United States

In the United States, nursing homes are required to have a licensed nurse on duty 24 hours a day, and during at least one shift each day, one of those nurses must be a Registered Nurse. In April, 2005 there were a total of 16,094 nursing homes in the United States, down from 16,516 in December, 2002. Some states have nursing homes that are called nursing facilities (NF), which do not have beds certified for Medicare patients, but can only treat patients whose payments source is Private Payment, Private Insurance or Medicaid

Services

Services provided in nursing homes include services of nurses, nursing aides and assistants; physical, occupational and speech therapists; social workers and recreational assistants; and room and board. Most care in nursing facilities is provided by certified nursing assistants, not by skilled personnel. In 2004, there were, on average, 40 certified nursing assistants per 100 resident beds. The number of registered nurses and licensed practical nurses were significantly lower at 7 per 100 resident beds and 13 per 100 resident beds, respectively.

Nursing facilities that participate in the Medicare and Medicaid programs are subject to federal requirements regarding staffing and quality of care for residents.^[1] In 2004, 98.5% of the 16,100 nursing facilities nationwide were certified to participate in Medicare, Medicaid, or both.

Medicare covers nursing home services for beneficiaries who require skilled nursing care or rehabilitation services following a hospitalization of at least three consecutive days. The program does not cover nursing care if only custodial care is needed — for example, when a person needs assistance with bathing, walking, or transferring from a bed to a chair. To be eligible for Medicare-covered skilled nursing facility (SNF) care, a physician must certify that the beneficiary needs daily skilled nursing care or other skilled rehabilitation services that are related to the hospitalization, and that these services, as a practical matter, can be provided only on an inpatient basis. For example, a beneficiary released from the hospital after a stroke and in need of physical therapy, or a beneficiary in need of skilled nursing care for wound treatment following a surgical procedure, might be eligible for Medicare-covered SNF care.

SNF services may be offered in a free-standing or hospital-based facility. A freestanding facility is generally part of a nursing home that covers Medicare SNF services as well as long-term care services for people who pay out-of-pocket, through Medicaid, or through a long-term care insurance policy. Generally, Medicare SNF patients make up just a small portion of the total resident population of a free-standing nursing home.

Medicaid also covers nursing home care for certain persons who require custodial care, meet a state's means-tested income and asset tests, and require the level-of-care offered in a nursing home. Nursing home residents have physical or cognitive impairments and require 24-hour care.

Almost no one can afford to pay for nursing home care "out of pocket."^[clarify] They cost $5,000 per month or more.^[clarify] Some deplete their resources on the often high cost of care. If eligible, Medicaid will cover continued stays in nursing home for these individuals. However, they require that the patient be "spent down" to poverty levels first, thus depleting their life savings.

Government regulations and oversight

All nursing homes in the United States that receive Medicare and/or Medicaid funding are subject to federal regulations. People who inspect nursing homes are called surveyors or, most commonly, state surveyors.

The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.

For United States homes, the Centers for Medicare and Medicaid Services has a website which allows users to see how well facilities perform in certain metrics (see "Nursing Home Compare Tool" in the external link section below). CMS also publishes a list of Special Focus Facilities - nursing homes with "a history of serious quality issues."^[2][3] The US Government Accountability Office (GAO), however, has found that state nursing home inspections understate the number of serious nursing home problems that present a danger to residents. The GAO concluded that while CMS oversight has improved, there are still weaknesses in its oversight of nursing homes.^[4][5]

Care homes for adults in England are regulated by the Commission for Social Care Inspection.

Nursing homes are subject to federal regulations and also strict state regulations. The nursing home industry is considered one of the two most heavily regulated industries in the United States (the other being the nuclear power industry).^[6]

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 U.S as a result of the Real Choice Systems Change Grants, shows that many 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.

When considering living arrangements for those who are unable to live by themselves, potential customers consider it to be important to carefully look at many nursing homes and assisted living facilities as well as retirement homes, keeping in mind the person's abilities to take care of themselves independently. While certainly not a residential option, many families choose to have their elderly loved one spend several hours per day at an adult daycare center.

Beginning in 2002, Medicare began hosting an online resource known as Nursing Home Compare . The program is intended to foster quality improving competition between nursing homes. Informed consumer choice has long been missing from decisions regarding the placement of the elderly in need.

The website My Patient Guide provides a directory of New Jersey nursing homes and assisted living communities, along with a question-and-answer section.

Trends

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 "hospital-like." In these homes, nursing home 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 far more choices about when they awake, when they eat and what they want to do during the day. They also have access to more companionship such as pets. Some organizations working toward these goals are the Greenhouse nursing home, the Pioneer Network, and the Eden Alternative. Many of the facilities utilizing these models refer to such changes as the "Culture Shift" or "Culture Change" occurring in the LTC industry

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