Nursing Homes — How to Find the Right Facility

Nursing homes can be large or small, rural or urban. They vary widely in terms of the nursing care plans, activities and services they offer.

Nursing homes provide care for people whose medical needs require the attention of licensed nurses, but not the more intensive care of a hospital. Admission requires a doctor’s order. Nurse’s aides provide much of the day-to-day care. Social workers and case managers help seniors and their families with insurance issues and the coordination of nursing care plans. Dietitians, physical and occupational therapists and other health professionals help support and sustain patients’ physical and emotional well-being.

In the past, nursing homes were synonymous with old age homes — they provided long-term custodial care for patients who could no longer take care of themselves, usually for the rest of their lives. Today, less than one-fourth of new patients in nursing homes fall into this category.

Now, most admissions to nursing homes follow hospitalization, especially for Medicare patients under its Skilled Nursing Facility benefit. These are typically short-term stays for rehabilitation until patients have recovered enough to be sent home to complete recovery. If your loved one is a recovering Medicare patient, you should start planning for their going home in the very near future. (Medicare benefits cover only an average of 22⁽¹⁾ days of care in nursing homes.)

The nursing home you choose could have a profound impact on your loved one’s quality of life and sense of dignity. But, some aspects of selecting a nursing home depend on whether your loved one needs long-term care, or short-term recovery care. For the most part, the following nursing home checklist has been designed to help you for either type of care. But, where there is a special consideration for short-term recovery patients, we’ve included appropriate commentary. And, some questions in the checklist may be less relevant for short-term care.

Step One — Determine what your loved one can afford

Short-Term Recovery Care

Medicare covers most admissions to skilled nursing facilities (nursing homes) for patients recovering after a hospital stay. As long as a patient continues to be eligible, Medicare pays 100% of the eligible expenses for the first 20 days, and all but $170.50 a day (2019 deductible amount) for up to 80 more days. If the patient is covered under a Medicare HMO, or has a Medicare Supplemental insurance policy for:

Plan A or B, Medicare pays nothing (you pay the entire $170.50 daily deductible)
Plan C, D, F, G, M or N, that plan will pay the $170.50 a day (you pay $0) for as long as you continue to be eligible for coverage, up to the 80-day maximum.
Plan K pays only $85.25 a day (you pay $85.25 a day)
Plan L pays only $127.88 a day (you pay $42.63 a day)

But, on average, Medicare discharges patients after just 22⁽¹⁾ days of care in total.

Long-Term Custodial Care

Contrary to the belief of most seniors, Medicare pays nothing for long-term custodial care. It doesn’t matter if the care is provided at home, in an assisted living facility, or in a nursing home.

Perhaps the confusion arises because Medicare can temporarily pay for nursing home care for recovering patients, as described in the section above. But, after they’ve recovered, Medicare’s benefits stop even though the patient may remain in the nursing home as a permanent long-term resident.

Medicaid currently pays nearly half of all nursing home expenses. However, Medicaid reduces a senior’s options to just one — a Medicaid nursing home with at least one roommate (no privacy). If local homes are full, the senior goes wherever a bed is available — even if it is hours away from family and friends. While no one really knows how this affects people with advanced Alzheimers or senility, it can be devastating for an elderly person who is very frail but still mentally alert.

9 out of 10 nursing homes that accept private-pay patients also participate in the Medicaid program. If your loved one is not on Medicaid when they move into one of these homes, they cannot be discharged later if they run out of money and have to go on Medicaid. But, the nursing home can move them, without anyone’s permission, into a lower-cost room, including a ward-type room with several roommates, or into a special Medicaid section of the facility.

To help avoid that possibility, we recommend that you look over your loved one’s finances with the goal of stretching their available funds to last as long as possible. That may mean they won’t be able to afford the most luxurious facility. But, the good news is that nursing home care is not as expensive as it seems at first. Instead, to an extent that varies from one person to another, it simply involves a shift of expenses from one living arrangement into another.

After an elderly person’s capabilities have declined to the point where they need to move into an nursing home, the move is almost always permanent. When their former home is sold, or its lease terminated, most of the expenses they had been paying for it can then be used to help pay their nursing home expenses. And, the money resulting from the sale of their home can be used, for example, to purchase a CD or annuity that pays monthly interest to boost income.

Also, since nursing home fees include all meals, your loved one will no longer have to buy groceries, thereby freeing up even more money. To help you evaluate your loved one’s financial situation, we’ve included a worksheet, Worksheet: Nursing Home Expenses — Finding the Money to Pay for Care.

The worksheet assumes that no assets are being spent down; in other words, they will remain intact with only the interest/dividend income they produce being used to supplement your loved one’s income. But, if they are short of the funds needed for nursing home care, some or all of their assets will have to be spent down. That is, the principal value of an asset will have to be converted into a stream of monthly income payments.

However, several factors need to be kept in mind …

Your loved one’s income needs will increase from month-to-month due to inflation. The cost of nursing home care has been increasing nearly twice as fast as inflation in general.
You need to decide how many years the income should last (the longer the period, the lower the income). Some people might use the remaining life expectancy to calculate monthly payouts, but that would be a mistake. By definition, life expectancy is an average for all people; therefore, half of us will live longer than our life expectancy.Instead, you want to be as certain as possible, without overdoing it, that your loved one won’t outlive their income. To accomplish that, we recommend you select a payout period based on a 90% probability that they won’t. The following pull-down menus, based on the current age of your loved one, show our recommended payout periods⁽²⁾ for ages 65 through 90.

	Men	Women

Work with a trusted financial advisor to assist you in converting each financial asset into a stream of monthly payments.

Step Two — Determine your loved one’s needs

The types of care available can vary widely from one nursing home to another. To be certain that a facility can provide the care necessary for your loved one, first determine what your loved one’s needs truly are (they may be different than you think). Use our checklist How to Tell if Your Elderly Loved One Needs Help.

When you compare nursing homes, some factors matter more than others. No perfect home exists. Finding one that meets your loved one’s needs is Goal Number 1. But don’t underestimate Goal Number 2, that is, getting them to accept your loved one. When you tour a home and interview its staff, be thorough, clear and professional. Show them that you’re part of the solution and will work closely with them to achieve the best care possible for the new member of their community.

Be ready to:

Explain the type of care your loved one needs. Ask the facility to describe how it will meet those needs, for example, assistance with dressing, taking medications, incontinence, or general supervision. A nursing home should provide enough care and support to meet your loved one’s needs while encouraging and allowing them to remain as independent as possible. And, don’t forget that your loved one may need more care as time passes; ask questions that don’t apply now, but may in the future.
Visit several facilities; services and fees will vary greatly. Our checklist will help you compare facilities and organize your impressions of different homes.

Step Three — Select a general location

After you’ve determined how much your loved one can afford to pay for nursing home care, select the city or region where their facility should be. (Many nursing homes are part of retirement communities that offer a wide variety of living arrangements from completely independent living to 24-hour skilled nursing care.)

After making your preliminary choices, you can narrow them down by using Medicare’s free reports. Each year, the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers both programs, inspects each nursing home that it certifies and includes the results in free reports available online. Reading the reports for the facilities on your list before you visit might alert you to possible problems or special areas of interest. To find the CMS’s latest reports, go to Medicare’s Nursing Home Compare.

Another very useful comparison tool is ProPublica’s Nursing Home Inspect. Use this tool to compare nursing homes in a state you select based on the deficiencies cited by regulators and the penalties imposed on each home in the past three years. This tool also flags those nursing homes that have a history of repeated serious quality issues. (ProPublica is an independent, non-profit newsroom that produces investigative journalism in the public interest.)

If your loved one needs short-term recovery care, Medicare could have a few nasty surprises in store for you:

Medicare saves money by getting patients out of the hospital and into a skilled nursing facility as quickly as possible. But, Medicare won’t pay for the cost of transportation between the hospital and skilled nursing facility. Instead, the patient has to pay for it out of their own pocket, even if an ambulance is used. Consequently, we recommend you select a skilled nursing facility near your loved one’s home and, at the same time, as close as reasonably possible to the hospital where they were confined — the shorter the distance between the hospital and the skilled nursing facility, the lower the transportation cost.But, don’t let the transportation cost be the sole deciding factor for your choice of a skilled nursing facility. We recommend that you select the one that, while being relatively nearby, will provide the best possible medical care for your loved one.

The article, A Top-Rated Nursing Home Can Be Hard to Find, clearly demonstrates the importance of using Medicare’s and ProPublica’s free reports to find the best nursing home for your loved one — not picking one just because it’s nearby and convenient for you, or the most beautiful home you’ve ever seen.
Do your homework when selecting a skilled nursing facility. If you don’t, and you decide later to move your loved one into a better facility to complete their recovery, Medicare won’t pay for the second one, regardless of the reason for the move.

If your loved one needs long-term custodial care and is still mentally alert, we strongly recommend that you include them in the selection process. After all, it is their future home you are selecting. Remember, it is your role as a caregiver to help them maintain as much control over their lives as feasible, not take it away; this includes allowing them to make their own decisions whenever possible.

Step Four — Go

Make an appointment for each home you want to tour. Ask to see more than the public areas. Visit several residents’ rooms. Ask if both you and your loved one can join the residents for lunch or dinner. And, if possible, stroll through the facility on your own. This will allow you to experience it without an official interpretation. Talk to the residents; ask them what they like most — and what they feel could be improved.

Take a deep breath and clear your mind. You’re ready. Nursing Home Checklist. (Take a blank checklist with you for each home you visit.)

Sources

⁽¹⁾U.S. Department of Health and Human Services, LongTermCare.gov, Who Pays for Long-Term Care?

⁽²⁾Based on United States Life Tables, 2010, National Vital Statistics Reports, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Volume 63, Number 7, November 4, 2014.