Skilled Nursing Facility
Skilled Nursing Homes may be freestanding, or part of a seniors community and offer the following services:
- Congregate or "Independent Living"
- Assisted Living
- A continuum of care
The type of care that may be administered "only by a nursing home" in your state, is defined by state regulations. Generally "medical procedures" and assistive acts requiring a nurse to physically "handle" a patient are limited to nursing home providers, when not in a hospital. Changing bandages deep wounds is often only permitted in Nursing Homes as is turning a patient in bed. To learn where the line between a Nursing Home and Assisted Living is drawn in your state, see regulations in your state and also speak with the discharge planner at the hospital because they deal with the fine line between levels of care needed on a regular basis. They will know if a patient needs a Nursing Home, or can receive the care they require in Assisted Living.
Both freestanding and senior multi-level campuses (those which offer different lifestyles and/or levels of care to meet resident's needs) with a nursing facility affiliated, generally accept residents for long term stays, as well as for short term recovery. Acceptance is based on availability, the nature of care needed, and ability to pay or their acceptance of Medicaid.
A Nursing Home may not accept an Alzheimer's patient, whose illness is too advanced for them to be safely accommodated in a an Assisted Living setting. If their behavior is disruptive to other nursing home patients, who do not have Alzheimer's, they may need to move into a specific Alzheimer's Nursing Home. The physical structure and layout of a home specific to Alzheimer's patients should better meet their needs, and staff training will better be able to deal with erratic or dangerous behavior.
Nursing facilities are licensed by the States who determine the number of skilled and nursing home beds in the state as well as the staffing requirements.
Skilled care is the highest level of care and is defined as:
- Requiring every patient to be under supervision of a physician
- Having a transfer agreement with a local hospital
- Requiring 24 hour nursing supervision
- Having a physician on-call for emergency.
States also require a higher ratio of RNs and aides per patient with skilled than with non-skilled nursing homes. To differentiate them from skilled care, other facilities are often called intermediate care facilities. The on-call requirements, 24-hour nursing and staffing levels are not as stringent for intermediate care. Some facilities, called residential care--typically 3 to 10 bed converted homes--are licensed for room and board only with no formal medical staff. They provide help with ADLs but cannot handle medical problems. As of 1997, 47.8% of elderly nursing home residents were receiving skilled care, 47.8% were receiving intermediate care and 3.6% were receiving residential care. Medicare will only reimburse for skilled care. Medicaid will reimburse for skilled or intermediate.
Because of lower staffing ratios one would expect intermediate and residential care to be less expensive than skilled care. This is true for residential but might only be true if you can find an intermediate-only facility. As of 2001, Only 12.9% of all facilities were licensed as non-skilled. Despite national statistics, some states have great numbers of Intermediate care facilities whereas other states have few. The lower daily bed rates in some states often reflect lower costs of having more intermediate care facilities in that state. Some states only allow skilled nursing for acute and long-term care residents and will only license ICFs for the mentally retarded. Nationally, 87.1% of facilities were dual licensed for skilled and non-skilled care. As a rule, most facilities can offer many levels of care and don't differentiate on price but charge a flat rate per bed regardless of the type of care. Some special services such as diapering, hand feeding, personal items, hair styling and medicines are added as surcharges to flat rates.
Classification By Location
Nursing facilities can be housed in a variety of locations. About 12% of these facilities are found in or nearby hospitals and are owned and operated by the hospital. These hospital operations, known as skilled nursing units, are typically used as a cost-effective way to extend patient stays in an era where managed care and Medicare are turning people out of hospital beds before they are fully recovered. But SNUs may also be used for long-term care patients as well and some even offer assisted living.
A very small percentage of nursing facilities are operated as room and board residences in remodeled homes, offering perhaps 3 to 10 beds. No medical care is available in these so-called residential care nursing facilities. In another location-type arrangement called Continuing Care Retirement Communities, some independent retirement communities offer on-site assisted living and nursing facilities so that residents won't have to leave a familiar environment and family or friends if the need for care arises. As an extension of this concept, there are a number of exclusive and expensive retirement housing developments that offer a complete continuum of retirement living from a fancy retirement condo to in-home help, assisted living, nursing home and hospice. The vast majority of nursing facilities are stand-alone units with anywhere from 50 to 300 beds. The average beds per facility stand at 108 beds nationwide and this number has been growing over the past decade. Apparently there is economy of scale in operating facilities in this bed range.
Classification By Owner
As mentioned above, 12% of nursing facilities are owned by hospitals. Another 45% of facilities are independent operations with 1 or more facilities in a local area. The remaining 33% are owned by national or regional nursing home chains, with each chain under a single corporate management. About 65% of facilities are operated for profit and another 28% are nonprofit operations often owned by religious organizations, or community organizations. Some of these non-profits will subsidize low-income residents or members of their religious faith. Non-profits typically receive the least amount of government reimbursement--about 50% of income compared to about 85% of income for profits. The government runs the remaining 7% of facilities in the form of Veteran's Administration Nursing Homes. The VA will also subsidize nursing home stays for qualifying, low-income veterans.
Classification By Government Certification
About 70% of all nursing home costs are paid by Medicare or Medicaid so it's not surprising that most facilities would want to be certified by either or both of these government programs. Out of approximately 1,850,000 nursing home beds in this country, 3.4% are certified for Medicare only, 45.6% are certified for Medicaid only, 44.9% are certified for both and 6% are not certified. Non-certified facilities either do not meet government standards or they have deliberately chosen to avoid government red tape and only service private-pay residents. Medicaid is administered by each state and because of a desire to shift long-term care services away from nursing homes, some states choose to restrict the number of Medicaid beds. However, Federal mandates will not allow States to restrict supply of beds such that access to Medicaid is impeded. In areas of high demand the State may not bring new beds on-line fast enough and potential Medicaid residents in high-demand areas may have to go on a waiting list for a Medicaid bed or find a vacant bed hundreds of miles away from family or friends.
Medicare is administered by the federal government. Certification is Federal and payments are only made to certified, skilled nursing facilities. Reimbursement rates and covered days of care vary from state to state and area to area. A 1997 survey shows Medicare reimbursement rates ranging from a low of $203 per day for Vermont to a high of $425 per day for Nevada. Average covered days per stay range from a low of 14 days for Iowa to a high average of 41 days for New York. Nationally the weight-adjusted average daily payout was $318 and the weight-adjusted average stay was 23 days. Total average payout per stay was $6,779. In general, reimbursement per stay appears to be lowest in states with rural populations and highest in states with urban populations. This is not surprising since rural nursing homes are often constrained by government mandate and market forces to charge less than their urban counterparts. With full implementation of the Medicare Prospective Payment System for Nursing Care since 2000, we can expect regional differences and rural-urban discrepancies to be less pronounced. PPS interim measures, since being implemented in 1997, have resulted in lower daily payouts and will also most likely result in a decrease of covered days per stay.
Classification By Specialty
The States license a large number of intermediate care facilities for mentally retarded or developmentally disabled people. But most elderly long-term care recipients will not use these facilities. They may, however, use a growing number of specialty long-term care beds. In 1997, 6.7% of all nursing home beds were used for special care beds. The distribution of these beds was as follows: 71% for Alzheimer's, 15% for special rehab, 2% for AIDs patients, 3% for hospice care, 5% for ventilator/respiratory patients and the other 4% for other special care needs. This trend towards specialization, especially for Alzheimer's care is growing each year.
Combined Care Facilities
As with the trend for retirement communities to offer assisted living, nursing care and sometimes hospice, there is a growing trend for nursing homes to offer the less intensive services in reverse. This trend is also being encouraged by a number of states to reduce an overabundance of Medicaid nursing home beds by converting these beds to Medicaid assisted living. With this encouragement and also to attract more private pay residents, many nursing homes have added or converted to assisted living wings as well as to hospice wings. Since assisted living is less expensive than nursing care, it's a cost advantage for residents not needing nursing care to receive help with ADLs while at the same time having access to nursing care if needed.
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