Nursing Homes: A Comprehensive Guide

Aug 22, 2023

Fact Checked

Edited by: Donya Currie, MA, Senior Editor at NCOA

Reviewed by: Kathleen Cameron, BSPharm, MPH, Senior Director, NCOA Center for Healthy Aging

Key Takeaways

Nursing homes, also called skilled nursing facilities, are for older adults in need of short or long-term care, which can no longer be provided at home or in an assisted living facility.
Services provided in nursing homes range from personal care, like helping older adults with activities of daily living (ADLs) ⓘActivities of daily living, also called ADLs, are activities related to necessary personal care. These include bathing, dressing, toileting, eating, walking, and transferring in and out of a bed or chair., to skilled nursing care, such as wound care or diabetes management.
Medicare will help pay for up to 100 days of rehabilitation in a skilled nursing facility, but it will not pay for long-term care. Medicaid is the primary payer of nursing home care for older adults who qualify.

Nursing home facilities offer short-term and long-term solutions for older adults needing specialized care outside the home. But the nursing home landscape can be confusing.

You might be approaching this big life decision with unanswered questions: Do my needs require a nursing home level of care? Will Medicare cover my nursing home stay? Do I need assisted living, or is a nursing facility a better option? How will I pay for it?

In this comprehensive guide, our Local Care Reviews Team explains what a nursing home is and lets you know what to expect regarding cost, services, and how to determine if a nursing home is right for the kind of care you need.

Why you can trust our expert review

Our team works hard to provide clear, transparent information to older adults seeking senior living and home care. To provide you with the best possible information, we have spent more than 250 hours:

Consulting with our advisory board, which consists of a certified life care manager, a board-certified geropyschologist ⓘA geropyschologist is a professional psychologist who specializes in the needs and well-being of older adults., and a geriatric nurse practitioner
Analyzing and synthesizing nationwide data from the Centers for Medicare & Medicaid Services (CMS), the National Investment Center for Seniors Housing & Care (NIC), and the National Center for Assisted Living (NCAL)
Analyzing and synthesizing state-specific data from government health regulatory agencies
Surveying thousands of older adults and their caregivers about their search for senior living facilities
Conducting focus groups with caregivers helping older adults find assisted living
Mystery shopping dozens of brands and facilities associated with long-term care for older adults

What is a nursing home?

Nursing homes offer the highest level of care in the spectrum of senior living options. With both short-term and long-term residential care, nursing homes are designed for older adults requiring ongoing medical attention and assistance with most or all activities of daily living (ADLs), such as bathing and getting in and out of bed. A nursing home may be a good option if you or someone you care for has a chronic disease, significant physical or cognitive decline, or complex medical needs that cannot be managed at home.

What is a skilled nursing facility?

In the long-term care community, the terms skilled nursing facility and nursing home are used interchangeably. In addition to skilled nursing, nursing homes provide rehabilitation and personal care ⓘPersonal care, sometimes called custodial care, refers to non-medical care provided by professional caregivers, such as assistance with bathing or toileting..

Skilled nursing may include wound care, managing an insulin pump, or any care provided by or performed under a registered nurse’s (RN) supervision.
Rehabilitation needed as the result of an injury, disease, or disability can also be provided in a nursing home. These services may include physical therapy, occupational therapy, or speech therapy.
Long-term care in a nursing home is defined by Medicaid as “health-related care and services (above the level of room and board) not available in the community, needed regularly due to a mental or physical condition.” Long-term care may include skilled nursing and rehabilitation, dementia-specific care, or assistance with activities of daily living (ADLs), like bathing and bed transfer. ^[1]

Do all nursing home facilities offer memory care?

The Alzheimer’s Association reported 58% of long-stay nursing home residents have Alzheimer’s or another form of dementia. ^[2] Many, but not all facilities, will have a dedicated memory unit or floor. When you tour facilities, ask about the availability of memory care and whether staff receive dementia-specific training.

Nursing home facilities for long-term care

When an older adult reaches a level of care no longer available at home or in an assisted living community, it might be time for long-term nursing care.

Long-term care received in a nursing home setting is often made up of:

Medication management and administration
Assistance with ADLs, such as bathing, toileting, and transferring to and from bed or a wheelchair
Skilled nursing care, such as wound care, catheter care, blood pressure monitoring, and injections
Attention to one’s overall health and well-being, including prepared meals and social activities

Nursing home facilities for short-term care

After a qualifying inpatient hospitalization, older adults may require a short stay in a nursing home, often called rehabilitation or rehab. All nursing home residents can receive skilled nursing care, regardless of the length of their stay. Short-term residents will also receive prepared meals, medication management, and as-needed help with ADLs.

Short-term care received in a nursing home setting often consists of:

Physical, occupational, or speech therapy to help someone recover from an illness, injury, or stroke
Physical and occupational therapy to help restore mobility, strength, and endurance
Social and psychological services

The Green House model of nursing home care

The Green House® Project (GHP) aims to create non-institutional eldercare environments to empower residents and those caring for them. Green House homes, the majority of which are licensed skilled nursing facilities, are small in scale with private rooms and bathrooms, living rooms, and other features differentiating them from traditional institutional care settings. Currently, 400 Green House homes exist in 32 states. ^[3] A Green House may be the preferred model for those who like a smaller and more home-like environment compared to traditional nursing homes.

Nursing Home Level of Care and services

For an older adult to qualify for skilled nursing care, a health care professional must indicate a need for a Nursing Home Level of Care (NHLOC).

What do I need to know about nursing home level of care?

NHLOC has no universal definition across all 50 states. Each state defines this level of care differently, and definitions can be complex. For example, one of the criteria for NHLOC in North Carolina is the need for a registered nurse (RN) for a minimum of eight hours each day. ^[4] In other states, the criteria are more general. Pennsylvania’s primary criteria for nursing home eligibility, for example, is a diagnosis and required treatment impacting an individual’s physical and/or psychological ability to manage their care. ^[5]
NHLOC is used to determine Medicare and Medicaid funding. In most cases, a physician must determine whether a person is eligible for NHLOC, according to state standards, before Medicare or Medicaid will approve funding.
Older adults usually qualify for NHLOC due to a combination of medical, cognitive, behavioral, and functional factors. For example, someone l may meet the requirement for nursing home care if they demonstrate a need for medical assistance, such as help with a CPAP machine or catheter, and functional assistance, such as help with ADLs.
The term for NHLOC is different across states. It may also be referred to as Nursing Facility Level of Care (NFLOC), Nursing Facility Clinically Eligible (NFCE), or Level of Care Determination (LOCD).

What services are provided at skilled nursing facilities?

The services provided in a nursing home partially depend on the requirements of NHLOC in the state where the facility is located. However, general federal guidelines for services provided in nursing homes offer oversight for skilled nursing as a whole. ^[6]

Nursing homes are federally required to provide the following services to residents:

Skilled nursing and related services
Rehabilitation services to support and maintain the physical and mental health of residents
Medically related social services, such as making arrangements for adaptive equipment
Pharmaceutical services
Customized dietary services
Social activities to support the psychosocial needs of residents
Regular and emergency dental services
Personal hygiene items and services
Assistance with ADLs, such as bathing and toileting, when residents cannot perform these tasks on their own

Based on the need of residents, nursing homes may also provide the following services: ^[7]

Maintenance of vision or hearing abilities, including assistive devices like hearing aids
Treatment for and prevention of pressure sores
Treatment to increase or maintain range of movement, including physical therapy and ambulatory devices, such as walkers
Treatment to maintain mental and psychosocial health
Supervision of medical care by a physician or advanced practice provider ⓘAn advanced practice practitioner (APP) is a medical provider, such as a nurse practitioner (NP) or physician’s assistant (PA), with training similar to a physician’s. APPs work in all areas of hospitals and clinics under a physician’s supervision and can prescribe medications and order tests for all procedures.
Transportation for specialized medical or therapeutic care

Most nursing homes do not provide: services like television and telephone; personal comfort items, including candy and tobacco products; cosmetic products and services beyond those included in basic service; personal clothing; personal reading materials; flowers or plants; and social events beyond what is offered by the facility. These items and services will usually need to be provided by the resident or the resident’s family.

Nursing homes compared to other senior care options

On the spectrum of long-term residential care options for older adults, nursing homes offer the highest level of care. To determine which housing option is right for you or someone you care for, you should know what each setting offers.

Assisted living vs. nursing homes

Assisted living is ideal for older adults who need help with certain ADLs but still want to live independently. In an assisted living community, residents live in a private or shared apartment and enjoy communal meals, daily social activities, and as-needed 24/7 care for medication management and help with ADLs, such as bathing and dressing.

Unlike nursing homes, assisted living facilities do not require a registered nurse on staff, so they do not offer ongoing medical care to residents. According to the National Center for Assisted Living, 60% of assisted living residents will transition to a skilled nursing facility after a median stay of 22 months. ^[8] This is usually due to an increased need for medical care or help with more ADLs, such as bed transferring or toileting.

Nursing homes vs. memory care facilities

Memory care units are often co-located in assisted living or are stand-alone memory care facilities. If someone living with Alzheimer’s or another form of dementia can perform most activities of daily living without additional assistance, a locked memory care unit in an assisted living facility may provide a sufficient level of care. But as an individual’s dementia progresses, symptoms like incontinence, difficulty feeding oneself, or behavioral disturbances such as aggression may require transitioning to a skilled nursing facility.

Home care vs. nursing homes

In-home care is often more personalized and less expensive than nursing home care, although it may require someone living in the home to be a full-time caregiver, which can be a financial and emotional strain. While skilled nursing can be delivered in both settings, older adults aging at home won’t have 24/7 access to a registered nurse, as they would in a nursing home.

Table 1 Nursing homes vs. other types of residential care for older adults

	Nursing home	In-home care	Assisted living	Memory care
Skilled nursing services	✓	✓		✓*
Medication management	✓	✓	✓	✓
24/7 emergency care	✓		✓	✓
Social activities with peers	✓		✓	✓
Secured to prevent wandering			✓	✓
Three communal meals per day	✓		✓	✓
Help with activities of daily living	✓	✓	✓	✓
Rehabilitation services	✓	✓

* Skilled nursing is available in memory care if the unit is in a skilled nursing facility.

When is a nursing home the right choice?

Many older adults wish to maintain their independence as long as possible, and a nursing home might not be a first choice. But if you or someone you care for needs more care than a home setting or assisted living facility can provide, a nursing home might be the best option.

Key signs indicating the need for nursing home care

A nursing home might be the right choice if you or someone you care for has:

A history of falls, mobility issues increasing the risk of a fall, or further needs for falls prevention
Decreased ability to complete ADLs, such as bathing or toileting, without assistance
An ongoing or new medical diagnosis, such as dementia, stroke, or diabetes, which can no longer be managed at home but does not require hospitalization
Significant memory loss or decreased cognitive function
A recent hospital stay requiring subsequent rehabilitation or skilled nursing care
A need for around-the-clock care or supervision

Essential qualifications for nursing home care

If you or someone you care for needs nursing care, the nursing home will require a referral from a licensed physician or advanced practice provider. This referral form is different in every state, but it usually confirms current diagnoses and provides an overview of the patient’s functional status, such as their inability to perform ADLs.

In addition to the referral form, potential nursing home residents will need to provide a current list of medications, submit a negative TB test, and finalize payment arrangements with the nursing facility staff.

The most direct way to find placement in a nursing home is directly following a hospital stay or a rehab placement following a hospital stay.

An image showing five benefits of nursing home facilities, which are 24/7 access to care, social engagement, registered nurse onsite, nutritious diet, and help with activities of daily living — Nursing home facilities offer a number of benefits for older adults and their caregivers.

Six benefits of nursing home facilities

1. Assistance with activities of daily living

Personal care, or non-medical care provided by professional caregivers, is available to all residents of nursing homes. This includes assistance with ADLs, like bathing, dressing, and toileting.

2. Around-the-clock access to care

In a nursing home, registered nurses (RNs) are available 24/7 to address residents’ skilled nursing needs, such as wound or catheter care.

3. Socialization opportunities

Social engagement is critical to everyone’s overall well-being. Nursing homes provide regular interaction with peers through communal meals and meaningful social activities, like concerts and craft projects. However, the activities and socialization opportunities vary significantly from nursing home to nursing home. Take the time to inquire about the type and frequency of social activities offered.

4. Nutritious diet

Nursing homes provide three balanced meals per day and can customize diets according to a resident’s medical needs.

5. Specialized care and services

In a nursing home, you can receive specialized medical and personal care services. Nursing staff are required by federal law to regularly assess residents and determine changes in resident status and which services are needed, from help with daily activities to diabetes monitoring.

6. Greater opportunity for Medicare and Medicaid coverage

Medicare won’t pay for long-term care, but it will cover most short-term stays of up to 100 days in nursing facilities. Also, in most states, you’re much more likely to receive Medicaid coverage for a nursing home than for an assisted living facility if you qualify.

In my experience…

“The primary advantage of nursing homes over assisted living or in-home care services is the relatively quicker availability of on-site skilled nursing services. This doesn’t mean that in a nursing home someone will be at your side the moment you pull your call light, but skilled care is available more readily. Skilled nursing facilities have at least one registered nurse on-site at all times, whereas assisted living facilities are not typically staffed with RNs, and in the case of in-home care, an RN needs to travel to your residence if skilled services are needed. In skilled nursing facilities, there are still holes in the safety net, but those holes are perhaps smaller and further apart than in other care settings.”

– Christopher Norman, Geriatric Nurse Practitioner, and Holistic Nurse

Understanding the costs associated with nursing homes

The monthly median cost for a nursing home facility in the United States is $7,908 for a shared room and $9,034 for a private room. ^[9] For many Americans, this is not a manageable out-of-pocket expense.

Nursing homes offer the highest level of care on the spectrum of residential housing options for older adults, but also come with the highest price tag. However, more government funding options are available for nursing homes than for other types of senior living.

Table 2 The cost of nursing homes vs. other types of senior care

	Monthly median cost	Annual median cost
Nursing home, private room	$9,034	$108,408
Nursing home, semi-private room	$7,908	$94,896
Memory care	$6,160	$73,920
Assisted living	$4,500	$54,000
Home health aide*	$5,148	$61,776

Source: Genworth Cost of Care Survey and Dementia Care Central ^[9] ^[10]

*This number reflects the monthly cost of professional in-home care provided for 44 hours per week.

Payment options and financial assistance for nursing homes

If you’re considering nursing home care for yourself or someone you care for, the cost is a genuine concern. While more aid is available for nursing homes than other types of senior housing, Medicaid policies and coverage will vary depending on where you live.

Here’s an overview of the ways people pay for nursing home care:

Private pay

Methods of private pay for nursing home residents include personal savings, Social Security benefits, proceeds from the sale of a home or stocks, 401(k) or IRA accounts, or financial assistance from friends or family members.

Insurance

In most cases, older adults with long-term care insurance can be reimbursed for the cost of nursing home care. Some policies come with an initial out-of-pocket period, so if you begin nursing home care before the out-of-pocket period has expired, you could be facing thousands of dollars in non-reimbursable expenses. Know the details of your policy and the length of any out-of-pocket period.

Some older adults sell their life insurance policies to pay for nursing home care. This can occur through life settlements or accelerated death benefits. Life settlements allow policyholders to sell their policy for the cash value of the death benefit. In this arrangement, you may not receive the benefit’s total cash value. This is also true for accelerated death benefits, which are tax-free advances on a policy’s death benefit, often capped at 50% of the policy’s full benefit. ^[11] Always talk with a trusted financial advisor before making this kind of financial decision.

Government funding

Medicare, Medicaid, and the Department of Veterans Affairs (VA) can help to cover the cost of nursing home facilities for older adults. ^[12] The Kaiser Family Foundation reported that Medicaid pays for the majority of long-term nursing home care, with 6 in 10 residents relying on Medicaid coverage. However, you must qualify for Medicaid to receive coverage.

Table 3 Primary government insurance programs to pay for nursing home care

Program	Coverage
Medicare	Medicare will fully pay for up to 20 days of rehabilitation in a skilled nursing facility, and will provide partial coverage for up to 100 days. Medicare does not pay for long-term care.
Medicaid	Medicaid will pay for long-term nursing care for Medicaid-eligible older adults. But the terms of eligibility, such as income limit and qualifying factors, vary widely by state. Your state’s Medicaid office can help determine your eligibility.
Department of Veterans Affairs (VA)	With VA benefits, United States veterans can receive long-term, residential nursing care in one of three possible settings: a Community Living Center, which are VA nursing centers designed to feel like home; Community Nursing Homes, which are non-VA nursing homes the VA contracts with to provide care to veterans; and State Veterans Homes, which are state-run facilities providing full-time care for veterans and, sometimes, their non-veteran spouses.

Source: ^[13]

Understanding Medicare coverage for nursing home care

Medicare is a national health care program with federal oversight, so the rules for Medicare coverage of nursing home care are the same in every state.

These are the Medicare guidelines for coverage of services received in a skilled nursing facility:

Medicare will not pay for any form of long-term care, including nursing home care.
Medicare will help cover the first 100 days of care received in a skilled nursing facility.

Specifically, the rules for Medicare coverage of skilled nursing are as follows:

Medicare covers skilled nursing facility stays only after a person has been a hospital inpatient for at least three days.
For days 1-20, services are entirely covered by Medicare.
For days 21-100, the Medicare beneficiary may be responsible for up to $200 per day.
For days 101 and beyond, the Medicare beneficiary is responsible for 100% of costs. ^[14]

How to choose and move into a nursing home

Because nursing homes are both medical and residential facilities, they may not feel as inviting as other senior living options, such as assisted living or independent living. To find a place where you or someone you care for can receive quality care, look beyond aesthetics and focus on issues of staffing and availability of services.

Narrowing down your nursing home search

Touring nursing homes can be an overwhelming experience. Before you begin, narrow your search to a handful of facilities.

These tips can help you narrow your nursing home search:

Find facilities in locations where friends and family can visit frequently. Frequent visits improve the quality of life for nursing home residents and show staff your involvement in your friend or family member’s care.
Learn about the Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System and find the quality rating for the facilities you’ll visit. ^[15]
Visit Medicare’s Nursing Home Comparison tool to compare local nursing homes and learn about their quality of care, staffing ratios, and more.
Make a list of what’s most important to you in a nursing facility, such as access to skilled nurses, daily social engagement, or dementia-specific care. Refer to this list as you begin to tour facilities.

Evaluating staffing and care standards in a nursing home

Unfortunately, nursing homes often experience staffing shortages. The Kaiser Family Foundation reported 24% of nursing facilities in the United States experienced staffing shortages as of March 2022. ^[16] You can make a difference in the nursing home experience of someone you care for by staying involved in their care plan and getting to know the staff caring for them.

Ask about these staffing and care standards when you tour a nursing facility:

The mix of nursing staff is a key metric in understanding the staffing competencies of a particular facility. For example, a facility could have plenty of certified nursing assistants (CNAs) but only one registered nurse (RN) delivering skilled nursing care. This could be problematic for residents with feeding tubes or other medical devices requiring monitoring by an RN.
Management of each resident’s care plan is another vital factor in the quality of care received in a nursing home. Older adults’ social, emotional, and medical needs will change over time, and the care plan will need to be updated accordingly. Check with the nursing staff at the facilities you tour to find out how often care plans are updated, and how family members are included in the process.
Safety and well-being checks throughout the day help keep nursing home residents safe, comfortable, and engaged. Ask how often the staff performs these checks and what they entail.

Ensuring quality of life and care in a nursing home

Nursing home residents deserve to live meaningful lives and to be treated with dignity. To help ensure someone you care for is living well in a nursing home, pay attention to the quality of social activities and look for signs of elder abuse.

Social connection is essential to everyone’s overall well-being. When touring facilities, look for community gathering areas where residents engage with one another. Are residents sitting in wheelchairs or sleeping at the nurses’ station? This may mean social engagement is lacking. Talk with residents about their experiences and, if possible, ask to speak to the activities director.
Know the signs of elder abuse and have a plan to address any issues. To report elder abuse, get in touch with Adult Protective Services in your state, contact your state’s Long-Term Care Ombudsman, or if someone is in immediate danger, call 911.

Planning for the transition to a nursing home

People often enter nursing homes following an unexpected hospital stay, making it challenging to plan for the transition. Still, you can help someone you care for make the transition, even if they’ve already been living in a nursing home for a few days or weeks.

Tips for a smooth transition to a nursing home

If possible, help the person you care for to emotionally prepare for the move by talking to them about it in advance. Show photos of the facility, if you have any, and talk through any worries they may have about the move.
Bring personal belongings to make the nursing facility feel more like home. These items might include family photographs, plants, or a preferred bedspread or blanket. Use a permanent marker or fabric labels to label all belongings.
Help the person you care for get involved in social activities as soon as possible. If you can, attend a few of the facility’s activities with your friend or family member to help them get used to the new environment.
Be their advocate. Check in frequently with your friend or family member and ask them how they feel. Help them talk with nursing home staff about any issues.
Attend family nights and meetings. Most nursing homes have regular family nights or update meetings. This is a great opportunity to learn about happenings in the facility, such as staffing changes. You can also use this time to bring issues to the administration’s attention and discuss potential problems and solutions.

Resources for finding a nursing home near you

If you’ve determined a nursing home is the right option for you or someone you care for, the next step is selecting a nursing facility to meet your needs. Work with friends and family members to make this decision, and draw from the community resources available to you.

Strategies for researching nursing homes near me

Many older adults are admitted to nursing homes after a stay in the hospital. In this case, ask the hospital social worker or discharge planner to provide a list of nursing homes in your community. Ask for advice and recommendations from friends and family members with experience searching for nursing homes, or direct experience with local nursing homes.

Finally, don’t rely solely on word of mouth, an internet search, or even a star rating to determine the quality of a nursing home. Visit the facilities yourself to learn about the kind of care provided.

List of nursing home resources

This list of resources can help you find the information you need about nursing homes and the care provided there:

BenefitsCheckUp: Discover your coverage options.
Medicare Care Compare: Find and compare nursing homes near you.
Eldercare Locator: Locate the Area Agency on Aging near you, and find other resources supporting older adults in your community.
Caregiver Action Network: Connect with other family caregivers and find support.
Rights and Protections as a Nursing Home Resident: Familiarize yourself with the Centers for Medicare & Medicaid’s Rights and Protections for Nursing Home Residents.

Bottom line: making informed decisions about nursing homes

Nursing homes provide complex, comprehensive care for older adults who can no longer be cared for at home, but do not require hospitalization. In both short-term and long-term residential settings, nursing homes provide a range of services like: help with ADLs, like bathing and getting in and out of bed; rehabilitation services, like physical and occupational therapy; and skilled nursing services, such as wound or catheter care.

Compared to other senior living options, nursing homes are the most expensive and offer the highest level of care. Most nursing homes offer some form of memory care for residents with Alzheimer’s or another form of dementia. Each state has different standards for how a person qualifies for skilled nursing care. People usually qualify due to a combination of medical, cognitive, behavioral, and functional factors.

If you or someone you care for needs nursing home care, tour facilities before making a final decision. During your tours, talk to as many people as possible, and ask a lot of questions. Seek out community resources, and enlist friends and family members to help with decision-making. Moving to a nursing home is a major life transition. You don’t have to go through it alone.

Frequently asked questions

Medicare does not cover long-term care, including nursing homes, but it will help to pay for up to 100 days of rehabilitation in a skilled nursing facility following a three-night hospital stay.

The monthly median cost for a nursing home facility in the United States is $7,908 for a shared room and $9,034 for a private room.

To qualify for nursing home care, a physician must determine whether a person meets state standards for Nursing Home Level of Care (NHLOC). Each state defines NHLOC differently, but it usually requires a person to have a combination of medical, cognitive, behavioral, or functional needs.

Medicare will help pay for up to 100 days of rehabilitation in a skilled nursing facility. After the first 100 days, the patient is responsible for 100% of nursing home costs. Medicaid can help pay for nursing homes for those who meet the income requirements. Other options include personal savings, proceeds from the sale of a home or life insurance policy, long-term care insurance, or VA benefits.

Have questions about this article? Email us at reviewsteam@ncoa.org.

Sources

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