"Nursing home" is a catch-all term for any residential facility where people receive health care. Some are meant to provide transitional rehabilitation to people well enough to leave a hospital bed but not yet ready to go back to their independent home living; others provide long term care for people who cannot be cared for at home. Many are stand-alone facilities, but some are associated with hospitals and others with retirement communities for those still living independently. Some are operated by large commercial enterprises owning chains of facilities, some are individually owned (I know of one in Miami run by the same family for three generations), and some are non-profits operated by religious or other organizations. All they have in common is health care and living spaces. But a MacArthur Foundation study quoted in one of the newsletters I worked on says that 5.2% of Americans over 65 live in some sort of nursing home.
For four and a half years as of this writing, I've worked for a service that publishes newsletters for nursing and rehabilitation facilities. Working with each facility's material gives one an interesting view of what different American nursing homes do. As my mother pointed out, we may have a selection of higher-end facilities if they are willing to spend money on having these newsletters and/or calendars professionally printed, but in some places having the publication helps fulfill state requirements that the nursing home residents or their family members be informed of things going on at the facility.
Almost all facilities have:
- an overall administrator;
- a medical director (who may be an MD, an RN, or even an LPN) supervising the overall medical care;
- a director of nursing who is in charge of the largest portion of the facility's staff, nurses and nursing assistants; the nursing assistants "provide 90% of the hands-on resident care." (NCCNHR) Physical/occupational/speech therapists may be under a separate rehabilitation department, and medical records is also sometimes spun off;
- an activities department in change of doing things to keep the residents from being bored or lonely;
- a department of admissions/marketing, in charge of the facility's public relations and drawing residents to choose the facility to live in;
- a social services deparment, usually with at least one social worker, who counsel the residents emotionally, deal with interpersonal conflicts such as roommate problems, and often help with things like applying for Medicare;
- a food services department with one or more dieticians to plan the meals nutritiously, as well as the cooks who make them;
- a business office who actually take care of the residents' payments;
- a housekeeping/laundry department which takes care of bed linens, towels, washing clothes, and keeping the facility clean -- given the high rate of turnover among nursing assistants, these may be the most familiar visitors to the residents in some facilities;
- a maintenance department which deals with electricity/water/physical plant matters
It seems expensive for a person to live in a nursing home, but that facility has a fleet of staff available to take care of the resident's needs for food, nursing, counseling, activity, socializing with peers, help with activities of daily living such as bathing and getting dressed, laundry, housework, physical therapy, and everything else that can overwhelm a home caretaker.
Long-term care is certainly expensive, and long term care insurance plans, Medicare, and Medicaid are generally necessary to cover the cost without running through the resident's assets and into those of their family members. Some facilities become political lobbyists in an attempt to keep the government programs running which allow their residents the money to be cared for. (Other facilities accept only private pay and not Medicare/Medicaid.) It may be a lot for one person to pay, but when the salaries and wages of all those staff are paid, the food, medical, and other supplies are bought, the upkeep of the building paid for, many facilities are short on money for extras. A lot of the Activity Departments ask for donations -- videotapes for the residents to watch, small knick-knacks to give out as prizes in bingo and other games, craft supplies, and things to sell at fundraising bazaars.
The facilities also ask for help from the families and friends of the residents -- bringing in family photographs and holiday decorations, volunteers to come in and visit with residents in their rooms or accompany residents on group outings, and even changing the residents' closets over from warm weather to cool and back again several months later, because there's usually not much storage space in the rooms. Volunteers bring in pets to visit the residents, hold religious services for them, or perform music for them. The activity staff, generally not more than five people, is busy with morning coffee klatches, light exercise of many types, Snoezelen and other kinds of sensory-awareness events, manicures and makeovers, reminscing groups, shopping trips, movies, card and table games, Bible/Torah study groups, cooking classes, crafts, trivia, word games, walks in the garden, parties/socials, and men's clubs (both the resident population and the employees tend to be have a large female majority, and it can be hard for the male minority. My late grandfather Saunders was very dissatisfied with the first home he was in because he couldn't find any male friends; my uncle found another facility with more men in it and Granddaddy was much happier during the time he was there.) All those activities in places where many of the residents may need help to get out of bed, much less down the hall to the activity room. One-on-one room visits are also included when possible; anything to make the institution a little more homelike or at least comfortable to live in.
A special subset of nursing homes is the Alzheimer's unit. Many facilities have a separate wing dedicated to people with dementia, and this area has its own special requirements. It needs to be physically secure -- Alzheimer's patients have a tendency to wander around in their confusion, so they can't be able to get out of the wing. (In fact, one facility had a problem with dementia residents going into each other's rooms without invitation -- they had to install a system where chimes would go off to alert the staff when a room door was opened. A buzzer would have disturbed the residents.) Activities have to be specially designed for the cognitively impaired. Staff also have to be trained to deal with residents whose problems, such as sundowning, manifest more in the mind than the physical ones that usually bring residents to the other wings.
Many retirement communities for the still-active and healthy person have a nursing home as part of the community. This can come in handy as people get older -- my great-aunt Jean and her husband Arthur bought an apartment some years ago in a retirement community, and Jean still lives there even though Arthur has had to be moved to the nursing home's Alzheimer's Unit. It works out well for her -- she sees Arthur daily, even on icy winter days when driving to a nursing facility would be difficult if she still lived at their old house.
In the U.S., each state has its own legal requirements for nursing homes. Usually, each facility is surveyed annually by a state team to make sure it meets the requirements. If there are a few small deficiencies, the facility is just required to correct them, but one facility's administrator pointed out in 2003, when the Tampa Bay Buccaneers won the Super Bowl, that if the facility had as bad a record as the Bucs had in this successful season, it would be closed down. The survey results are publicly available to the residents and to people who are interested in evaluating facilities -- Medicare.gov, among other sources, has a web page where one can search and compare facilities in the same geographical area. Most states also have an agency or ombudsman's office where complaints about nursing facilities can be sent and acted on.
In choosing a nursing home for a loved one, the public information on its state surveys can be a great help. Different consumer organizations also put together checklists on what to look for in a nursing home; all of them recommend visiting multiple homes (particularly during mealtimes and in the evenings when fewer staff are on duty), talking to residents, their family members/friends, and staff, and keeping an eye out for little things. There are good homes and bad ones; a little extra work in the deciding process is worth it to make sure your loved one will be in a good one.
Sources (and further reading for those faced with finding a good nursing home):
helping prepare nursing home newsletters from July 1998 to March 2003 when I updated this writeup.