This page is dedicated to providing helpful tips to caregivers faced with deciding where his/her loved one would receive the BEST care when living at home is no longer an option. Learn alternatives to nursing home placement, how to choose a nursing home if that is the BEST option, and the differences between Nursing Homes, Skilled Nursing Facilities, and Assistive Living Facilities.
The Primary Caregiver Shift
Illness, injury, disease, and or surgery can trigger the caregiver shift. For example, one moment your loved one was independent, capable of driving, preparing meals, completing household chores, bathing, dressing, and walking without any falls or concerns. Then you receive an unexpected call from the hospital or your loved one’s doctor because he/she suffered a STROKE, massive HEART ATTACK, substantial FALL with a BROKEN HIP/INJURY, and/or diagnosis of ALZHEIMER’S DEMENTIA, PARKINSON’S DISEASE, or CANCER. Life changes drastically in a moment’s notice and you realize you now have to make numerous decisions regarding the most appropriate setting for your loved one to either recover, rehabilitate and/or permanently reside based on:
- his/her potential to achieve their prior level of function
- future fall risk
- and level of care needed to provide the optimal quality of life, functional independence, and safety.
Researching and deciding on an alternative residence for your loved one can be emotional, physical and mentally exhausting. Perhaps you experienced a similar decision-making process for your own children when you had to consider childcare in a home, church or daycare center; however, instead of dropping your child off and picking them up in 5-8 hours, you might be dropping your loved one off at a Nursing Home for the remainder of his/her life– hence the additional anxiety, fear and stress into your already busy LIFE!
Where do you start and what should you know when faced with possible placement of a loved one? As a Physical Therapist, I am going in and out of different settings (Assistive Living, Nursing Home/Long-Term Care, Residential/Community Living Homes, Skilled Nursing and private homes) every day and at various times of the day. Coordination of care with nurses, bath aides, other therapists and doctor’s appointments results in unexpected arrival times and behind-the-scenes insight. Therefore, I recommend the following tips when looking and choosing a care home or facility for your loved one.
1. Friendly Advice – You are neither the first nor the last person in this situation. Talk to friends, co-workers,and church members. Listen to their experiences, concerns, and tips–especially if you have someone in your inner circle that works as a C.N.A, nurse, or therapist in one of the settings you are having to consider.
2. Unexpected Visit – Be an undercover investigator! Walk in unexpectedly to any setting and get a first impression “feel” for yourself. Listen to your internal radar – does the environment feel warm, inviting, LOVING or do you feel like an intruder?
Get a “sense” of the environment. What does it smell like? Hopefully, it does not smell like bleach, ammonia, urine, or burned food. What does it look like? Take notice of the furniture, walls, other residents, and the employees. Pay particular attention to the last two: other residents and the employees. The residents should be groomed, using equipment that is not FILTHY or BROKEN, and fairly content/social if they are out of their rooms. Are the clients/patients and employee interactions appropriate? The employees should be actively engaged in providing care, managing fall risks, and pleasant/welcoming when interacting with fellow co-workers and residents. In other words, the employees should not be on private cell phones, ignoring call lights, avoiding care and fall risk management opportunities, demeaning or short-tempered, and appearing “put out,” apathetic, or inconvenienced with co-workers or residents. In the same manner, do you see someone roll their eyes when waiting for a resident that requires increased time to transfer, move in his/her wheelchair or walk? Do you see anyone walking around with dirty shirts/pants either from eating or having an accident? Do you see stains on the floor, holes in the walls, or “OUT OF ORDER” signs throughout the facility?
3. Too Good To Be True – If you get the sense that you are observing “Top Notch” facility operations and patient care, be sure to intentionally look for a group of individuals with clipboards, dressed in business attire, and interviewing or closely observing the facility–this is a clear indication the facility is currently under STATE inspection. The Centers for Medicare & Medicaid (CMS) a division of the U.S. Department of Health and Human Services conducts an inspection of every patient care facility every 12-15 months. The inspection process can take several days and can be a “surprise” visit, but some of the process includes:
- Touring/Observing the facility’s daily operation
- Interviewing/Observing a sample (several residents) selection of clients and employees
- Monitoring the Kitchen/Food preparation and quality
- Observing Medication preparation and administration
- Reviewing the Abuse Prevention protocol
- Evaluating Quality of Life Measures and Assessment procedures
- Determining/Document any below standard care or deficiencies
There will be a NOTICE on the door when INSPECTORS ARE present in the building; however, if you are walking into a facility that is BUSY and FRANTICALLY completing repairs, cleaning, and taking care of patients–the facility is most likely EXPECTING or ANTICIPATING an audit or inspection. Sometimes facilities are reviewed more often than 12-15 months as a result of numerous filed complaints or increased frequency of falls, slips, trips and injuries. For a more in-depth explanation of the Inspection Process, you can click on this link: [PDF] The Nursing Home Inspection Process – Office of the Legislative Auditor. You can ask employees if you suspect you are observing “Too Good To Be True” patient care and facility operation, but you might not get a straight answer. Therefore, I recommend waiting it out and returning several times over a period of a few weeks.
4. Utilize the power/convenience of Web-based Research – If you want to look up specific data on specific care facilities, you can click on these links:
These websites provide information regarding patient care facilities and their State inspection data related to Quality Measures (statistics about falls, pressure sores, urinary tract infections, etc…) and how facilities compare to the STATE and NATIONAL average. In addition, you can compare specific facilities with the STATE and NATIONAL averages regarding how much time per day a patient spends with each discipline (Nurses, Certified Nurses Aides, and Physical Therapists).
INTERESTING TREND: I reviewed several facilities using these 2 websites. Facilities with Higher Star Ratings (4 or More) in both Quality Measures (Falls) and Staffing (Time spent with each discipline), had less than the average number of falls when patients spent more time with Physical Therapists and Nurses! In other words, if a patient spent more than the state and national average time with C.N.A’s and less with Nurses/Therapy, the fall frequency INCREASED!
5. Loved One Follow-up and Feedback – Listen and Observe your loved one for any signs/symptoms of neglect, abuse, failure to thrive, complaints/compliments to ultimately determine if your loved one’s needs and quality of life are being met. Remember YOU can relocate your loved one at any time! Red flags and common warning signs/symptoms can be reviewed by clicking on this link: HELPGUIDE.ORG
Proper placement of a loved one also depends on the level of care and rehabilitation potential of your family member. For instance, if your loved one just had surgery and is slow but able to stand up, walk short distances, get in/out of bed, go to the bathroom, shower and dress, then placement in a Long Term Care Facility is NOT appropriate!
The Difference Between Each Facility/Setting
Type of Facility
Long Term Care/Nursing Home
Skilled Nursing/Rehabilitative Facility
Assistive Living Home/Facility
|Brief Description||On-site full staff including nursing (RNs, LVNs, CNA’s), full-service medication administration/management and business staff (Administrator, Director of Nurses, Maintenance, etc…) to provide skilled care 24 hours/7 days a week||On-site full staff including nursing (RNs, LVNs, CNA’s), full-service medication administration/management and business staff (Administrator, Director of Nurses, Maintenance, etc…) to provide skilled care 24 hours/7 days a week||Limited to no nursing (RN/LVN) staff on-site, full-service medication management to assist patients with medication administration/management. On-site business staff (Administrator, Director of Nurses, Maintenance, etc…) available in the facility but less likely in a residential-based assistive living site.|
|Rehab Services||Generally offers limited or NO rehabilitative services (Physical, Occupational/Speech Therapy)||Readily available, daily rehabilitation services by Physical Therapy, Occupational Therapy and Speech Therapy depending on the patient’s needs. For example, a patient admitted for total knee replacement rehab does not require Speech Therapy, but a patient with the diagnosis of a recent stroke would benefit from PT/OT and ST. Physical therapy evaluates and treats any deficits involving the legs (walking, transferring, bed mobility, and standing balance). Occupational therapy evaluation and treat any deficits involving the arms (dressing, bathing, toileting, eating, meal preparation). Speech therapy evaluates and treats any speech, swallow, and cognitive deficits.||Rehabilitation is offered by either on-site therapists or contract (off-site) therapists through Home Health Agencies. Therapy requires a doctor’s order and rehab is NOT a daily service. Generally, patients receive therapy either twice or three times per week.|
|General Patient Rehab Potential||Poor. Poor rehab potential means an individual either cannot or will not benefit from skilled therapy based on physical limitations (quadriplegia, advanced Parkinson’s Disease with contractures, unresponsive/coma), mental impairments (advanced Alzheimer’s/Dementia) and/or personality/emotional barriers (refuses to participate in therapy, becomes physically/verbally aggressive with therapy, is content with his/her level of independence/dependence).||Fair to Good. Initially patients require MAX (patient completes 25%, caregiver 75% or more) ASSISTANCE. However, the patient is expected to progress with skilled therapy and eventually discharge home with home health services or home with doctor’s orders for outpatient rehabilitation.||Fair+ to Good. Initially, patients require MINIMUM (patient completes 75%, caregiver 25%) to CGA/Contact-Guard Assistance (caregiver touches the patient but the patient completes 100% of the transfer/bed mobility). If patients receive therapy, the patient is expected to progress with skilled therapy and eventually discharge at indirect SPV/Supervision (patient completes 100% mobility and transfers and staff “watches” intermittently or as needed to decrease fall/injury risk) or MI/Modified Independence (patient completes 100% mobility and transfers but uses medical equipment such as a walker, wheelchair, or power chair)|
|General Patient Care Needs||High – Patients/Residents require TOTAL (patient completes 0%, caregiver provides 100%) to MAXIMUM (patient completes 25%, caregiver provides 75%) assistance from 1 or more caregivers for bathing, toileting, dressing, eating, transferring, walking or wheelchair-based mobility||Initially High to Moderate but as the patient progresses with therapy, he/she generally discharges home at MODERATE (patient completes 75%, caregiver 25%) to MINIMUM (patient completes 50% and caregiver 50%) ASSISTANCE levels.||Mild initially and eventually LOW. Residents can transfer without assistance, get around using a wheelchair, scooter, walker, or cane without caregiver assistance, and are generally able to continue driving and/or enjoy planned community-based activities (shopping, BINGO, movies, etc…)|
These are general descriptions, the level of care guidelines, and some facilities will provide higher levels of care regardless of the patient’s rehab potential. For example, I have provided treatment to a patient in an ALF (Assistive Living Facility) that required MAX A (the patient could not transfer, walk, or get in/out of bed without a great deal of efforts and consistent 75% or greater caregiver-assist level). Generally, patients in an ALF should be able to transfer without the skilled assistance of a caregiver, nurse or therapist because most ALF’s DO NOT have or provide ON-SITE, SKILLED NURSING or REHABILITATION! If your loved one requires assistance every time he/she transfers, walks, or gets in/out of bed, I recommend an SNF (Skilled Nursing/Rehab Facility) or Home Health with therapy until he/she is able to transfer, walk and get in/out of bed with less assistance.
Thank you for visiting my site and I sincerely hope you learned something to make the decision for placing your loved one in an alternative care setting easier. However, if you have any questions or need further advice, please contact me. If I do not know the answer, I will put forth my best effort to find the answer or tell you I do not know the answer. I am honored to have you visit my site, and I honestly strive to make caregiving easier and safer.
Til next time,