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Rest home for seniors in Český Těšín, Czech Republic

A nursing home, convalescent home, Skilled Nursing Unit (SNU), care home or rest home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living. Residents include the elderly and younger adults with physical or mental disabilities. Eligible adults 18 or older can stay in a skilled nursing facility to receive physical, occupational, and other rehabilitative therapies following an accident or illness.

United States

In the United States, a "Skilled Nursing Facility" or "SNF" is a nursing home certified to participate in, and be reimbursed by Medicare. Medicare is the federal program primarily for the aged who contributed to Social Security and Medicare while they were employed. A "Nursing Facility" or "NF" is a nursing home certified to participate in, and be reimbursed by Medicaid. Medicaid is the federal program implemented with each State to provide health care and related services to those who are "poor." Each State defines poverty and; therefore, Medicaid eligibility. Those eligible for Medicaid may be aged, disabled or children (e.g. Children's Health Insurance Programs - CHIPs and Maternal-Child wellness and food programs).

In the United States, each State "licenses" its nursing homes, making them subject to the State's laws and regulations. Nursing homes may choose to participate in Medicare and/or Medicaid. If they pass a survey (inspection), they are "certified" and are also subject to federal laws and regulations. All or part of a nursing home may participate in Medicare and/or Medicaid.

In the United States, nursing homes which participate in Medicare and/or Medicaid are required to have licensed practical nurses (LPNs) (in some States designated "vocational nurses" or "LVNs") on duty 24 hours a day. For at least 8 hours per day, 7 days per week, there must be a registered nurse on duty. Nursing homes are managed by a Licensed Nursing Home Administrator. Unlike U.S. nursing there are no standardized training and licensing requirements for administrators, though most states require a Federal License, and many states such as California have their own licensure for administrators. In April 18, 2005 there were a total of 16,094 nursing homes in the United States, down from 16,516 in December 12, 2002.

There are states that have other levels of care offered to elderly and other adults who need assistance and are able to live in the community. For instance, Connecticut has Residential Care Homes or RCH that are licensed by the State Department of Public Health. These homes provide 24-hour supervision and typically offer a more "home-like" environment. Many are actually large homes that have been converted to dwellings that offer a residential community that promotes an independent lifestyle and fosters fellowship with others who need some form of assistance to live in the community (see http://CARCH.NET).


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 homes 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 20 to 100 days 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.

Medicare 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.

The cost of staying in a Nursing home can cost several thousand per month or more.[2] Some deplete their resources on the often high cost of care. If eligible, Medicaid will cover continued stays in nursing home for these individuals for life. However, they require that the patient be "spent down" to a low asset level first by either depleting their life savings or asset-protecting them, often using an elder law attorney.

U.S. 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. State surveyors may inspect for compliance with licensure (State regulations) and/or certification (Medicare and Medicaid regulations).

The "Mininimum Data Set" assessment (MDS) is part of the U.S. federally mandated process for comprehensive assessment of all residents in Medicare or Medicaid certified nursing homes. The MDS assessment is a screening assessment that forms the basis of a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify and help residents meet or cope with health and other needs. The MDS also yields "Resource Utilization Groups" (RUGS) which are used for all Medicare reimbursement to SNFs, and is used in many States to set reimbursement for NFs.

For United States SNFs and NFs, 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."[3][4] 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.[5][6] A report issued in September 2008 found that over 90% of nursing homes were cited for federal health or safety violations in 2007, with about 17% of nursing homes having deficiencies causing "actual harm or immediate jeopardy" to patients.[7]

SNFs and NFs 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).[8]

Medicare and Medicaid surveys

Federal regulation and inspection (surveying) of SNFs and NFs applies a model of health care quality created for research by Avedis Donabedian in 1965. The model uses the concepts of structure, process and outcome.


For surveying, structure is the nursing home's resources. That includes staff, their knowledge and skills, policies, procedures, records, equipment, buildings, etc. Structure surveying looks at the instrumentalities of care and their organization.


Process is the nursing home's resources in action. Process surveying looks at the appropriateness, timeliness and quality of care and services in relation to each resident's needs. Process can be organized into 5 kinds of intellectual and physical activities: assessing, planning, implementing (acting), evaluating, and communicating. These activities must be integrated and often occur together. Unfortunately these processes can be task or resident-centered. A task nurse implements a physician ordered-dressing change, perhaps assessing the wound while it is uncovered. A resident-centered nurse would already know if the treatment causes the resident pain and pre-medicated the resident. During the care, she (or he) will talk with the resident about topics they have both shared before, distracting the resident from discomfort and addressing social needs. Communication is heightened when residents feel comfortable discussing various issues with someone who is experienced with their particular case. In this particular situation nurses are also better able to do longitudinal follow up, which insures the implementation of more lasting results.


In Donabedian's model, outcome is assumed to result from processes and processes are assumed to require structures. An outcome may be a facility outcome which indirectly supports direct resident care. An example of an indirect or facility outcome would be supervising and correcting or training staff That changes staff knowledge and skills. Staff applying those new skills is a process which should yield better resident outcomes. Resident outcomes may be classified as physical (death, disease, disability or dysfunction) and psychosocial (discomfort, dissatisfaction). Resident outcomes are usually specified in terms of health, well-being, patient satisfaction, etc. Resident outcomes are usually improved when staff provide and residents experience resident oriented care.

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 comparison site intended to foster quality improving competition between nursing homes.


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 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. Many of the facilities utilizing these models 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."

Quality of life

Task-oriented care

Task oriented care is where nurses are assigned specific tasks to perform for numerous residents on a specific ward. Residents in this particular situation are exposed to multiple nurses at any given time. Because of the random disbursement of tasks, nurses are declined the ability to develop more in depth relations with any particular resident. Licensed (vocational) nurse training in the United States is task oriented. The primary care giver in a certified nursing home is a "Certified Nurses Aide" (CNA). CNAs receive a minimum of 75 hours of didactic and practical task-oriented training and must pass an oral or written test. Thus, in U.S. nursing homes, the training of the majority of direct care-givers in nursing homes is task oriented.

Resident-oriented care

Resident oriented care is where nurses are assigned to particular patients and have the ability to develop relationships with individual patients. Patients are treated more as family, as opposed to random patients in an institution. Using resident-oriented care, nurses are able to become familiar with each patient and cater more to their specific needs, whether they be emotional or medical. In contrast, institutional care is institution-centered. The focus is staff convenience and efficiency. Staff perform tasks rather than interact with residents to achieve desirable resident outcomes. Where resident-centered staff know residents by name, institutional staff identify residents by room number, diagnosis, or a task like "feeders" for residents who need help to eat.

Scientific findings

According to various findings residents who receive resident-oriented care experience a higher quality of life, in respect to attention and time spent with patients and the number of fault reports after the introduction of Primary Nursing. Once they experience it, nurses often prefer resident-oriented settings, too. Although resident-oriented nursing does not lengthen life, nursing home residents are able to connect with someone, which allows them to dispel many feelings of loneliness and discontent.

"Resident assignment" refers to the extent to which residents are allocated to the same nurse. With this particular system one person is responsible for the entire admission period of the resident. However, this system can cause difficulties for the nurse or care-giver should one of the residents they are assigned to pass away or move to a different facility, as the nurse/caregiver may become attached to the resident(s) they are caring for.

Various findings suggest that task-oriented care produces less satisfied residents. In many cases, residents are disoriented and unsure of who to disclose information to and as a result decide not to share information at all. Patients usually complain of loneliness and feelings of displacement.

"Resident assignment" is allocated to numerous nurses as opposed to one person carrying the responsibility of one resident. Because the load on one nurse can become so great, various nurses are unable to identify with gradual emotional and physical changes experienced by one particular resident. Resident information has the ability to get misplaced or undocumented because of the numerous amounts of nurses that deal with one resident. [citation needed]


Some commentators have been highly critical of nursing homes. Bioethics scholar Jacob M. Appel has written of a "nursing home-industrial complex" which would "lose billions of dollars" if alternatives to nursing home care, such as assisted suicide, were to be legalized.[9] In one highly publicized case in 2009, Paul Weinstein, a pharmacist from New Rochelle, New York, shot to death his demented wife to prevent her from entering a nursing home.[10]

Emergency management

Dealing with an emergency in nursing home is always a formidable task which involves the damage control and mitigation of the event. Not many written plans or standard operating procedures are available publicly, except for a few [11]. However, there are published academic reviews about the topic written by many authors [12], [13], [14].

United Kingdom

In the 2002 nursing homes became known as care homes with nursing and residential homes became known as care homes [15].

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, you need an assessment of needs and of your financial condition from your local council. You may also have an assessment by a nurse, should you 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. Patients who require additional nursing care are assessed for this (Hampshire nursing limit 2009 £483pw) and receive additional financial support (£103.80pw) through the National Health Service (NHS); this is known as NHS Continuing Healthcare [16].

Care homes for adults in England are regulated by Care Quality Commission or CQC [17], 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 the Scottish Commission for the Regulation of Care and in Northern Ireland the Regulation and Quality Improvement Authority in Northern Ireland.

See also

  • American Health Care Association
  • American Geriatrics Society
  • American Society of Consultant Pharmacists
  • Care Quality Commission previously known as Commission for Social Care Inspection
  • Eldercare
  • Home care
  • International Association for Homes and Services for the Aging
  • Psychiatric units
  • Retirement communities
  • Sanatoriums


  1. 42 CFR Part 483
  3. Special Focus Facility (“SFF”) Initiative, Centers for Medicare and Medicaid Services (accessed 4/24/2008)
  4. "Medicare: CMS Adds Searchable Database of Lowest-Quality Nursing Homes Nationwide to Web Site," Kaiser Daily Health Policy Report, Kaiser Family Foundation, April 24, 2008
  5. United States Government Accountability Office, "NURSING HOMES: Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses," GAO-08-517, May 2008 (GAO Summary)
  6. "Coverage & Access | Inspectors Often Overlook Serious Deficiencies at U.S. Nursing Homes, GAO Report Finds," Kaiser Daily Health Policy Report, Kaiser Family Foundation, May 15, 2008
  7. Robert Pear, "Violations Reported at 94% of Nursing Homes," The New York Times, September 29, 2008
  8. NFPA Journal - Behind Closed Doors
  9. "Mercy Killing": When Love & Law Conflict, Huffington Post, September 25, 2009
  10. 'Mercy killing' NY husband charged with wife's murder New York Post, Sept 24, 2009
  11. Florida Department of Elder Affairs Office of Disaster Preparedness and Emergency Operations. (PDF) URL accessed on 25 July 2008.
  12. Tumosa, Nina (2007). Disaster: Nursing Homes Need to be Prepared. Journal of the American Medical Directors Association 8 (3): 135–137.
  13. Fox, Michael H. et al. (2007). Disaster Preparedness and Response for Persons With Mobility Impairments. Journal of Disability Policy Studies 17 (4): 196–205.
  14. Castle, Nicholas G. (2008). Nursing Home Evacuation Plans. American Journal of Public Health 98 (7): 1235–1240.
  15. Age Concern - NHS Continuing Healthcare, NHS funded healthcare and intermediate care, August 2007

External links

United States

United Kingdom

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