Nursing home care

Christmas 2012 at a nursing home in Norway.

A nursing home, convalescent home, skilled nursing facility (SNF), care home, rest home or intermediate care provides a type of residential care. It is a place of residence for people who require continual nursing care and have significant difficulty coping with the required activities of daily living. Nursing aides and skilled nurses are usually available 24 hours a day.

Residents include the elderly and younger adults with physical or mental disabilities. Residents in a skilled nursing facility may also receive physical, occupational, and other rehabilitative therapies following an accident or illness. Some nursing homes assist people with special needs, such as Alzheimer patients.

Residents may have specific legal rights depending on the nation the facility is in.

History

Before the Industrial Revolution, elderly care was largely in the hands of the family who would support elderly relatives who could no longer do so themselves. Charitable institutions and parish poor relief were other sources of care.

The poorhouse-workhouse

Poorhouses/workhouses were the first implemented national framework to provide a basic level of care to the old and infirm. Pictured, is "The workroom at St James's workhouse" from The Microcosm of London (1808).

The first government attempts at providing basic care for the elderly and the infirm took place at the dawn of the industrial era with the New Poor Law of 1834. Mass unemployment followed the end of the Napoleonic Wars in 1815, and the introduction of new technology to replace agricultural workers and the rise of factories in the urbanized towns, meant that the established system of poor relief was proving to be unsustainable. The New Poor Law curbed the cost of poor relief, which had been spiralling throughout the previous decades, and led to the creation of workhouses for those who were unemployed. Most workers in the workhouse were set tasks such as breaking stones, bone crushing to produce fertilizer, or picking oakum using a large metal nail known as a spike.

Although conditions in the workhouse were intended to be harsh, to act as a deterrence, in areas such as the provision of free medical care and education for children, inmates were advantaged over the general population. By the late 1840s most workhouses outside London and the larger provincial towns housed only "the incapable, elderly and sick". Responsibility for administration of the Poor Law passed to the Local Government Board in 1871, and the emphasis soon shifted from the workhouse as "a receptacle for the helpless poor" to its role in the care of the sick and elderly. By the end of the century only about 20 per cent admitted to workhouses were unemployed or destitute, but about 30 per cent of the population over 70 were in workhouses. The introduction of pensions for those aged over 70 in 1908 did not result in a reduction in the number of elderly housed in workhouses, but it did reduce the number of those on outdoor relief by 25 per cent.

Expansion and privatization

A Royal Commission of 1905 reported that workhouses were unsuited to deal with the different categories of resident they had traditionally housed, and recommended that specialised institutions for each class of pauper should be established, in which they could be treated appropriately by properly trained staff. The Local Government Act of 1929 gave local authorities the power to take over workhouse infirmaries as municipal hospitals and elderly care homes, although outside London few did so.

Eventide: A Scene in the Westminster Union (workhouse), 1878, by Sir Hubert von Herkomer

Although the Act formally abolished the workhouse system in 1930, many workhouses, renamed Public Assistance Institutions, continued under the control of local county councils. It was not until the National Assistance Act of 1948 that the last vestiges of the Poor Law disappeared, and with them the workhouses. Many of the buildings were converted into old folks' homes run by local authorities; slightly more than 50 per cent of local authority accommodation for the elderly was provided in former workhouses in 1960.

In Britain in the 1950s and 60s, the quality of nursing care steadily improved, with the mandatory introduction of central heating, single rooms and en-suite lavatories. In the 1980s a significant shift from the public sector provision of elderly care to private sector homes occurred, with the proportion of private facilities increasing from just 18% in 1980 to 85% by the end of the century.

In the United States, the national social insurance program Medicare, was established by the U.S. federal government in 1965, which guaranteed access to health insurance for Americans aged 65 and older. This program prompted many new nursing homes to be set up in the following years, although private nursing homes were already being built from the 1930s as a consequence of the Great Depression and the Social Security Act of 1935.

Nursing home staff

In most jurisdictions, nursing homes are required to provide enough staff to adequately care for residents. In the U.S., for instance, nursing homes must have at least one registered nurse available for at least 8 straight hours a day throughout the week, and at least a licensed practical nurse on duty 24 hours per day.

Administration

Once a patient has moved into the nursing home, their relatives may not have significant contact with the administration team, unless there are specific concerns that arise. Depending on the size of the nursing home, the administration staff may be very small, consisting of only a handful or people, or it may have dozens of staff responsible for individual departments (i.e., accounting, human resources, etc.). In most countries, nursing home administrators are required to be licensed to run nursing facilities.

Direct care staff

Nurse at a nursing home in Norway

The direct care staff have direct, daily contact with the patient. This includes registered nurses, licensed practical nurses and nursing assistants.

Support personnel

Some staff members focus solely on caring for the buildings and grounds. Custodians, maintenance staff, and groundskeepers, for example, keep the inside and outside of the building in clean, working order.

Additional support personnel also include people who may have some contact with the patient in the nursing home, but it may not be daily or even regularly. For example, nursing homes may have an activities director who is responsible for planning and implementing holiday events, daily and weekly educational and social activities, coordinating special visitors and religious services. Larger facilities may have multiple staff members, such as chaplains or activity assistants, who take on some of those roles. Physical therapy staff may also be available, depending on the home.

Services

Nursing homes offer the most extensive care a person can get outside a hospital. Nursing homes offer help with custodial care—like bathing, getting dressed, and eating—as well as skilled care given by a registered nurse and includes medical monitoring and treatments. Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists.

The services nursing homes offer vary from facility to facility. Services can include:

• Room and board
• Monitoring of medication
• Personal care (including dressing, bathing, and toilet assistance)
• 24-hour emergency care
• Social and recreational activities

Occupational Therapy

Rest home for seniors in Český Těšín, Czech Republic

Some individuals that are housed in a nursing home require ongoing occupational therapy. Occupational Therapists "promote the health and participation of people, organizations, and populations through engagement in occupation". These specialists provide intervention in areas of occupation such as: activities of daily living (such as bathing, dressing, grooming; instrumental activities of daily living (home and financial management, rest and sleep, education, work, play, leisure) and social participation.

They also develop and implement health and wellness programs to prevent injuries, maintain function, and improve safety of residents. For example, Occupational Therapists can take a leadership role in developing and implementing programs to educate clients on compensatory techniques for low vision, customized exercise programs, or strategies to prevent falls. Occupational therapy practitioners may also consult with other staff within the facility or in the community on a variety of topics related to increasing safe engagement in activities. Occupational therapy practitioners can provide a variety of services to short- and long-term residents of a SNF. Based on a client-centered evaluation, the occupational therapist, the client, caregivers, and/or significant others develop collaborative goals to identify strengths and deficits and address barriers that hinder occupational performance in multiple areas. The intervention plan is designed to promote a client’s optimal function for transition to home, another facility, or long-term care.

Physical therapy

Some of the individuals that are housed in a nursing home need ongoing physical therapy. This can be for any number of reasons. Perhaps a person has motor skills that never fully developed or have stopped functioning for some reason. Perhaps an individual has undergone a surgery or medical procedure that requires some manner of physical restitution on a personal level. Nursing homes offer specialists that are well versed in the field of rebuilding muscle or helping one regain their confidence when it comes to doing something physical. This is one of the most common therapies that are done in these nursing homes.

Medical needs

Nearly all residents in a nursing home have some type of medical need, ranging from basic care requirements to more specialized needs. Most nursing facilities are equipped to deal with most general medical needs likely to emerge. Most of the staff will have ample training in how to deal with patients with specific needs.

In fact, the staff that interact daily with the patients are normally registered nurses, who have spent years training for all contingent situations that they may encounter in a nursing home.

Regulations and oversight

In most countries, there is a degree of government oversight and regulation over the nursing home industry. These regulatory bodies are usually tasked with ensuring patient safety for the residents and improving the standard of care. In the U.S. Centers for Medicare and Medicaid Services ensures that every Medicare and Medicaid beneficiary receives seamless, high-quality health care, both within health care settings such as nursing homes, and among health care settings during care transitions.

To ensure that nursing homes meet the necessary legal standards, the authorities conduct inspections of all nursing home facilities. This process plays a critical role in ensuring basic levels of quality and safety by monitoring nursing home compliance with the national legal requirements. Surveyors will conduct on-site surveys of certified nursing homes on average every 12 months to assure basic levels of quality and safety for beneficiaries. The authority might also undertake various initiatives to improve the effectiveness of the annual nursing home surveys, as well as to improve the investigations prompted by complaints from consumers or family members about nursing homes.

Alternative care models

In recent years, there has been a general movement toward implementing alternative care models. Some have tried to create a more resident-centered environment, so that they should become more "home-like" and less institutional or "hospital-like". In these homes, units are replaced with a small set of rooms surrounding a common kitchen and living room. The staff giving care is assigned to one of these "households".

Residents have more choices about when they wake, when they eat, and their schedule for the day. They also have access to pets. The facilities utilizing these models may refer to such changes as the "Culture Shift" or "Culture Change" occurring in the Long Term Care, or LTC, industry. The Green House Project is one such organization.

Task-oriented care

In 1953, a leading American nurse educator, Eleanor Lambertson, proposed a system of team nursing to overcome the fragmentation of care resulting from the task-oriented functional approach. Team nursing would ideally respond to the needs of both the patient and the staff. The team leader's function is to stimulate the team to learn and develop new skills. The team leader instructs the team members, supervises them, and provides assignments that offer them potential for growth. Team nursing is characterized by the following:

• Direct patient care accomplished by a specific group of nurses and allied health care workers
• Accomplished by using the nursing process
• Comprehensive, holistic nursing care when the team functions at a high level of efficiency
• Composed of a team leader who coordinates patient care and supervises team members, who are responsible for total care given to an assigned group or number of patients
• Requires cooperation and effective communication with all staff members

Basic to team nursing are the team conference, nursing care plan, and leadership skills.

• The conference is led by the team leader, and all personnel assigned to the team should be included. The team leader should discuss the needs of the patients, establish goals, individualize the plan of care for each patient, instruct the team members, and follow up on all directions previously given to the team.
• The nursing care plan is a written guide that organizes information about a patient's health. It focuses on the actions that must be taken to address the patient's identified nursing diagnoses and meet the stated goals. It provides for continuity of care by a constantly changing nursing staff. The team leader starts the care plan as soon as the patient is admitted to the medical treatment facility. In response to changes in the patient's condition, and evaluation of goal achievement, the nursing care plan is updated and revised throughout the patient's hospital stay.

Resident-oriented care

With resident-oriented care, residents are able to make more choices and decisions about their lifestyle. Their families are more involved in the residents care, and employees have a greater degree of participation with the residents. Resident-oriented care combines the clinical models of care with a flexible social models.

Nursing Facilities that implement this approach to elder care strive to respond to each resident's spiritual, physical, and emotional needs. Every member of a facility's team, care for the residents, from administrators to the nurse aides. For example, all call lights are answered immediately. Whoever is close when the call is placed, responds - even if this is a member of the administration.

By country

Canada

Main article: Nursing home care in Canada

Long-term care facilities exist under three types: public, subsidized and private. Public and subsidized differ only in their ownership, all other aspects of funding, admission criteria, cost to the individuals are all regulated by the Quebec Ministry of Health and Social Services.

Private facilities are completely independent from government ownership and funding, they have their own admission criteria. They must maintain certain provincial standards, and they require licensing from the ministry.

United Kingdom

Main article: Nursing home care in the United Kingdom

Care homes, both private and local authority, are regulated by SCSWIS (Social Care and Social Work Improvement Scotland) in Scotland. In England, care homes are regulated by the CQC – The Care and Quality Commission.

In 2002 nursing homes became known as care homes with nursing, and residential homes became known as care homes.

In the United Kingdom care homes and care homes with nursing are regulated by different organisations in England, Scotland, Wales and Northern Ireland. To enter a care home, a candidate patient needs an assessment of needs and of their financial condition from their local council. The candidate may also have an assessment by a nurse, should the patient require nursing care. The cost of a care home is means tested in England.

As of April 2009 in England, the lower capital limit is £13,500. At this level, all income from pensions, savings, benefits and other sources, except a "personal expenses allowance" (currently £21.90), goes towards paying the care home fees. The local council pays the remaining contribution provided the room occupied is not more expensive than the local council's normal rate.

The NHS has full responsibility for funding the whole placement if the resident in a care home with nursing that meets the criteria for NHS continuing Health Care. This is identified by a multidisciplinary assessment process.

Care homes for adults in England are regulated by Care Quality Commission, which replaced the Commission for Social Care Inspection, and each care home is inspected at least every three years. In Wales the Care Standards Inspectorate for Wales has responsibility for oversight, In Scotland Social Care and Social Work Improvement Scotland otherwise known as the Care Inspectorate, and in Northern Ireland the Regulation and Quality Improvement Authority in Northern Ireland.

In May 2010, the Coalition Government announced the formation of an independent commission on the funding of long-term care, which was due to report within a 12-month time frame on the financing of care for an Ageing population. It delivered its recommendations on Monday 4 July 2011. The Care Quality Commission have themselves implemented a re-registration process, completed in October 2010, which will result in a new form of regulation being outlined in April 2011.

United States

Main article: Nursing home care in the United States

In the United States, there are three main types of nursing facilities (NFs).

An intermediate care facility (ICF) is a health care facility for individuals who are disabled, elderly, or non-acutely ill, usually providing less intensive care than that offered at a hospital or skilled nursing facility. Typically an ICF is privately paid by the individual or by the individual's family. An individual's private health insurance and/or a third party service like a hospice company may cover the cost. Board and Care Homes are special facilities designed to provide those who require assisted living services both living quarters and proper care. Often referred to as residential care homes, these facilities can either be located in a small residential home or a large modern facility. In fact, a large majority of board and care homes are designed to room less than 6 people. Board and care homes are typically staffed by licensed professionals, including nurses, doctors and other medical professionals. These facilities are highly regulated in order to ensure that the best possible care is being provided for the residents. Board and care homes offer residents 24 hour assistance, making them a highly popular choice for those in need of regular assistance.

Assisted living residences or assisted living facilities (ALFs) are housing facilities for people with disabilities. These facilities provide supervision or assistance with activities of daily living (ADLs); ALFs are an eldercare alternative on the continuum of care for people, for whom independent living is not appropriate but who do not need the 24-hour medical care provided by a nursing home and are too young to live in a retirement home. Assisted living is a philosophy of care and services promoting independence and dignity.

A skilled nursing facility (SNF) is a nursing home certified to participate in, and be reimbursed by Medicare. Medicare is the federal program primarily for the aged (65+) who contributed to Social Security and Medicare while they were employed. Medicaid is the federal program implemented with each state to provide health care and related services to those who are below the poverty line. Each state defines poverty and, therefore, Medicaid eligibility. Those eligible for Medicaid maybe low-income parents, children, including State Children's Health Insurance Programs (SCHIPs) and maternal-child wellness and food programs. seniors, and people with disabilities.

The Centers for Medicare and Medicaid Services is the component of the U.S. Department of Health and Human Services (DHHS) that oversees Medicare and Medicaid. A large portion of Medicare and Medicaid dollars is used each year to cover nursing home care and services for the elderly and disabled. State governments oversee the licensing of nursing homes. In addition, states have a contract with CMS to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries. Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid. These requirements are broadly outlined in the Social Security Act, which also entrusts the Secretary of Health and Human Services with the responsibility of monitoring and enforcing these requirements. CMS is also charged with the responsibility of working out the details of the law and how it will be implemented, which it does by writing regulations and manuals.

See also

• Care Quality Commission previously known as Commission for Social Care Inspection
• Certified Medical Director
• Eldercare
• Home care
• International Association for Homes and Services for the Aging
• LGBT ageing
• List of companies operating nursing homes
• Retirement village

References

• "Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes," by Dr. Lapane, Carmel M. Hughes, Ph.D., Lori A. Daiello, Pharm.D., and others in the Journal of the American Geriatric Society 59, pp. 1238–1245, 2011.
• "Potential underuse, overuse, and inappropriate use of antidepressants in older veteran nursing home residents," by Joseph T. Hanlon, Pharm.D., M.S., Xiaoqiang Wang, M.S., Nicholas G. Castle, Ph.D., and others in the August 2011 Journal of the American Geriatric Society 59(8), pp. 1412–1420.
• "Diagnosis and treatment of depression in older community-dwelling adults: 1992-2005," by Ayse Akincigil, Ph.D., Mark Olfson, M.D., James T. Walkup, Ph.D., and others in the Journal of the American Geriatrics Society 59(6), pp. 1042–1051, 2011.
• "Implications of the accuracy of MEPS prescription drug data for health services research," by Dr. Hill, Dr. Zuvekas, and Mr. Zodet, in the Fall 2011 Inquiry 48(3), pp. 242–259. Reprints (Publication No. 12-R026) are available from the AHRQ Publications Clearinghouse.

External links

Australia

• Aged Care Home Finder Australia - Department of Health and Ageing Australia

United Kingdom

• Care Home Review Service — Reviews, ratings and CQC's inspection reports of care homes in the UK
• MHA Charity providing care — Amongst the largest charities in Britain, providing services and specialist dementia care to older people for nearly 70 years

United States

• Nursing Home Compare Tool — Medicare's past performance results of every certified nursing home in the USA