Nursing Homes: The Basics
Sarah Greene Burger, RN-C, MPH, FAAN
Ethel Mitty, EdD, RN
Mathy Mezey, EdD, RN, FAAN
Hartford Institute for Geriatric Nursing,
New York University College of Nursing
Module 1 of Nursing Homes as Clinical Placement Sites for Nursing Students Series
Acknowledgments
This is a joint project of
With support from
Grant to the
University of Minnesota
School of Nursing
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
This project is endorsed by:
Project Steering Committee
View List of Members
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
About Module 1- Nursing Homes: The Basics
Objectives/Purpose:
At the end of this module
you will be able to:

Evaluate attributes of nursing homes that can affect the
educational experience of students

Compare and contrast quality of care in nursing homes
using objective criteria

Explain how nursing homes are regulated and
reimbursed

Evaluate the potential for a nursing home to serve as a
clinical training site for nursing students
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nursing Home Characteristics and Services
Most Nursing
Homes (67%)
are for-profit
16,000+
Nursing
Homes
1.5 million+
people (6%+
of people >65
years old) are
in Nursing
Homes
1.7 Million
Medicare
and/or
Medicaid
certified beds
Average
Nursing
Home Size:
104 beds
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resident Characteristics
Most residents are white
(86%), female (62%), married
(17%) and live alone
Age range: 75-84: 30%,
>85 y/o: 45%,
<65 y/o: 12%
Assistance
needed with 3-4
ADLs: 95%
Incontinent of
bladder or
bowel: 50%
Dementia of
some kind: 65%
Depressed (at
least one clinical
symptom): 20%
Physical restraint use:
6% (some NHs: 0%)
Receiving psychotropic
medication: 63%
46% of residents are admitted from
acute care
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resident Length of Stay
50%+
2.5 years
(mean)
50% +
14-32 days
(mean)
Short-Term (typically Medicare
covered)
Long-Term (typically Medicaid
covered)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Hospitalization of Residents
 Between 25%-50% of
residents are hospitalized
during any one year
 Some residents can be
hospitalized as many as 4
times in one year (e.g.
with diagnosis of COPD,
CHF)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Reasons for Hospitalization
Reasons for hospitalization
include:




Physician practice pattern
and hospital vacancy rate
Resident’s Medicare
eligibility
Nursing Home resources
(staffing; IV administration;
diagnostic services)
Family pressure
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Special Care Units (SCU)
3000 Nursing Homes (19+%) have designated a
Special Care Unit (SCU)
Dementia SCUs are the most common type (22%) (Originally for residents
with mild/moderate stage dementia)
Sub-acute Care Units provide short-term intensive rehab and continuous
medical monitoring
Types of Sub-acute Care Units include ventilator dependent, traumatic
brain injury, oncology, pressure ulcer care, AIDS, skilled rehab,
palliative care and hospice units
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nursing Home Regulations: The Nursing Home
Reform Act 1987 (NHRA [OBRA’87]) (PL 100-203)
Most federal regulation of Nursing Homes stems from The Nursing
Home Reform Act 1987. Components of the Act include the following:




Nursing homes are certified as a Medicare and/or Medicaid skilled
nursing facility by the federal government (Centers for Medicare and
Medicaid [CMS]).
“Conditions of Participation”: Spells out the mandates that a nursing
home is obliged to meet in order to remain Medicare/Medicaid certified
and eligible for reimbursement
Specifies that people living in a nursing home are “residents” – not
patients.
Requires that every facility is “to care for its residents in such a manner
and in such an environment as will promote maintenance or
enhancement of quality of life of each resident” and to “provide services
and activities to attain or maintain, for each resident, the highest,
practicable physical, mental and psychological well-being.”
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Staffing in Medicare and Medicaid Skilled
Nursing Homes





On-site supervision 24/7 by a licensed nurse (RN, LPN); an RN
must be on duty 8 hrs/day, 7 days/wk.
-Nursing: 66%+ of Nursing Home staff (RN, LPN, Certified
Nurse Assistant or CNA)
See Module 2: An Overview of Nursing homes Generally
Full-time licensed administrator
Therapeutic staff: social worker, activities therapist, nutritionist,
and rehab therapy staff (full or part time required)
Medical director (at least 20% time)
Physician for every resident
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
CMS Mandated Services and Committees in
Medicare and Medicaid Skilled Nursing Homes
Podiatric, ophthalmology and dental services
 Rehabilitation services (PT, OT, ST) intensity
can vary)
 Pharmacy, clinical lab, radiology
 End of Life (EOL) Care
 Psychiatry consultation
 Resident and Family Council (to express
concerns & interests, and receive information and
updates).
 Committees: Pharmacy & Therapeutics (P&T),
Infection Control, Quality Assurance, Safety (Risk
Management), Utilization Review

© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
CMS Mandate for Interdisciplinary Team in
Medicare and Medicaid NHs
Physicians are the legal head of the team and
the team includes nursing, social worker,
activities therapist, nutritionist, rehabilitation,
and others (e.g. psych) on ad hoc basis
CNAs
can (and should) be a member of the
interdisciplinary team
Resident,
family, health proxy/surrogate, if
resident wishes, are also part of the team
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Oversight and Monitoring of Nursing Homes
The following are used in monitoring Nursing Homes:




State Departments of Health: Conducts surveys on
behalf of CMS
CMS 5-Star Quality Rating System
Long Term Care Ombudsman: State office
(federally funded) investigates and resolve
complaints regarding resident rights, quality of care
(in most but not all nursing homes).
Joint Commission: optional except for Nursing
Homes seeking managed care contracts or that
are hospital-based
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
State Departments of Health Surveys on
Behalf of CMS
Surveys assess 17 different
Categories, including:
Survey assessment of individual
residents includes:
 Resident rights
 Admission and discharge rights
 Resident behavior and facility
practices
 Quality of life
 Resident assessment
 Quality of care
 Nursing services
 Dietary services
 Infection control






Use of physical restraints
Psychotropic medication
Staff training & supervision
Staffing
Care planning
Specific outcomes of care and
others…
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
CMS 5 Star Quality Rating System
The CMS 5 Star Quality Rating System is a nationally recognized
standard against which to assess nursing homes.
Star rating reflects a Nursing Home’s quality status for the past
12-15 month period.
Higher star ratings reflect better quality:
 5 Stars: top 10% of nursing homes within the state
 2, 3, 4 Stars: middle 70% of nursing homes within the state
 1 Star: bottom 20% of nursing homes within the state
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Sample Nursing Home Rating
View the Nursing Home Compare web site
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
CMS 5 Star Quality Rating System: 3 Domains
(Performance Measures)
There are 3 performance measures of the CMS 5
Star Quality Rating System:
 Staffing (Nursing) Domain
 Quality Measures Domain
 Health Inspection Domain
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Staffing (Nursing) Domain of CMS 5 Star Quality
Rating System
The Staffing (Nursing) Domain,
consists of the following
characteristics:
 Nurse staffing includes RNs, LPNs, and
Certified Nursing Assistants (CNAs)
 Nurse staffing typically reported as hours
per resident day (HPRD). HPRD computed
for RNs only and for total nursing staffing. *
 Relationship of staffing to quality. CMS
studies show a clear association between
nursing staffing and quality of care
outcomes
 Staff-to-resident ratios indicate when NH
residents are at high risk for quality
problems (CMS data).
*Nurse staffing data provided by Nursing Homes is available in the annual federal On-line Survey,
Certification and Reporting system.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Quality Domain of the CMS 5 Star Quality Rating
System
The Quality Domain,
consists of the following
characteristics:

Assessment of Quality based on data in
the Minimum Data Set

Quality Measures (QMs) are issued by
the NHQI Quality Initiative*

All QMs are validated, reliable and
endorsed by the quality measure rating
agency: National Quality Forum
Quality Measures (QMs) are believed to be within the NHs ability to
influence and control
Seven Long-stay QMs: The percent of residents (1) whose need for
ADL assistance increased; (2) whose in-room mobility decreased; (3)
are “high-risk” and have pressure ulcers; (4) have an indwelling urinary
catheter; (5) are physically restrained; (6) have a UTI; (7) have
moderate to severe pain.
Four Short-stay QMs: The percent of residents with (1) pressure
ulcers; (2) delirium; (3) moderate to severe pain.
For comparison of quality measures across homes go to www.medicare.gov/NHCompare
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Health Inspection Domain of the CMS 5 Star
Quality Rating System
The Health Inspection Domain carries the strongest weight.
It uses annual health survey and complaint data and also
indicates the relative performance of a nursing home within
the state.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resident Assessment:
The Minimum Data Set (MDS)
 The Minimum Data Set (MDS) is:
 a functional assessment instrument; required
by NHRA [OBRA ’87]
 provided by the interdisciplinary team members
according to their specialty.
 the basis for interdisciplinary assessment, care
planning, reimbursement, and quality
monitoring.
Click here for more information about MDS
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
NH Costs and Reimbursement
 The mean national cost for a nursing home stay is $
62,000+/year. A two-bed shared room is $169/day
 62%+ of residents are dually Medicare and Medicaid
eligible.
 Medicare is primary payer for residents in a Nursing Home
for post-hospital skilled nursing and/or rehab (100 days
maximum).
 Medicaid is primary payer for residents in a Nursing Home
for an entire year (or longer).
 Other residents are “private pay,” i.e. they pay for Nursing
Home care “out of pocket.”
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resource Utilization Groups III (RUGs)
 Resource Utilization Groups III (RUGs) is a method of assigning
payment for care in NHs (achieving a similar aim as DRGs in
hospitals)
 It is a case-mixed reimbursement system in which ADL data is
essential. It also reflects the amount of resources (human and other)
needed to provide care
Click here for more information about RUGs
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Recap: Key Points about
Nursing Homes: The Basics

Knowing the characteristics of
residents in nursing homes is
helpful in creating strong clinical
assignments for students

Objective criteria exist for
comparing and contrasting
quality of care in nursing homes

Understanding regulation and
reimbursement in nursing homes
can help students meet learning
objectives related to the health
care system
We present the following
key points to consider:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Please Proceed to the following modules of the Series
Nursing Homes as Clinical Placement Sites
for Nursing Students
Overview of the Project
Module 1: An overview of nursing homes generally
Module 2: An overview of nursing in nursing homes
Module 3: Content on resident directed care and culture change
Module 4: Selecting and structuring clinical placements in nursing
homes
Module 5: A case study to help faculty introduce resident directed care
and culture change
Module 6: Strategies to help nursing homes position themselves as
clinical placement
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing