11

Nursing Facilities

JESSICA DORNIN

JAMIE FERGUSON-ROME

NICHOLAS G. CASTLE

INTRODUCTION

The National Nursing Home Survey defines nursing homes as “facilities with three or more beds that routinely provide nursing care services” (Jones, 2002, p. 1). Nursing homes typically act as short-term rehabilitative facilities (most often, but not necessarily exclusively the clientele is elderly) and/or serve as an individual’s permanent residence home; (Castle, Ferguson, & Hughes, 2009). The majority of nursing homes are certified by Medicare and/or Medicaid, whereas others are licensed by individual states (Fairchild & Knebl, 2002). Approximately 1.5 million people reside in the nation’s 16,100 nursing homes each day (Centers for Disease Control and Prevention [CDC], 2013).

As noted later in the text, complements and alternatives to nursing homes exist, including home- and community-based service (HCBS) initiatives. The aging baby boomers will continue to increase the demand for nursing homes and their services (Kaiser Family Foundation [KFF], 2013). It is estimated that by 2030 almost 20% of the U.S. population will be over the age of 65 (Federal Interagency Forum on Aging-Related Statistics, 2012). As the number of aging individuals increases, the burden of care on nursing homes and health care spending will increase (Bohm, 2001).

Nursing homes have been and continue to be an integral part of American society and the American health care system, and it is likely that they will remain so in the foreseeable future. In this chapter, we provide a brief history of the development of nursing homes, review operation of nursing homes today, and elaborate on current and future challenges and opportunities nursing homes face.

HISTORICAL DEVELOPMENT OF NURSING HOMES

Historically, the burden of caring for elderly people fell to individuals’ relatives or willing neighbors, thereby allowing individuals to maintain their standard of living (Lidz, Fischer, & Arnold, 1992). This type of community-based assistance was referred to as “outdoor relief” because those in need were allowed to remain in the home environment (Bohm, 2001). In accordance with the English Poor Law of 1601, government aid was only provided to those individuals whose family or friends were incapable of providing for them (Bohm, 2001). Assistance was provided to those deemed worthy of government aid in the form of “money, wood, or clothes” (Haber, 2002, p. 1006). As the number of older adults began to rise, so did the need for establishments capable of housing such individuals (see also Chapter 2).

In order to meet the needs of the growing number of older adults and keep up with the evolving complexity of society, larger facilities were erected to care for them, and the switch from “outdoor relief” to “indoor relief” began (Lidz et al., 1992). During this time, “indoor relief,” or care in the form of institutions (such as almshouses or poorhouses), became a focus in caring for older adults (Lidz et al., 1992). Almshouses were not originally developed to house the elderly population (Bohm, 2001). Furthermore, there were negative connotations associated with residing in almshouses due in part to the deplorable conditions of these facilities (Bohm, 2001).

The 20th century brought with it the Great Depression and increased questioning of the nature of almshouses and the propriety of institutionalizing older adults (Lidz et al., 1992). As an overwhelming number of individuals began inundating the almshouses, the burden became more than the institutions could bear (Watson, 2009). Horrible living conditions in the almshouses were revealed, evoking sympathy for older adults and fueling increasing demand for public pensions (Lidz et al., 1992; Watson, 2009). Gradually, the almshouses were replaced by public nursing homes (Bohm, 2001).

With the passage of the Social Security Act in 1935, the nursing home environment, as well as attitudes toward older adults, began to change (Bohm, 2001). Qualified individuals were able to obtain unemployment insurance, old-age insurance, and take part in welfare programs after the passage of the Social Security Act (Social Security Administration [SSA], 2005). In an effort to discourage the use of public nursing homes, social security specified that public institutions were not eligible to receive federal funds (Watson, 2009). This stipulation was put in place under the Old Age Assistance (OAA) program, which was created under Title I of the Social Security Act (Emerzian & Stampp, 1993). The resulting action spurred an increase in the number of private care homes, and the shift from public nursing homes and almshouses to private nursing homes began (Bohm, 2001).

The transition from public to private institutions did not necessarily improve the quality of care residents were receiving (Bohm, 2001). Numerous quality complaints went unaddressed, leading to the demand for more medicalized care (Lidz et al., 1992). With the passage of the Hill–Burton Act in 1946, an increase in the number of hospitals constructed was realized as federal funds were set aside for this purpose (Lidz et al., 1992). The Hill–Burton Act provided funds for the improvement of existing nursing homes as well (Health Resources and Services Administration [HRSA], n.d.). However, it was not until the 1960s, with the passage of the Kerr–Mills Act and subsequently, the development of Medicare and Medicaid, that the growth of nursing homes increased (Watson, 2009). The implementation of Medicare and Medicaid not only spurred an increase in government (federal and state) funds provided to nursing homes, but also developed regulations and standards that participating facilities were required to follow (Emerzian & Stampp, 1993). To ensure that the various facets of Medicare and Medicaid ran smoothly, the Health Care Financing Administration (HCFA) (later renamed the Centers for Medicare & Medicaid Services [CMS]) was developed in 1977. The HCFA became responsible for the certification process required for nursing homes as well as the creation of certification standards (Castle & Ferguson, 2010).

The 1987 passage of the Omnibus Budget Reconciliation Act (OBRA ’87) further reformed the nursing home environment by increasing the standards that participating facilities had to maintain to qualify for Medicare and Medicaid reimbursement (Emerzian & Stampp, 1993). Although the implementation of the improved standards and enforcement was slow, the quality standards currently in place in certified nursing facilities can be attributed to OBRA ’87 (Castle & Ferguson, 2010).

NURSING HOMES TODAY

The term nursing home has been replaced in recent years with the term nursing facility. The use of the term nursing facility is predominantly regulatory in nature and came about with the passage of OBRA ’87 (Pratt, 1999). To be more specific, nursing facilities are defined as “health care facilities licensed by the state offering room, board, nursing care, and some therapies” (Pratt, 1999). Also included in this term are skilled nursing facilities (SNFs), which provide around-the-clock nursing care and other specialized services such as speech pathology and physical therapy (Pratt, 1999).

Nursing facilities continue to play a vital role in the provision of long-term care services for the elderly. Although facilities themselves have undergone major changes since their conception, the following section provides statistics about the current structural characteristics of nursing facilities, the staff who provide care, resident characteristics, payments and reimbursements, and challenges nursing homes currently face.

STRUCTURAL CHARACTERISTICS OF NURSING FACILITIES

According to the Nursing Home Data Compendium, there was a decline in the number of nursing facilities in operation during the first decade of the 21st century, with a slight increase in 2011 (CMS, Department of Health and Human Services, 2012b). In 2011, 15,683 nursing facilities were in operation (CMS, Department of Health and Human Services, 2012b). California has the most nursing homes of all states, with a total of 1,232 facilities. The largest concentration of certified nursing home beds is located in central United States, with 56.1 to 68.7 beds per thousand persons aged 65 and older (CMS, Department of Health and Human Services, 2012b).

A majority of today’s nursing facilities are private, for-profit facilities owned by an “individual, partnership, or corporation,” with the remaining portion of nursing homes being nonprofit or government owned (Grabowski & Stevenson, 2008). In essence, for-profit organizations exist to generate revenue; excess earnings are then distributed among the company’s investors (Miller & Hutton, 2000). Conversely, nonprofit organizations are generally exempt from paying taxes and are prohibited from distributing their earnings (Scalesse, 2013). In government-owned organizations, operational monies are generated through taxes or fees coming from state or federal resources (Pratt, 1999). Beyond these three ownership types (i.e., for-profit, not-for-profit, and government run), controlling entities are varied and include limited partnerships (LPs), limited liability partnerships (LLPs) and limited liability corporations (LLCs), general partnerships (GPs), and sole proprietorships (Stevenson, Bramson, & Grabowski, 2013).

FIGURE 11.1 Nursing facility ownership and affiliation in 2011.

Source: KFF (2013).

Statistics show that for-profit facilities have increased in number, whereas nonprofit and government-owned facilities have decreased in number (CMS, Department of Health and Human Services, 2012b). For-profit facilities account for 69% of today’s nursing homes, whereas nonprofit and government-owned facilities account for the remaining 31% (see Figure 11.1), or, 25.3% and 5.7%, respectively (CMS, Department of Health and Human Services, 2012b).

It is important to point out that multifacility chain ownership (often shortened to “chain ownership”) and hospital-based affiliation also exist. Chains are defined as two or more homes under one ownership (State Operations Manual, 2012) and are typically large businesses that own multiple nursing facilities. Many chains are for-profit (KFF, 2013). Overall, chain ownership accounts for about 55% of U.S. nursing facilities (KFF, 2013). Hospital-based nursing homes are defined as having an affiliation with a hospital (State Operations Manual, 2012). Approximately, 6% of nursing homes are hospital based (KFF, 2013).

Bed size refers to the number of beds in a given facility (KFF, 2013). In 2011, the average number of certified beds in U.S. nursing facilities was 108.5 (see Figure 11.2; KFF, 2013). This number reflects a slight increase from previous years, with 108.4 beds in 2010, 108.3 in 2008, and 107.8 in 2006 (KFF, 2013). The average number of beds varies significantly across states with Alaska having the lowest average at 42.5 beds and New York having the highest with 186 beds (KFF, 2013).

FIGURE 11.2 Average number of certified nursing facility beds.

Source: KFF (2013).

The beds in nursing facilities are often divided into sections called units. A typical 108-bed facility has four units. Units are defined as a number of rooms or even a section of a facility devoted to providing specific care (State Operations Manual, 2012). That is, units are typically set up to provide a multitude of different services, ranging from basic caregiving to rehabilitative services (KFF, 2013). Typically seen in SNFs, rehabilitation units (i.e., rehabunits) are devoted to providing rehabilitation to postoperative patients or those recovering from a stroke (Rau, 2013; Skillednursingfacilities.org, 2010). These units are noteworthy because they most often provide care for Medicare patients. The patient’s length of stay is usually brief (National Stroke Association, 2006; Skillednursingfacilities.org, 2010). These patients are often termed “short-stay residents” (with an average length of stay of 27 days) and account for approximately half of all residents (Grabowski, 2010).

Specific units within a nursing home are called special care units (SCUs) and are created to provide care for a particular group of residents with unique needs or medical conditions (Pratt, 1999). SCUs typically require specific licensure or certification requirements (e.g., those providing dementia-related care; Estabrooks, Morgan, Squires et al., 2011). SCUs in nursing homes exist for conditions including, but not limited to, dementia, Parkinson’s disease, wound care, and brain injuries (Pratt, 1999).

STAFFING

Federal government regulations address staffing standards in nursing homes (primarily coming from The Nursing Home Reform Act [NHRA], which was included in the 1987 Omnibus Budget Reconciliation Act). Government regulations (for Medicare/Medicaid-certified facilities) require that a “facility provide services by a sufficient number of nursing personnel on a 24-hour basis to provide the required care in accordance with care plans. A nursing home must have (a) a licensed nurse who functions as a charge nurse on each shift, (b) a registered nurse (RN) on duty at least eight consecutive hours per day, seven days a week, and (c) an RN designated as the director of nursing on a full-time basis who can also serve as the charge nurse when the average daily occupancy is 60 or fewer patients” (Decker et al., 2001, p. 17). In addition, minimum hours per resident day staffing-level standards also exist in many states, ranging from 3.6 hours per resident day (in Florida) to 1.76 hours per resident day (in Oregon; Mueller et al., 2006). These staffing standards are noted by many to be inadequate (Harrington et al., 2000).

In reality, much of the physical care in nursing facilities is administered by certified nursing assistants (CNAs). Of the 952,100 full-time employees (FTEs) in U.S. nursing facilities in 2012, CNAs accounted for 65.4%, or the majority (Harris-Kojetin, Sengupta, Park-Lee, & Valverde, 2013). The remaining percentage comprised RNs at 11.7% and licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) at 22.9% (Harris-Kojetin et al., 2013). On average, residents received 3.83 hours of direct care a day from a combination of these caregivers, although most care was provided by CNAs (Harris-Kojetin et al., 2013). Other staff employed by nursing homes include administrative and support personnel, social workers, dietitians and food services staff, pharmacists, therapists, activity directors, housekeeping, and maintenance staff (Table 11.1; Pratt, 1999).

TABLE 11.1 Number and Percentage Distribution of Staffing Characteristics in Nursing Homes, 2012

Source: Harris-Kojetin et al. (2013).

According to 2004 to 2005 data from the National Nursing Home Assistant Survey, the average hourly wage rate for CNAs was $10.36 (National Nursing Home Assistant Survey [NNHAS], 2008). Data from this survey also demonstrates that women constitute the majority of CNAs with 646,100 employed as compared to 56,300 men (CDC, 2008). The largest age group for CNAs was those aged 35 to 44 years followed closely by workers aged 25 to 34 years (NNHAS, 2008). The majority of these employees had only a high school diploma and a family income of less than $20,000 a year (NNHAS, 2008).

All CNAs working in Medicare- and/or Medicaid-certified facilities are required by federal regulations to “complete a State-approved training program, pass a competency exam, and receive certification from the State in which they are employed” (Health and Human Services: Office of Inspector General [OIG], 2002, p. 5). These training programs “must be a minimum of 75 hours and include 16 hours of supervised clinical training” (OIG, 2002, p. 5). Additionally, “all NAs must complete 12 hours of continuing education annually” in order to maintain certification (OIG, 2002, p. 5).

The adequacy of the training that nursing assistants (NAs) receive in training programs is widely debated. It is noted that numerous state officials perceive the initial training hours required of NAs to be insufficient (Sengupta, Harris-Kojetin, & Ejaz, 2010). Similarly, various national organizations have advocated for an increase in the number of hours of federally mandated training, suggesting upwards of 150 to 160 hours as opposed to the currently mandated 75 hours (Harrington, Kovener, Mezey, et al., 2000; Sengupta et al., 2010). These concerns are not unwarranted, as the federally mandated training requirements have remained unchanged since their inception in 1987 (Sengupta et al., 2010) and in subsequent years nursing homes have seen an increase in the complexity of residents care needs (Paraprofessional Healthcare Institute [PHI], 2012). Another concern centers on the disparity between in-class training and hands-on training, with hands-on training typically receiving fewer hours in many training programs (Sengupta et al., 2010) resulting in “a divide between the classroom and the workplace” (PHI, 2012, p. 2).

RESIDENT CHARACTERISTICS

According to information gathered from the 2012 Nursing Home Data Compendium, the vast majority of nursing facility residents are non-Hispanic Whites (78.9%), with women comprising a large percentage (67.2%) of the resident population (CMS, Department of Health and Human Services, 2012b). Furthermore, of the 1.5 million residents in nursing facilities at the end of 2011, residents age 65 and older accounted for approximately 42.1% of the resident population, whereas those ages 85 and older accounted for approximately 42.9% (CMS, Department of Health and Human Services, 2012b). Thus, roughly 85% of the residents in nursing facilities are age 65 and older (see Table 11.2; CMS, Department of Health and Human Services, 2012b).

TABLE 11.2 Characteristics of Nursing Home Residents

Stay updated, free articles. Join our Telegram channel

Join