Medicare beneficiaries often need care in a skilled nursing facility after an inpatient hospitalization. For these patients, hospitals are responsible for identifying skilled nursing facilities within the geographic region that can meet their medical needs. Until such a placement is found, the beneficiary will not be responsible for her hospital stay. However, once a placement is found, if the patient no longer needs a hospital level of care, she will become financially responsible for her continuing hospital stay. Unfortunately, patients, families, and friends are often not happy with the hospital identified skilled nursing facility placement. Here are some tips to help families and friends evaluate identified placements and to potentially identify better options.
The following may be helpful in assessing and choosing a nursing facility:
- Elder Care Locator (Information about local resources for persons in need of elder care): http://eldercare.gov/
After typing in your zip code or the city and state where you reside, the Elder Care Locator provides contact information for local area agencies on aging, state agencies on aging, health insurance counseling programs, legal services, and the Long-Term Care Ombudsman. As more fully discussed in the glossary below, these agencies can help you identify and evaluate nursing facilities.
- Research the Facility on the Internet
While Nursing Home Compare can be helpful, it is important to visit the websites of particular facilities. It is also important to review newspaper articles and discussions about the quality of care and treatment of residents in particular facilities, as well as reviewing written commentary from current and former residents and their families.
- Nursing Home Compare (A website that allows one to compare nursing facilities in a given location) http://www.medicare.gov/nursinghomecompare/search.html
Nursing Home Compare, developed by the Centers for Medicare & Medicaid Services (CMS), uses a 5-star rating system to classify the quality of care in a given care facility. Although potentially helpful, ratings through Nursing Home Compare should not be the major factor in choosing a facility, as many of the quality ratings criteria are self-reported by facilities (See http://cma.benfredaconsulting.com/the-myth-of-improved-quality-in-nursing-home-care-setting-the-record-straight-again/). Information available through Nursing Home Compare includes:
- Five Star Quality Ratings Generally (A brief explanation of the measures on which the 5 Star Rating system is based): http://www.medicare.gov/NursingHomeCompare/About/Ratings.html
- Inspection and Complaint Information (How to read inspection and complaint information): http://www.medicare.gov/NursingHomeCompare/About/Inspections-and-Complaints-Info.html
- Staffing Information (Staff found in nursing homes and how staffing measures are reported): http://www.medicare.gov/NursingHomeCompare/About/Staffing-Info.html
- Quality Measures (How quality measures are reported): http://www.medicare.gov/NursingHomeCompare/About/Quality-Measures-Info.html
- Penalties (Common penalties assessed against skilled nursing facilities): http://www.medicare.gov/NursingHomeCompare/About/Penalties-Info.html
- State Survey Reports (These reports by each state's department of health or similar state entity explain problems that a state has identified in a facility and the seriousness and breadth of the identified problems): http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationEnforcement/2567report.html
- Patients or Family Members Should Visit Identified Facilities
Once you have developed a list of potential facilities, visiting can be helpful in evaluating the facility's level of care, quality, and feel.
Things to Consider Before Your Visit:
- Addressing Your Individual Needs: Call the facility and ask for a specific accommodation such as meeting special dietary needs. See how they respond. Are they helpful or are they dismissive? Do they seem rushed when speaking to you?
- Special Services: When a facility advertises that it offers certain services such as physical therapy, be aware that the Nursing Home Reform Law requires all nursing facilities to provide skilled nursing and therapy services designed to accommodate a patient's specific health needs, and provide necessary durable medical equipment.
Planning Your Visit:
- When to Visit: Visit during meal times, evening hours, on weekends and at times when staff shifts are changing. Observing these important time periods can provide insight into the culture and practices of a particular facility. Nursing homes often look best on weekdays during the day, when more fully staffed.
- Location: Be aware of the location of the nursing home. The closer the patient is to friends and family who can visit regularly, the better. Choosing a location in or close to the patient's neighborhood (or within a reasonable driving distance) may be preferred as it can give residents a sense of comfort and connection.
Other Observations of Potential Nursing Facilities:
- Smell Test: Be aware of the smell of the facility. The smell of urine indicates a facility that does not adequately take care of incontinent patients. Conversely, a strong smell of disinfectant could indicate the facility is hiding other odors.
- Look Test: Do not be too easily impressed by the lobby of a facility. While a clean and impressive first floor could indicate good care throughout the facility, it also could just be a façade. Tour several areas of the facility, including the dining room (are residents engaged in conversation with each other? Helped to eat if they need assistance? Eating their meals?). If possible, and with the permission of the resident, visit a resident's room (is the room personalized? Is there privacy?). Observe the interactions of staff and residents (does the staff greet residents by name or do they appear rushed?)
- Restraint Use: The Nursing Home Reform Law bans the use of restraints (physical or chemical) that are not required to treat the patient's actual condition. Ask about restraint use. Look around to see if physical restraints are being used. Identifying the use of chemical restraints is more difficult. For that, it may be best to look at federal survey reports about a particular facility.
- Lost Items: Ask how the nursing home addresses the prevention of the loss or theft of a resident's belongings.
- Talk to Residents/Visitors: When staff members are not present and with the permission of a resident or visitor, try to get a sense of his or her satisfaction with the facility. Ask if there is a family council and, if so, for the name of a contact person on the council.
- After You Have Gathered Information
When you have completed gathering information and have identified your preferred facilities, communicate your preferences to the hospital's discharge planning staff and to your physician(s).
- If You Do Not Feel Ready to Leave the Hospital at Discharge
If you do not feel ready to leave the hospital at the time you have been discharged, you can appeal the hospital's discharge decision. Detailed instructions on how to do this can be found at; http://cma.benfredaconsulting.com/medicare-info/discharge-planning/#appeal
- Other Helpful Resources
- Long Term Care Planning (Information and resources for long-term care planning): http://longtermcare.gov/
- National Long-Term Care Ombudsman Resource (Long-term Care Ombudsman can further assist you in finding and placing yourself in a nursing facility): http://www.ltcombudsman.org/
- Alternatives to a Nursing Facility
- Inpatient Rehab Facility (CMS's coverage criteria are listed under 42 C.F.R. §412.622(a)(3)): http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec412-622.pdf
Since most people prefer living in their own homes, explore the possibility of returning home for post-acute care and services.
- Home Health Services (General overview of Medicare-covered home health services and who is eligible for them): http://www.medicare.gov/coverage/home-health-services.html
- Home Health Compare (CMS's evaluation of home health services in your area): http://www.medicare.gov/homehealthcompare/search.html
- National Association of Professional Geriatric Care (A non profit organization that assists older adults with long-term care arrangements): http://www.caremanager.org/
- Further Understanding Your Healthcare Plan
For persons using health plans under Medicare's coordinated care options (Medicare Advantage, including HMOs, PPOs), it is important to understand what your health plan covers and its network limitations. It is also important to have a current list of the physicians and specialists in your plan's provider network. This information should include the services covered by your health plan, the costs you must cover (copayments, deductibles) and when you use plan providers or when you use service providers who are outside your plan's network. Keep in mind that the cost of using out-of-network providers may be higher than it would be if you use in-network providers. And, depending on the plan, it may not cover any of the cost of using out-of-network providers without first obtaining the plan's approval. A set of tips that can be helpful as you explore your Medicare Advantage plan options is available at: http://marketplace.cms.gov/help-us/c2c-roadmap.pdf?linkId=8267630.
Useful Terms and Organizations
- Area Agency on Aging (AAA): "A public or private non-profit agency designated by the state to address the needs and concerns of all older persons at the regional and local levels. By providing a range of options that allow older adults to choose the home and community based services and living arrangements that suit them best, AAAs make it possible for older adults to remain in their homes and communities as long as possible." For more information go to: http://eldercare.gov/Eldercare.NET/Public/About/Aging_Network/AAA.aspx
- Acute Care Hospital: A hospital where the average length of stay is 25 days or less and patients generally receive intensive but short-term care.
- Health Insurance Counseling and Assistance: "This program utilizes paid professionals and trained volunteers who offer unbiased, one on one counseling to help consumers understand their Medicare health insurance benefits and resolve billing problems. They also address issues related to supplemental insurance and long term care insurance options."
- Inpatient Rehabilitation Facility: CMS states that inpatient rehabilitation facility (IRF) benefits are "designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care."
- Legal Assistance: "Legal advice and representation is available to persons aged 60 and over for certain types of legal matters including government program benefits, tenant rights, and consumer problems."
- Long-Term Care Ombudsman Program: "Long-Term Care Ombudsmen are advocates for residents of nursing homes, board and care homes, assisted living facilities and similar adult care facilities. They work to resolve problems of individual residents and bring about changes at the local, state and national levels that will improve residents' care and quality of life."
- State Agency on Aging: "State Agencies on Aging are units of state and territorial governments designated by governors and state legislatures to administer, manage, design and advocate for benefits, programs and services for the elderly and their families and, in many states, for adults with physical disabilities.
Although choosing a nursing facility is often a stressful life event, being aware of one's rights is an important aspect of the process of finding a nursing facility that meets the needs of the Medicare beneficiary.
The Center for Medicare Advocacy thanks Health Policy Fellow Sophia Schechner for her work on this Alert.
July 17, 2014
Sophia Schechner with Alfred J. Chiplin
 For information on assessing nursing home quality, see http://assets.aarp.org/www.aarp.org_/promotions/text/life/NursingHomeChecklist.pdf (site visited June 16, 2014); see also http://theconsumervoice.org/issues/family/fact-sheets#Selecting%20a%20Nursing%20Home (site visited June 16, 2014).
 Definitions can be found at http://eldercare.gov/ (Site visited at June 16, 2014).
 Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf (Site visited July 14, 2014).