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Nursing Home

A nursing home, convalescent home, skilled nursing facility (SNF), care home, rest home or intermediate care[1] provides a type of residential care. They are a place of residence for people who require continual nursing care and have significant deficiencies with 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.[2]

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



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

United Kingdom

In 2002 nursing homes became known as care homes with nursing, and residential homes became known as care homes.[4]

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), will go to 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, currently £364.48 for Hampshire for example. If the resident is paying more than this the council will not pay anything and contributions from a third party or charity must be found or the resident move to a cheaper care home. Between the lower and the upper capital limits, the resident pays their income less personal expenses allowance + £1/week for every £250 capital between lower and higher limit. The council pays the rest, subject to the same conditions as before. It is therefore preferable to find a home within the council's limit if council funding is likely to be required to avoid a forced move later. Patients with capital over more than £23,000 pay the full cost of the care home, until the total value of their assets fall below the threshold.[5] Patients who require additional nursing care are assessed for this.[6] and receive additional financial support (£103.80 weekly) through the National Health Service (NHS). This is known as Funded Nursing Care.

The NHS has full responsibility for funding the whole placement if the resident in a care home with nursing meets the criteria for NHS continuing Health Care. This is identified by a multidisciplinary assessment process.[7]

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. [8]

United States

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

Intermediate care facility (ICF)

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 facility (ALF)

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.[9]

Skilled nursing facility (SNF)

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 (CMS) 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.[10]

Typical nursing home staff


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.). Most states require nursing home administrators to have a license to run a facility.

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.

Direct care staff

The direct care staff have direct, daily contact with the patient. The following are types of direct care staff included in all nursing homes:

Staffing requirements

Federal law requires all nursing homes to provide enough staff to adequately care for residents. There is no current federal standard for optimal nursing home staffing levels. The nursing home must have at least one RN for at least 8 straight hours a day, 7 days a week, and either an RN or LPN/LVN on duty 24 hours per day. Certain states may have additional staffing requirements. CNAs provide care to nursing home residents twenty four hours per day, seven days a week.[11]


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 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

Some of the individuals that are housed in a nursing home need ongoing occupational therapy. Occupational Therapists (OTs) and Occupational Therapy Assistants (OTAs) "promote the health and participation of people, organizations, and populations through engagement in occupation" (American Occupational Therapy Association [AOTA], 2008). OTs and OTAs provide intervention in areas of occupation such as: activities of daily living (ADLs) including bathing, dressing, grooming; instrumental activities of daily living (IADLs) including home and financial management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2008). They also develop and implement health and wellness programs to prevent injuries, maintain function, and improve safety of residents. For example, OTs and OTAs 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 the need for some type of medical need. It can be anything from basic care of a medical inadequacy to something more specialized such as someone that is missing an appendage. These nursing facilities can take care of just about any medical need that needs to be taken care of. Most of the staff at these nursing homes has ample training in how to deal with patients that have some manner of specialized need. In fact, the staff that interacts with the patients the most are normally registered nurses that have spent years training for any situation that they may encounter during a patients stay at one of these nursing homes.


Payment for nursing home care can be made through Medicare, Medicaid, private insurance, and personal funds.

  • Medicare is a federal health insurance program providing health care benefits to all Americans age 65 and over. Insurance protection intended to cover major hospital care is provided without regard to income. Medicare will only provide 100 days of nursing care, and only if a person requires skilled care and is referred by a doctor when discharged from the hospital. If a person needs custodial care alone, Medicare will not cover it. Medicare only pays for skilled care in a nursing facility that has a Medicare license.
  • Medicaid is a joint federal/state health insurance program providing medical care benefits to low income Americans who meet certain requirements. Nursing home care is covered through Medicaid, but the requirements and covered services vary widely from state to state. To become eligible for Medicaid coverage, people usually have to spend all of their assets first. This means that they might pay for nursing home care out of pocket initially. Once their money runs out, Medicaid would kick in. It's a good idea to work with a lawyer who specializes in elder law when determining Medicaid eligibility.
  • Private long-term care insurance is a health insurance option that, if purchased, supplements Medicare coverage. Private long-term care insurance policies vary greatly. Each policy has its own eligibility requirements, restrictions, costs, and benefits.

Regulations and oversight

CMS is tasked with improving patient safety for nursing home residents. CMS has a number of initiatives underway to improve care across settings, including by ensuring better care transitions. CMS is committed to ensuring 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. More than 3 million Americans rely on services provided by nursing homes at some point during the year and 1.4 million Americans reside in the nation’s 15,800 nursing homes on any given day. Those individuals, and an even larger number of their family members, friends, and relatives, must be able to count on nursing homes to provide reliable, high-quality care. A number of divisions within CMS work together to promote nursing home safety and quality improvement, address reimbursement issues, and enforce Medicare Conditions of Participation. The combined levers of technical assistance, payment reform, oversight, and enforcement create a powerful system that promotes safety and quality care in nursing homes.

To ensure that nursing homes meet both federal and state standards, CMS conducts initial and ongoing inspections of all facilities participating in Medicare and Medicaid. The Survey and Certification process plays a critical role in ensuring basic levels of quality and safety for Medicare and Medicaid beneficiaries by monitoring nursing home compliance with federal and state requirements. Within the Survey and Certification Group, the Division of Nursing Homes focuses on optimizing the health, safety, and quality of life for people living in nursing homes, through close coordination with other divisions. Approximately 5,000 federal and state surveyors conduct on-site surveys of certified nursing homes on average every 12 months to assure basic levels of quality and safety for beneficiaries. CMS has undertaken several initiatives over the past several years 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.

CMS acts to combine, coordinate, and mobilize people and techniques through a partnership approach. Survey agencies, ombudsmen, quality improvement organizations (QIOs), and other partners are committed to the common endeavor of promoting quality and safety in nursing homes. Although these entities have different responsibilities, their distinct roles can be coordinated in a number of ways to achieve better results than can be achieved by any one agency alone. Collectively, CMS’ work to enhance quality and safety in nursing homes is focused in five major areas: 1) enhancing consumer engagement; 2) strengthening survey processes, standards and enforcement; 3) promoting quality improvement; 4) creating strategic approaches through partnerships; and 5) advancing quality through innovation and demonstrations. Through coordinating and aligning these initiatives, CMS is working to spearhead ongoing improvements in quality and safety in nursing homes.[12]

Consumer choices

Current trends are to provide people with significant needs for long term supports and services with a variety of living arrangements. Indeed, research in the United States as a result of the Real Choice Systems Change Grants, shows that some people are able to return to their own homes in the community. Private nursing agencies may be able to provide live-in nurses to stay and work with patients in their own homes.


In 2012 in the U.S. a few nursing homes are beginning to change the way they are managed and organized to create a more resident-centered environment, so they are 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. Sometimes this kind of nursing home is called a "greenhouse".

User reviews

In addition to the Medicare Ratings, after the advent of social internet, websites have made it possible for families and seniors to submit user reviews about nursing homes. The largest such a repository of user reviews in the United States can be found in the external links section.

Quality of life

Task-oriented care

In 1953, Eleanor Lambertson and her colleagues proposed a system of team nursing to overcome the fragmentation of care resulting from the task-oriented functional approach. Team nursing responds 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.

As Nursing Facility implements this approach to elder care, CMS strives 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 answers, and this could be a member of the administration.[13]

Scientific findings

In September 2011 researchers conducted interviews with 378 adults aged 60 and over who were receiving services from an aging services center in Rochester, New York. Participants in the study were asked questions from validated survey instruments to determine their present state of well-being and social situation. Areas covered included anxiety levels, other mental disorders, social support, physical health and disability, and if the individuals had experienced stressful life events recently.

It was found that anxiety is common in the elderly, affecting an estimated 1 in 10 older adults. If left untreated, it can turn into depression, cause significant disability, and boost health care costs. More than 10 million older adults receive services from approximately 30,000 local and state aging services agencies. More than a quarter of this group had significant levels of anxiety, according to a new study.

Of 377 participants with complete data, 27.3 percent had significant symptoms of anxiety. Those with anxiety were more often younger and had lower incomes compared with non-anxious participants. There was a significant correlation between anxiety and depression, with more than half (54 percent) of those suffering from anxiety also having depression. Factors also associated with anxiety included higher levels of pain, having five or more medical conditions, and experiencing recent stressful life events. The study's findings support greater interventions to identify anxiety in this service population and to link aging services with primary care and behavioral health providers.

In January 2012 it was found that clinical informational monitoring tool helps reduce adverse drug events in nursing home settings In nursing homes, 40 percent of residents use at least nine different medications, and adverse drug events (ADEs) are common. ADEs may be preventable with adequate medication monitoring. The use of the Geriatric Risk Assessment Med Guide (GRAM), a clinical informational tool that implements prospective monitoring plans, markedly reduced the risk of potential delirium in newly admitted and long-stay nursing home residents, according to a new study. Potential hospitalizations and deaths due to ADEs and mortality were also reduced, but the effect was weaker in longer-stay residents. There was no effect of the monitoring system on the incidence of falls.[14]

Kate L. Lapane, Ph.D., of Virginia Commonwealth University, worked with Janice Feinberg, Pharm.D., J.D., of the American Society of Consultant Pharmacists Foundation that developed the tool, and colleagues to test the GRAM software in 26 nursing homes during 2003-2004. This technology was designed to assist health care professionals with expertise in geriatric pharmacol therapy in problem identification when evaluating complex medication regimens of older adults. It was used to engage consultant pharmacists and nursing staff to identify residents at risk for delirium and falls, implement proactive medication monitoring plans as appropriate, and provide reports to assist consultant pharmacists in conducting the medication regimen review.

The researchers point out that systems using information technology to improve the monitoring stage of the medication-use process are sparse. How to pay for such services has yet to be determined, because information technology adoption in nursing homes has been slow.

In February 2012 it was found that older residents in Veterans Affairs (VA) Community Living Centers (CLCs), the equivalent of nursing homes, often fail to get optimal treatment with antidepressants, concludes a new study. It found that 25 percent of the 877 residents with depression did not receive antidepressant drugs. In addition, 58 percent of the 654 residents with depression and receiving antidepressant medication had evidence of possible inappropriate use (most commonly, potential drug-drug or drug-disease interactions). Among the 2,815 residents without diagnosed depression, 42 percent received at least one antidepressant drug. Depressed black residents were about half as likely as depressed whites to experience potential inappropriate use, while depressed residents with cancer were less likely to experience either possible under use or inappropriate use.

The researchers also found that non-depressed residents who received anti-psychotic drugs without a diagnosis of schizophrenia and or those with a history of stroke or anxiety were about 1.5 times more likely to be given an antidepressant. The findings were based on data on 3,692 veterans admitted to 133 VA CLCs over a 17-month period ending in early June 2005. The CLCs were from 21 VA regions across the United States.

In March 2012 it was found that depression is quite common in the elderly, and can lead to reduced life expectancy, hospitalization, and even suicide. Both drugs and psychotherapy are effective in treating depression, although their combined use has been shown to be more effective than either one alone. A new study found that depression diagnosis and treatment rates have increased over time. In addition, drugs have become the preferred method of treatment over psychotherapy.

Researchers analyzed national Medicare data from 1992 to 2005 on fee-for-service Medicare beneficiaries who lived in the community. They identified individuals with a diagnosis of depression and the types of treatment they received. Between 1992 to 1995 and 2002 to 2005, the overall annual rates of depression in this group doubled from 3.2 percent to 6.3 percent. Along with this increase in diagnosis was an increase in treatment. Antidepressant use increased from 53.7 percent to 67.1 percent. At the same time, the use of psychotherapy declined from 26.1 percent to 14.8 percent. Among those 85 years of age and older, the increased use of antidepressants was greatest, rising from 42 percent to 65 percent. By 2005, less than half of patients with major depressive disorder received psychotherapy. Only 5.6 percent of patients with other depression diagnoses were treated in this manner.

See also

Health portal
Home portal


  • "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


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

United Kingdom

  • 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
  • Directory of Care Homes and Care Agencies — Directory of Nursing Homes, Care Homes and Care Agencies

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United States

  • Medicare's past performance results of every certified nursing home in the USA
  • [1]- Comprehensive Nursing Homes Directory
  • [2]- Today's nursing home services provided

Occupational Therapy'

  • [3]


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