedules. Traditionally, many nursing homes have had residents wake, eat, bathe and go to bed at the same times.

Consistent assignment, meanwhile, simply means that the same staff members — doctors, nurses, aides — treat the same patients each shift. The continuity of care reduces errors or problems and helps residents and staff members to develop a lasting relationship that can significantly improve a resident’s emotional well-being.

“Imagine how much nicer it would be to know the same person will bring your tea each evening and already knows you like sugar in it,” Ms. Benner said. “We know from the evidence out there that a strong relationship between residents and staff consistently leads to better care.”

It can also lead to lower staff turnover, because employees are naturally more engaged in their jobs and less willing to leave if they have developed relationships with their patients.

Be sure to ask each nursing home you visit what percentage of their staff leaves each year. Less than 30 percent annually is considered good. More than 50 percent is a sign to look elsewhere.

A nursing home is not obliged to disclose this information to you, but if it does not, “that tells you something, too,” Mr. Minnix said.


CALL YOUR OMBUDSMAN

Each state has a federally funded long-term care ombudsman who is an advocate for nursing home patients.

This person can tell you if there are state rankings or surveys available in addition to the Medicare ratings. The ombudsman can also help you find the latest health inspection reports, which are public information, on specific nursing homes. Ombudsmen can also tell you how many complaints the office has collected about a specific nursing home and the nature of those complaints.

You can find the ombudsman in your state online at the National Long-Term Care Ombudsman Resource Center.
http://www.ltcombudsman.org/ombudsman

Maybe most important, a good ombudsman will know about recent significant changes at various nursing homes.

When Ms. Wells recently helped a family member find a nursing home, for example, she was considering a three-star center close to home. But when she called the ombudsman’s office she discovered that the well-regarded director of that center had moved to a nearby one-star home. Ultimately, Ms. Wells decided to go with the lower-ranked facility because of the change in management.