Finding a nursing home requires advance work

08/09/2014 2:58 PM

08/13/2014 12:34 PM

Nobody looks forward to spending the last years of life in a nursing home, yet 1.4 million Americans are living in this often-feared institutional setting.

You may not want to place a loved one in a nursing home for more than a short-term recovery, but never promise an aging relative that it won’t happen.

“When faced with the responsibilities of providing 24-hour care for an aging person with ever-increasing physical needs beyond what one person can physically handle, a nursing home frequently becomes the best alternative,” Joanna R. Leefer writes in “Almost Like Home,” a useful guide to choosing a nursing home.

Nursing homes generally have had a bad reputation as smelly, indifferent places where people go to die. But “there are some homes that are better than being at home,” Leefer said. “And there are many more good facilities than bad ones.”

Leefer developed her expertise through personal and professional experience, and her book is replete with checklists and scores of relevant websites. She learned a lot firsthand as primary caregiver for her aging parents, one of whom lived three years with nursing-home-type care. She worked five years for an advocacy organization for older adults, and she founded a consulting firm, ElderCareGiving, to help families make difficult care decisions.

Finding a place that suits the needs of an aging relative or friend, and those who plan to visit, requires considerable preparation.

“The biggest mistake people make is waiting until the last minute, when faced with a crisis, to find a suitable facility,” Leefer said. “You’re forced into an impulsive decision that you’re not likely to be happy with unless you’re really very lucky.”

She likened it to shopping for a car: “Do the research, start looking around, find out what’s available, what each facility offers, what’s best for your loved one,” she said. “Become an educated consumer.”

Crass as it may seem, you might start with the cost. When paid for privately, the average ranges from $10,000 to $15,000 a month. Medicare does not pay for long-term nursing home care, only temporary skilled care, usually in the rehabilitation section of the home.

If the patient qualifies for Medicaid, and the nursing home accepts it, most of the cost is generally covered. The beneficiary must be 65 or older, disabled and a U.S. citizen. He or she can have no more than a certain amount in assets, as determined by the state. Some patients become eligible by transferring savings and assets to a third party at least five years ahead of time.

Next, choose a reasonably convenient location for likely frequent visitors. You can search for possibilities online by township or ZIP code. Ask neighbors and friends for recommendations or information they might have about homes in the area.

Make a list of homes in the chosen area and check out the government’s report card at Medicare.gov’s Nursing Home Compare site. Every home that receives federal funding must be evaluated and rated on a scale of 1 to 5 (5 being best). The assessments are far from perfect; a recent study, for instance, found that star ratings often don’t correspond to how patients feel about their nursing homes.

Still, Leefer suggests considering only homes with a rating of 3 or higher. Then start examining their characteristics.

What specialized services might the patient need? A dementia program? Mobility practice? Hospice care? Are there medical specialists on call? Is the home affiliated with a good nearby hospital? If the patient has a personal physician, you might prefer a home where that doctor has privileges.

If the patient is not fluent in English, are there staff members (and other residents) who speak the person’s language? Are there activities that would interest the patient, including opportunities to go outdoors?

Don’t rely on brochures. Take a tour, preferably more than once at different times, including mealtimes. Visit more than one floor. Does the place look and smell clean? An odor of urine is a clue to neglect. Are the rooms light and airy? Are residents permitted to have a few personal decorative items or furnishings?

Observe how patients are treated by staff members. Are they courteous, patient, friendly and respectful of patients’ privacy? Are patients greeted by the staff and addressed by name? Are those who need it helped with eating and drinking?

Are there rigid wake-up, bed and meal times, or do patients have some choice? Do the menus offer selections? If possible, talk with a few residents and their family members.

Leefer suggests preparing a checklist for the nursing homes you are considering, listing issues relevant to quality of life, quality of care, safety, nutrition and hydration.

Admission to a nursing home is not automatic but based on such factors as availability, care requirements and the patient’s condition. It is best to submit applications to chosen homes well in advance of a needed admission. Waiting lists can be longer than a year.

Your job does not end once a family member is admitted; monitoring the care is critical. At first, expect resistance from the patient, often accompanied by a loud desire to “get me out of here now.” Visit often and stay as long as possible to ease the transition, Leefer says.

Be sure you or someone trustworthy is authorized to serve as the patient’s health care proxy so critical medical decisions can be made when he cannot speak for himself. Make sure you have access to medical records and be present when the patient is examined and dressed. Check for any hints of physical abuse and signs of incipient or existing bed sores, which can become infected and hasten death.

Find out the names of staff in charge of various services, and speak to them about the patient’s special needs or problems. Keep notes, dated, with any issues of concern.

Try to solve any problems with the nursing home staff. Be polite and soft-spoken, and avoid confrontation. A hostile approach puts people on the defensive and is unlikely to get the patient’s needs addressed.

If necessary, speak to the heads of departments; filing a formal complaint with the health department should be a last resort.

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