How to choose a nursing home
By Lisa DeWitt, RN, LNC
When her husband was diagnosed with Alzheimer’s disease, Caroline (not her real name) promised to care for him at home. As the years went by and his symptoms progressed, she brought in professional caregiving help. Eventually, his needs intensified and caregiving became more challenging—so much so, that it began to affect her health.
After long conversations with their children, her closest friends, her husband’s health care providers, and her own doctors, Caroline made a difficult decision—it was time for nursing home care. She knew of several facilities nearby, but, like most people, she didn’t know how to choose the right one.
The decision's been made—now what?
When deciding that a loved one should move to a nursing home, different emotions can come up. For example, you may experience guilt or worry about having others take care of your loved one in an institutional setting. And if your loved one lives with you, it can be hard to imagine being apart. At the same time, you might feel relieved to have a difficult situation change while also being overwhelmed by having to choose a nursing home.
It’s important to remember that any feelings you have are normal. Moving a loved one to a nursing home isn’t easy. Acknowledging your feelings will help you cope with this transition.
Next is to explore the nursing home options that are available. Here are 3 important things to consider:
- Location. How long will it take for you and others to get there? Is it close enough that you, friends, and relatives can visit as often as you want?
- References. You can ask nursing home administrators for references. But it’s even more important to also ask people you know and trust. If your friends and relatives don’t have firsthand experience with a facility, ask if they know someone who does.
- Costs. The financial implications of admitting your loved one to a nursing facility can be confusing. You can look to attorneys or nursing home staff (the social worker can be a good person to start with) for help with understanding how the costs work. Ask what happens if your loved one starts by paying out-of-pocket (also called private pay) but eventually will rely on Medicaid coverage. Keep in mind that not all nursing homes are certified by Medicaid.
See how they rate
There are federal and state agencies that rate nursing homes regularly. These ratings—which are based on multiple data sources, including inspections, staffing, and quality measures—can give you a snapshot of the nursing homes you’re considering.
The federal government inspects and rates every nursing home that is certified by Medicare and Medicaid. Nursing Home Compare provides the ratings and detailed information on quality of care and staffing.
In Massachusetts, the Department of Public Health (DPH) evaluates nursing homes every 9 to 15 months, with more inspections as needed. These unannounced evaluations are to make sure the facilities are following federal care standards such as staffing ratios, care quality, and cleanliness. The ratings are available through the Nursing Home Survey Performance Tool.
While the ratings from both state and federal governments are valuable, I encourage you to use them as just part of your assessment. The DPH evaluations, for example, provide opportunities for a facility’s management to assess and then address weaknesses. So, if you notice a lower rating in a specific area, you may want to ask the nursing home how they've addressed those weaknesses.
See things for yourself
Reviewing online ratings and recommendations is important, but so is seeing things for yourself. Try stopping by a nursing home without an appointment the first time you visit. It’ll give you a good sense of what daily life there is like.
As you explore the facility, pay attention to details, like:
- Do residents appear clean, comfortable, and well cared for?
- Are there activities going on and, if so, are the residents engaged?
- Are staff members such as CNAs (certified nursing assistants) and RNs (registered nurses) kind, attentive, and respectful with residents and their families?
- Does the space look clean and feel welcoming?
An unplanned visit is effective in 2 ways—you may see things that don’t sit well with you, or you may learn things that inspire confidence. After that first visit, you can schedule an official appointment where you can ask questions and take a closer look.
Questions to ask
While you’re on your scheduled visit, take advantage of the opportunity to ask questions of the other people you meet, in addition to the person giving you the tour. Here are a few to consider:
- How are care plans developed? How often are they reviewed and updated? Are families involved in the process? Are residents’ individual care goals assessed regularly?
- Does the food service program include accommodations for special diets and cultural preferences? Can residents choose when they eat?
- What is the ratio of staff to residents? Keep in mind that requirements will vary by state, number of residents, and level of care provided.
- How high is staff turnover? Are staff assigned to care for specific residents? For example, will your loved one have the same people working with them on a regular basis?
- What types of activities are offered? How much variety is there in the activities schedule?
- Is transportation provided for off-site medical and social purposes?
- Are there regular opportunities for residents to safely spend time outdoors?
- What do residents and their visitors like/dislike about the nursing home?
Medicare.gov provides the following resources that you and your loved one may find helpful:
Specialized care for people with dementia
If your loved one has Alzheimer’s disease, another type of dementia, or cognitive impairment that affects memory, safety, behavior, or judgment, you may want to find a facility with specialty care. When you do:
- Ask about the ratio of nursing staff to residents. There are usually more staff members for residents with Alzheimer’s. (Also ask about the ratio of CNAs to residents.)
- Find out if there is a dedicated floor or wing for residents with these issues. Staff members in these units have typically gone through extensive Alzheimer’s and dementia care training. The training enables them to better meet the needs of residents with cognitive impairment. Ask if this floor/wing is secure. Otherwise, residents may wander outside the facility alone.
- Check out whether there are activities, so residents are occupied. These activities should engage residents in a way that meets their individual needs, based on their current abilities and stage of cognitive impairment. For example, doors may be decorated with photos and other items the resident will recognize—like a photo of someone from 20 years ago or a shadow box with treasured items.
- See if the nursing home offers medical care on the Alzheimer’s or dementia floor. If so, your loved one may be able to get the care they need without moving to another area. Because a move can be challenging for someone with Alzheimer’s or dementia, this can help.
Signs your loved one is receiving good care
Once your loved one settles into this new living arrangement, you’ll want to see signs that they’re being well taken care of. Here are things to look for:
- Hearing aids are in
- Glasses are on or within easy reach, and they're clean
- Dentures are in during the day (ask if they're being cleaned regularly)
- Clothes are clean and suitable for the environment and season
- Showers are given regularly
- Your loved one is participating in their own care and making decisions to the extent possible
- The plan of care is being adjusted as needed to align with your loved one’s clinical needs, abilities, and care goals
If you have concerns about your loved one’s care, talk with the care staff and the facility administrator. Problems can usually be addressed and are often the result of miscommunication.
An advocate is available if you need help
It may be valuable to have an outside party to help you advocate for your loved one. Each nursing facility has long-term care ombudsmen who provide support for residents of nursing homes and other long-term care facilities.
Ombudsmen work with residents and their families, as well as staff and administrators, to resolve issues that come up. Your local nursing home ombudsman can also be a source of information as you’re exploring the options.
Remember why you made the decision
It can be easy to imagine that things would have turned around for your loved one, if only you’d kept them at home. That’s why it’s important for you to remember the circumstances that led to this decision.
Yes, your role will shift. But you’ll still be a caregiver and remain an important part of your loved one’s life, because you’ll continue to make sure your loved one gets the care they need.
Caroline eventually found the right nursing home for her husband. After he moved in, it was an adjustment for them both. Once they became accustomed to the new arrangement, though, Caroline began to feel relieved. Her husband was being well cared for, and she could simply be his wife again.
Lisa DeWitt, RN, LNC, is the Site Director for Fallon Health’s Summit ElderCare® Program of All-Inclusive Care for the Elderly (PACE) Center in Webster, Massachusetts.