Nursing Homes Today

As of 2011, there are over 15,600 nursing homes in the United States compared to approximately 6,500 hospitals. Of these nursing homes, 67% are for-profit facilities, 26% not-for-profit, and the remainder are government owned. At any one time, nursing homes have over 1.3 million residents.

According to the 2004 National Nursing Home Survey, the mean length of time since admission for nursing home residents is 835 days or a little over two years. Fifty-five percent of residents reside in a nursing home for more than one year. The 45% of residents who are in a nursing home less than a year reflect the significant growth in sub-acute or transitional care units in nursing homes.

Patients in sub-acute units, housed in nursing homes, do not need high-technology monitoring or complex diagnostic procedures. Rather, they need care and monitoring provided by registered nurses and the coordinated services of an interdisciplinary team. Typically, such patients have complex medical needs requiring wound care, infusion therapy, post-surgical care, and pain management. Others are admitted to sub-acute care for intensive rehabilitation services. Some facilities have a specialty focus for their sub-acute units such as ventilator care, traumatic brain injury, and even pediatrics.

The cost of care and services provided to residents admitted to sub-acute or transitional units, involving short-term care after a hospital discharge, are reimbursed through Medicare.

The cost of care for residents who are not on these units, is paid through Medicaid or self-pay.

Overall, nursing homes’ primary source of payment is Medicaid (64%) followed by private pay and other payor sources (22%), and Medicare (14%).

Nursing home residents, particularly those who live in a nursing home for more than one year, require significant assistance with activities of daily living (or ADL) as well as supervision and support, due to cognitive impairment. Residents need assistance with four activities of daily living, on average. The greatest needs are for bathing, dressing, toileting, and transferring.

Over half of nursing home residents are chair bound, that is, they are unable to ambulate. Only approximately 39% can ambulate independently or with an assistive device. Many fewer (3.5%) are completely bedfast. Immobility can be compounded by being physically restrained. The prevalence rate for the use of physical restraints has dramatically been reduced in the last 10-15 years. Currently, slightly over 3% of residents are restrained on a daily basis. The desired prevalence rate is 0%.

Bowel and bladder incontinence is quite prevalent for nursing home residents. Over half of residents experience urinary incontinence and very few have some type of intervention to reduce or prevent this condition. This care area is greatly in need of quality improvement efforts. Like the use of physical restraints, due to the promulgation of practice standards and quality improvement efforts, the percent of residents that have urinary catheters is quite low at less than 6%.

Almost half of all nursing home residents have some type of dementia, and behavioral symptoms can often accompany this devastating diagnosis. A response has been to prescribe psychoactive medications, even though only 25% have a psychiatric diagnosis. This is another area where clinical practice guidelines and quality improvement efforts are needed.

Another clinical issue common with nursing home residents is pain management. The prevalence rate for severe pain among nursing home residents is documented to be over 41%, yet only 28% are receiving pain management interventions. An excellent website that provides tools for assessment and management of pain for older persons is geriatricpain.org. Source: Teno, J., Weitzen, S., Wetle, T., Mor, V. (2001), Persistent pain in nursing home residents. JAMA, 285(16), 2081.

Pressure ulcers continue to be a vexing problem in nursing homes, but significant strides have been made in keeping the prevalence rate of pressure ulcers low. Approximately 6.5% of nursing home residents have a pressure sore and 3.7% of residents are admitted with a pressure ulcer.

An aspect of nursing homes that can be difficult for students to understand is nurse staffing. Students have often had the experience of being in a hospital where patients receive an average of eight nursing care hours each day, compared to 3.5 hours a day from all types of nursing staff in nursing homes. Further, over 80% of the care is provided by nursing assistants who are unlicensed. In sum, residents receive limited care directly from registered nurses.

Nurse staffing has been identified as an important contributor to poor quality care in nursing homes. It is important for nursing students to know that the only federal requirement for RN staffing in nursing homes is that the director of nursing needs to be an RN and even though a licensed nurse must be present 24 hours/day, 7 days a week, only eight of those hours needs to be an RN. Federal regulations also require that nursing homes provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Discussions with students about nurse staffing and how a registered nurse is accountable for nursing care, in the context of a large number of unlicensed nursing staff, can be a very provocative and interesting discussion.

Reference for the majority of statistics: http://www.ahcancal.org/research_data/oscar_data/Pages/default.aspx