With more than 15,000 nursing homes in the United States, even a modest-size city is likely to have 20 or more within a short drive. How can a manageable list be sifted out of so many possibilities?
[See America's Best Nursing Homes and search for one near you.]
The guiding principle is to balance practical considerations, such as distance and expense, with issues of quality, such as results of health and fire safety inspections. You can readily obtain quality-related information by mining such resources as the new U.S. News "America's Best Nursing Homes" rankings, which rely on information collected, analyzed, and converted into ratings by the federal Centers for Medicare and Medicaid Service (CMS). Some states also post data online.
You may find the thought of wading through data wholly unappealing, but the numbers have power well worth tapping. They will help you whittle down the nursing home universe to a short list of prospects and provide fodder for the types of questions to ask nursing home administrators when visiting the final candidates.
Make distance a priority. The best prescription for fending off depression and feelings of isolation in nursing home residents is to make sure they frequently see the significant people in their lives—adult children, of course, but also a neighbor dropping in for a meal or a grandchild coming to show off a good report card. Distance matters. "[A] facility that is a five-minute drive away may be best," says Phyllis Brostoff, president of the National Association of Professional Geriatric Caregivers, even if its marks are comparatively lower than those of another home an hour away. Close proximity also makes it easier to keep tabs on the quality of care a loved one is getting.
Work from the top down. Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care, suggests searching for places rated by the federal government at four or five stars overall and eliminating lower-starred facilities. "You might end up having to keep the threes in there, but start with the top," she says. Consumer advocates are especially leery of a category of nursing homes labeled Special Focus Facilities by the government. Because of their history of poor performance, the 135 homes on the SFF list get twice the scrutiny that even one-star homes receive. But higher-ranking homes, she warns, are more likely to have a waiting list and may take only private payers. And while the star ratings are a good place to start, they cannot capture all of life's aggravating realities—such as having limited choices if you live in a thinly populated part of the country.
Count the nurses. The number of nurses and nurse aides is one of the best indicators of good care. An ample supply means they have the time to help your mother out of bed and into her slacks or nudge her to engage with peers. It means her array of blood pressure and pain medications is closely tracked and she is monitored for side effects, drug interactions, and overmedication. You can easily compare staffing at different homes because those that take Medicare or Medicaid residents must provide CMS with nurse staffing data, which is converted into the amount of nursing time per resident.
But the numbers should be used only as a rough guide: They reflect the average number of nurses and nurse assistants in the two-week period before the most recent health inspection survey. While the surveys are unannounced—and alerting a nursing home to the date of a coming inspection is a federal crime—administrators know that surveys are conducted at least every 15 months. If it's been 10 or 11 months since the last one, homes may staff up a bit more heavily in anticipation. Staffing information also is unaudited and its accuracy is suspect. Use the reported numbers to shape your short list, says Harrington, but draw conclusions only after visiting.
Good turnover data, if they were available, would be a much better indicator of the quality of staffing. It is not unusual for a home to have annual nursing turnover of 50 or 100 percent or even higher. Because of low pay and demanding physical requirements, turnover is especially high among aides, who have the most frequent direct contact with residents. The payroll data that would allow calculating turnover are not now collected. CMS plans to begin requiring homes to submit the information, but that could be a year or more away. It is a topic very much worth raising when you visit. Step 3 will give you turnover rates to compare with the answers you get.
Buddy up to an advocate. Every state has a long-term care ombudsman whose responsibilities include pursuing complaints made about a specific nursing home, usually by a resident's family member or friend. The ombudsman is likely to know whether a facility has improved or has recently attracted a slew of complaints and should be willing to share these insights. You should also get his or her reaction to a nursing home's star ratings in the Best Nursing Home rankings for overall quality, health inspections, staffing, and medical measures. "Ask if they think the ratings are accurate," suggests Janet Wells, director of public policy at the National Citizens' Coalition for Nursing Home Reform. Advocacy groups such as hers are another information source worth tapping—and the local ones may be more ready to dish about especially good or bad nursing homes, she says. The National Citizens' Coalition for Nursing Home Reform lists contact information for all state ombudsmen and advocacy groups.
Ombudsmen and advocacy organizations should also be able to clue you in to disturbing events, such as an outbreak of C. difficile or MRSA infections, which are common in hospitals and nursing homes. And they can discuss a particular state's nursing home regulations, which can be more stringent than federal standards, as well as details of citations for any violations. If a nursing home is implicated in a resident's death in California, for example, the state ombudsman's office can disclose the violation. Publicly available federal data might not reflect the specifics of the incident. "It might say there was a [citation that put residents in] jeopardy, but it might not be in there at all," says Toby Edelman of the Washington, D.C.-based Center for Medicare Advocacy. Some state watchdogs are better than others, she adds. And the quality and level of knowledge varies widely: An ombudsman may be a part-time volunteer, for example, or might not be a particularly dogged advocate for nursing home residents.
Exploit state information. Some states have their own nursing home quality measures and post the results online. The trick is finding the information. It may be hosted by the department of public health or buried in nursing home "licensing and certification" sections. Dig around on the state's home page, its department of public health page, and anything you can find on nursing homes or certification and licensing. Terms to guide your clicking: violations, deficiencies, state surveys, inspections, and 2567 forms.
The details can be telling. While some states simply rehash the federal information, others unveil specific results from the previous health and fire inspection as reported by the surveyors on federal form 2567, which describes investigations that earned violations for the facility—staff neglect that contributed to a resident's injury from a fall, for instance, or a resident's violent agitation because nurses failed to follow medication instructions. The Illinois Department of Public Health Website, for example, posts some 2567 forms online with their nursing homes. They also have a roundup section that lists, by quarter, the fines slapped on specific nursing homes, though not the details of the violations that garnered them. The California Department of Public Health website has a separate page that allows users to identify homes the state found responsible in the death of a resident and to read the 2567 forms to see what happened.
Broader nursing home information is not limited to federal or state websites. For example, the California Health Care Foundation website, which Harrington helped create, lists helpful information such as the percentages of residents at a home who require certain kinds of special care because of, say, reduced physical function or impaired cognition, compared with the state nursing home average. That will give you an advance sense of a home's ability to provide a service that your loved one may need. Hourly nursing staff wages and rates of staff turnover, with comparisons to regional averages, also are available.