Nursing Homes: Consumer Information

Every year over 1.5 million people (of all ages) in the United States spend some time in a nursing home (McKnight's; Kassner and Bectel). Although many return home after a brief stay, others spend their last years as nursing home residents. Whether one plans to stay for a few weeks or a few years, choosing a nursing home is a difficult decision. Nursing homes vary in services provided, amenities available, type of staff, types of residents, and quality of care. Fortunately a great deal of information is available to assist prospective nursing home residents and their families in choosing the nursing home that best meets their needs. This information is largely of two types—general advice about how to choose a nursing home and what to look for when one visits, and specific information that allows consumers to compare individual nursing homes. This entry will discuss these two broad categories of information, explain how the information is gathered, and provide suggestions about how to use the information to make an informed decision.

General advice

Before focusing on nursing homes specifically, a good starting point is to understand the array of options called long-term care.

The federal Administration on Aging (AoA) has one of the most comprehensive Web sites for issues relating to older people, their families, and the general public. Covering everything from Alzheimer's disease to federal aging policy and government programs, the AoA Web site () provides numerous links for consumers seeking information about older adults, long-term care in general, and nursing homes in particular.

Since nearly half of all the people who turned sixty-five in 1990 will spend some time in a nursing home (Kemper and Murtaugh, 1991), choosing a nursing home before one is actually needed is a valuable activity. Available advice includes how to discuss nursing home choices with family members, financial planning, how to purchase long-term care insurance, and guides for visiting nursing homes, with questions to ask and things to observe. Organizational and governmental sites such as AARP (), the Centers for Medicare and Medicaid Services (), the American Association of Homes and Services for the Aging (), and the American Health Care Association () have publications that can be downloaded. Similar information is also available on commercial sites such as , , and . Many state and local departments on aging have similar materials with a special focus on local or state long-term care services. Because of the wide availability of these kinds of guides, no one should begin the nursing home search without one. Checklists can be printed from Web sites and completed for each facility one visits. After four or five facilities have been visited, the completed checklists provide important comparative information with which to make the choice that best meets the needs of the prospective resident.

Nursing home information

Specific information about individual nursing facilities has become widely available on the Internet. The federal government (at ), state nursing home associations, state government departments, and newspapers have all gotten into the business of comparing nursing homes. More states are adding Web sites each year. Some Web sites use a report card grading system; others use stars, akin to restaurant and hotel rating systems. While these provide quick comparative information, not everyone's needs are the same. The things about a facility that are most important to one person may not be the things that those who developed the ranking system had in mind.

Facility deficiencies. One component included in almost all national- and state-level sites is information from the annual inspection survey. Every nursing facility that is certified to receive Medicaid or Medicare payments is visited at least once a year. At the annual visit the survey team collects information about the staff and residents, conducts interviews with a sample of residents; reviews a sample of resident records, inspects the physical aspects of the facility, and observes the provision of care. Over 150 different aspects of care are observed during each survey. In each area that the nursing home fails to meet the regulated standard, a deficiency is recorded. Deficiencies are classified according to their severity (the amount of potential harm that could come to residents), and their scope (whether the potential harm was isolated, affecting only one resident, or widespread, affecting many). In 2001 the national average number of deficiencies cited is six. Some Web sites post the proportion of compliance, which can be misleading. For example, Ohio surveys for 192 deficiencies, and the poorest performing facility was in 80 percent compliance, a B- in most grade books. Deficiency information is most useful when comparing one facility with another, and when the reasons for the deficiency can be explored.

The most comprehensive source of deficiency information is medicare.gov, the Medicare Web site; their Nursing Home Compare provides survey information for all Medicare and Medicaid facilities in the United States. Knowing whether a home has a history of harming residents, providing poor care, or otherwise jeopardizing those in its care is an important factor in the decision-making process.

However, this information has some limitations. First, surveys are conducted at approximately one-year intervals, so the information may be out of date. The nursing home may be quite different today than it was when the deficiencies were found. Historical survey data can help in interpreting the latest survey because they show whether a facility is improving or declining. No matter what is shown on the Internet, a visit to the facility should be part of the selection process.

Another limitation of survey data is that they may not be reliable. Different surveyors may produce very different lists of deficiencies for the same nursing home. It is not uncommon for nursing homes to find that a practice that has not caused a deficiency for years has suddenly become unacceptable when a new team of surveyors is sent in.

The deficiency language (which most Web sites use) is broad and general, so it is not clear what actually caused the deficiency. The Pennsylvania Department of Health posts the deficiencies, and the explanation of what caused each deficiency. This is helpful because it provides examples of the kinds of things that result in particular deficiencies. The department of health Web site in one's state should be checked to see if this information is available.

Despite the limitations mentioned above, comparative survey information is one important component of the nursing home choice. Knowing how one facility compares with the average in the state or with the facility down the street can certainly help in narrowing a search. It also provides guidance about what kinds of questions should be asked during a visit to a particular facility. Many high-quality facilities receive survey deficiencies; the things surveyors cite may not affect a resident's satisfaction with the facility at all. Some Web sites post results from resident and family satisfaction surveys—these results are important to consider in conjunction with the results collected during the annual survey.

Residents. Several Web sites (Medicare, Texas Department of Health) provide information about the characteristics of residents who live in each facility. Knowing more about the residents living in a facility can be useful in matching the needs of the prospective resident with the residents already being served. For example, if a facility has a much higher than average proportion of residents with behavioral symptoms (one of the resident classifications), it may specialize in dementia residents. On the other hand, there may be a higher proportion of residents with behavioral symptoms because the staff is poorly trained in behavioral management. Resident information can be useful in deciding whether the prospective resident is likely to fit in, and whether the facility has experience caring for others with similar needs. Quality indicators, taken from assessments of resident conditions, appear on some Web sites. They suggest areas where a facility has potential problems in providing care for certain kinds of residents. If quality indicators for the facilities in one's state cannot be located, one should ask to see the facility's quality indicator report.

Staff. Information about the number and type of staff is collected when each facility has its annual survey. The Nursing Home Compare Web site posts this information as nursing staff per resident. If one is choosing a nursing home for someone with complex medical conditions, then the number of registered nurses in the facility is likely to be more important than for someone who needs only basic assistance with bathing or dressing. A 2000 report to Congress recommended an optimal staffing measure of 2.9 hours of certified nurse aide staffing, per resident, per day (Health Care Financing Administration). However, if this standard is not met in the facilities being considered, it may be because the facility serves a diverse group of residents, some of whom require much more or much less care than the average.

Using information wisely

A search for Nursing Home Survey, or Choose a Nursing Home, or a visit to any of the Web sites mentioned in this entry will provide plenty of information about long-term care and making nursing home comparisons. Internet information is highly useful for developing an understanding of long-term care and long-term care planning in general, locating facilities in the area one is interested in, learning more about those specific facilities, and preparing for nursing home visits. One can download a checklist for a visit and prepare specific questions about a facility's survey history, residents, care specialties, and staffing. One can easily make comparisons to narrow the search to the facilities most likely to meet the prospective resident's needs. However, gathering consumer information from the Internet is no substitute for the sights and sounds of a nursing home visit.