Appendix E:
Long-Term Care Nursing Homes

Available Topics:

What Are Nursing Homes?

Who Are the Providers of Nursing Home Services?

How Are Nursing Homes Services Paid For?

Who should I Contact for Additional Information?

What Are Nursing Homes?

Nursing homes are long-term care facilities that offer a protective, therapeutic environment for those who need rehabilitation or can no longer live independently because of chronic physical or mental conditions that require round-the-clock care. Nursing homes are licensed facilities that provide 24 hour-per-day skilled nursing care, physical and mental rehabilitation, assistance with activities of daily living, nutritional management, and activities that address social, spiritual, and recreational needs. Meals, laundry, and housekeeping services are also provided. Residents typically have a private or semi-private room with a bath. Nursing homes are sometimes referred to as convalescent homes, rest homes, intermediate or extended care facilities, or skilled nursing facilities.

While all nursing homes provide general medical and social services to residents, they may also specialize in care for certain types of residents, such as those who need physical therapy, Alzheimer's care, or other specific types of care. In general, most nursing homes offer a variety of specialized services. Many specialty services are not part of the care covered by the facility contract or daily rate and therefore cost extra.

The goals of nursing home admission are different for every resident. Some residents will return home after a brief rehabilitative stay. Others may be very ill and may live only a short time. Many may need care for an extended period of time. Whatever the case, good nursing facilities enable residents to capitalize on their strengths and compensate for their weaknesses in an atmosphere as homelike as possible. They involve residents and their families in decisions about their care and the nursing home environment. In addition, a good nursing home should help residents maintain self-esteem, build strength, continue social relationships and interests formed over a lifetime, and even assist in developing new ones.

Who Are the Providers of Nursing Home Services?

Nursing homes are licensed by the Texas Department of Human Services and must meet state and federal government licensing standards. They are monitored by the Texas Department of Human Services, the U.S. Department of Health and Human Services, the U.S. Occupational Safety and Health Administration, state and local fire safety agencies, and a variety of other government agencies. In all, there are about two dozen agencies monitoring licensed facilities on a regular basis.

A board of trustees determines the general policies of the home and implements its mission of care and service to the total person. Trustees are volunteers who often are leaders of the local community.

The administrative staff is responsible for the day-to-day planning and operations of the home. Personnel usually include an administrator or executive director, and admissions, personnel, and financial officers. A director of nursing is usually a registered nurse who manages the daily activities of other registered nurses, licensed vocational nurses, and nursing assistants. Other health care professionals, such as therapists, social services staff, nutritionists, and pastoral care staff provide a variety of services.

Each nursing home has a designated medical director who coordinates with other staff to ensure the adequacy and appropriateness of the medical services provided to the residents. Often, the medical director is the primary physician for many of the residents; however, the resident can use his or her own physician provided the physician agrees to visit the resident at the nursing facility.

How Are Nursing Homes Services Paid For?

Nursing home care, like all good health care, is costly. Before you agree to pay for services, be sure you understand completely all the financial arrangements of the nursing home.

Almost one-third of all Texas nursing home residents pay for costs out of personal resources. Many people enter a nursing home and begin paying for their care out of their own income and savings. Because of the high costs of such care, they deplete their resources.

Traditionally, private insurance has not paid for nursing home care. However, this is beginning to change and some private insurance policies cover nursing home care. The insurance policy should detail any long-term care coverage and a policy-holder should check with the insurance provider to see what services and charges will be covered.

Medicare is a federal health insurance program for people over 65 years of age and people with disabilities. Nursing facility coverage under this program is very limited - up to 100 days per spell of illness. Generally, the first 20 days are fully covered by Medicare, with the resident being responsible for a sizable co-payment for the remaining 80 days. The total daily rate for days 1 - 100 generally runs $200 to $250. To qualify for Medicare payments in a nursing facility, a person must have recently been in the hospital for at least three days and must be medically unstable at the time of entering a Medicare-certified nursing home.

Medicaid is a joint federal/state program for lower-income people. As the major payor of long-term care, Medicaid will pay for care for those who meet both medical and financial criteria. The financial criteria is adjusted each year, but generally, a person will qualify for assistance from Medicaid if his or her monthly income is about $1300, with total assets of $2,000 or less. Different criteria are used for a married resident who has a spouse at home. Texas requires Medicaid recipients to contribute all but $30 of their monthly income toward the costs of nursing home care. A nursing home must be Medicaid certified, or at least have a portion of the facility for Medicaid residents. Eligibility is determined by the Texas Department of Human Services according to the state formula.

The Veterans Administration contracts with some nursing homes to care for qualified veterans. In many cases, these are short stays of three to six months, although sometimes the VA will cover the costs for longer periods.

Nursing home costs are generally calculated on a daily rate. Nursing home costs vary in Texas based on the facility and level of care that is required by the resident. Those individuals who have higher skilled nursing needs can expect to pay a higher rate than those with less skilled nursing needs. For those nursing home costs that are reimbursed by a third party, the rate is determined by the third party payor, i.e., Medicaid, Medicare. The average nursing home rate for a private-paying individual in Texas is $100.00 per day. However, costs may vary based on the level of care needed, location of the facility, and other services and amenities that are offered by the facility.

Who to Contact for Additional Information:

Texas Department on Aging

1949 IH-35 South

Austin, Texas 78741

(800) 252-9240 (you should be automatically connected to the Agency on Aging nearest you).

Texas Department of Human Services

P.O. Box 149030

Austin, Texas 78714-9030

(800) 252-9240 (to find out your local contact agency)

Texas Association of Homes and Services for the Aging

2205 Hancock Drive

Austin, Texas 78756

(512) 467-2242

Texas Health Care Association

P.O. Box 4554

Austin, Texas 78765

(800) 380-2500

Tips:

1. If you are looking for a nursing home, make sure the facility has a current state license. Ask to see the facility's state inspection report. If you get the run-around or if the report contains any unexplained health, safety, or quality of life deficiencies, consider dropping that facility from your consideration.
2. If Medicaid or Medicare are paying for the care, make sure the facility is a certified Medicare and/or Medicaid provider.
3. Talk with your physician about the level of care and any specific services that are needed and make sure the facility can meet those needs. Find out what medical, therapeutic, and other specialty services are available.
4. What services are included in the basic daily rate? Ask for a complete list of specific services and benefits not covered in the basic rate.
5. Make a worksheet for evaluating each facility you are considering. Select the criteria you feel are important and "weight" the different criteria based on what is most important to you and what is less important.
6. When evaluating a nursing home, it's important that you get answers to whatever questions you may have, that you not feel intimidated, and that you have a tour of the entire facility. Spend plenty of time at each of the facilities. Make return visits to the facilities that look promising.
7. Talk with everyone from the administrator to the director of admissions, nurses, visitors, volunteers, family members of residents at the facility. Notice the interaction between staff and residents, interaction among the staff, and the activity level of residents. Is family involvement encouraged and, if so, how?
8. When trying to decide on which homes to visit, talk to your physician, friends who have had experiences with local facilities, hospital social workers, and religious organizations. Referrals from someone you know and trust are often your best source.
9. Both the Texas Health Care Association and the Texas Association of Homes and Services for the Aging have checklists for helping select a quality nursing home that best meets your needs. See "Who to Contact for Additional Information" above for the addresses and phone numbers.
10. Keep in mind that in-home and community-based services may be options that can allow a person to remain in their own home or in the community as long as possible. Consider checking out some of these options, such as home health care, personal assistance services, homemaker/chore services, adult day care and respite care.
11. If you have a problem involving a nursing home, contact the State Long-Term Care Ombudsman at (512) 444-2727.

References

Health Care Financing Administration. April 1996. Medicare Handbook. Washington, D.C. (Pamphlet).

Komisar, Harriet L., Jeanne M. Lambrew, and Judith Feder. Long-Term Care for the Elderly, Institute for Health Care Research and Policy, Georgetown University. December, 1996.

Texas Association of Homes and Services for the Aging, What You Should Know About Housing and Services for Older Adults, Austin, Texas. (Pamphlet).

Texas Health and Human Services Commission, Texas Medicaid in Perspective, Austin, Texas, May, 1994.

Texas Health Care Association, Choosing the Right Care, Austin, Texas, 1994. (Pamphlet).