Growth of the home health care industry in the early 1990s only slightly slowed the increase in the numbers of Americans entering nursing homes. Assisted living and continuing-care retirement communities offer other alternatives to nursing home care. When it is possible, many older adults prefer to remain in the community and receive health care in their homes.
Types of Nursing Homes
Nursing homes fall into three broad categories: residential care facilities, intermediate care facilities, and skilled nursing facilities. Each provides a different range and intensity of services:
- A residential care facility (RCF) normally provides meals and housekeeping for its residents, plus some basic medical monitoring, such as administering medications. This type of home is for persons who are fairly independent and do not need constant medical attention but need help with tasks such as laundry and cleaning. Many RCFs also provide social activities and recreational programs for their residents.
- An intermediate care facility (ICF) offers room and board and nursing care as necessary for persons who can no longer live independently. As in the RCF, exercise and social programs are provided, and some ICFs offer physical therapy and rehabilitation programs as well.
- A skilled nursing facility (SNF) provides a round-the-clock nursing care, plus on-call physician coverage. The SNF is for patients who need intensive nursing care, as well as such services as occupational therapy, physical therapy, respiratory therapy, and rehabilitation.
Number of Nursing Home Residents Rising
The National Nursing Home Survey (NNHS) is a continuing series of national sample surveys of nursing homes, their residents, and their staff. The surveys were conducted in 1973–74, 1977, 1985, 1995, 1997, and 1999. Although each survey focused on different aspects of care, they all provided some common basic information about nursing homes, their residents, and their staff from two perspectives—that of the provider of services and that of the recipient. Data about the facilities include characteristics such as size, ownership, Medicare/Medicaid certification, occupancy rate, number of days of care provided, and expenses. The surveys gathered demographic data, health status, and services received by nursing home residents. The most recent NNHS was conducted in 1999. The nursing homes included in this survey had at least three beds and were either certified (by Medicare or Medicaid) or had a state license to operate as a nursing home.
According to the 1999 NNHS, the nation's eighteen thousand nursing homes had occupancy rates of almost 87% in 1999. Nursing homes averaged about 105 beds per facility. In 1999 about 1.5 million adults age sixty-five and older were nursing home residents. Of those, most were white (87.1%) and female (74.3%). If the 158,700 residents under sixty-five are added to the total, there were 1.6 million nursing home residents in 1999, with women (nearly 1.2 million) outnumbering men (457,900) by almost three to one. There were more than six times as many white nursing home residents as African-Americans and other racial minorities.
By 2001 the nation's 16,675 certified nursing homes housed 1,779,924 beds and had occupancy rates of 82.5%. The distribution of nursing home beds and occupancy rates varied by geography—the East North Central states boasted 364,309 beds while the less populated Mountain states had just 74,034 beds. Occupancy rates ranged from a high of 90.3% in the Middle Atlantic states to a low of 71.3% in the West South Central states of Arkansas, Louisiana, Oklahoma, and Texas. (See Table 3.7.)
Most residents of nursing homes are the "oldest old." Out of the total 1.6 million nursing home residents in 1999, 90% were sixty-five years old and older, according to the 1999 NNHS. People age eighty-five and older (the so-called oldest old) are a fast-growing segment of the population and accounted for almost half (46%) of all nursing home residents.
In 1999, 92% of all nursing homes were privately owned, according to NNHS data. Most (67%) nursing homes were company-owned and operated on a for-profit basis. Another 27% were operated by nonprofit, volunteer organizations, and only 12% were operated by governmental agencies. More than 80% were certified (approved for payment) by both Medicare and Medicaid. About half of all current nursing home residents were admitted directly from a hospital, and about 30% came from the community.
Diversification of Nursing Homes
To remain competitive with home health care and the increasing array of alternative living arrangements for the elderly, many nursing homes began to offer alternative services and programs. New services include adult day care and visiting nurse services for persons who still live at home. Other programs include respite plans that allow caregivers who need to travel for business or vacation to leave an elderly relative in the nursing home temporarily.
One of the most popular nontraditional services is subacute care, which is comprehensive inpatient treatment for people recovering from acute illnesses such as pneumonia, injuries such as a broken hip, and chronic diseases such as arthritis that do not require intensive, hospital-level treatment. This level of care also enables nursing homes to expand their markets by offering services for younger patients.
Innovation Improves Quality of Nursing Home Care
While industry observers and the media frequently raise concerns about the care provided in nursing homes and publicize instances of elder abuse and other quality of care issues, several organizations have actively sought to develop models of health service delivery that improve the clinical care and quality of life for nursing home residents. In August 2002 the Commonwealth Fund published a report examining one such model in eastern Wisconsin, Evaluation of the Wellspring Model for Improving Nursing Home Quality. Researchers from the Institute for the Future of Aging Services and American Association of Homes and Services for the Aging evaluated the Well-spring model of nursing home quality improvement.
Wellspring is a group of eleven not-for-profit nursing homes governed by a group called the Wellspring Alliance. Founded in 1994, the alliance aimed to improve simultaneously clinical care delivered to its nursing home residents and the work environment for its employees. Education and collaboration are hallmarks of the Wellspring philosophy, and this program began by equipping nursing home personnel with the skills needed to perform their jobs and organizing employees in teams working toward shared goals. The Wellspring model of service delivery uses a multidisciplinary clinical team approach—nurse practitioners, social service, food service personnel, nursing assistants, facility and housekeeping personnel—to solve problems and develop approaches to better meet residents' needs. The teams represent an important innovation because they allow health professionals and other workers to interact as peers and share resources, information, and decision-making in a cooperative, supportive environment.
Shared resources, training, ideas, and goals have had a powerful impact on care at the Wellspring facilities. The researchers observed more cooperation, responsibility, and accountability within the teams and the institutions than observed at other comparable facilities. In addition to finding a strong organizational culture that seemed committed to quality patient care, the researchers also documented measurable improvements in specific areas including:
- Wellspring facilities had lower rates of staff turnover than comparable Wisconsin facilities during the same time period, probably because Wellspring workers felt valued by management and experienced greater job satisfaction than other nursing home personnel.
- The Wellspring model did not require additional resources to institute, and Wellspring facilities operated at lower costs than comparable facilities.
- Wellspring facilities' performance, as measured by a federal survey, improved.
- Generally, Wellspring personnel appeared more attentive to residents' needs and problems and sought to anticipate and promptly resolve problems.
The researchers concluded that the organizational commitment to training and shared decision-making along with improved quality of interactions and relationships among staff and between staff and residents significantly contributed to enhanced quality of life for residents.
TABLE 3.7
| Nursing homes, beds, occupancy, and residents by geographic division and state, 1995–2001 | ||||||||||||||
| [Data are based on a census of certified nursing facilities] | ||||||||||||||
| Nursing homes | Beds | Residents | Occupancy rate1 | Resident rate2 | ||||||||||
| Geographic division and state | 1995 | 2000 | 2001 | 1995 | 2000 | 2001 | 1995 | 2000 | 2001 | 1995 | 2000 | 2001 | 1995 | 2000 |
| United States | 16,389 | 16,886 | 16,675 | 1,751,302 | 1,795,388 | 1,779,924 | 1,479,550 | 1,480,076 | 1,469,001 | 84.5 | 82.4 | 82.5 | 404.5 | 349.1 |
| New England | 1,140 | 1,137 | 1,110 | 115,488 | 118,562 | 115,939 | 105,792 | 106,308 | 104,573 | 91.6 | 89.7 | 90.2 | 474.2 | 419.5 |
| Maine | 132 | 126 | 126 | 9,243 | 8,248 | 8,002 | 8,587 | 7,298 | 7,189 | 92.9 | 88.5 | 89.8 | 417.9 | 313.0 |
| New Hampshire | 74 | 83 | 83 | 7,412 | 7,837 | 7,883 | 6,877 | 7,158 | 7,126 | 92.8 | 91.3 | 90.4 | 434.1 | 392.6 |
| Vermont | 23 | 44 | 44 | 1,862 | 3,743 | 3,636 | 1,792 | 3,349 | 3,293 | 96.2 | 89.5 | 90.6 | 207.0 | 335.0 |
| Massachusetts | 550 | 526 | 506 | 54,532 | 56,030 | 54,514 | 49,765 | 49,805 | 48,876 | 91.3 | 88.9 | 89.7 | 477.3 | 426.8 |
| Rhode Island | 94 | 99 | 97 | 9,612 | 10,271 | 10,183 | 8,823 | 9,041 | 8,923 | 91.8 | 88.0 | 87.6 | 476.9 | 432.6 |
| Connecticut | 267 | 259 | 254 | 32,827 | 32,433 | 31,721 | 29,948 | 29,657 | 29,166 | 91.2 | 91.4 | 91.9 | 541.7 | 461.4 |
| Middle Atlantic | 1,650 | 1,796 | 1,799 | 244,342 | 267,772 | 268,888 | 228,649 | 242,674 | 242,784 | 93.6 | 90.6 | 90.3 | 384.0 | 354.2 |
| New York | 624 | 665 | 669 | 107,750 | 120,514 | 121,592 | 103,409 | 112,957 | 114,141 | 96.0 | 93.7 | 93.9 | 371.8 | 362.6 |
| New Jersey | 300 | 361 | 364 | 43,967 | 52,195 | 52,463 | 40,397 | 45,837 | 45,672 | 91.9 | 87.8 | 87.1 | 351.6 | 337.0 |
| Pennsylvania | 726 | 770 | 766 | 92,625 | 95,063 | 94,833 | 84,843 | 83,880 | 82,971 | 91.6 | 88.2 | 87.5 | 419.2 | 353.1 |
| East North Central | 3,171 | 3,301 | 3,265 | 367,879 | 369,657 | 364,309 | 294,319 | 289,404 | 284,563 | 80.0 | 78.3 | 78.1 | 476.1 | 414.3 |
| Ohio | 943 | 1,009 | 998 | 106,884 | 105,038 | 103,974 | 79,026 | 81,946 | 80,930 | 73.9 | 78.0 | 77.8 | 499.5 | 463.5 |
| Indiana | 556 | 564 | 560 | 59,538 | 56,762 | 56,861 | 44,328 | 42,328 | 41,946 | 74.5 | 74.6 | 73.8 | 548.9 | 462.3 |
| Illinois | 827 | 869 | 854 | 103,230 | 110,766 | 108,287 | 83,696 | 83,604 | 81,749 | 81.1 | 75.5 | 75.5 | 495.3 | 435.4 |
| Michigan | 432 | 439 | 434 | 49,473 | 50,696 | 49,535 | 43,271 | 42,615 | 41,508 | 87.5 | 84.1 | 83.8 | 345.0 | 299.1 |
| Wisconsin | 413 | 420 | 419 | 48,754 | 46,395 | 45,652 | 43,998 | 38,911 | 38,430 | 90.2 | 83.9 | 84.2 | 518.9 | 406.9 |
| West North Central | 2,258 | 2,281 | 2,247 | 200,109 | 193,754 | 191,091 | 164,660 | 157,224 | 154,804 | 82.3 | 81.1 | 81.0 | 489.6 | 429.8 |
| Minnesota | 432 | 433 | 427 | 43,865 | 42,149 | 40,836 | 41,163 | 38,813 | 38,052 | 93.8 | 92.1 | 93.2 | 537.4 | 453.4 |
| Iowa | 419 | 467 | 466 | 39,959 | 37,034 | 36,944 | 27,506 | 29,204 | 28,825 | 68.8 | 78.9 | 78.0 | 458.0 | 448.5 |
| Missouri | 546 | 551 | 545 | 52,679 | 54,829 | 54,882 | 39,891 | 38,586 | 38,706 | 75.7 | 70.4 | 70.5 | 432.8 | 391.5 |
| North Dakota | 87 | 88 | 87 | 7,125 | 6,954 | 6,757 | 6,868 | 6,343 | 6,279 | 96.4 | 91.2 | 92.9 | 522.0 | 430.7 |
| South Dakota | 114 | 114 | 112 | 8,296 | 7,844 | 7,568 | 7,926 | 7,059 | 6,952 | 95.5 | 90.0 | 91.9 | 543.3 | 438.8 |
| Nebraska | 231 | 236 | 230 | 18,169 | 17,877 | 17,369 | 16,166 | 14,989 | 14,492 | 89.0 | 83.8 | 83.4 | 501.4 | 441.5 |
| Kansas | 429 | 392 | 380 | 30,016 | 27,067 | 26,735 | 25,140 | 22,230 | 21,498 | 83.8 | 82.1 | 80.4 | 528.9 | 429.4 |
| South Atlantic | 2,215 | 2,418 | 2,410 | 243,069 | 264,147 | 265,149 | 217,303 | 227,818 | 228,961 | 89.4 | 86.2 | 86.4 | 335.4 | 291.9 |
| Delaware | 42 | 43 | 42 | 4,739 | 4,906 | 4,736 | 3,819 | 3,900 | 3,950 | 80.6 | 79.5 | 83.4 | 448.7 | 369.7 |
| Maryland | 218 | 255 | 251 | 28,394 | 31,495 | 30,507 | 24,716 | 25,629 | 25,361 | 87.0 | 81.4 | 83.1 | 432.7 | 383.1 |
| District of Columbia | 19 | 20 | 21 | 3,206 | 3,078 | 3,136 | 2,576 | 2,858 | 2,863 | 80.3 | 92.9 | 91.3 | 297.6 | 318.4 |
| Virginia | 271 | 278 | 277 | 30,070 | 30,595 | 31,102 | 28,119 | 27,091 | 26,875 | 93.5 | 88.5 | 86.4 | 385.2 | 310.4 |
| West Virginia | 129 | 139 | 139 | 10,903 | 11,413 | 11,373 | 10,216 | 10,334 | 10,304 | 93.7 | 90.5 | 90.6 | 355.2 | 325.2 |
| North Carolina | 391 | 410 | 413 | 38,322 | 41,376 | 42,194 | 35,511 | 36,658 | 37,106 | 92.7 | 88.6 | 87.9 | 401.1 | 347.6 |
| South Carolina | 166 | 178 | 179 | 16,682 | 18,102 | 18,185 | 14,568 | 15,739 | 16,117 | 87.3 | 86.9 | 88.6 | 366.0 | 313.1 |
| Georgia | 352 | 363 | 361 | 38,097 | 39,817 | 39,806 | 35,933 | 36,559 | 36,356 | 94.3 | 91.8 | 91.3 | 496.0 | 416.1 |
| Florida | 627 | 732 | 727 | 72,656 | 83,365 | 84,110 | 61,845 | 69,050 | 70,029 | 85.1 | 82.8 | 83.3 | 228.2 | 208.4 |
| East South Central | 1,014 | 1,071 | 1,080 | 99,707 | 106,250 | 107,656 | 91,563 | 96,348 | 96,598 | 91.8 | 90.7 | 89.7 | 416.6 | 385.5 |
| Kentucky | 288 | 307 | 304 | 23,221 | 25,341 | 25,482 | 20,696 | 22,730 | 22,776 | 89.1 | 89.7 | 89.4 | 391.9 | 390.1 |
| Tennessee | 322 | 349 | 349 | 37,074 | 38,593 | 38,923 | 33,929 | 34,714 | 34,588 | 91.5 | 89.9 | 88.9 | 479.6 | 4260.1 |
| Alabama | 221 | 225 | 228 | 23,353 | 25,248 | 25,797 | 21,691 | 23,089 | 23,538 | 92.9 | 91.4 | 91.2 | 370.1 | 343.1 |
| Mississippi | 183 | 190 | 199 | 16,059 | 17,068 | 17,454 | 15,247 | 15,815 | 15,696 | 94.9 | 92.7 | 89.9 | 405.3 | 368.7 |
| West South Central | 2,264 | 2,199 | 2,143 | 224,695 | 224,100 | 220,048 | 169,047 | 159,160 | 156,961 | 75.2 | 71.0 | 71.3 | 486.1 | 397.6 |
| Arkansas | 256 | 255 | 250 | 29,952 | 25,715 | 25,061 | 20,823 | 19,317 | 18,677 | 69.5 | 75.1 | 74.5 | 508.3 | 415.5 |
| Louisiana | 337 | 337 | 332 | 37,769 | 39,430 | 38,861 | 32,493 | 30,735 | 30,127 | 86.0 | 77.9 | 77.5 | 639.3 | 523.8 |
| Oklahoma | 405 | 392 | 379 | 33,918 | 33,903 | 32,776 | 26,377 | 23,833 | 22,640 | 77.8 | 70.3 | 69.1 | 499.1 | 416.8 |
| Texas | 1,266 | 1,215 | 1,182 | 123,056 | 125,052 | 123,350 | 89,354 | 85,275 | 85,517 | 72.6 | 68.2 | 69.3 | 439.9 | 358.4 |
| Notes: Annual numbers of nursing homes, beds, and residents are based on the Centers for Medicare & Medical Services (CMS) 15-month Online Survey, Certification, and Reporting (OSCAR) database reporting cycle. | ||||||||||||||
| 1Percent of beds occupied (number of nursing home residents per 100 nursing home beds). | ||||||||||||||
| 2Number of nursing home residents (all ages) per 1,000 resident population 85 years of age and over. | ||||||||||||||
| SOURCE: "Table 110. Nursing Homes, Beds, Occupancy, and Residents, according to Geographic Division and State: United States, 1995–2001," in Health, United States, 2003, National Center for Health Statistics, 2003, http://www.cdc.gov/nchs/data/hus/tables/2003/2003/03hus110.pdf (accessed July 2, 2004) | ||||||||||||||
| Mountain | 800 | 827 | 806 | 70,134 | 75,152 | 74,034 | 58,738 | 59,379 | 59,395 | 83.8 | 79.0 | 80.2 | 335.9 | 271.2 |
| Montana | 100 | 104 | 103 | 7,210 | 7,667 | 7,594 | 6,415 | 5,973 | 5,928 | 89.0 | 77.9 | 78.1 | 491.4 | 389.5 |
| Idaho | 76 | 84 | 84 | 5,747 | 6,181 | 6,368 | 4,697 | 5,640 | 4,619 | 81.7 | 75.1 | 72.5 | 321.7 | 257.0 |
| Wyoming | 37 | 40 | 39 | 3,035 | 3,119 | 3,098 | 2,661 | 2,605 | 2,546 | 87.7 | 83.5 | 82.2 | 468.2 | 386.8 |
| Colorado | 219 | 225 | 223 | 19,912 | 20,240 | 20,119 | 17,055 | 17,045 | 16,855 | 85.7 | 84.2 | 83.8 | 420.6 | 353.5 |
| New Mexico | 83 | 80 | 80 | 6,969 | 7,289 | 7,263 | 6,051 | 6,503 | 6,364 | 86.8 | 89.2 | 87.6 | 332.0 | 279.0 |
| Arizona | 152 | 150 | 139 | 16,162 | 17,458 | 16,836 | 12,382 | 13,253 | 13,455 | 76.6 | 75.9 | 79.9 | 233.3 | 193.4 |
| Utah | 91 | 93 | 92 | 7,101 | 7,651 | 7,683 | 5,832 | 5,703 | 5,592 | 82.1 | 74.5 | 72.8 | 323.5 | 262.2 |
| Nevada | 42 | 51 | 46 | 3,998 | 5,547 | 5,073 | 3,645 | 3,657 | 4,036 | 91.2 | 65.9 | 79.6 | 312.0 | 215.3 |
| Pacific | 1,877 | 1,856 | 1,815 | 185,879 | 175,994 | 172,810 | 149,479 | 141,761 | 140,362 | 80.4 | 80.5 | 81.2 | 302.4 | 241.3 |
| Washington | 285 | 277 | 268 | 28,464 | 25,905 | 24,983 | 24,954 | 21,158 | 20,663 | 87.7 | 81.7 | 82.7 | 362.5 | 251.6 |
| Oregon | 161 | 150 | 145 | 13,885 | 13,500 | 12,977 | 11,673 | 9,990 | 9,444 | 84.1 | 74.0 | 72.8 | 244.9 | 173.9 |
| California | 1,382 | 1,369 | 1,342 | 140,203 | 131,762 | 129,928 | 109,805 | 106,460 | 105,923 | 78.3 | 80.8 | 81.5 | 302.9 | 250.1 |
| Alaska | 15 | 15 | 15 | 814 | 821 | 882 | 634 | 595 | 638 | 77.9 | 72.5 | 72.3 | 348.0 | 225.9 |
| Hawaii | 34 | 45 | 45 | 2,513 | 4,006 | 4,040 | 2,413 | 3,558 | 3,694 | 96.0 | 88.8 | 91.4 | 178.5 | 202.6 |
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