Nursing Homes: Services Offered, Facility Types & Costs

Out of all of the different types of long-term care, nursing homes (also known as nursing facilities) provide for the broadest range of services and support. Most nursing homes offer room and board, nursing care and a host of medical, personal and social services. The distinguishing characteristic of nursing homes is that they are essentially medical facilities and often look more like hospitals than independent living communities^[1]. Unlike other forms of senior living, nursing homes are required by law to have licensed nurses on staff at all times. These additional resources make nursing homes far more expensive than other forms of senior living, but also in most cases allow nursing homes to provide better care to older less healthy residents.

In most cases, the nursing home is the last resort for seniors who require too much assistance with daily living and medical care to continue living at home or in assisted living. Often, these seniors have lived in independent or assisted living communities or received home health care services before being transferred into the nursing home. In other situations, seniors find themselves in nursing homes after a major surgery or injury following their discharge from the hospital. Many residents have chronic medical conditions and in most cases, multiple medical conditions. However, in many cases due to the deterioration of their physical and/or mental condition, these residents require care and supervision on a 24-hour basis, even if the vast majority of their care is not medical in nature. 

There are many different types of nursing facilities that go by a host of different names, but generally they can all be classified into four basic groups: hospital-based skilled nursing facilities, skilled nursing facilities, intermediate care facilities and custodial care facilities^[2].

Custodial Care Facilities

Custodial care facilities offer an entry level array of services, but are still places where many of their residents will be able to spend the rest of their lives. The reality is that many nursing home residents do not require advanced medical care and simply are no longer capable of performing activities of daily living without assistance. These residents primarily need help with bathing, dressing, eating, movement, using the bathroom and continence. Many of these facilities do not offer any skilled nursing or therapy, at least not on a regular basis. These facilities will be staffed primarily by nurse’s aides or home health aides. Residents requiring additional care may either be able to purchase that care for an additional charge or arrange for a qualified professional to come to the facility and care for them. Keep in mind that these types of facilities have a variety of names, including convalescent homes, residential-care facilities, board and care homes and many others.

Intermediate Care Facilities

Intermediate care facilities (“ICF’s”) are a step below skilled nursing facilities in terms of the level of care available, but are still able to offer their residents skilled nursing care. Residents at ICF’s tend to be long-term residents who simply require too much skilled nursing care to live in custodial care facilities. Often, these residents may suffer from chronic illnesses, which require daily medical care but not the level of rehabilitation offered by a skilled nursing facility. Similar to custodial care facilities, the primary objective of these facilities is often tending to residents’ personal care needs, such as assistance with activities of daily living^[3].

Skilled Nursing Facilities (SNF)

Skilled nursing facilities (“SNF’s”) and inpatient rehabilitation facilities are most commonly associated with rehabilitation or short-term nursing home care. This level of care may also be referred to as sub-acute care. SNF’s specialize in providing various types of therapy, including physical therapy, occupational therapy, speech therapy, oxygen therapy, respiratory therapy and recreational therapy. SNF’s also provide both skilled nursing care, including woundcare and administration of intravenous drugs. Seniors are likely to find themselves in SNF’s following their discharge from the hospital or a hospital-based skilled nursing facility following a surgery or accident. Nursing homes with skilled nursing facilities also provide skilled nursing care and other services to their long-term residents when such care is required. While many nursing homes now offer skilled nursing care and therapy to varying degrees, SNF’s are generally able to provide this care to their residents on a more regular basis. In recent years, an increasing number of nursing homes are adding skilled nursing facilities or at least offering some of the applicable additional services.

Hospital-Based Skilled Nursing Facilities

Finally, hospital-based skilled nursing facilities are actually connected to hospitals. Some people refer to these as extended care facilities. These facilities provide by far the highest level of medical care due to having access to more highly trained medical personnel and high-tech medical equipment. For most nursing home residents, these additional services and capabilities would be unnecessary. If you find yourself in one of these facilities, you were likely just discharged from acute hospital care with a major injury^[4]. After just a few days, you typically would be discharged to a traditional skilled nursing facility for rehabilitation.

Sizing Up A Nursing Home and Its Services

It is not always clear from a nursing home’s name whether it is a custodial care facility or intermediate care facility, as both are commonly simply referred to as “nursing homes”. SNF’s on the other hand will typically be called skilled nursing facilities. If you are looking more for long-term care than rehabilitation, it is likely that you need a either an ICF or a custodial care facility. It is important that you inquire with the facility to conform that its scope of services matches your needs. As mentioned above, you may need some of the services commonly associated with SNF’s, yet still be a better candidate for an ICF due to the long-term nature of your medical needs. Below is a summary of the scope of personal care and medical services often provided by nursing homes, but it is critical that you understand that not all nursing homes will offer all of the services.

Personal Care

Most commonly, nursing homes provide their residents assistance with activities of daily living, including bathing, dressing, eating, using the bathroom, transferring between bed and chairs and continence. In addition, they also provide meals, health monitoring, assist their residents with taking their medications and provide transportation to medical appointments in the community. 

Medical Care

With the modern trend of residents entering nursing homes later in life with more health issues and living much longer than in the past, nursing homes have been expanding their scope of services. Many nursing homes now offer many of the following services^[5]:

• Nursing Care
• Woundcare
• Intravenous Therapy
• Physical Therapy
• Occupational Therapy
• Speech and Language Therapy
• Respiratory Therapy
• Recreational Therapy
• Audiologists
• Dental Services
• X-Ray and Laboratory Services
• Nutritional Counselling
• Dermatologists
• Orthopedics
• Psychiatrists

While all nursing homes have a medical director who is a physician, this physician does not necessarily work full-time. Some nursing homes have physicians available for routine medical care, while others only have physicians available on an emergency basis. If the nursing home you are considering does not have a full-time physician able to provide medical care, you should inquire whether your primary care physician will be able to care for you at the facility. 

Memory Care Services

Many nursing homes also provide special care units (“SCU’s”), which are designed to address the needs of patient populations with specific health conditions. With nearly 60% of all nursing home residents suffering from Alzheimer’s or dementia^[6], the most common type of SCU’s are memory care units. Residents with Alzheimer’s often require unique care due to their cognitive impairment, including in some cases constant supervision. As a result, memory care units often have higher staffing ratios than other units of nursing homes. Also, these residents are often in better physical condition than other residents so they may not require extensive personal care services or medical services for other health conditions. Seniors with Alzheimer’s or dementia should confirm that any nursing home they choose has a memory care unit available even if such extensive care is not necessary when they enter the nursing home.

Costs and Paying for Nursing Home Care

The average cost of nursing home care is over $250 per day nationally and is generally much higher in areas with high cost of living or a shortage of nursing home beds. We would typically expect custodial care facilities to be the least expensive, while SNF’s and hospital-based facilities to be the most expensive. In fact, SNF’s commonly charge more than $500 per day. 

The average stay in an SNF for rehab is approximately 27 days and the average long-term stay in a nursing home is about one year^[7]. Short-term stays of 100 days or less make up the majority of all nursing home stays across the board. However, some residents end up living in nursing homes for a prolonged period of time, often the entire remainder of their lives. The average stay in a long-term care facility is about one year^[8], but up to ten percent of residents end up living in these facilities for three years or longer^[9]. Given the high prices of nursing homes, costs can add up in a hurry.

Unfortunately, very few people have insurance coverage that will pay for nursing home costs. For the lucky few who purchased long-term care insurance, they may have coverage as long as the policy has adequate coverage. For others who are in an SNF for rehabilitation immediately following a hospitalization, Medicare may cover up to 20 days of nursing home care in full, followed by a period of up to 80 additional days at a co-pay of $176 per day. Note that this co-pay may be covered by a Medigap or supplemental plan. 

For others, the only option is to private pay and for many, these expenses will exhaust their resources. The majority of all nursing home costs are now paid by Medicaid long-term care, which subjects participants to a rigid income and asset test. If you believe you may qualify for Medicaid long term care now, or that you will in the future after spending down your assets on nursing home costs, you should confirm that any nursing home you are considering accepts Medicaid and that it has available Medicaid beds. Keep in mind that many nursing homes that accept Medicare will not accept Medicaid due to its lower reimbursement rate^[10]. For a more detailed explanation of Medicare, Medicaid and other forms of coverage, as well as the specific rules in your state visit our state pages to see specifics. Finally, a limited number of veterans will qualify for coverage through the Department of Veterans Affairs.

Nursing Homes: Good, Bad, and Ugly

With the glut of horror stories in the news and urban legends about nursing homes, it is important to separate fact from fiction in making your decision. Many nursing homes are staffed by qualified and caring professionals who dedicate their lives to patient care. Similarly, many nursing homes are stocked with patients who’s lives have been vastly improved by the enhanced personal and medical care they are receiving, as well as the additional socialization and camaraderie they receive from being surrounded by their peers. Also, for many nursing home residents with declining health and no family or friends capable of providing the requisite level of care, they simply have no other choice. 

On the other end of the spectrum, there are also plenty of nursing homes that have been cited for abuse and fraud over the years. The data indicates that others may be providing substandard nursing services resulting in poor care for their patients, as evidenced by excessive hospitalizations, falls resulting in major injury, pressure ulcers and other often preventable ailments.

Elder Guide has prepared a sophisticated tool to assist you in assessing the nursing homes in your preferred location based on a wide range of criteria and data we have identified. We hope that you will find this tool, in combination with your own research and visitation of nursing homes, to be useful in selecting a first-rate nursing home that will improve your quality of life.