Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
CHAPTER FOUR: NURSING FACILITIES
CHAPTER HIGHLIGHTS
Introduction
Nursing facilities used to be called “nursing homes”
They include those certified by Medicare as Skilled Nursing Facilities (SNF) and what
used to be called Intermediate Care Facilities (ICF), the primary difference being the
amount of nursing care provided.
How nursing facilities developed
Nursing homes grew out of early charity-based forms of care for people without family to
care for them or other sources of help.
They came into their own when the federal government became involved with Helping
the needy with passage of the Social Security Act in 1935 and the Medicare and
Medicaid amendments in 1965.
They suffered through a lingering poor public image.
Philosophy of care
Medical vs. Social Model – Nursing facilities find themselves sitting solidly astride the
line between acute care and long-term care.
A Multidisciplinary Approach – They utilize a combination of medical, social, residential,
and other allied professionals to provide needed services, blending those disciplinary
specialties to develop and implement care plans for individual consumers.
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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Family Involvement – Another distinguishing characteristic of long-term care in general,
and nursing facilities in particular, is the degree to which family members are involved in
the care of the primary consumer.
Ownership of Nursing Facilities
More for-profit than nonprofit
More than half owned by national multi-facility chains
Occupancy
The occupancy rate for nursing facilities has declined from a high of 89.0 percent in 2007
to 86.0 percent to 2013.
This may be due to competition from community-based services.
Services Provided
Nursing
Physical therapy
Occupational therapy
Speech therapy
Medical and dental services
Medications
Laboratory and x-ray services as needed.
Special Care Units – many facilities created special care units to meet the needs of a wider
variety of residents. They may be:
Based on a Specific Diagnosis or Disability
Alzheimer’s Disease
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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Mental Health & Mental Retardation
Brain Injury
AIDS
Based on Age
Pediatric
Young Adults
Consumers Served
By age:
Mostly elderly
By care Needs:
Admitted because of functional disabilities, resulting from a number of medical or
physical conditions
May include both physical and mental disabilities
By gender Mix:
Three-quarters women
Market Forces Impacting Nursing Facilities
Need-Driven Vs. Choice-Driven Admissions – most residents do not choose to be
admitted, but must be due to their conditions.
Family/Physician Initiated Admissions – admission is usually not at the request of the
resident but by family or a family physician.
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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Hospital Readmissions – under the Affordable Care Act’s Hospital Readmissions
Reduction Program, hospitals that readmit “excessive” numbers of Medicare patients
within 30 days of discharge now face significant penalties.
Location Relative to the Resident’s Family – facilities are often chosen so the resident
can be close to family members.
Alternative Types of Care (or Lack of) – some are admitted to nursing facilities because
of a lack of other alternatives (e.g., community-based care).
Regulations
There are three primary categories of regulations:
Affecting Residents – Regulations concerning care and quality of care
Affecting Employees – regulations protecting employees from unfair treatment
Affecting Building Construction and Safety – regulations assuring proper construction
and maintenance of facilities.
Financing Nursing Facilities
Medicaid is the largest source (two-thirds)
It covers the medically indigent
Medicare is the next largest
It provides limited coverage
Other sources include insurance and out-of-pocket
Staffing/Human Resource Issues
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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Nature of the Work Force – nursing facilities utilize a staffing mix that combines both
highly trained and relatively untrained staff.
Must provide both clinical and non-clinical care
Government regulations, particularly OBRA and Medicare, specify the numbers of
staff on duty on each work shift and the mix of personnel categories making up that
staff.
Nursing
Certified Nurse Aides
Medical Coverage
Other Specialists
Recruitment/Turnover Issues
Aging of the workforce – the population group available to provide care is getting
smaller due to aging
Relatively low pay – the amount allowed by Medicaid (the primary payment source)
is not adequate
Competition from other sectors – staff can make more working elsewhere, even in
fast-food restaurants
Legal/Ethical Issues
Day-To-Day Quality of Life Issues
Desire for privacy, personal autonomy
Individual vs. group choice is an issue
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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
End of Life Issues
Many residents live out their last days in a nursing facility
Competency and choice are issues
Management of Nursing Facilities
Management Qualifications:
Must be licensed by states
Some variation in state regulations
Management Challenges & Opportunities:
Balancing Cost and Quality – never enough resources
Integration of Differing Levels of Service – many are part of a multi-level facility
providing several types of care, possibly including Helped living, home health care
and/or subacute care in addition to skilled and nursing care.
Coordination with Other Facilities, Organizations – it is no longer possible/feasible to
stand alone.
Significant Trends and Their Impact on Nursing Facilities
Rising Acuity Levels – as acute care hospitals try to save money, higher acuity patients
are sent to nursing facilities.
Managed Care – has become a primary form of reimbursement and comes with strings
attached.
Other Reimbursement Trends:
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Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
Prospective Payment
Private LTC Insurance – not a large enough source of reimbursement
Payment Bundling – the ACA created a system of payment bundling where a single
entity would receive a sum of money to cover the costs of an episode of care spanning
two or more providers
Rising Liability Insurance Costs – threaten the survival of providers
Consumer Choice – the single, most important trend today is the demand by consumers
for more choice in their care
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Fourth Edition of Long-Term Care: Managing Across the Continuum
Pratt, John R.
NURSING FACILITIES (CHAPTER 4)
HIGHLIGHTS FROM EACH CHAPTER
Introduction
Nursing facilities used to be referred to as “nursing homes.” They include Medicare-certified Skilled Nursing Facilities (SNF) and what were previously known as Intermediate Care Facilities (ICF), with the key difference being the amount of nursing care given.
How nursing homes arose Nursing homes arose from early charity-based types of care for those who lacked family or other sources of Helpance.
They rose to prominence after the federal government became involved in supporting the poor with the introduction of the Social Security Act in 1935 and the Medicare and Medicaid Amendments in 1965, but they still have a bad public image.
Philosophy
