What Is a Nursing Home?

A Nursing Home is not a place to go to die. Today’s Nursing Home has transformed into a transitional healthcare setting for Seniors on their way to recovery.

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A Nursing Home is not a place to go to die. Today’s Nursing Home has transformed into a transitional healthcare setting for Seniors on their way to recovery.

Since the inception of the Patient Protection and Affordable Care Act in 2010, America’s Nursing Homes have been forced to take on a new and more complex identity in both the care they deliver and the amenities they offer. Nursing Homes deliver high levels of care, and you’d be surprised at some of the care outcomes nationally. The ACA promulgated a historical shift of patient acuity and illness into the Nursing Home setting while the country was simultaneously experiencing what is referred to as the “Silver Tsunami” - America’s baby boomer population over 65 years old. For these reasons, the question “What is a Nursing Home” can be difficult to answer during a time when the industry is still radically transforming.

A Nursing Home is a healthcare setting in which Skilled Nursing Care and Long-Term Care are delivered 24/7 to our Elderly population. As of 2020, there are approximately 15,000 Nursing Homes in the US. The Centers for Medicare and Medicaid Services is the regulatory body of Nursing Facilities.

As we unpack this question of “What is a Nursing Home?”, you will come to understand that it is not a simple answer. The Nursing Homes we know today are holistically advancing and are beginning to provide some cutting edge treatments, making the industry’s future trajectory both exciting and complex. The terms “Skilled Nursing”, “Intermediate Care”, and “Therapy” are implied terms yet they fail to capture the redefined role and types of care that Nursing Homes are now tasked to offer.

Today’s Nursing Home looks a lot like yesterday’s Transitional Unit or Sub-Acute unit in a Hospital. Nursing Home Services now encompass Case Management, Chronic Disease and Acute Care Management, and Mental Health Services. Therapy Services now have more focus on Speech Therapy and helping Seniors reach their Prior Level of Function. Physician and Occupational Therapy is based on measured goal achievement by the Senior in a defined period of time. With shifting demographics, new technologies, and consumer speculation and distrust, the Nursing Home of Tomorrow will look nothing like what you and I see today.

As a Skilled Nursing Administrator and Executive for almost 8 years, I joined the industry as an Administrator at the cusp of the Affordable Care Act. This Act was the lynchpin that provoked radical change to the industry that still permeates today. I have operated facilities in multiple states and in both rural and urban settings and I could write a best-selling book on the experiences, stories, incidents, and successes that I’ve been a part of. Nursing Homes are truly one the most dynamic and challenging businesses to operate consistently - but not impossible. Looking at the industry through the optics of an Administrator and Regional Executive, I hope to shed light on what the general public may not know or understand about Nursing Homes.

Table of Contents

Nursing Home Services and Standards

Though not comprehensive, here is a list of Nursing Home services that are to be delivered on a day to day basis by qualified staff:

Skilled Nursing Services:

Daily Skilled Assessments Charting, IV Management, Pain Management, Complex Wound Care, Care with Activities of Daily Living, Lab Work, Bariatric Care, Respiratory Therapy, Cardiac Care, and other Post-Acute Clinical Pathways

Intermediate Care Nursing:  

Chronic Illness Management, assistance with Activities of Daily Living, Tube Feeding Management, Wound Care Skin Integrity, Hygiene and Oral Care Needs, Monitoring of Wandering residents, Routine Labs, Podiatry/Dental/Vision services, Routine Care Planning.

Therapy Services:

Physical Therapy, Occupational Therapy, Speech Therapy.

Case Management/Social Services:

Coordination of care with Insurance companies, Capturing and documenting care and services given, and transitional services. Emotional support services for PTSD and other emotional needs.

Other services:  

Dietary Services under the direction of a Registered Dietician, Housekeeping Laundry Services, Transportation, and General Maintenance and Care of facility safety security mechanisms.

The above care and services must be delivered by qualified and competent staff. The duration and scope of these services is somewhat dependent on the Seniors payor source. For example, a resident who is living at the facility with Medicaid services is not typically going to receive a high utilization of therapy services unless clinically indicated. It would be both a waste of resources and not supported by any prominent research today. Conversely, it wouldn’t matter what payor source a Senior was if the Senior acquired a stageable wound, or was at high risk for skin breakdown. It is the facility’s responsibility to maintain skin integrity no matter the payor source. In addition to these services, some states are providing waivers and allowing Nursing Facilities to retrofit unoccupied rooms with other in-patient services like Hemodialysis and in-patient Hospice.

Nursing Home Standards are ruled on and enforced under the Division of Health and Human Services and administered by the Centers for Medicare and Medicaid Services. Nursing Homes receive federal funding and, hence, must conform to the standards of participation set forth by this regulatory body. Funding via State Medicaid programs is also used to support Nursing Home care and, thus, there are State Nursing Facility standards that may exceed or add to federal regulations. The Nursing Facility must adhere to the most strict of the two regulations in this case. CMS contracts with Regional and State Health Inspection offices to oversee and conduct routine and complaint health inspections and, if necessary, cite deficiencies or Civil Monetary Penalties if the deficiency reaches a certain severity. Fun Fact - America’s Nursing Home Industry is one of the most regulated industries in the world; A Nursing Home can fall under several different regulatory bodies both at the federal and state level.

A One-Size-Fits-Insurance Experience

If you or a loved one has turned 65 recently, you will have undoubtedly received a solicitation in the mail for a Managed Care or Medicare Replacement Plan.Perhaps the largest codependent relationship in Nursing Home operations is Insurance. Managed Care and Medicare Advantage Insurance companies have positioned themselves to be a close and necessary partner with Nursing Homes, impacting all operations and care delivery of the care teams. With razor thin margins nationally, Nursing Homes are completely reliant on effectively partnering with these Insurance carriers. According to CMS’s most recent 2020 Fast Facts, nationwide enrollment in Medicare Advantage has increased from twenty million enrollees to close to twenty five million enrollees from 2018 to 2020. These plans have been gaining in popularity among Seniors since ~ 2010 and, in some geographic areas, have a majority market share of eligible Seniors enrolled.

This is not by chance, but by design. The federal government has propped up and supported different frameworks of insurance to divert the rampant costs of Medicare. These plans aim to replace the Medicare benefits with a more hands-on, Case Management-style product. Every procedure, treatment, and Therapy must get “Prior Approval”, hence the term “Managed Care”. This impacts Nursing Home Care because Managed Care organizations want to get Seniors to a lower level of care as soon as possible, or transition the enrollee to Medicaid or Private Pay if feasible. It is no longer the goal to get to the highest possible level of care, but rather functional enough to transition to a lower level of care for cost saving purposes. If the Nursing Home does not capture your progress or lack of progress, you or your loved one could be negatively affected and be cut off from any additional skilled services.

The Nursing Home of Tomorrow

The Baby Boomer Generation and proceeding Generation X have influenced a changing business strategy for America’s Nursing Home operators. Campuses with outdated infrastructure, semi-private room accommodations (some even have Ward Rooms of 3 and 4 beds), and bare bone amenities will eventually be the exception and not the norm. Long-Term Care trade shows are now packed with demonstrations of technology, AI (artificial intelligence) software, cutting edge therapies and nursing treatments, evolving pharmaceuticals, and even caregiving robotics.

Because older generations are projected to make up close to ⅓ of America’s population, Industry Leaders and experts predict Senior Health services,in general, will continue to be in high demand and thus a safe and consistent mode of investment. New initiatives and strategic investments from flagship companies like Walmart, Amazon, and Google into alternative Senior Care options not only speak to this demand, but also may indicate that Aging In Place is a long-term strategy and a likely more viable alternative in the next 10-15 years, even for chronically ill residents.

Another emerging concept, or perhaps a trend repackaged, is the idea of healthcare ecosystems in which Skilled Nursing Homes are a part of. In other words, one geographical area like a campus having all pre-and-post acute services available before and after a hospital stay. This concept takes a Continuing Care Retirement Community and adds a Skilled Nursing option, and perhaps other inpatient options like Hospice and Dialysis. The goal is to drive down care costs and drive up consistent and streamlined care. Plus, the providers of these healthcare ecosystems can likely solidify a Senior care reimbursement over the course of 7 to 15 years, sometimes longer!

In tomorrow’s Nursing Home, care will be delivered predictively using a Senior’s diagnosis and current ailments, and there will be more emphasis on cutting edge treatments, top amenities that are de-institutionalized, and excellent customer experience. If facilities fail to adapt, they will simply fail to succeed.

Alternatives to Nursing Home Care

The term Aging in Place is becoming a widely accepted idea in America given the negative sentiment most American’s feel when thinking about Nursing Homes. The desire to remain at home or in apartment-style settings is what most older Americans would choose. Though currently you would not get the same level of care at home as you would in a Nursing Home, the push from both consumers and insurance organizations have shifted investment into Preventative Care education, Home Health and outpatient Therapy, as well as new adaptive devices and equipment to keep Seniors in place while they age. Seniors are now even managing intravenous antibiotics from a hospital stay from their home!

One prominent emerging technology has been TeleHealth which, in my opinion, is still underutilized and under valued by health systems and health insurance organizations. Primitive Telehealth services allowed video chat and check ups with a physician. Current Telehealth platforms give patients and doctors an interactive, digital meeting space in which the physician can wear headphones and listen to lung sounds, or check other vitals in real-time like Pulse Oximeter results. Some systems even have what’s called a Skin Pen or a Wound Wand which is a hi-definition, pen-shaped plug-in that magnifies wound beds and skin conditions simply by putting the tip of the pen optic close to the wound or skin condition.

Nursing Homes are a necessity to our care continuum in America. They care for our most critically ill and frail Seniors. To define Nursing Homes broadly would be hard given the pace of change in the industry. The key takeaway is that Nursing Homes are going through a period of uncomfortable transformation that has caused a shock to the system for many Nursing Homes. Most operators will admit that there seems to be no end in sight to the constant changes, burdensome regulations, and increased care demands. But, fundamentally, these care centers all strive to provide care and services and care with one overarching goal in mind - patient satisfaction through the delivery of consistent and quality of care.

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