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Nursing homes are facilities that have at least three or more beds at which health care workers (nursing assistants, licensed practical nurses, and registered nurses) regularly provide nursing care services for persons unable to care for themselves due to physical or mental health problems, cognitive impairment, or disabilities. Despite extensive governmental regulation, nursing home care has become a social problem that is often synonymous with elder abuse, neglect, maltreatment, and despair. Many Americans see nursing homes as places of last resort for the unwanted elderly--a place where one goes to die. Recent studies by the Institute of Medicine confirm these categorizations: care deficiencies in nursing homes have caused harm to patients, and the numbers of nursing home staff are often not adequate to provide quality care. However, many older people also receive superior care and benefit from the security and stability that nursing homes provide.

Despite a common belief that most elderly people live in nursing homes, according to the U.S. 2000 census, only about 4.5 percent of those age 65 and older reside there--a decline since 1990, when 5.1 percent of those over 65 lived in nursing homes. The reduction is due, in part, to changes in governmental funding, increased usage of alternatives to nursing homes, such as home health care services, assisted living facilities, family caregiving, adult day care, assistive devices, and an overall decline in disabilities for the elderly. However, the aging of the baby boom generation (those born between 1946 and 1964) will likely result in increased demand for quality nursing home care in the near future. Although a small number of disabled and chronically ill children and adolescents live in nursing homes, most residents are elderly: in 2000, more than 1.5 million nursing home residents were age 65 and over.

The likelihood of living in a nursing home increases with age. According to the U.S. census in 2000, 1.1 percent of the 65-74 age group live in nursing homes, increasing to 4.7 percent of the 75-84 age group, and greater than 18 percent for those 85 years and older. The majority of older nursing home residents are women (around 75 percent) due in part to the longer lives of women and the reality that most female residents of nursing homes are widowed. Elderly women are more likely than elderly men to be isolated, left without a partner caregiver, increasing the risk of nursing home institutionalization. In terms of race and ethnicity, most nursing home residents are white (around 80 percent, according to the U.S. census) followed by African American at around 10 percent, and an additional 3 percent who are Latino/a, American Indian, or Pacific Islander. The difference in proportion to population rates may be due to different cultural beliefs for the aged, resistance to institutionalization of elderly, and greater kinship and support networks among some minority group members, although nursing home utilization rates for African Americans are increasing and rates for whites are on the decline.

Increasingly, proprietary or for-profit nursing homes are replacing state-funded nursing homes. While the cost of long-term care at nursing homes is high (averaging around $160 per day), older people with the need to be institutionalized tend to have limited health insurance coverage for that purpose. According to the U.S. Department of Health and Human Services, Medicare provides only limited coverage for long-term nursing home care, skilled facilities, and home health care. Once Medicare benefits are exhausted, many nursing home residents use Medicaid, a needs-based program that varies greatly from state to state. A recent study found that 16 percent of nursing home users began as private payers and then had to convert to Medicaid use once funds were gone. An additional 27 percent were covered by Medicaid upon admission and remained on it throughout their nursing home stay. Medicaid is the largest payer of nursing home care, with costs that totaled about $38 billion in 2005.

Most nursing home residents, particularly the oldest-old (85+), need assistance with multiple activities of daily living (ADLs), such as help with bathing, showering, and dressing, to more intensive services such as assistance with eating meals and toileting. Nursing home residents are often frail and in failing health; some are confused, needing to be fed, many with bladder and bowel incontinence problems that require adult diapers. Only about 11 percent of nursing home residents are able to care for their own basic needs. Compared to the nursing home residents of 30 years ago, today's nursing home patients tend to be sicker and in greater need of intensive services such as intravenous (IV) medications. Nursing home staff members often complain to administrators and researchers that they lack sufficient time to adequately care for the residents, given the high level of patient needs.

One of the main issues identified in nursing home care is the problem of neglect, which is a crisis both of quality of care in terms of meeting mandated governmental standards and quality of life issues for residents. Increased governmental regulation has been a possible solution to the crisis of nursing home care. The Omnibus Budget Reconciliation Act of 1987 raised the quality of care standards in nursing homes that receive Medicare and Medicaid funds (approximately 76 percent) and provided nursing home residents with a mechanism to ensure protection of their rights. According to the Administration on Aging, nursing homes in every state must provide advocacy for the elderly under the Older Americans Act. Long-term care ombudsmen intercede on behalf of residents' complaints of improper care; elder abuse such as slapping, hitting, or verbal assaults; complaints concerning chemical or physical restraints; withholding of medical care; lack of privacy; and untimely discharge. These ombudsmen handle approximately 260,000 complaints per year. However, many complaints go unreported because nursing home residents and their families fear reprisal from nursing home staff and administrators.

Currently, nursing homes operate under elaborate systems of rules and regulations designed to maintain caregiving standards for the elderly. Nursing homes must collect and report data on use of physical restraints, presence of skin pressure ulcers, patient weights, and other quality assurance measures. While standards have improved quality of care in some states, there is wide variation. Such regulations have also had unintended consequences. Critics charge that the "human element of care" is lost in the paperwork, as the emphasis on federal and state bureaucratic documentation takes nursing time away from the provision of the emotional care that patients need. With positive and negative sanctions for nursing homes determined by the successful completion of paperwork, the completion of the paperwork becomes a goal in and of itself. As a result, nursing home residents suffer when it becomes more important to document care than to actually give it. However, proposals to change the structure of nursing home care, including the paperwork systems, frequently meet with resistance from the nursing home industry.

Although there is no single solution to the problem of poor-quality care in nursing homes, advocates suggest that increasing levels of staffing and raising wages of nursing home workers should be high-priority actions. Because nursing assistants (also called nurses' aides) provide approximately 60 percent of direct nursing home care, their training, retention, experience, and supervision merit our attention. Nursing home workers work for little pay (median wage of $9.86 per hour in 2004) and tend to be disproportionately drawn from lower socioeconomic class backgrounds. According to the Bureau of Labor Statistics, nursing assistants may or may not be required to have a high school diploma or GED as a condition of employment. Nursing assistants are almost always women and frequently are racial and ethnic minority group members.

Nursing home care appears to be a contradiction between capitalism and care giving. In some ways, we are getting what we pay for. Changing philosophies concerning the valuation of caring work can improve the problems in nursing home care, as can the willingness to look to other, less institutionalized forms of care delivery. For example, the Eden Alternative committed to decreasing the dehumanization of the elderly gives them the opportunity to care for plants or pets or to assist in childcare, depending on their level of ability.

References:

1) Diamond, Timothy. 1995. Making Gray Gold: Narratives of Nursing Home Care. Chicago: University of Chicago Press.

2) Foner, Nancy. 1994. The Caregiving Dilemma: Work in an American Nursing Home. Berkeley, CA: University of California Press.

3) Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? Washington, DC: National Academy Press.

4) U.S. Census Bureau. 2001. "The 65 Years and Over Population: 2000." Census 2000 Brief.

5) Wiener, Joshua M. 2003. "An Assessment of Strategies for Improving Quality of Care in Nursing Homes." Gerontologist 43:19-27.

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