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About Nursing Home Care

Q: How do I pay for nursing home care?

There are several options that will all depend on your personal situation, including long term care insurance, Medicaid, Medicare, Veteran's benefits, life insurance, reverse mortgage funding, or private funds.

A nursing home can be a good option if a senior loved one is in need of more care than a residential facility is capable of providing them - for example if they have medical needs or significant problems attending to daily activities. Seniors that may need nursing home care include those who require help managing medications, as well as those who are in need of mobility help, assistance with hygiene issues such as bathing, dressing, and incontinence, and more. Nursing homes typically include private, semi-private, and shared rooms as well as facilities such as dining halls, social areas, and outdoor areas. They provide a higher level of care with more medical attention than assisted living facilities.

Top Cities for Nursing Homes in the US

More About Nursing Home Care

A nursing home can be a good option if a senior loved one needs more care than a residential facility can provide. For example, they may need help managing medications, getting around safely, and hygiene care such as bathing, dressing, and incontinence. Nursing homes typically include private, semi-private, and shared rooms as well as facilities such as dining halls, social areas, and outdoor areas. In the spectrum of senior living options, nursing homes offer a higher level of medical care and supervision than assisted living and may be provided at a continuing care retirement community or a standalone nursing care facility.

What is Nursing Home Care?

Nursing home facilities, also referred to as long-term or convalescent care facilities, provide extended senior care, meals, and medical assistance to those who cannot live independently and perform daily living activities like bathing due to disabling medical issues, or other physical or mental conditions that require continuous supervision. In addition, a nursing home offers social, recreational and spiritual activities.

Nursing homes tend to provide more frequent and comprehensive personal care services than what is found in assisted living facilities. They also provide easier access to skilled nurses and often have a skilled nursing unit within the facility. The facilities are licensed to provide care to those who are unable to take care of daily living needs. The average stay for those in a nursing home was 835 days according to a Centers for Disease Control 2004 Nursing Home Survey.

What is the Difference Between Skilled Nursing and Nursing Home Care

Typically referred to as a nursing home, a skilled nursing facility (SNF) or a skilled nursing unit is similar but more often a temporary solution to a specific medical need or to aid in recovery after a hospital stay. Offering rehabilitative care, such as physical, occupational, and speech therapy, or specialized care for Alzheimer's patients, a SNF offers more medically involved services and medical staff than a basic nursing home.

SNFs are mostly intended for those who need short-term medical care or services outside of a hospital following surgery or other serious medical treatments. Often those who discharge from a SNF will remain in a basic nursing home if care is still required. Examples of services provided at a SNF include:

Planning, managing, and evaluating patient care
Giving injections
Inserting catheters and feeding lines
Using aspiration devices
Treating skin diseases and applying dressings for wound care

A SNF has specialized staff for the rehabilitation of patients that do not require long-term care services. According to the Centers for Medicare and Medicaid Services, the average stay in a SNF is 28 days. This type of care is also referred to as post-acute care, in that it typically is provided following an emergency hospital stay.

Increasingly, many nursing facilities have skilled medical staff, and for clarity it is assumed that the use of the term "nursing home" includes access to the care that a SNF or an onsite skilled care nursing unit provides.

Nursing Home Care vs. Assisted Living

The difference between these services is that the custodial care in an assisted living facility doesn't require the skills of a registered or licensed nurse or physician. Nursing homes have a stronger focus on skilled care for medical conditions. The average stay in a nursing home and an assisted living facility are each just over two years. As one might guess, the access to skilled staff at a nursing home increases the costs. According to a survey conducted by Genworth in June 2017, the national average monthly cost for a semi-private room in a nursing home is $7,148 versus a cost of $3,750 for a one bedroom in an assisted living facility.

Nursing Home Care vs. Home Health Care

Home health care is very similar to a nursing home in that it can provide the same level of skilled nursing staff to provide services such as injections, health monitoring and care evaluations, wound care and intravenous or nutrition therapy but it allows the resident to remain at home. Unlike a nursing home with 24-7 monitoring, home health is usually provided for fewer than eight hours per day and is typically less expensive than a nursing home. According to a survey conducted by Genworth in June 2017, the national average monthly cost for home health services is about $4,100 versus a cost of $7,148 for a semi-private room in a nursing home facility.

What is Short-Term Nursing Home Care?

Short-term nursing care is also referred to as post-acute rehabilitation. After a major injury, surgery, or a sudden condition like a stroke, many patients cannot care for themselves. For example, after a total joint replacement, a patient needs physical therapy to strengthen muscles and to learn to walk safely. This type of care helps a patient make the transition to self-care as quickly and safely as possible. The goal is to return home as soon as possible. The length of a short-term stay depends on the patient's condition and medical needs. Care includes basic activities of daily living as well as nursing care. This may include personal hygiene, assistance with meals or getting to the bathroom. Specialists may provide physical, occupational or speech therapy.

How Much Do Nursing Homes Cost?

According to Northwestern Mutual, the national average for a semi-private room runs $245 a day, while a private room averages $281 a day - or about $89,000 to almost $103,000 a year.

Across the country, the state with the highest average was also in one of the most remote areas: Alaska, where a private room averages $536 a day. Connecticut and Massachusetts followed close behind, at $468 and $426 per month, respectively. States in the South were among the least expensive for nursing homes: Louisiana, Missouri and Arkansas all had averages below $200 a day for private rooms.

In addition to the location, the cost depends on the type and duration of care you need, the provider you use and any extra charges beyond the basic room, such as food and housekeeping charges, although many have "all inclusive" fees.

How Do I Pay for Nursing Home Care?

Considered a long-term care option, nursing home expenses are most frequently paid for out-of-pocket or by a combination of other methods such as Social Security, pensions, Veterans benefits, insurance, home equity, and various savings. We've provided more details on some of the options below.

Long-Term Care Insurance

Long-term care insurance is a policy that is purchased through a private insurance company. Like health insurance policies, the price varies greatly depending on age, general health and amount of coverage needed. Coverage could be denied for people with pre-existing conditions such as Alzheimer's disease or Parkinson's disease. Not all insurance will deny based on these conditions, so it is important to explore different insurance companies.

Medicaid

Medicaid is a Federal and State health insurance program for those with low income and limited assets. Administration of the program varies by state, according to the Centers for Medicare and Medicaid Services (CMS). Medicaid may pay for a stay in a nursing home if the individual meets nursing home functional eligibility criteria and has income and assets below certain guidelines. Many Medicaid certified nursing homes and SNFs are available in each state. Unlike Medicare, Medicaid has strict eligibility requirements.

Medicare

Medicare is a federal government program for those 65 or older with low income and limited assets. Medicare generally does not pay for long-term care like a stay in a nursing home, but it will pay for acute care like that received in a short stay at a SNF. It may pay for rehab while someone recovers from an illness, injury, or surgery.

Aid and Attendance Benefit for Veterans

According to the VA website, the Aid and Attendance (A&A) benefit is a special benefit for war era veterans and their surviving spouses. It is a tax-free benefit designed to provide financial assistance to help cover the cost of long-term care in the home, in an assisted living facility or in a nursing home. This benefit is for those who live in a nursing home or are mentally or physically incapacitated or require the regular attendance of another person or caregiver in at least two of the daily activities of living. To learn more about the eligibility requirements and to apply for these veteran benefits visit VeteransAid.org online.

Reverse Mortgage Loans

The Home Equity Conversion Mortgage (HECM) is a reverse mortgage that seniors take against their home's equity. Insured by the federal government, it is only accessible via lenders approved by the Federal Housing Administration (FHA). Once finalized, the lender makes payments in a single lump sum, monthly installments, or as a line of credit. The loan does not have to be paid back until the last borrower passes away or moves from the home for one full year. The home is usually sold, and the lender is paid back the full loan amount plus interest.

Life Insurance

Some life insurance policies may provide options to help pay for nursing home care. These options greatly depend on the type of life insurance policy so it's best to discuss with an insurance broker or financial advisor.

Life Settlement - You can sell your life insurance policy to a third party for market value and use the proceeds to fund a long-term care benefit plan.
Surrender Policy - You give up ownership and the death benefit. If the policy has accumulated cash, the insurance company writes you a check for the full amount of cash value, which is often taxed.
Policy Loan - You can take a loan from your life insurance policy, which means you won't pay taxes. However, you can't take it all or the policy will lapse.
1035 transaction - This allows you to exchange cash value from an existing life insurance policy into a new life insurance policy with long-term care insurance benefits tax-free.

Private Funding

In situations when costs aren't covered through other means, paying via private funds is an option. Sources of private funds for assisted living include retirement accounts and 401Ks, savings accounts, annuities and insurance plans (including life settlements), trusts and stock market investments. Home equity and bridge loans can also be used when transitioning to a nursing home or assisted living facility. Social Security can also be used as a means of paying for a nursing home, and this can be an ideal solution for those who are receiving most of their care through a nursing facility.

When Should You Consider a Nursing Home

Medical Issues

If a senior has a sudden injury or illness that's treatable with skilled nursing and physical therapy, a nursing home placement is a great option. This would be a temporary arrangement until a less intensive option is viable - like returning home, or assisted living, or home care services. Your senior can get both the personal and medical care needed.

Daily Living Assessments

When your loved one has a chronic illness, increasing dementia, or simply has lost certain abilities due to the aging process, the decision isn't as black and white. Fortunately, there are some helpful tools to guide your decision-making and remove some of the emotions that cloud judgment. The Activities of Daily Living (ADL) Assessment measures basic tasks that must be accomplished every day for an individual to thrive. Typically, these are in four categories: personal hygiene, continence management, dressing, and ambulating. Each area is rated by total independence in completing the task to total dependence on another. For example, the feeding section rates these from 0-4.

Eats without assistance
Eats with minor assistance at meal times, with help preparing food or with help in cleaning up after meals
Feeds self with moderate assistance and is untidy
Requires extensive assistance for all meals
Does not feed self at all and resists efforts of others to feed him

The Instrumental Activities of Daily Living (IADLs) is a secondary assessment that goes into more detail. There are questions regarding:

Companionship and mental support
Transportation and shopping
Preparing meals
Managing household
Managing medications
Communicating with others
Managing finances

An example from the ability to use telephone section of the assessment:

Operates telephone on own initiative; looks up and dials numbers, etc.
Dials a few well known numbers
Answers telephone but does not dial
Does not use telephone at all

As you can see, by rating different areas of daily living abilities, you can get a clearer picture of what your senior loved one needs and if a nursing home is the best choice. Every person is different, so you might consider hiring an in-home nurse to help with certain activities and tasks. You should complete the assessment with your loved one and also get feedback from others who see them often, like family and friends, to get a complete picture. If your family member has difficulty with many of these tasks, it's likely time to move them into a nursing home facility.

Evaluating Nursing Homes

With the number of nursing home options, it can be overwhelming to choose. After all, it's a life-changing decision for your loved one and you want what's best for them. Here are some helpful strategies for evaluating nursing homes. But most importantly, trust your gut. If you have any reservations, move on to the next option.

Medicare.gov Nursing Home Compare

If skilled nursing care is needed, we recommend reviewing the Medicare.gov Nursing Home Compare. This program features a quality rating system of Medicare-approved nursing homes. The ratings are based on health inspections, staff ratings, and quality measures.

Evaluate Long Term Needs

Do you anticipate that your loved one will need specialized care for dementia in the future or skilled nursing care for deteriorating medical conditions? Even if they don't need these services now, it might be make sense to choose a facility that can respond to their changing needs over time. That way, you can avoid the expense and disruption of moving.

Ask Around

Check out online overviews and reviews on third-party sites. While the nursing home website may appear perfect, it's vital to get feedback from individuals who have experienced their services first-hand. Ask your doctor, family, friends, neighbors and clergy what experiences they have with nursing homes. Ask a hospital's discharge planner or social worker for recommendations, especially if your senior was in the hospital recently.

Tour Nursing Home Facilities

Tour several facilities once you've narrowed down your list. We recommend making multiple visits during your decision making process. For your first visit, make an appointment with the admissions director to tour on a weekday. Late morning and mid-day hours are usually the best times to get a feeling for the day-to-day operations of a home.

Keep Track of Nursing Home Comparisons

We've summarized key points from a helpful caregiver checklist from AARP. This checklist is printable, so you can use the same criteria as you tour each nursing home. Although this provides a starting point, be sure to add your own questions as they pertain to the specific needs and preferences of your senior, such as whether pets are permitted, if couples can live together, how they welcome LBGT residents, and if they have bilingual staff.

Basic Questions

Is the facility Medicare certified?
Is the facility Medicaid certified?
Has your license ever been revoked?
Are you accepting new patients? Is there a waiting period?
Do you conduct background checks on all employees?
What kind of training do your employees receive?
What is the patient-to-staff ratio?
Is transportation available for the residents?

Safety

Are stairs and hallways well lit?
Are exits well marked?
Do the hallways have handrails?
Do rooms and bathrooms have grab bars and call buttons?
Are there safety locks on the doors and windows?
Are there security and fire safety systems?
Is there an emergency generator or alternate power source?
Is the floor plan logical and easy to follow?

Care

Does the facility smell fresh and clean?
Are residents bathed and well groomed?
Do the staff members interact well with residents?
Do residents participate in activities and exercise?
Do residents have the same caregivers daily?
Does the food look and smell good?
Are nutritious snacks available throughout the day?

Quality of Life

Are residents' rights posted?
Do staff knock before entering a resident's room?
Are doors shut when dressing and bathing a resident?
Does the nursing home meet cultural, religious or language needs?
Does the nursing home provide outdoor areas?
Are residents allowed to make choices about daily routines, such as when to go to bed, when to get up, when to bathe, or when to eat?
Can residents have personal articles and furniture in their rooms?
Are staff friendly, considerate and helpful?

Nursing Home Regulations

Nursing homes are state regulated by the Department of Health in conjunction with the U.S. Centers for Medicare and Medicaid Services (CMS). Subject to inspections called "surveys," nursing homes are evaluated for any violations or immediate threats to patient safety and satisfaction. Unsatisfactory surveys are remedied by the nursing home administrator by proposing a plan of correction. Failure to improve on any violation could induce fines, reappointing managers, or suspension of new resident admissions or a facility's license, or even revoke a facility's license. SNFs are subjected to even more comprehensive evaluations due to the medical staff and more acute care nature of the facility.

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