Why It Matters
Nursing homes are one of the most misunderstood services available for older adults.
Since 2017, the Institute for Healthcare Improvement (IHI) and the Age-Friendly Health Systems (AFHS) team have been working on programs and services to improve care for older adults. IHI and AFHS participants have talked with state and federal legislators, agency directors, local and state leaders, and members of the public about their knowledge of programs and services for older adults. In many cases, this understanding is limited. For example, state legislators have asked, “Is assisted living different from a nursing home?” Some have asked, “Aren’t there health services or a clinic in senior housing buildings?” In some cases, agency directors do not know who lives or works in settings that serve older adults.
To help fill knowledge gaps like these, we offer a three-part informational series about nursing homes, one of the most misunderstood services available for older adults. We start by explaining basic terminology used in the United States and provide information about who lives in nursing homes and what daily life is like for residents.
Description of Settings and Services
Let’s start by clarifying commonly used (and misused) terms.
Congregate (“Institutional”) Settings providing clinical care and/or support services 24/7:
- Nursing Home — This term is used in some laws and regulations to describe a place where people live and may receive help with certain activities or care.
- SNF/NF — These terms are used in the CFR (Code of Federal Regulations) and many state regulations to refer to skilled nursing and rehabilitation facilities (SNF) and nursing facilities (NF). “Nursing Home” is a more general term that includes both.
- Post-Acute and Long-Term Care (PALTC) — This newer term includes SNF or PAC (post-acute care or care after a hospitalization) and NF (long-term care).
- LTACH or long-term acute care hospital — Patients in this setting require a higher level of care (i.e., more hands-on assistance which may include help walking, dressing, bathing, or managing their toileting) than may be delivered in a SNF/NF and often have longer lengths of stay.
- Terms for other types of settings include board and care homes, boarding houses, rest homes, retirement homes. These are defined in each state’s regulations.
The terms below describe programs or services that may also be available to older adults:
- Home and community-based services or HCBS — Community-based programs or services
- Assisted Living Residence or Facility (ALR or ALF) — Most residents in these settings have fewer needs than nursing home residents and are more independent. Some drive cars, have jobs, volunteer, or travel. ALR provides basic assistance with daily needs. Memory Care units may be available for individuals living with dementia. ALRs may also be called residential or personal care homes. ALRs do not have a licensed nurse onsite 24/7.
- Senior living or independent living — These terms refer to housing that may or may not have health care as part of the program or service package. Services may be provided by employed staff or contracted out. Many are landlord-tenant housing arrangements with limited or no health services. Some have clinics onsite while others do not.
- Adult Day Health, Social Day Care, Program for All-Inclusive Care of the Elderly (PACE), Adult Family Care and others — These are all different services, and their availability and payment systems varies from state to state.
- Area Agencies on Aging (AAAs), Councils on Aging (COAs), senior centers — These programs are located in communities and offer services and events for older adults. AAAs may arrange in-home care or other services. AAA programs and services vary by location.
Some older adult housing options are simply a place to live and have a landlord-tenant relationship. Other older adult housing options have varying types of health care services onsite. (There may be an extra charge for these services.) Some include no health care services at all. ALRs include basic support and health and wellness services, but do not have 24-hour nursing care. Nursing homes provide 24/7 nursing/health care as well as room and board.
Each setting is regulated differently. Nursing homes have both federal and state regulations, whereas assisted living is only regulated by each state. Older adult housing/senior living has some federal regulations through the US Department of Housing and Urban Development (HUD) but is less regulated in terms of health care.
Life in US Nursing Homes
About 1.3 million older adults (people over age 65) or 4.5 percent of the older adult population live in 15,000 nursing homes across the US. Over 50 percent have dementia or cognitive impairment. Most nursing home residents require assistance with one or more activities of daily living (ADLs), including managing continence, mobility, dressing, eating, bathing, medications, and health conditions. Residents typically have sensory challenges (vision, hearing), and many have mental or psychological diagnoses that require behavioral support. Most nursing home residents are women, but the gender, racial, and ethnic composition varies from home to home.
Daily life varies based on whether a person is a short-term patient or a long-term resident. Many short-term patients are in a nursing home for a few weeks for rehabilitation or treatment of a medical issue and their plan is to return home. Others may stay longer, and some become long-term care residents. Most residents have come from the hospital, and many are very ill or unstable. Some require intensive physical or occupational therapy and intensive nursing treatments each day. For most long-term nursing home residents, the center is their home.
What Do Residents Want?
Nursing home residents care about the quality of food and activities. They want highly skilled staff who care about them, a comfortable and familiar environment, and to be treated with respect and humanity. Residents seek opportunities for person-centered and person-directed living. They want to be involved in making decisions or setting goals that have a direct impact on their lives.
Many residents want to live in a place that focuses on what matters most to them. Nursing home residents, like other people, want to have meaning and purpose in their lives. They want to make their goals, preferences, and priorities known and have them addressed.
One way to promote person-directed living that addresses What Matters is implementation of Age-Friendly Health Systems and the 4Ms framework.
IHI focuses on each nursing home’s mission and vision to engage them in age-friendly care: their residents, their team, their organization, and the community. We first seek to understand each staff member in their role or job type. We ask about challenges and opportunities: “What has worked in the past and why?” “What has not succeeded in the past and why not?” We work to build rapport and trust. We help organizations build on their strengths and accomplishments.
Alice Bonner, PhD, RN, is IHI’s Senior Advisor for Aging. Amanda Meier, BSW, MA, is IHI’s Project Manager, Age-Friendly Health Systems. If you have any questions or ideas about nursing homes or related policy issues, please feel free to reach out to Alice Bonner (abonner@ihi.org) or Amanda Meier (ameier@ihi.org).
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See Part II of this series (coming soon!) for more details on nursing home regulation and oversight, who works in nursing homes, and who pays for nursing home care.
Centering What Matters: The Core of Age-Friendly Care