• Introduction
• Step 1: Building a Network
• Step 2: Long-Term Care Options
• Step 3: Gathering Information

Reader Notice: The Health Care Financing Administration (HCFA), the Federal Agency that oversees Medicare and Medicaid, wants you to be aware of the two issues involving nursing homes. First, nursing homes cannot require pre-payment from residents who are relying on Medicare or Medicaid to pay for their nursing home services. Second, nursing homes may not use physical or chemical restraints on residents, except when medically necessary.

Pre-Payment: If you are a Medicare or Medicaid beneficiary applying for admission to a nursing facility for care that will be covered by Medicare or Medicaid, it is unlawful for the facility to require you to pay a cash deposit. Federal law prohibits nursing facilities from requiring a pre-payment as a condition of admission for care covered under either Medicare or Medicaid. The facility may, however, request that a Medicare beneficiary pay coinsurance amounts and other charges for which a beneficiary is liable. You pay those charges as they become due, not before. A facility may also require a cash deposit before admission if your care will not be covered by either Medicare or Medicaid.

Restraints: You should also be aware that Federal Law prohibits nursing homes from using physical or chemical restraints on residents for discipline or for the convenience of nursing home staff. Restraints increase the chances that residents will develop incontinence, impaired circulation, and swelling. Restrained residents also tend to suffer decreased functional ability, lower self-esteem, and feelings of depression anger, and stress. Restrained residents are not safer than they would be if left unrestrained. Restrained individuals are more likely to suffer serious injuries when they fall. It is important that nursing home residents, whenever possible, be left unrestrained.

Restraints may be used only when necessary to treat medical symptoms or to ensure the safety of other nursing home residents. Except in emergencies, physical and chemical restraints may be used only under the written orders of physicians. Physical restraints include articles, such as belts or vests, that secure a resident's limbs or bind a resident to a bed, chair, or other stationary item. In addition, common nursing home items, such as lap trays and bed rails, when employed solely to keep a resident from moving about, are considered restraints. Chemical restraints include drugs that are administered to keep a resident subdued.

If you know of a nursing facility that is improperly demanding prepayments or restraining residents, you should contact your State's survey agency immediately.

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Selecting a nursing home is one of the most important and difficult decisions that you may be asked to make. Though it may be difficult to admit, you may spend several years in a nursing home. So it is important that you make the best decision possible, and base your decision on the most complete and timely information available.

The Health Care Financing Administration (HCFA) wants you to make a good choice when choosing a nursing home. This booklet is designed to help you choose a nursing home. It provides you with a step-by-step process that will assist you. It also provides you with some key resources that will help you conduct a wise search for the nursing home or long-term care facility that best fits your needs.

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Before you begin searching for a nursing home, it is a good idea to put together a network of people who can help you make the right choice. This team should include the family and friends who are important to you. It should also include the doctors and health professionals who understand your needs. Clergy and social workers may also be valuable network members.

Consult with your network. Family and friends may be willing to share responsibilities and should be treated as partners. Remember that two heads are better than one, and many heads are better than two.

If you are helping to select a nursing home for a relative, make every effort to involve your relative in the selection process. If your relative is mentally alert, it is essential that his or her wishes be respected. People who are involved in the selection process are better prepared when the time comes to move into a nursing home.

Finding a nursing home that provides the right services for you in a pleasant, comfortable environment atmosphere often requires research. Ideally, you will have ample time to plan ahead, examine several nursing homes, and make the appropriate financial plans. By planning ahead, you will have more control over the selection process, more time to gather good information, and more time to make certain that everyone in your network is comfortable with the ultimate choice. Planning ahead is the best way to ease the stress that accompanies choosing a nursing home, and helps assure that you will make a good choice.

Unfortunately, a great many people must select a nursing home with little notice -frequently during a family crisis or right after a serious illness or operation. If you are in this situation, this booklet should still be helpful. Though you may not be able to follow all of the steps in the upcoming pages, by reading this booklet you will gain valuable information about nursing homes, learn about the people who might be able to help you, and pick up some tips about what to look for in a nursing home.

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Until recently, few alternatives to nursing homes existed for people who could no longer take care of themselves. Even today, some people are placed in nursing homes simply because neither they nor their family know about the alternatives to nursing homes. Today, people who cannot live completely independently may choose from a variety of living arrangements that offer different levels of care. For many, these alternatives are preferable to nursing homes.

Home and Community Care
Most people want to remain at home as long as possible. A person who is ill or disabled and needs help may be able to get a variety of home services that might make moving into a nursing home unnecessary. Home services include meals on wheels programs, friendly visiting and shopper services, and adult day care. In addition, there are a variety of programs that help care for people in their homes. Some nursing homes offer respite care -- when they admit a person for a short period of time to give the home caregivers a break. Depending on the case, Medicare, private insurance, and Medicaid may pay some home care costs.

Subsidized Senior Housing
There are Federal and State programs that subsidize housing for older people with low to moderate incomes. A number of these facilities offer assistance to residents who need help with certain tasks, such as shopping and laundry, but residents generally live independently in an apartment within the senior housing complex. In this way, subsidized senior housing serves as a lower cost alternative to assisted living - though assisted living communities are frequently newer and more luxurious.

Assisted Living (Non-Medical Senior Housing
Some people need help with only a small number of tasks, such as cooking and laundry. Some may only need to be reminded to take their medications. For those people who need only a small amount of help, assisted living facilities may be worth considering. Assisted living is a general term for living arrangements in which some services are available to residents (meals, laundry, medication reminders), but residents still live independently within the assisted living complex. In most cases, assisted living residents pay a regular monthly rent, and then pay additional fees for the services that they require.

Board and Care Homes
These are group living arrangements (sometimes called group or domiciliary homes) that are designed to meet the needs of people who cannot live independently, but do not require nursing home services. These homes offer a wider range of services than independent living options. Most provide help with some of the activities of daily living, including eating, walking, bathing, and toileting. In some cases, private long-term care insurance and medical assistance programs will help pay for this type of living.

Continuing Care Retirement Communities (CCRCs)
CCRCs are housing communities that provide different levels of care based on the needs of their residents -- from independent living apartments to skilled nursing in an affiliated nursing home. Residents move from one setting to another based on their needs, but continue to remain a part of their CCRC's community. Many CCRCs require a large payment prior to admission, then charge monthly fees above that. For this reason, many CCRCs are too expensive for older people with modest incomes.

What is a Nursing Home?
A nursing home is a residence that provides room, meals, recreational activities, help with daily living, and protective supervision to residents. Generally, nursing home residents have physical or mental impairments which keep them from living independently. Nursing homes are certified to provide different levels of care, from custodial to skilled nursing (services that can only be administered by a trained professional).

Before deciding which care setting is most appropriate for you or your relative, talk to your doctor or a social worker and get a realistic assessment of care needs. If you are considering home care, be sure you understand all the work that comes with caring for a chronically ill person. If you are considering independent living, consider the risks associated with an unsupervised environment.

Be sure to discuss long-term care options with family members who will be the main home care givers and/or visitors to your new home. Consider how you will pay for your own long-term care.

Remember that caring for someone who is very sick requires a lot of work. Nursing homes are designed to meet the needs of the acutely or chronically ill. The options discussed above may work for people who require less than skilled care, or who require skilled care for only brief periods of time, but many people with long-term skilled care needs require a level and amount of care that cannot be easily handled outside of a nursing home.

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Once you have decided that a nursing home is the right choice for you, it is time to gather information about the nursing homes in your area. A good first step in this process is finding out exactly how many nursing homes there are in your area (because nursing homes are frequently located in out of the way areas, there might be more than you think).

There are a number of ways that you can learn about the nursing homes in your area. The easiest ways to find out about local nursing homes begin with the phone book. Your yellow pages list many of the nursing homes in your area. In addition, your local Office on Aging (in the Blue Pages of your Phone Book) should have a listing of nursing homes in your area and will be able to refer you to your local Long-Term Care Ombudsman.

You can get information on the nursing homes in your area from a variety of sources. Word of mouth can be a good source of information. Ask your friends and neighbors if they know people who have stayed in local nursing homes. Learn all you can from these different sources.

Some Facts About Nursing Homes
On any given day, nursing homes are caring for about one in twenty Americans over the age of 65. Almost half of all Americans turning 65 this year will be admitted into a nursing home at least once. One fifth of those people admitted into nursing homes stay at least one year--one tenth stay three years or more.

The Long-Term Care Ombudsman
One of the best sources of information is your local long-term care ombudsman. Nationwide, there are more than 500 local ombudsman programs. Ombudsman visit nursing homes on a regular basis -- their job is to investigate complaints, advocate for residents, and mediate disputes. Ombudsman often have very good knowledge about the quality of life and care inside each nursing home in their area.

Ombudsman are not allowed to recommend one nursing home over another. But when asked about specific nursing homes they can provide information on these important subjects:

the results of the latest survey,

the number of outstanding complaints,

the number and nature of complaints lodged in the last year,

the results and conclusions of recent complaint investigations.

In addition, the ombudsman may provide general advice on what to look for when visiting the various area nursing homes.

Other Community Resources In addition to the Long-Term Care Ombudsman, there are many other resources that you should consult before selecting a nursing home. Some other people who might be helpful are:

hospital discharge planners or social workers, physicians who serve the elderly, clergy and religious organizations,

volunteer groups that work with the elderly and chronically ill,

nursing home professional associations.

By using these resources, you will tap into a community of people who understand nursing homes and have a good deal of knowledge about the homes in your area. You should now be able to make a list of the homes in your area which have good reputations.

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Other Information You Will Need
There are also some types of basic information that should help you narrow your list of nursing homes. Consider some of these factors - a quick phone call to the nursing home should answer these concerns:

Religious and Cultural Preferences: If you have religious or cultural preferences, contact the nursing homes on your list and see if they offer the type of environment which you would prefer.

Medicare and Medicaid Participation: If you will be using Medicare or Medicaid, make certain that the nursing homes on your list accept Medicare or Medicaid payment. Often, only a portion of the home is certified for Medicare or Medicaid, so make sure that the home has Medicare or Medicaid "beds" available. For more information how Medicare and Medicaid pay for nursing home care, scroll to the end of this section.

HMO Contracts: If you belong to a managed care plan that contracts with a particular nursing home or homes in your area, make sure the homes you are considering have contracts with your HMO.

Availability: Make certain that the nursing homes on your list will have space available at the time you might need to be admitted.

Special Care Needs: If you require care for special medical conditions or dementia, make sure that the nursing homes on your list are capable of meeting these special circumstances.

Location: If you have a large number of nursing home choices, it is usually a good idea to consider nursing homes that your family and friends can visit easily.

Why Location is Important: In most cases, it is a mistake to select a nursing home that is difficult to visit on a regular basis. Frequent visits are the best way to make sure that you or your relative does well in the nursing home. Visitors are important advocates for chronically ill residents. Frequent visits often make the transition to the nursing home easier for new residents and their families.

You may will now be able to figure out which homes in your area may or may not be worth visiting. You will also now be better informed when you begin visiting your area's nursing homes.

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Paying for Nursing Home Care Nursing home care is expensive (a skilled nursing home will cost about $200 a day in many parts of the country). For most people, finding ways to finance nursing home care is a major concern. there are several ways that nursing home care is financed:

Personal Resources:
About half of all nursing home residents pay nursing home costs out of personal resources. When most people enter nursing homes, they usually pay out of their own savings. As personal resources are spent, many people who stay in nursing homes for long periods eventually become eligible for Medicaid.

Long-Term Care Insurance:
Long-Term Care Insurance is private insurance designed to cover long-term care costs. Plans vary widely, and you would be wise to do some research before purchasing any long-term care policy. Generally, only relatively healthy people may purchase long-term care insurance. For further information on this type of insurance, contact the National Association of Insurance Commissioners and ask for their free booklet, The Shopper's Guide to Long-Term Care Insurance. Call (816) 374-7259 for your copy.

Medicaid:
Medicaid is a State and Federal program that will pay most nursing home costs for people with limited income and assets. Eligibility varies by state, and you should check into your state's eligibility requirements before assuming that you are either eligible or ineligible. Medicaid will only pay for nursing home care provided in Medicaid-certified facilities.

Medicare:
Under certain limited conditions, Medicare will pay some nursing home costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, you must (after a qualifying hospital stay) receive the services from a Medicare-certified skilled nursing home. HCFA's book, Your Medicare Handbook, discusses the conditions under which Medicare will help pay for nursing home costs in a Medicare-certified nursing home. To obtain a free copy of Your Medicare Handbook, call (800) 638-6833.

Medicare Supplemental Insurance:
This is private insurance (often called Medigap) that pays Medicare's deductibles and co-insurances, and may cover services not covered by Medicare. Most Medigap plans will help pay for skilled nursing care, but only when that care is covered by Medicare.

In addition, some people have nursing home costs covered, or partially covered, by managed care plans or employer benefit packages.

If you have any questions about how you will pay for nursing home care, what coverage you may already have, or whether there are any government programs that will help with your expenses, there are people who can help. Your State's Insurance Counseling and Assistance (ICA) program has counselors ready to help you figure out how you can finance your long-term care.

(From Publication No. HCFA 02195 Revised April 1996)

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