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Chart of Rate of Nursing Home Residence Among Persons Age 65 or Older, by Sex and Age Group, 1985, 1995, and 1997.  See text for details.

The majority of nursing facility services are funded by the Medicare and Medicaid programs . Medicare long term care services are covered by Part A, "Skilled Nursing Facility" (SNF) services which are associated with post-operative or post-hospitalization including rehabilitation therapies. Medicaid "Nursing Facility" (NF) services are provided to state residents who meet the Medicaid eligibility requirements.

Nursing facility providers in the United States(1)

1,813,665 total nursing facility beds;

16,995 total nursing facilities;

13 percent of facilities are hospital-based;

52 percent of facilities are part of a chain ("Chain" facilities are owned or leased by a multifacility organization. The remaining facilities are individually owned and operated);

107 facility bed size (average);

83 percent nursing facility occupancy rate.

Nursing facility ownership in the United States (1)

66 percent for profit;

27 percent not-for-profit;

7 percent government.

Nursing facility direct care staff in the United States (1)

53 total direct care staff (average);

35 certified nurse assistants (average);

11 licensed practical nurses (average);

6 registered nurses (average).

Nursing facility reimbursement in the United States (1)

8 percent Medicare;

68 percent Medicaid;

23 percent private pay.

Nursing facility special care beds in the United States (1)

105,066 total special care beds; including

65,304 Alzheimer beds;

3,013 AIDS beds;

4,304 hospice beds;

5,699 ventilator beds;

26,746 other special care beds.

Elderly Population in the United States (4)

The elderly population, ages 65-74 is 7 percent (18,759,000 people) of the total population;

The elderly population, ages 75-84 is 4 percent (11,145,000 people) of the total population;

The elderly 85 and older are 1 percent (3,625,000 people) of the total population; and

The total elderly population, aged 65 and older is 13 percent of the total population.

Medicaid in the United States (2, 3)

1,031,364 Medicaid only beds;

400,122,716 Medicaid nursing facility days;

1,667,319 total Medicaid nursing facility residents;

$85.05 per diem Medicaid nursing facility rate.

Ancillary services -- included in the per diem Medicaid rate.

Medicare in the United States (1)

53,138 Medicare only beds;

608,070 Dual certification beds;

1,113,237 total Medicare stays;

$234 average per diem Medicare rate;

27 days covered by Medicare (average);

$1,092 total copayment for a Medicare stay (average).

1. HCFA's Online Survey, Certification and Reporting Date (March 1997)

2. HCFA's Medicaid Statistical Information System (MSIS) (1995)

3. HCFA's Medicaid Data System (1995)

4. US Bureau of the Centus, Statistical Abstract of the United States 1996

PRIVATE VERSUS PUBLIC NURSING HOMES: 1998 (Brookings institution) Nursing homes with private care patients generally provide higher quality care than facilities dependent on Medicaid patients. National Senior Citizens Law Center states that nursing homes discriminate against Medicaid patients versus private pay. The difference may be a special wing of a home, eviction of Medicaid patients and inferior food and services. One expert noted that nine out of ten attorneys give bad advice on qualifying for Medicaid. Approximately 63% of nursing-home patients of cognitively impaired.

MEDICAID PLANNING: (1998) Readers know that I do not agree with many Eldercare attorneys in attempting to get the elderly on Medicaid. If money is available, I unquestionably believe that the purchase of some type of long-term care policy is beneficial. Some of the detriment to Medicaid planning comes from a book called Advising the Elderly Client by William Overman, "planning for Medicaid eligibility severely restricts options, it would not be in the best interest many clients." For example, consideration should be given to the following possible consequences of transferring resources in an attempt to meet resource eligibility requirements: 1 possible loss of economy, pride, and dignity; 2 inability to purchase services not available under Medicare or Medicaid; 3 reluctance of nursing homes to admit Medicaid as opposed to private pay patients; 4 donees of transferred assets may be or become unwilling to provide financial assistance to the donor when needed; 5 resource depletion and 6. limited accessibility of obtaining entry to facilities that do not accept Medicaid patients. Frankly, I think this all can be summed up by one statement that must be made to the elderly person. "Mom we want you to die in a Medicaid ward with a bunch of other screaming Alzheimers patients." Given all the objections above, I submit that most people would opt to pay for long-term care policy.

NURSING HOMES: 1998 (Smart Money) While I continually focus on the need for a long-term care policy, I must stress the absolute necessity of extended review of a nursing home before you would ever commit a loved one. In such regard, I urge you to take a look at my WebSite and the commentary by the nurses who at work in such institutions. Books also include, "Nursing Homes" by Forest and "How To Find a Nursing Home" by Joanne Meshinsky. As is quite obvious, not all the homes are the same. An article in the February Smart Money magazine noted some of these major problems that existed in nursing homes.

According to the health care financing administration, the percentage of nursing homes cited for dispensing unnecessary drugs has risen steadily to 11% in 1996 from 2% in 1992. I have commented on this previously but is not solely the nursing homes fault. Druggist's are not being informed of the various prescriptions that may come from various pharmacies.

Staffing: it is true, and one of the major problems with nursing homes, that the staffing may be inadequate. Some say that the federal regulations established in the nursing home reform act of 1987 are unduly vague: they merely require a facility to have "sufficient staff" without addressing any minimum ratios. According to a professor at the University of California,a nurses aid-the person providing the bulk of care by feeding, bathing and clothing patients-should have no more than three people to care for during a meal and no more than six during non-meal times. The ratio may be one aid for 15 patients during the night however. The article noted, however, that it is not unusual to find a lone nurses aid caring for his many as 30 people.

The article additionally noted that just 38 % of a nursing homes budget goes directly for a patient care including nursing costs. Nurses aids average wage is $6.65 per hour.

According to the New York State attorney, 25 % of nursing home aids prosecuted for abusing residents had a prior criminal record. A 1994 survey indicated that approximately 5 % of the nurses aids on file with state regulators had a criminal record involving violence and/or theft.

Malnutrition: A professor of German to at St. Louis University estimated that the rate of patients malnutrition varies from about 4 % in the good nursing homes to perhaps 50 % at the bad ones.

RESTRAINTS: (1998) Pursuant to the passage of the Nursing Home Reform Act of 1987, the use of physical restraints has dropped about half. However it is indicated that still as many is 20 % of nursing home residents are at some point restrained. But I wouldn't necessarily be concerned by that figure unless something comes up later to show that this is also excessive. There are simply times when some of these patients must be formally restrained.

LONG TERM CARE COSTS: (1998) "Researchers at the Health Care Financing Administration, which supervises the Medicare program, have identified 44 different types of care a facility could provide. In the absence of standard terminology, it's impossible to know whether one facility's enriched residential care is similar to another's intermediate. Price isn't necessarily related to quality. One firm compared daily rates at 60 facilities in metropolitan centers around the country, trying to compare price with the quality of care. There was no relationship."

NURSING HOMES: (1998) 43% of those people who turned age 65 in 1990 will enter a nursing home at some time during their life. The same study reported that among all persons who live to age 65, only 1 in 3 will spend three months or more in a nursing home; about 1 in 4 will spend  one year or more in a nursing home; and only about 1 in 11 will spend five years or more in a nursing home. In other words, 2 out of 3 people who turned 65 in 1990 will either never spend any time in a nursing home or will spend less than three months in one.

So, of course, a lot of people will not consider a policy due to the odds. But the odds for a house burning down are even less. Does that mean you shouldn't buy fire insurance? Or the odds of using a $1,000,000 personal liability policy is low. So, does that mean you go without? Certainly if you don't have enough money, your purchases of insurance will be limited and you are exposed to more risk. If, however, you can afford coverage, insurance covers both the financial problem as well as some immeasurable emotional ones.

Further statistics from the New England Journal of Medicine indicated that 52 percent of all women and 33 percent of all men who are now 65 will spend their last years in a nursing home. So maybe these brand new statistics puts even a greater focus on long term care policies.

But here we go again. Consumer Reports recommends that if you can set aside about $160,000 (or enough to cover four years of care), you may not need long-term care insurance. Frankly, I don't think that is much different than stating that if you got $250,000 (or whatever), you don't need to buy fire insurance for your house. Or if you got $1,000,000, don't bother with liability insurance.

Insurance is a dirty word with many people but it simply is a way of playing the odds and spreading them over a very large group. You do NOT want to commit large sums. You want to commit small sums where you may never get a return of premiums because the problems (loss, sickness, accident, etc) never befall you. And another gem from Consumer's Union. "If you buy a policy early, you may want to make sure that it contains a non-forfeiture clause. Under most policies, if you let your coverage lapse, you get nothing for all the premiums you've paid in the past." True, but it may cost you 15%+ more. And I'll state the obvious once again. You don't get anything back if your house does not burn down. I have not had an auto accident in over 30 years. I ain't getting any of my premiums back. That's O.K.- I didn't want an accident in the first place. Consumer Reports seems to have forgotten what insurance is and how it is supposed to work- long term care or otherwise

NURSING HOME COSTS: (1998) The cost of nursing home care rose an average of 9.7% a year between 1985 and 1994. Average length of long term care nationally is about 2 years.

NURSING HOME COSTS: 2000 (Pete Peterson) Per capita nursing home spending on the frail elderly aged eighty-five and over is OVER TWENTY TIMES HIGHER than spending on the young elderly, aged sixty-five to sixty-nine. Second, the number of these frail elderly is expected to triple or quadruple as America ages. We have no choice but to close loopholes that allow seniors to qualify for Medicaid through subterfuge--for instance, by transferring assets to their children.

NURSING HOME PATIENTS: (2000) About 2/3rd's of people in nursing homes have no living relatives. And about 70% of all nursing home patients are women.

More Nursing Home Data (2000) The racial composition of the nursing home population remained unchanged from 1987 to 1996, according to this report from the Agency for Healthcare Research and Quality (AHRQ). However, in 1996 there was an increase in the proportion of men. The majority of nursing home residents were women, and the nursing home population remained almost entirely white. Women made up approximately two-thirds of the nursing home population in both 1987 (69.7 percent) and 1996 (65.9 percent). In both years, approximately 90 percent of  nursing home residents were white.

Bad Nursing Homes (PDF) (National Citizens' Coalition for Nursing Home Reform 2000) At least a third of nursing home residents in the U.S. may suffer from malnutrition or dehydration; lack of adequately trained personnel and high staff turnover are largely to blame

Just one more reason why you do not want to die in a Medicaid ward. If you have money, buy a long term care policy

Nursing Home Statistics (2000) The analysis of the data from three States demonstrated that after controlling for case mix, staffing thresholds exist below which quality of care may be seriously impaired. The thresholds were at staffing levels that were above staffing ratios for a significant percentage of facilities. In addition, the analyses suggested that minimum levels may reduce the likelihood of facilities. In addition, the analyses suggested that minimum levels may reduce the likelihood of quality problems in several areas, but higher "preferred minimum" levels existed above which quality was improved across the board. These levels are outlined below.
Staff` Minimum/Staff Level Below Standard
Aide 2.00 hrs/resident day 54%
RN and LPN .75 hrs/resident day 23%
RN .20 hrs/resident day 31%
Preferred Minimum Level
Aide 2.00 hrs/resident day 54%
RN and LPN 1.00 hrs/resident day 56%
RN .45 hrs/resident day 67%

Here are the average daily nursing home costs per region for a private room: (Met Life 2000)

Albany, NY $200 Miami, FL $123

Atlanta, GA $110 Middlesex Cty., NJ $195

Baltimore, MD $163 Milwaukee, WI $179

Battle Creek, MI $195 Minneapolis, MN $106

Birmingham, AL $105 Nashville, TN $135

Boston, MA $278 New Brunswick, NJ $161

Bristol County, VA $199 New Haven, CT $227

Buffalo, NY $193 New Orleans, LA $97

Charleston, SC $108 New York, NY (Manh) $295

Chattanooga, TN $136 Newark, DE $139

Cherry Hill, NJ $193 Newark, NJ $228

Chicago N. Suburbs $165 North Metro Atlanta, GA $131

Chicago S. Suburbs $138 Oakland, CA $157

Chicago, IL $120 Oklahoma City, OK $134

Cincinnati, OH $127 Omaha, NE $149

Cleveland, OH $200 Orlando, FL $125

Columbia, SC $120 Pensacola, FL $123

Columbus, OH $162 Philadelphia, PA $163

Dallas, TX $149 Phoenix, AZ $152

Dayton, OH $162 Pittsburgh/Napa Cty., CA $127

Denver, CO $141 Pittsburgh, PA $181

Des Moines, IA $102 Portland, ME $192

Detroit, MI $113 Portland, OR $144

Dover, NH $200 Providence, RI $160

Fairfax County, VA $172 Provo, UT $135

Flint, MI $134 Raleigh, NC $120

Florence & Decatur Cty., AL $108 Richmond, VA $147

Fort Wayne, IN $137 Rochester, NY $187

Gary, IN $98 Salt Lake City, UT $135

Grand Rapids, MI $154 San Antonio, TX $114

Greensboro, NC $132 San Diego, CA $149

Hartford, CT $210 San Francisco, CA $169

Hibbing, MN $90 Savannah, GA $103

Houston, TX $111 Seattle, WA $174

Huntsville, AL $113 Springfield, MA $181

Indianapolis, IN $161 Stamford, CT $286

Int. Falls, MN $91 St. Louis, MO $138

Jacksonville, FL $150 Summit, NJ $242

Kansas City, KS $117 Syracuse, NY $196

Las Vegas, NV $133 Tampa, FL $128

Lehigh Valley, PA $167 Toledo, OH $128

Long Beach, CA $138 Trenton, NJ $195

Los Angeles, CA $122 Tucson, AZ $149

Macon, GA $98 Washington, DC $165

Maryland (Suburban D.C.) $173 Winston-Salem, NC $137

Here are the average hourly home health care aide costs from a licensed agency in selected areas:

Alameda, CA $19 Mercer County, NJ $16

Allegheny, PA $16 Miami, FL $14

Atlanta, GA $15 Milwaukee, WI $17

Baltimore, MD $15 Minneapolis, MN $19

Battle Creek, MI $15 Monroe County, NY $17

Birmingham, AL $14 Nashville, TN $14

Boston, MA $19 New Castle, DE $20

Chattanooga, TN $15 New Orleans, LA $13

Chicago, IL $17 New York, NY $14

Cleveland, OH $17 Oklahoma City, OK $14

Columbia, SC $13 Omaha, NE $16

Columbus, OH $16 Onandaga, NY $15

Dallas, TX $15 Orlando, FL $15

Danbury, CT $21 Pensacola, FL $14

Dayton, OH $16 Philadelphia, PA $14

Denver, CO $22 Phoenix, AZ $17

Des Moines, IA $18 Providence, RI $15

Detroit, MI $17 Raleigh, NC $15

Essex, NJ $16 Richmond, VA $13

Ft. Wayne, IN $17 San Antonio, TX $12

Gary, IN $16 San Francisco, CA $17

Grand Rapids, MI $16 Savannah, GA $12

Hartford, CT $24 Seattle, WA $19

Hibbing, MN $14 St Louis, MO $19

Houston, TX $16 Stamford, CT $19

Indianapolis, IN $17 Tampa, FL $16

Jacksonville, FL $14 Toledo, OH $15

Kansas City, KS $16 Tucson, AZ $15

Lansing, MI $16 Washington, DC $16

Las Vegas, NV $18 Winston-Salem, NC $14

Los Angeles, CA $17 

 Indicator 30 Nursing Home Utilization
1985 1995 1997
65 OR OLDER 54.0 45.9 45.3
65 TO 74 12.5 10.1 10.8
75 TO 84 57.7 45.9 45.5
85 OR OLDER 220.3 198.6 192.0
65 OR OLDER 38.8 32.8 32.0
65 TO 74 10.8 9.5 9.8
75 TO 84 43.0 33.3 34.6
85 OR OLDER 145.7 130.8 119.0
65 OR OLDER 61.5 52.3 51.9
65 TO 74 13.8 10.6 11.6
75 TO 84 66.4 53.9 52.7
85 OR OLDER 250.1 224.9 221.6
Note: Rates for 65 or older category are age-adjusted using the 2000 standard population. In 1997 population, figures are adjusted for net underenumeration using the 1990 National Population Adjustment Matrix from the U.S. Census Bureau.
Reference population: These data refer to the resident population. Persons residing in personal care or domiciliary care homes are excluded.
Source: National Nursing Home Survey.

1985 1995 1997
65 OR OLDER 1,318 1,423 1,465
65 TO 74 212 190 198
75 TO 84 509 512 528
85 OR OLDER 597 720 738
65 OR OLDER 334 357 372
65 TO 74 81 79 81
75 TO 84 141 144 159
85 OR OLDER 113 133 132
65 OR OLDER 984 1,066 1,093
65 TO 74 132 111 118
75 TO 84 368 368 369
85 OR OLDER 485 587 606
Reference population: These data refer to the population residing in nursing homes. Persons residing in personal care or domiciliary care homes are excluded.
Source: National Nursing Home Survey.

  1985 1997 1985 1997 1985 1997 1985 1997
65 OR OLDER 75.7 79.3 55.0 64.9 40.9 45.1 32.5 35.7
65 TO 74 61.2 73.1 42.9 59.2 33.5 42.1 25.7 30.7
75 TO 84 70.5 77.1 55.1 64.3 39.4 44.8 30.6 34.5
85 OR OLDER 83.3 82.6 58.1 66.9 43.9 46.1 35.6 37.8
65 OR OLDER 71.2 76.3 54.2 65.0 36.0 42.8 28.0 33.6
65 TO 74 55.8 72.3 38.8 60.1 32.8 42.7 24.1 32.9
75 TO 84 65.7 75.1 54.4 65.9 32.6 43.7 25.5 34.6
85 OR OLDER 79.2 78.3 58.1 65.6 39.2 42.1 30.9 33.0
65 OR OLDER 77.3 80.2 55.4 64.8 42.4 45.6 33.9 35.9
65 TO 74 64.5 73.7 45.4 58.6 34.0 41.6 26.7 29.2
75 TO 84 72.3 78.0 55.3 63.6 42.0 45.3 32.6 34.4
85 OR OLDER 84.3 83.5 58.1 67.2 45.0 46.9 36.7 38.8
Note: Residents dependent in mobility and eating require the assistance of a person or special equipment. Residents who are incontinent have difficulty in controlling bowels and/or bladder or have an ostomy or indwelling catheter. Rates for the 65 or older category are age-adjusted using the 1995 National Nursing Home Survey population.
Reference population: These data refer to the population residing in nursing homes. Persons residing in personal care or domiciliary care homes are excluded.
Source: National Nursing Home Survey.

Women in nursing homes are at high risk for breaking bones (Journal of the American Medical Association 2000) Thinning bones put many older women at risk of fractures-half of all American women older than 65 years will have an osteoporosis-related bone break. For women in nursing homes, the risk is even higher.

Nursing Homes 2000: Five of the nation's 10 largest nursing home chains have filed for bankruptcy in the past year. The nursing homes in bankruptcy represent 10 percent of nursing homes.

The Effects of Financial Screening and Distinct Part Rules on Access to Nursing Facilities (pdf 2000) This inspection looks at the extent to which financial screening and distinct part rules limit access to nursing facilities for Medicare and Medicaid beneficiaries. Overall, we found that distinct part rules do not appear to limit access for Medicaid or Medicare beneficiaries. As for financial screening, we found that nursing facilities commonly request financial information as part of the admissions process. However, when financial screening occurs, it primarily affects access for Medicaid beneficiaries.

Nursing Home Deaths: (2001) The number of deaths in New York City nursing homes has jumped to 6,475 in 1999 from 3,891 in 1990, a 66% increase over the past decade. People are going into nursing homes older, nursing home administrators say. "Nursing homes get reimbursed at a higher rate for patients who require greater care, including those closer to death. "[Nursing homes] are choosing the people who are more likely to die.

U CARE WE CARE Links to external websites and contact information for hundreds of homes across the UK.

Nursing Homes:  (2001) In the past 12 months, there have been verdicts of $312 million and $82 million in Texas, $5 million in California, $20 million in Florida and $3 million in Arkansas. Dozens more cases have been settled before reaching trial; hundreds more are in pretrial stages. According to the nursing home industry, greedy plaintiffs' lawyers are targeting a vulnerable industry, unfairly charging the homes with causing the deteriorating condition or death of residents who were already in severely declining health. According to plaintiffs' lawyers, the nursing homes, particularly those owned by large for-profit corporations, are systematically operating at inadequate staffing levels to maximize profits.

It's a bit of both folks. But no matter how you cut it, nursing homes do not get enough money to offer the best of care WHENEVER there is a large group of Medicaid patients. Medicaid traditionally pays only about 80% of private pay and not enough for good care overall. It's NOT a diatribe against Medicaid- it's just what the public is willing to shell out for the elderly.

Nursing Homes: (US News 2001) In the past decade, there has been about a 10% decline in residency as people find more options. There are about 1.5 million people in homes over age 65. Assisted living cover about 800,000 (and about 40% of these facilities are in California, Florida and Pennsylvania.). 90% of these people pay out of pocket.

625,000 live in assisted care facilities. And tens of thousands live in adult foster care facilities and group homes. About 6 million still receive intensive care at home.

That last part needs expanding. Who do you think takes care of these 6 million elderly? Mostly women. And if you want this type of care in your home, consider the expensive option of home health care.

A continuing Care Facility average cost is about $110,000 PLUS average monthly fees of $2,000.

Average costs for a home health aids is $15 per hour.

Nurses: (2001) The shortage of nurses and nurse aides is rapidly reaching the crisis point and is threatening the quality of patient care.

Nurses: (2001) Between 1991 and 2020, the AHCA study predicts the following growth in demand for nurses and nurse assistants:

*nursing facilities: registered nurses 66%; licensed practical and vocational nurses 72%; nurse assistants 69%.

*home health settings: registered nurses 270%; licenses practical and vocational nurses 268%; nurse assistants 263%.

The average nurse working in a long-term care facility earned 17% less than a comparable nurse working in an acute care hospital in 1996

Nursing homes help document end-of-life wishes (2001) Nursing homes can help patients address and record how they wish to be cared for in the event of a serious illness, according to a team of researchers.

American Journal of Public Health (AJPH, Vol. 91, No. 9, September 2001, "Does Investor Ownership of Nursing Homes Compromise the Quality of Care?," by Charlene Harrington, Steffie Woolhandler, Joseph Mullan, Helen Carillo, and David Himmelstein, answers its own question in the strongest possible affirmative: "Our results suggest that investor-owned nursing homes deliver lower quality care than do nonprofit or public facilities." (p. 1454)

"Objectives. Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality.

"Methods. We analyzed 1998 data from state inspections of 13,693 nursing facilities. We used a multivariate model and controlled for case mix, facility characteristics, and location.

"Results. Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes.

"Conclusions. Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes." (p. 1452)

"Investor-owned facilities had more Medicaid patients (68% of all residents) than did nonprofit facilities (49%) or public facilities (62%)." (p. 1453)

"Homes with a higher ADL index had more deficiencies, as did those with a higher proportion of Medicaid patients." (p. 1453)

"Skimping on staffing by for-profit homes may partly explain their lower quality." (p. 1454)

"We (and others) have found lower quality at facilities with more Medicaid patients, presumably because Medicaid payments are generally low, and Medicaid patients have fewer options for care." (p. 1454)

"Despite clear federal guidelines, surveyors' decisions may be somewhat subjective, and perhaps some are biased against for-profit homes." (p. 1454)

"The most obvious explanation for our findings is that profit seeking diverts funds and focus from clinical care." (p. 1454)

"Nursing homes care for many people who are too frail, too sick, too poor, and too powerless to choose or even protest their care. We believe that it is unwise to entrust such vulnerable patients to profit-seeking firms." (p. 1455)

Factors Affecting the Unplanned Hospital Readmission of Elderly Patients With Cardiovascular Disease Patients with cardiovascular disease have been found to have particularly high rates of readmission to hospital.

The Office of Inspector General has released a final inspection report, "Psychotropic Drug Use in Nursing Homes (OEI-02-00-00490; 11/01 2001) pdf," on the use of psychotropic drugs in nursing homes, along with supplemental information intended to provide content for the main report. This inspection was conducted in response to concerns expressed by the Senate Special Committee on Aging about the use of psychotropic drugs as inappropriate chemical restraints. OIG found that this is not a pervasive problem. These drugs are generally being used appropriately. Where there are problems, they are related to inappropriate dosage, chronic use, a lack of documented benefit to the resident, and unnecessary duplicate drug therapy. OIG also noted a lack of adequate documentation for residents' psychotropic drug use in some cases. OIG recommends in its report that CMS consider educating providers to better document the use of these drugs. Source: OIG (5 Nov 2001)

Nursing Home: (Atlanta Journal-Constitution 2002) Almost 33% of Georgia's nursing homes have been understaffed at least once below the state minimums since 1999, directly impacting residents' quality of care.

Current state policy -- one of the "more stringent" in the country -- requires nursing homes caring for Medicaid beneficiaries to hire "enough staff to provide an average of 2.5 hours of care" per resident per day.

"I do think there is a direct correlation between the problems [with care] we're seeing and the difficulties the facilities are having in attracting and maintaining adequate numbers of trained staff." said commissioner of the state Department of Community Health

Nursing home care: (2002) From an administrator- "If you got money, you can find a (nice) place. If you don't, it's very hard."

And "Eighty percent of the state's facilities are certified to accept Medi-Cal patients. But that does not stop facilities from practicing subtle- and not so subtle- discrimination against people on Medi-Cal, especially who require heavy care".

As to such discrimination, they noted, "Should the Hilton accept homeless people"

Nursing Homes:  (2002)The Centers for Medicare & Medicaid Services may be going too easy on nursing homes that settle charges of being out of compliance with Medicare conditions of participation, according to the General Accounting Office. CMS policy gives nursing homes accused of a deficiency 60 days to waive their right to an administrative hearing in exchange for a 35 percent reduction of the civil monetary penalty amount. If the facility doesn't choose to settle within that period, any later settlement resolution should not be on better terms than the 35-percent offer. In 41 percent of the cases reviewed, however, GAO found that CMS settled at amounts that exceeded the 35-percent discount threshold, resulting in a loss in millions of dollars of potential civil monetary penalty collections. GAO urges CMS to adopt formal policies and procedures relating to CMP settlement discounts -- advice CMS is reluctant to heed due to fears that the move would add needless and cumbersome rigidity to the nursing home survey process.

Nurses (Spooner2002) Nearly 60% of the RN work force is over 40 years of age and the percentage of nurses under 30 has fallen 40% since 1980. 10% of falls occur in health care institutions (undoubtedly more since they go unreported) and it is due in large measure to the lack of trained aides and nurses. The understaffing of hospitals occurs in an environment where, according to the 199 National Hospital Discharge Survey, patients over 65 years of age accounted for 48% of discharges and 48% of hospital care days.

Weekends and, evenings and holidays are particularly hazardous. Increasingly, family and friends are staying in hospitals to ensure that the patient is accompanied when out of bed or in the bathroom.

Nursing Home Care Expenditures Aggregate and per Capita Amounts and Percent Distribution, by Source of Funds: Selected Calendar Years 1980-2000

Table 7: Nursing Home Care Expenditures Aggregate and per Capita Amounts and Percent Distribution, by Source of Funds: Selected Calendar Years 1980-2000

Year Total Out-of-Pocket Payments Third-Party Payments Medicare2 Medicaid3
Total Private Health Insurance Other Private Funds Public
Total Federal1 State and Local1
  Amount in Billions
1980 $17.7 $7.1 $10.6 $0.2 $0.8 $9.6 $5.7 $3.9 $0.3 $8.9
1988 40.5 15.6 24.9 2.2 2.7 20.1 12.0 8.1 $0.7 $18.4
1990 52.7 19.8 32.9 3.1 3.9 25.9 15.8 10.2 1.7 23.2
1993 65.7 19.6 46.1 3.4 4.9 37.8 24.0 13.8 4.0 32.4
1994 68.3 18.5 49.9 4.3 4.1 41.5 26.7 14.9 5.8 34.1
1995 74.6 20.1 54.5 5.6 4.8 44.1 28.5 15.5 6.9 35.4
1996 79.9 20.4 59.6 6.7 5.0 47.8 31.7 16.1 8.3 37.7
1997 85.1 21.7 63.3 7.1 5.2 51.1 34.1 17.0 9.7 39.6
1998 89.1 24.7 64.4 7.4 4.7 52.3 35.1 17.2 10.3 40.1
1999 89.3 24.9 64.3 7.5 4.6 52.2 34.3 17.9 8.4 41.8
2000 92.2 24.9 67.4 7.4 4.0 55.9 37.8 18.2 9.5 44.4
  Per Capita Amount
1980 $77 $31 $46 $1 $3 $42 $25 $17 -- --
1988 163 63 100 9 11 81 48 32 (4) (4)
1990 207 78 130 12 16 102 62 40 (4) (4)
1993 250 75 176 13 18 144 91 53 (4) (4)
1994 258 70 188 16 15 157 101 56 (4) (4)
1995 278 75 204 21 18 165 107 58 (4) (4)
1996 296 75 220 25 19 177 117 60 (4) (4)
1997 312 80 232 26 19 187 125 62 (4) (4)
1998 324 90 234 27 17 190 127 63 (4) (4)
1999 321 90 232 27 17 188 124 64 (4) (4)
2000 329 89 240 27 14 200 135 65 (4) (4)
  Percent Distribution
1980 100.0 40.0 60.0 1.2 4.5 54.2 32.0 22.2 1.7 50.2
1988 100.0 38.5 61.5 5.3 6.7 49.6 29.6 19.9 1.8 45.3
1990 100.0 37.5 62.5 5.8 7.5 49.2 30.0 19.3 3.2 43.9
1993 100.0 29.8 70.2 5.2 7.4 57.6 36.6 21.0 6.1 49.3
1994 100.0 27.0 73.0 6.3 6.0 60.8 39.0 21.8 8.5 49.9
1995 100.0 26.9 73.1 7.5 6.4 59.1 38.3 20.8 9.3 47.5
1996 100.0 25.5 74.5 8.4 6.3 59.9 39.7 20.2 10.4 47.2
1997 100.0 25.5 74.5 8.3 6.1 60.0 40.1 20.0 11.4 46.5
1998 100.0 27.7 72.3 8.3 5.2 58.7 39.4 19.4 11.6 45.0
1999 100.0 27.9 72.1 8.4 5.1 58.5 38.4 20.1 9.4 46.9
2000 100.0 27.0 73.0 8.1 4.3 60.6 40.9 19.7 10.3 48.1

1Includes Medicaid SCHIP Expansion & SCHIP

2Subset of Federal funds.

3Subset of Federal and State and local funds.

4Calculation of per capita estimates is inappropriate.

NOTES: Per capita amounts based on July 1 Census resident based population estimates for each year 1980-2000. Numbers and percents may not add to totals because of rounding.

SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Bureau of the Census.

(LTC) "Note that Medicaid paid only 48.1% of nursing home costs in 2000, up from 43.9% in 1990. This would suggest that Medicaid's contribution to nursing home costs is relatively minor, under half. The truth is, however, that Medicaid recipients must also contribute most of their income toward their cost of care on Medicaid. Thus, nearly 70% of all nursing home residents are on Medicaid even though Medicaid itself pays less than half of nursing home costs. Because Medicaid nursing home residents tend to be the longest stayers, nearly 80% of all nursing home patient days are paid, at least in part, by Medicaid.

The reason this is so critical is that if Medicaid pays even $1 of a resident's cost of care, the nursing home receives the notoriously low Medicaid reimbursement rate--80% of the private pay rate on average and often less than the cost of care. That has been borne out by repeated statistics at this page.

BDO Seidman reports that Medicaid pays nursing $3 billion per year less than the cost of care nationally.

2. Consider that out-of-pocket (OOPs) nursing home costs as reported by CMS for 2000 are only 27.0%, down 28% from their level of 37.5% in 1990. Clearly, the public's direct exposure to nursing home costs has plummeted in the past decade. But the truth is much more dramatic than the statistics suggest. Approximately half of the so-called "out-of-pocket" costs reported by CMS are really just "spend-through" of Social Security income of people who are already on Medicaid!* This gives the lie to the conventional wisdom that people all across America are spending down into impoverishment to pay for nursing home care.

3. What about Medicare? We still see sales brochures that say Medicare pays for only 2% or 3% of nursing home expenses. That has not been true for over a decade. Medicare paid 10.3% of all nursing home costs in 2000, up from 3.2% in 1990, a 322% increase in only 10 years.

4. Finally, private long-term care insurance, how much does it pay for nursing home care? CMS reports that 8.1% of nursing home costs are paid by "private health insurance." We frequently see this figure reported as the amount private LTCI pays for nursing homes. That's not what the number means. LTCI usually pays a beneficiary, not a nursing home. No one knows how much LTCI benefits contribute toward nursing home costs, because there is no way to measure that amount. The misleading figure reported by CMS is a derived number computed by subtracting all the known sources of nursing home finances from the total and assigning the remainder to "private health insurance."

In other words it is a pure guess. The only hard data on private health insurance payments for nursing home care are for payments by major medical policies or Medicare supplemental insurance policies.

Bad nursing homes: (2002) "A crime is a crime, whether in or outside of a nursing home, where residents should not spend their days living in fear," Sen. John Breaux (D-La.), the chair of the committee, said (AP/Washington Times, 3/5). The GAO report, based on interviews and records in Georgia, Illinois and Pennsylvania, found that more than 30% of nursing homes have been cited by state inspectors for violations that "harmed residents or placed them in immediate jeopardy." And in half of the 111 abuse cases the report studied, nursing homes reported the incidents "days or weeks" after it occurred, despite a law requiring such instances to be reported within 24 hours (Kaiser Daily Health Policy Report, 3/4). Barbara Becker, an Indiana woman, told committee members how her 83-year-old mother died in a nursing home after being assaulted by an unstable patient, saying that nursing home crimes are treated "far more lightly" than others. "The biggest insult of the whole experience has been that had this happened in my own house, I would have been investigated. I would have been prosecuted, and I probably would have been put in prison.

LTC: (2002) A survey of nursing home costs commissioned by GE Long Term Care Insurance shows that spending a year in a nursing home in the ten most expensive areas of the country now carries a price tag of roughly $80,000 or more. Two other statistics bring the significance of GE's survey's findings into sharp focus: roughly 40 percent of those reaching the age of 70 are expected to need some type of long term care during the rest of their lives; yet only seven percent of Americans have done any planning at all for their long term care needs. According to the GE Long Term Care Insurance Nursing Home Survey, the national annual average cost of a year in a nursing home is $54,900. The survey evaluated the cost of assistance in a nursing home with the activities of daily living for a person suffering from a debilitation such as Parkinson's disease. It did not include costs for therapy, rehabilitation, or medications.

The ten most expensive areas in which to receive nursing home care are: -- 1 Alaska $163,400, -- 2 New York City metro area $106,500, -- 3 Connecticut $93,500, -- 4 New York state (outside NYC) $ 90,000, -- 5 District of Columbia $88,000, -- 6 Hawaii $86,000, -- 7 Massachusetts (outside Boston) $ 82,500, -- 8 Boston metro area $82,200 -- 9 New Jersey $80,900, -- 10 Philadelphia metro area $79,900 The lowest average annual cost was in Louisiana, at $36,000 per year. The survey also revealed that costs varied widely, from a low of $52.14 per day at one nursing home in Montana to a high of $704 per day at a facility located on an island in Alaska. The survey did not evaluate the cost of assistance with activities of daily living provided either in the home or other types of facilities, including adult day care centers or assisted care facilities.

Going to Eden: (2002) The nursing home industry is in a "state of near crisis" in the United States, but PBS' "NewsHour with Jim Lehrer" reports that "Eden Alternative" nursing homes, which provide improved living conditions for residents, may help address the problem. The industry faces a staffing shortage and low Medicare and Medicaid reimbursement rates, and a number of nursing homes in many states have closed or filed for bankruptcy. In addition, some nursing home residents suffer neglect or abuse by employees. A congressional report released last July found that state inspectors cited cases of "serious abuse" at one in 10 nursing homes. According to a new survey conducted by "NewsHour," the Kaiser Family Foundation and the Harvard School of Public Health, 45% of respondents said that patients who move into nursing home are "worse off" than before they entered, and 43% "would find it totally unacceptable" to move into a nursing home. Eden Alternative homes aim to improve the nursing home experience, featuring widespread plants, animals and onsite day care for children. About 240 nursing homes nationwide -- including St. Luke's Home in Utica, N.Y. -- have adopted the Eden Alternative approach (Dentzer, "NewsHour with Jim Lehrer," PBS, 2/27).

LTC: (GE Capital 2002) Spending a year in a nursing home in the ten most expensive areas of the country now carries a price tag of roughly $80,000 or more. Two other statistics bring the significance of GE’s survey’s findings into sharp focus: roughly 40 percent of those reaching the age of 70 are expected to need some type of long term care during the rest of their lives; yet only seven percent of Americans have done any planning at all for their long term care needs. According to the GE Long Term Care Insurance Nursing Home Survey, the national annual average cost of a year in a nursing home is $54,900.

The ten most expensive areas in which to receive nursing home care are: -- 1 Alaska $163,400, -- 2 New York City metro area $106,500, -- 3 Connecticut $93,500, -- 4 New York state (outside NYC) $ 90,000, -- 5 District of Columbia $88,000, -- 6 Hawaii $86,000, -- 7 Massachusetts (outside Boston) $ 82,500, -- 8 Boston metro area $82,200 -- 9 New Jersey $80,900, -- 10 Philadelphia metro area $79,900 The lowest average annual cost was in Louisiana, at $36,000 per year. The survey also revealed that costs varied widely, from a low of $52.14 per day at one nursing home in Montana to a high of $704 per day at a facility located on an island in Alaska. The survey did not evaluate the cost of assistance with activities of daily living provided either in the home or other types of facilities, including adult day care centers or assisted care facilities.

MetLife Market Survey On Nursing Home Costs 2002  Conducted by the MetLife Mature Market Institute.

Nursing Homes Are Cautiously Optimistic  Experts say staffing shortages and investor confidence are problems that plague the industry.

Kaiser/News Hour Study on Nursing Homes  (2002) A national survey by The NewsHour with Jim Lehrer, the Kaiser Family Foundation, and the Harvard School of Public Health finds that people who have substantial experience with a friend or family member in a nursing home, or have been in a nursing home themselves, have generally positive views about the care provided. A significant minority of those with nursing home experience, however, says that the person they know has received poor quality care in the nursing home, including about a quarter that report incidents of abuse or overmedication.

CMS Releases Phase II Report on Minimum Nursing Home Staff Ratios  (2002) the Centers for Medicare & Medicaid Services has officially transmitted to Congress "Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios In Nursing Homes Phase II Final Report."


Impending fee reductions for nursing home care under the Medicare program threaten both the quality of care for residents and the overall economic stability of the industry.

Nursing homes- The Centers for Medicare & Medicaid Services said May 13, 2002 it has placed the results of complaint investigations on its Web site. Individuals looking into nursing home care will find on the site a list of health deficiencies for nursing homes that have been filed, examined and confirmed due to complaints. The complaint is confirmed through an on-site investigation before it is posted on the Web, CMS said. In addition, state nursing home surveys are conducted every 10-15 months.

Nursing Home Inspections: (2002) The Occupational Safety and Health Administration said that it will begin this year inspecting 1,000 nursing or personal care facilities out of 2,500 that reported high injury and illness rates under a new National Emphasis Program. The program focuses on specific hazards that account for the majority of nursing home staff injuries and illnesses, including ergonomic back injuries from patient handling, bloodborne pathogens/tuberculosis, and slips, trips and falls.

Georgia Nursing Home Statistics (2002)

10 Solutions to the Nursing Home Crisis (Atlanta Journal 2002) Be sure to view the Eden alternative. about 250 organizations have embraced The Eden Alternative Philosophy.  Those homes instituting the Eden philosophy have noted,

A summary of significant cumulative findings include:

60% decrease in behavioral incidents

57% decrease in Stage I -- Stage II pressure sores

25% decrease in bedfast residents

18% decrease in restraints (personally, I enjoy restraints- but that is different story)

48% decrease in staff absenteeism

11% decrease in employee injuries

Staffing LTC: Quality of Nursing Home Care More Related to Staffing than Spending:  (2002)

In this report to the Senate Special Committee on Aging, the General Accounting Office set out to answer questions about how federal dollars are being spent and the relationship between nursing homes' spending and quality of care. GAO found that there was no clear correlation between higher nursing expenditures and the number of serious quality problems; but GAO did find that staffing is positively correlated with quality of care.

Nursing Home Groups Pledge Improvement in Quality of Care (2002) Three of the nation's largest long-term care organizations, together representing the majority of the nation's 17,000 nursing facilities, as well as several thousand housing, assisted living and community services providers, announced a broad program of voluntary changes that officials said were designed to promote ethical conduct by elder care facilities and to reestablish the public's faith in the nation's long-term care system. The initiative is called "Quality First: A Covenant for Healthy, Affordable and Ethical Long-Term Care." The American Health Care Association, the American Association of Homes and Services for the Aging, and the Alliance for Quality Nursing Home Care have signed "Quality First" covenants committing to seven principles: continuous quality assurance and quality improvement, public disclosure and accountability, resident and family rights, workforce excellence, public input and community involvement, ethical practices, and financial stewardship.

Nursing home care: (: Cowles Research Group's "2001 Nursing Home Statistical Yearbook") on a national level, government-owned and not-for-profit nursing homes averaged more direct patient care staff time than did for-profit facilities. Total registered nurse (RN) time averaged .90 hours per patient day (ppd) in not-for-profit homes, compared to .82 in government-owned facilities, and .56 hours ppd in for-profit homes.

The number of residents and the number of facilities have been falling steadily since 1998 when they peaked at 1.51 million residents in 17,259 facilities. The total number of beds in certified facilities has been falling since hitting a peak of 1.83 million in 1997. There were 1,779,924 nursing home beds, in America's 16,675 certified nursing homes in 2001. On an average day in 2001 these homes cared for 1,469,001 residents.

The number of residents and the number of facilities have been falling steadily since 1998 when they peaked at 1.51 million residents in 17,259 facilities. The total number of beds in certified facilities has been falling since hitting a peak of 1.83 million in 1997. There were 1,779,924 nursing home beds, in America's 16,675 certified nursing homes in 2001. On an average day in 2001 these homes cared for 1,469,001 residents.

The proportion of residents for whom Medicare was the primary payor reached an all time high of 9.55 percent in 2001. The previous high was 9.41 percent in 1998. There remains considerable interstate variation in payor mix. Medicare and Medicaid combined accounted for fewer than 60 percent of all nursing home residents in Nebraska in 2001, while in other states, like Georgia, Mississippi, and North Carolina, the two programs accounted for more than 85 percent of residents, and in Alaska Medicare and Medicaid were the primary payors for more than 91 percent of residents in 2001.

Changes in the distribution of the size of certified nursing homes between 1998 and 2001 have been particularly inte0

Nursing home resident acuity increased in 2001, continuing a long running trend. This is reflected in increases in ADLINDEX, ACUINDEX, PROPAC, and ADLSCORE and decreases in the percentage of residents who were independent at various activities

Nationally, occupancy rates have remained stable over the last 7 years at between 82 and 83 percent, although in some cases there have been strong counter-trends at the individual state level. Oregon, for example, has seen occupancy rates drop from 89 to 73 percent between 1995 and 2001.

Survey deficiencies continue to vary dramatically by state and class of ownership. In some states, such as Maryland, Rhode Island, Vermont, and Virginia, the standard annual health survey results in an average of three survey deficiencies while in others, such as Arizona, California and Nevada, the average survey results in 10 or 11 deficiencies. The not for profit facilities continue to average fewer deficiencies than government and for-profit facilities. This finding holds both nationally and at the individual state level.

More Than 75% of California Nursing Homes Fail To Meet Quality Standards

Hospital Group Advises Nursing Homes to Watch for Quality Scores (2002) In a Regulatory Advisory for American Hospital Association members issued late October 14, the AHA said the Centers for Medicare & Medicaid Services planned starting that day to provide nursing homes with their quality measurement scores online at Nursing Home Compare, Each facility has until October 22 to review the data, detect errors and notify CMS, AHA said. Beginning in mid-November, CMS will make this information available to the general public by publishing the scores, AHA noted. Also in November, scores for the 50 largest nursing homes in each state will be published in at least one newspaper in the state, informing consumers of the NHQI and that data is available to assist them in making decisions on nursing home care. The post-acute facility reports released at this time will be based on data from January through June 2002.

Hundreds of Nursing Home Residents Die of Neglect A review of government documents and court records indicates hundreds of elderly patients in nursing homes are dying from neglect, according to the St. Louis Post-Dispatch, in a weeklong series that began Sunday, October 13. The newspaper reported that the deaths are rarely detected by government inspectors, appraised by medical examiners, or investigated or prosecuted by law enforcers. Most of the deaths are caused by neglect traced to caregivers whom the elderly rely on for food and liquid, and for turning them in their beds to prevent life-threatening sores, investigators and researchers say. The latest national compilation of more than 500,000 nursing home deaths - for 1999 - lists starvation, dehydration or bedsores as the cause on 4,138 death certificates.

"Nursing Home Staffing Standards" This issue paper describes the current federal staffing requirements and how states separately regulate staffing levels in nursing homes. It also presents data showing that actual staffing levels in over half of this country's nursing homes exceed the levels that states and the federal government require.

"Nursing Home Quality: State Agency Survey Funding and Performance" This issue paper describes the resources, staffing, and performance of state licensing and certification agencies based on findings from a survey of state survey agency

Dying (USA Today 2003) Half of the 1.6 million people living in nursing homes suffer from untreated pain. A report on each states ability to provide eight end of life services generally got a rating of c, d or f.

Just 25% of Americans die at home surrounded by friends and family- though 70% would prefer to do so. That said, it is impossible to treat many of them at home with certain diseases though it still should be greater than 25%.

35 states have laws making it hard for doctors to prescribe medication to dying patients.

Mst Americans get aggressive end of life care in a hospital and not at home.

Most U.S. hospitals still do not have end of life programs that automatically deliver services to the dying patient.

Just 39% of doctors caring for dying patients had been trained in issues that some up as death approaches.  

CCRC: (2003) There are about 2100 Continuing Care Retirement Communities in the U.S. with about 20 being added annually. Average rent is about $3,000 monthly.

Only 340 are accredited by the Continuing Care Accreditation Committee.

Assisted Living Facilities

Inequalities in Nursing Home Care: (Milbank Quarterly 2004) African Americans are four times more likely than their white counterparts to reside in substandard nursing homes. The study reviewed over 140,000 non-hospital based Medicare and Medicaid certified nursing homes and found that 40 percent of African Americans live in a lower-tier nursing home compared to just 9 percent of white nursing home residents. Nursing homes are defined as lower-tier if they have high turnover rates, substandard care, a high concentration of Medicaid residents, limited resources and poor programming.

Nursing care: A study by University of Pennsylvania researchers showed that when a nurse is assigned more than four post-surgery patients, the risk of death goes up 7% for each additional patient.

A 1-to-10 ratio, which some in the hospital industry called for when California's law was first being discussed, would be too high. Many of the proposals now under consideration by hospitals and lawmakers are closer to a 1-to-5 ratio.

But the care won't come cheap- In-patient hospital care accounts for about one-third of the $1.6 trillion the nation spends annually on health care — and hospital spending has been rising rapidly. Labor is the biggest chunk of a hospital's expenses, so requiring hospitals to use more nurses won't be cheap. "It's clearly going to drive costs at a time when the country is looking at overall spending in the health care industry.

Nursing shortage: (2004) In the USA, hospitals average a 13% nurse vacancy rate, or about 126,000 vacancies nationwide, according to the American Nurses Association. About 2.7 million nurses are licensed in the United States, with about 59% working in hospitals, the rest in other areas of nursing. Causes of the shortage are varied: not enough faculty to expand nursing school enrollment, wider opportunities for nurses outside of hospital care and a decade of changes by the hospital industry that nurses blame for increased workloads, driving some to leave the profession.

Nurse Shortage or Nursing Shortage: Have We Missed the Real Problem?

QuickStats: Average Number of Bed Days* During the Preceding 12 Months Among Persons Aged >18 Years, by Age Group --- United States, 2003

Nursing Home (MetLife 2005) The average daily cost of a private room in a nursing home in the United States increased almost 6% from last year. the average nursing home cost is $203 per day, up 5.7% from last year’s $192.

That works out to $74,095 annually, compared to just over $70,000 in 2004.

The average daily rate for a semi-private room nationally was $176 ($64,240 annually), up 4.1% from $169 in 2004.

The study found that the cost per hour of a home health care aide increased $1, or 5.5%, to $19 per hour nationally, while homemaker-companion care averaged $17 per hour (homemaker-companion data was not included in prior MetLife studies).

The lowest costs for both home health care aides and homemakers-companions were $17 and $12 per hour in Shreveport, La. The highest cost for a home health care aide was Vermont at $31, while homemakers-companions cost the most in Rochester, Minn., at $23 per hour.

The average stay in a nursing home is 2.4 years, MetLife notes, citing data from the Centers for Disease Control and Prevention, Atlanta. That would bring the total average cost to $177,828 for a nursing home stay.

(A study published last year by University of California researchers found among more than 1.3 million nursing home residents, half needed help with five activities of daily living and 24% with four ADLs. About 95% required help with bathing, 87% with dressing and 51% with eating. Over 44% were diagnosed with dementia.)

If it goes bad, it will cost a lot of money. But if you got money, it may not be that bad: (Forbes 2006) Silverado specializes in residents with severe dementia. Most assisted-living homes quarantine such patients in separate wards or ship them off to nursing homes when their behavior becomes too unruly. Silverado deploys small armies of staff to keep residents engaged in activities like aerobics, art classes and group outings. The hands-on approach allows Silverado's doctors to swear off physical restraints and limit the use of mind-numbing sedatives.

The cushy service isn't cheap. At the Calabasas home Silverado charges $5,670 a month for a shared room, more than twice the regional average for a single. Private rooms run to a gasp-inducing $9,600. Silverado gets an additional $250 monthly "incontinence" fee, and 24-hour hospice services run an extra $142 per day. (Hospice is the only part of assisted-living costs covered by Medicare.)

Silverado's largest cost, 47% of revenues, is labor. For the first Escondido home Shook hired a registered nurse for $80,000 a year and seven licensed vocational nurses at $42,000 apiece. He added 45 caregivers, who make $20,000 per year, plus bennies, and 4 "activities coordinators," at $21,000 each. Silverado employs one staff member for every seven residents, compared with a national median of one to 14. A sizable staff is critical, because people with dementia are easily upset. Nurses patrol the hallways at Silverado, helping out confused residents before they become abusive. A common diversionary tactic: redirecting agitated folks to wall panels with disconnected rotary phones, latches and other gizmos for tinkering. The Silverado staff gives residents a lot of activities and outings--including spa treatments, poetry readings and trips to the racetrack.

Keeping active has a salutary effect. Some 900 residents who couldn't feed themselves on entering Silverado were later able to eat without assistance; 1,160 folks who couldn't walk became ambulatory. Silverado's doctors also halved the use of sedatives like Haldol and Trazodone and antipsychotics like Seroquel and Risperdal. "With close interaction you don't have to treat these people with chemical or physical restraints,"

Sudden Hospitalizations (Sandra Ray 2006) According to a new study published in the February 16, 2006 edition of the New England Journal of Medicine and sponsored by the National Institutes of Health, an elderly person’s hospitalization can affect the healthy spouse’s risk of death. The study reviewed areas such as reasons why the spouse was hospitalized, length of the hospitalization, and whether or not the person hospitalized was male or female. The study was carried out over nine years and surveyed more than half a million couples age 65 and older.

The results, reveals researcher Nicholas A. Christakis, M.D., Ph.D., M.P.H. of Harvard Medical School, indicate that the value of social networks in someone’s life is integrally connected to their health. “People’s health is interconnected,” Christakis noted.

The study reveals that if a woman is hospitalized with an illness like colon cancer, her husband may have a slight risk of dying in the next year. If that same woman is hospitalized for heart disease, dementia (or other psychiatric illnesses), or even a hip fracture, her husband’s risk of dying within the next year increases. There are similar findings among women whose husbands were hospitalized. Surprisingly, cancer in either men or women did not increase risks of death.

Many studies have pointed to a spouse essentially dying of a broken heart after the death of their spouse. This study, however, extends that phenomenon to a sudden hospitalization for illnesses like pulmonary disease, congestive heart failure, hip or other serious fractures, as well as other disabling conditions. Christakis said, “This is a hard and unambiguous endpoint.”

The real danger to the healthy spouse seems to lie in the first 30 days of the hospitalizations. As hospitalization stays increased beyond the 30 days, the risk of death decreases for a period of time (three to six months) before that risk goes back up again. Researchers theorize that initial stress and shock may be contributing factors to the increase in death rates. In the early days, regular routines such as meal times, exercise, and other coping strategies may have failed, leaving the healthy spouse vulnerable.

What are Social Networks?

Social networks refer to the amount of “connectedness” that an individual feels in their immediate life. These networks include friends, families, church or civic groups, and other people activities that someone engages throughout the normal course of their life. By their very definition, networks keep someone grounded in their daily life, focused on the next piece that life has to offer.

Social networks can positively or negatively impact lives in many different ways. The realization that people’s lives are connected on many different levels and in many different ways can help medical professionals focus attention on the healthy spouse, rather than devoting all their energies toward the hospitalized spouse. Caregivers should take note of this study and continue to develop coping strategies in order to prevent their health from being adversely affected.

Caregivers: Take Time for Yourself

More than anything, this study underscores the need for caregivers to take time for themselves in the midst of a difficult situation. Getting plenty of rest, eating properly, exercising (even modest amounts) can make a significant impact on their overall ability to cope with a partner’s disabling disease. As Christakis said, “It’s the disablingness of the disease, more than its lethality, that seemed to affect the other partner.” This could be one reason why a cancer diagnosis had little effect on a caregiver’s health and a serious hip fracture caused a dramatic increase in death.

These ideas, and many others, can help caregivers cope with the difficult days ahead that often accompany a sudden disability. Other ideas that may help are finding a community support network. For individuals age 60 and older, the Area Agencies on Aging are excellent resources to ask about caregiver support. Some of the services that these agencies offer include information and referral, benefits counseling, and, when resources are available, even respite care and minor home modifications. The Eldercare Locator is a free service of the U.S. Department of Health and Human Services and contains listings of all Area Agencies on Aging. Their number is 1-800-677-1116 or online at

Technology: A Double-Edged Sword

In times of disabling illnesses, technology can be one excellent resource to keep someone connected. The increasing use of technology in our daily lives means that we have more ways to both stay connected and stay isolated, all at the same time. By using technology to stay focused on the social network, rather than relying on it for your sole means of communication, can be an excellent way to stay connected.

Cell phones, for example, can help keep family informed and give the caregiver an outlet for expression. Cell phones are portable and can be used outside the hospital to give updates on your spouse’s condition. Since most hospitals do not allow cell phone use, getting outside to use one can also be an excellent way to get a small amount of exercise.

E-mail is also a tremendous resource for staying connected. Don’t be tempted just to jot down a few notes, press “send,” and make that the only means of reaching out each day. While e-mail is a good way to stay connected, make sure to take time to talk to others on a regular basis about what is going on in your life. A support group, a phone call, or meeting a friend for a quick lunch will also help tremendously.

Online bulletin boards often provide affirmation that someone else understands the situation. These are great resources for information, learning tips on how to take care of yourself, and even making useful friendships that foster self-confidence. Don’t let this be the only form of communication with others, though. Make sure not to substitute electronic contact for human contact.

Finally, remember that while a spouse’s hospitalization may pose dramatic life changes, there are still many opportunities for the healthy spouse. By staying focused on your own needs and keeping a good base of community support, you may be saving your own life as well.

Other ideas to help caregivers relax include:

Having someone prepare meals in advance so that all is needed is reheating.

Taking a short walk.

Eating properly.

Getting enough rest.

Having someone available to sit with your spouse while taking a short break from the hospital.

Finding a caregiver support group.

Staying connected to existing support networks: friends, family, or church.

Survey of Nursing Home & Home Care Costs 2007







NURSING HOME/ASSISTED LIVING INCREASES - MetLife has released their annual surveys on the costs of nursing homes and assisted living. In 2006, the average daily cost of a private room in a nursing home increased 1.5% to $206 per day or $75,190 annually. The average cost of assisted living facilities increased a bit more - about 2.2% from 2005 - to $2,968 per month or $35,616 annually.

NURSING HOME COSTS – (2007) According to the annual survey by MetLife's Mature Market Institute, the average daily cost of a private room in a nursing home increased from $203 in 2005 to $206 in 2006. That is just a 1.5% increase, but the annual average cost is $75,190. Highest room cost is $578 with the lowest of $111 in Shreveport, La. The cost of home health care aides was unchanged from 2005 and averaged $19 per hour.