Finding the right nursing home, step by step

1. Figure out whether a nursing home is needed

If you can draw on good local resources, the best choice for now might not even be a nursing home.

No one looks forward to moving into a nursing home or putting a loved one there. But what to do when Dad is losing an alarming amount of weight because he lives alone and doesn't eat well, or when Mom's deepening depression and forgetfulness make her neglectful of vital medications? A nursing home may truly be the best option.

You may be able to push back the day of reckoning for months or years. There is likely more support in your community than you suspect. Tap the local Meals on Wheels program to help your father stay well nourished, for instance, or adult day care to take the edge off your mother's depression by connecting her with other people. However, a frail elderly person who may have already fallen and broken a hip or who has been wandering the neighborhood because of progressing dementia must have full-time care.

We have created a four-step tool that first will help you determine whether nursing home care can be put off, at least for a while. Then, if you conclude that a move can no longer be delayed, we will help you find a home that best meets your loved one's needs — human as well as physical and medical. Finally, we will provide tips on how to stand watch so that he or she continues to receive skilled and compassionate care as time passes.

Arrange an evaluation. Your loved one should have a thorough geriatric assessment to evaluate his or her physical and mental status. A geriatrician, or a doctor or nurse practitioner with geriatric training, would be ideal, but such specialists can be challenging to find in some areas. Your mom or dad's primary care physician is another option; phone ahead for reassurance that they can do a thorough assessment. The most important element will be your loved one's degree of ability to conduct "activities of daily living" — sufficient upper-body strength to get out of a chair unassisted, adequate dexterity to bring fork to mouth, and enough range of motion to pull on pants or a sweater, for example. Balance will be checked to assess the risk of falls. Memory deficits, signs of depression or anxiety, and indications of dementia and Alzheimer's will be evaluated. Simply identifying all the issues can take a big weight off a worried family's shoulders. "When you frame it by what they need, then you can start putting together a plan," says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., which provides long-term care and services for the elderly. If your loved one doesn’t have a doctor or the means to get to one, the local Area Agency on Aging may be able to come to the house or to do an initial, if less thorough, assessment over the phone.

Add your own insights. Input from family members should be integrated into the evaluation. The particulars of day-to-day concerns — trouble persuading Mom to take a shower, or her habit of forgetting to turn off the stove — will help guide the assessment, inform the plan of care, and narrow the choices that will have to be made.

Look to your community for help. "If they don't need 24-hour care, many people could avoid a nursing home for one or two years," says Susan Reinhard, AARP senior vice president for public policy. The Area Agency on Aging will have a list of local services, from volunteer groups that arrange rides for older folks to get to doctors' appointments to the businesses that provide in-home nursing care and assisted-living facilities. The Eldercare Locator Web page, maintained by the federal government, is a good resource to use as a starting point. You can search for help by ZIP code.

Consider hiring a professional. Barbara Gortych, a Boston psychologist, recruited a geriatric care manager in Florida near her mother, to help find local resources and assist in care decisions. When Gortych was unable to visit, care manager Stephanie Swerdlow kept her informed about her mother's status and services that were needed. Over the years, she helped Gortych arrange for occasional companion care to help her mother shop for groceries; she helped find a much-loved aide who was with her mother daily, an assisted-living facility as dementia set in and, finally, a nursing home when 24-hour care was required. It was Swerdlow, in fact, who alerted Gortych that her mother needed the range of care that only a nursing home could provide. As her mother's mind faltered and her health declined, Swerdlow would make unannounced visits to the nursing home to check on her care. "If something wasn't right, she was the one who had the rapport," says Gortych. She credits Swerdlow with bringing her peace of mind as well as local knowledge.

A geriatric care manager can be particularly helpful when you live far away but also can benefit anyone at a loss for good services for an aging loved one. You can search for one by ZIP code on the National Association of Professional Geriatric Care Managers Web site. Many clients arrange for an initial consultation to help determine the kind and level of care required and plug the family into local options, says Phyllis Brostoff, the group's president, and then call on them as needed. A consultation typically costs several hundred dollars; as-needed help generally costs from $80 to $200 per hour, depending on prevailing rates in the area.

2. How to pick the best nursing home candidates

Distance matters, of course. Our rankings will help out by flagging top-performing nursing homes.

With more than 15,000 nursing homes in the United States, even a modest-size city is likely to have 20 or more within a short drive. How can a manageable list be sifted out of so many possibilities?

The guiding principle is to balance practical considerations, such as distance and expense, with issues of quality, such as results of health and fire safety inspections. You can readily obtain quality-related information by mining such resources as the new U.S. News America's Best Nursing Homes rankings, which rely on information collected and analyzed by the federal Centers for Medicare and Medicaid Service (CMS) and data many states post online. And while you might find the thought of wading through data wholly unappealing, the numbers do have power. Not only can they help you whittle down the nursing home universe to a short list of prospects, they can also provide fodder for the types of questions to ask nursing home administrators when visiting the final candidates.

Make distance a priority. The best prescription for fending off depression and feelings of isolation in nursing home residents is to make sure they frequently see the significant people in their lives — adult children, of course, but also a neighbor dropping in for a meal or a grandchild coming to show off a good report card. Distance matters. "[A] facility that is a five-minute drive away may be best," says Phyllis Brostoff, president of the National Association of Professional Geriatric Caregivers, even if its marks are comparatively lower than those of another home an hour away. Close proximity also makes it easier to keep tabs on the quality of care a loved one is getting.

Work from the top down. Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care, suggests searching for places rated by the federal government at four or five stars overall and eliminating lower-starred facilities. "You might end up having to keep the threes in there, but start with the top," she says. Consumer advocates are especially leery of a category of nursing homes labeled Special Focus Facilities by the government. Because of their history of poor performance, the 135 homes on the SFF list get twice the scrutiny that even one-star homes receive, as described in a separate feature. But higher-ranking homes, she warns, are more likely to have a waiting list and may take only private payers. And while the star ratings are a good place to start, they cannot capture all of life's aggravating realities — such as having limited choices if you live in a thinly populated part of the country.

Count the nurses. The number of nurses and nurse aides are one of the best indicators of good care. An ample supply means they have the time to help your mother out of bed and into her slacks or nudge her to engage with peers. It means her array of blood pressure and pain medications is closely tracked and she is monitored for side effects, drug interactions, and overmedication. You can easily compare staffing at different homes because those that take Medicare or Medicaid residents must provide CMS with nurse staffing data, which is converted into the amount of nursing time per resident.

But the numbers should be used only as a rough guide: They reflect the average number of nurses and nurse assistants in the two-week period before the most recent health inspection survey. While the surveys are unannounced — and alerting a nursing home to the date of a coming inspection is a federal crime — administrators know the surveys are conducted at least every 15 months. If it's been 10 or 11 months since the last one, homes may staff up a bit more heavily in anticipation. Staffing information also is unaudited and its accuracy is suspect. Use the reported numbers to shape your short list, says Harrington, but draw conclusions only after visiting.

Good turnover data, if they were available, would be a much better indicator of the quality of staffing. It is not unusual for a home to have annual nursing turnover of 50 or 100 percent or even higher. Because of low pay and demanding physical requirements, turnover is especially high among aides, who have the most frequent direct contact with residents. The payroll data that would allow calculating turnover are not now collected. CMS plans to begin requiring homes to submit the information, but that could be a year or more away. It is a topic very much worth raising when you visit. Step 3 will give you turnover rates to compare with the answers you get.

Buddy up to an advocate. Every state has a long-term care ombudsman whose responsibilities include pursuing complaints made about a specific nursing home, usually by a resident's family member or friend. The ombudsman is likely to know whether a facility has improved or has recently attracted a slew of complaints and should be willing to share these insights. You should also get his or her reaction to a nursing home's star ratings in the Best Nursing Home rankings for overall quality, health inspections, staffing, and medical measures. "Ask if they think the ratings are accurate," suggests Janet Wells, director of public policy at the National Citizens’ Coalition for Nursing Home Reform. Advocacy groups such as hers are another information source worth tapping — and the local ones may be more ready to dish about especially good or bad nursing homes, she says. The National Citizens’ Coalition for Nursing Home Reform lists contact information for all state ombudsmen and advocacy groups.

Ombudsmen and advocacy organizations should also be able to clue you in to disturbing events, such as an outbreak of C. difficile or MRSA infections, which are common in hospitals and nursing homes. And they can discuss a particular state's nursing home regulations, which can be more stringent than federal standards, as well as details of citations for any violations. If a nursing home is implicated in a resident's death in California, for example, the state ombudsman's office can disclose the violation. Publicly available federal data might not reflect the specifics of the incident. "It might say there was a [citation that put residents in] jeopardy, but it might not be in there at all," says Toby Edelman of the Washington, D.C.-based Center for Medicare Advocacy. Some state watchdogs are better than others, she adds. And the quality and level of knowledge varies widely: An ombudsman may be a part-time volunteer, for example, or might not be a particularly dogged advocate for nursing home residents.  

Exploit state information. Some states have their own nursing home quality measures and post the results online. The trick is finding the information. It may be hosted by the department of public health or buried in nursing home "licensing and certification" sections. Dig around on the state's home page, their department of public health page, and anything you can find on nursing homes or certification and licensing. Terms to guide your clicking: violations, deficiencies, state surveys, inspections and 2567 forms.

The details can be telling. While some states simply rehash the federal information, others unveil specific results from the previous health and fire inspection as reported by the surveyors on federal form 2567, which describes investigations that earned violations for the facility — staff neglect that contributed to a resident's injury from a fall, for instance, or a resident's violent agitation because nurses failed to follow medication instructions. The Illinois Department of Public Health Web site, for example, posts some 2567 forms online with their nursing homes. They also have a roundup section that lists, by quarter, the fines slapped on specific nursing homes, though not the details of the violations that garnered them. The California Department of Public Health Web site has a separate page that allows users to identify homes the state found responsible in the death of a resident and to read the 2567 forms to see what happened.

Broader nursing home information is not limited to federal or state Web sites. For example, the California Health Care Foundation Web site, which Harrington helped create, lists helpful information such as the percentages of residents at a home who require certain kinds of special care because of, say, reduced physical function or impaired cognition, compared to the state nursing home average. That will give you an advance sense of a home's ability to provide a service that your loved one may need. Hourly nursing staff wages and rates of staff turnover, with comparisons to regional averages, also are available.

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