Skilled Nursing Facilities

COVID-19 disproportionately impacted older adults in nursing homes in the United States. As of August 2024, over 2 million confirmed cases of COVID-19 and over 170,000 deaths among nursing home residents were reported. In addition, almost 2 million confirmed cases among nursing home staff were reported (1). During the COVID-19 pandemic, large numbers of nursing home staff suffered from mental distress and burnout and left the nursing home and, in some cases, the profession. Additionally, about 300 nursing homes closed during the COVID-19 pandemic, and more are expected to close in the future. Fortunately, there have been fewer deaths of both residents and staff in nursing homes since the COVID-19 vaccines became available. However, although most nursing home residents were vaccinated during the pandemic, vaccination rates have decreased since the end of the pandemic to approximately 30%. Additionally, as of the end of July 2024, only about 10% of nursing home staff are fully up-to-date with their COVID-19 vaccinations (see CDC: Nursing Home COVID-19 Vaccination Data Dashboard).

Physicians must complete the initial admission of residents to a nursing home. Then they may delegate follow-up of residents to a nurse practitioner or physician assistant, who alternate with the physician in visiting residents. Visits must be done as often as medically necessary but not less than every 30 days for the first 90 days and at least once every 60 days thereafter; however, some states require a minimum of one visit every 30 days. For long-term care patients, nurse practitioners may provide independent care of the residents (patients) depending on whether their state allows independent practice (1, 2).

During routine visits, patients should be examined, medication regimen assessed, and laboratory tests ordered as needed. Findings must be documented in the patient’s chart to keep other staff members informed. Some physicians, nurse practitioners, and physician assistants limit their practice to nursing homes. They are available to participate in team activities and staff education and to consult with other staff members, thus promoting better care than that given in hurried visits every other month. Some nurse practitioners and physicians collaborate to manage patients’ disorders. By administering antibiotics when appropriate and monitoring IV lines, suctioning equipment, and sometimes ventilators, nurse practitioners may help prevent patients from being hospitalized (3). Many physicians collaborate closely with a nurse practitioner or a physician assistant to provide team-based care.

Detecting and preventing abuse is also a function of physicians, nurses, and other health care professionals. All clinicians involved in care of older adults should be familiar with signs of abuse or neglect and be ready to intervene if abuse is suspected. A public advocacy system exists, and nursing homes can be cited by regulatory agencies.

The federal and state governments are legally responsible for ensuring that a facility is providing good care; surveyors attempt to assess a facility’s performance and to detect deficiencies by monitoring outcome measures, observing care, interviewing patients and staff members, and reviewing clinical records.

The COVID-19 pandemic has highlighted a number of problems with quality of care in nursing homes (4); it has caused government regulators to look more carefully at care in nursing homes. In response, regulators have provided enhanced training for nursing home staff about infection control and in some states require nursing homes to have full-time staff with expertise in infection prevention (5). In 2022, the National Academies of Sciences, Engineering, and Medicine (NASEM) formed the Committee on the Quality of Care in Nursing Homes to study the state of nursing home care in the United States. This committee issued the following recommendations for improving nursing home care (6):

• Deliver comprehensive, person-centered, equitable care that ensures the health, quality of life, and safety of nursing home residents; promote resident autonomy; and manage risks

• Ensure a well-prepared, empowered, and appropriately compensated workforce

• Increase transparency and accountability of finances, operations, and ownership

• Create a more rational and robust financing system

• Design a more effective and responsive system of quality assurance

• Expand and enhance quality measurement and continuous quality improvement

• Adopt health information technology in all nursing homes

In the upcoming years, efforts must be focused on implementing these recommendations to ensure that vulnerable older adults receive the high quality and safe care they deserve.

If hospitalization becomes necessary, the physician who cares for a patient in the nursing home should coordinate with the treating physician for that patient in the hospital. However, hospitalization is avoided whenever possible because of its risks, such as health care–associated infections.

When patients are transferred to a hospital, their medical records, as well as their advance directives and Medical (or Physician) Orders for Life-Sustaining Treatment (MOLST or POLST forms), should accompany them. A phone call from a nursing home nurse to a hospital nurse is useful to explain the diagnosis and reason for transfer and to describe the patient’s baseline functional and mental status, medications, and advance directives.

Similarly, when patients are returned to the nursing home from the hospital, a hospital nurse should call a nursing home nurse. Many nursing homes use an SBAR (Situation-Background-Assessment-Recommendation) form for all transfers to ensure that relevant information is provided to the hospital (see the SBAR toolkit at Institute for Healthcare Improvement).

Nursing home care is expensive in the United States, averaging about $225 a day or $6,844 per month for a semi-private room and $253 a day or $7,698 per month for a private room in 2016 (1). Nursing home care cost $21 billion in 1980, $70 billion in 2000, $121.9 billion in 2005, and > $157 billion in 2015. Federal and state governments pay almost 75% of the cost through Medicare, Medicaid, and the U.S. Department of Veterans Affairs (VA).

Critics suggest the following:

• The rate of reimbursement may be too low, limiting patient access to rehabilitation and services that enhance quality of life, especially for patients with dementia.

• Financial incentives to provide restorative care and rehabilitation for patients with limited functioning may be insufficient.

• Nursing homes may be motivated to foster dependence or to maintain the need for high-level care so that reimbursement is maximized.

In October 2019, Medicare changed its skilled nursing facilities reimbursement method from the Resource Utilization Groups (RUGS) model to the Patient Driven Payment Model (PDPM). RUGS primarily used the volume of therapy services provided as the basis for payment classification, which created an incentive for skilled nursing facilities to provide services to patients regardless of the patient’s needs. PDPM measures services provided to patients versus volume of services provided by the nursing home overall. PDPM includes 5 case-mix adjusted components (physical, occupational, and speech therapies, and nursing and non-therapy ancillary care) and one non-case-mix adjusted component to address resources used that do not vary by patient.

A patient’s preferences and needs can be determined most effectively through comprehensive geriatric assessment, including identification and evaluation of all disorders and evaluation of the patient’s functional ability. Disabling or burdensome disorders—most commonly dementia, incontinence, and immobility—may trigger consideration of nursing home placement. However, even modest amelioration of a disorder may forestall the need for a nursing home (see table Strategies for Avoiding Nursing Home Placement). Older adults are the primary users of long-term care services and comprise (1)

• 83% of nursing home residents

• 92% of hospice patients

• 99% of residential care residents

• 81% of home health patients

• 44% of participants in adult day services

Nursing homes vary in the types of medical, nursing, and social services provided. Some states set minimum nurse-to-patient ratios that are more stringent than federal requirements; the ratio of other staff members to patients varies considerably.

Physicians, nurse practitioners, and physician assistants should help families select a nursing home that matches the needs of the patient with the services of a nursing home. Clinicians should consider the following:

• Which clinical care practice model the nursing home uses (eg, private single-physician practices, large networks of primary care physicians who routinely visit a certain set of nursing homes)

• Which hospitals have transfer agreements with the nursing home

• Which special therapeutic services, palliative care, hospice, acute rehabilitation, and other services are available

• Whether staff members are employed full-time or part-time

• What the patient’s medical coverage is, particularly if it is a Medicare capitated program, which covers certain aspects of ongoing medical care but does not cover long-term custodial care

• What services are available at the nursing home (eg, physical, occupational, and speech therapy)

• What appropriate recreational activities are available

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

1. Nursing Home Compare: Provides detailed information about every Medicare- and Medicaid-certified nursing home

2. LongTermCare.gov: The Administration for Community Living combined information from the Administration on Aging, the Administration on Intellectual and Developmental Disabilities, and the Department of Health and Human Services Office on Disability to provide information on long-term care access and cost

3. Kaiser Family Foundation: Providers and Service Use Indicators: Nursing Facilities: A resource providing data about health care facilities, including hospitals, nursing homes, and community health centers and the health care workforce, such as physicians, nurse practitioners, and physician assistants

4. American Action Forum: The Ballooning Costs of Long-Term Care