One of the most common and familiar senior care options is a nursing home. While the term skilled nursing is often used interchangeably, they are quite different. One is a type of care (skilled nursing) and the other is a senior living option (nursing home). It is important to understand the difference so you can make an informed decision for your loved one.
What is skilled nursing care, or a Skilled Nursing Facility (SNF)?
Skilled nursing is a high level of medical care provided by trained individuals, such as registered nurses and therapists. This includes rehabilitative care such as physical, occupational, and speech therapy. There is also more specialized care offered for Alzheimer's and Parkinson's patients. Skilled Nursing involves professional medical staff able to administer medications and use special medical equipment.
A Skilled Nursing Facility is a licensed health facility that has at least one licensed health professional available to provide care 24 hours a day. This is certified or trained medical staff - a registered nurse, therapist, or doctor. Access to medication and assistance with activities of daily living is also part of skilled nursing care.
Where is skilled nursing provided?
Typically, the services provided by skilled nursing staff can occur in a variety of various care settings from nursing homes to other long-term and short-term care facilities. Skilled Nursing can be offered in a variety of different places including:
- A hospital wing
- An independent facility,
- A unit within a nursing home
- An assisted living home
- A personal residence or group home
- A Continuing Care Retirement Community (CCRC)
Skilled nursing services are increasingly in demand and offered in a variety of places to meet the needs of various patients.
What is the purpose of skilled nursing?
The purpose of skilled nursing care is to help seniors who need to recover from an injury, illness, or surgery. Seniors are often transferred to a skilled nursing facility or unit following a hospital stay. It's commonly referred to as post-acute care. In most cases, they are well enough to be released from the hospital, but still need significant medical care to recovery.
A skilled nursing facility is not a permanent living situation, but rather a temporary arrangement while the senior regains health, strength, and mobility. Skilled nursing is a phase of care at a certain level often with the goal of requiring less assistance afterward. Often those who discharge from a skilled nursing facility will remain in a basic nursing home if more care is still required. Skilled nursing facilities are beneficial for several reasons:
- 24-hour licensed staff - Trained and certified medical staff are always available.
- Therapy - Movement and exercise play a key role in mobility and physical recovery.
- Social Interaction - Sharing conversation, space, activities or experiences with others can aid in wellbeing and healing.
What services are involved in skilled nursing?
Staff at skilled nursing units or facilities provide assistance with daily living tasks, such as hygiene, bathing, dressing, meals, housekeeping, and other personal care. The care can vary depending on if the skilled nursing happens in a hospital setting or a nursing home or another location. Examples of typical services provided at a Skilled Nursing Facility include:
- Planning, managing, and evaluating patient care
- Giving injections
- Inserting catheters and feeding lines
- Using aspiration devices
- Treating skin diseases
- Therapy (physical, occupational, speech)
- Applying dressings for wound care
Specific care plans to help with common issues can be provided by a SNF, these include:
- Parkinson's or Alzheimer's Disease - some units offer specialized therapies and treatment plans
- Wound Care - Infection prevention and control, treatment, dressing and pain management
- Stroke - Therapy and helping patients to regain movement and motor skills
- Acute Illness - recovery of infections, injury, illness, symptoms and pain management
What services are provided at nursing homes?
- Room and board
- Monitoring of medication
- Personal care (including dressing, bathing, and toilet assistance)
- General care (using oxygen, catheter care, eye drops, vitamins, stretching, etc.)
- 24-hour emergency care
- Social and recreational activities
- Transportation services
- Housekeeping services
Nursing Home vs. Skilled Nursing Care
Skilled nursing care, whether short term or long term, is a comprehensive, high-quality, advanced care service for those transitioning after a major medical issue. The goal is to rehabilitate and improve symptoms so the patient can return home or to a lesser-care facility like a nursing home.
Often there is confusion when it comes to deciphering between nursing homes and skilled nursing facilities. A skilled nursing facility, or unit, is often referring to the level of care offered within a facility. According to the Centers for Medicare and Medicaid Services, the average stay in a Skilled Nursing Facility is 28 days. This type of care is also referred to as post-acute care, in that it usually follows a hospital stay.
On the other hand, nursing homes are intended for longer stays - 835 days on average - and for those individuals with less specialized or serious medical care needs. Nursing homes are not required to have licensed staff on site at all times, unlike skilled nursing facilities. A Skilled Nursing Facility offers more medically involved services and medical staff than a basic nursing home.
Increasingly, many nursing home facilities have skilled medical staff, and for the purpose of clarity it is assumed that the use of the term "nursing home" often includes access to care that an onsite skilled nursing unit provides. Additionally, nursing homes sometimes have special wings for dementia and Alzheimer's patients.
Skilled Nursing vs. Assisted Living vs. Nursing Home Care
These three different facilities offer similar care and can be easily confused since care overlaps. They all provide assistance with medication, dressing, bathing, grooming, meal prep, and other daily life tasks. However, assisted living centers and nursing homes provide a lesser level of medical care than skilled nursing facilities do. A SNF can provide more in-depth treatment due to skilled professional medical staff, as well as access to laboratories, radiology, and pharmacy services.
Age plays a role too. A SNF can have adult "residents" of all ages who are transitioning from a major illness or injury resulting in a hospital stay. These adults use a SNF because they aren't quite ready for bare-minimum care or homecare yet. In contrast, an assisted living home or nursing home typically is solely designed for the purpose of elderly adult residents over a certain age, usually 60 or 65.
Who are the professionals that staff a skilled nursing unit or facility?
- Registered Nurses
- Licensed Vocational Nurses
- Licensed Practical Nurses
- Occupational Therapists
- Physical Therapists
- Speech/Language Pathologists
- Registered Dietitians or Nutritionists
- Medical Directors
Each facility is different, but some facilities have an activities director. Though most seniors remain in a skilled nursing facility for a short time, the staff try to make the experience more warm and inviting than a hospital stay. This effort can improve the patient experience and thus health and healing outcomes.
Who are the professionals that staff a nursing home?
Certified Nursing Assistants provide much of the daily care with oversight. However, federal law requires that a registered nurse be present in Medicare and Medicaid-certified nursing homes at least eight hours straight a day, seven days a week, and that there be a licensed nurse, who can be an RN or LPN, present 24 hours a day. In addition, nursing homes typically have a dietician and activities director on staff.
How to Find and Compare Nursing and Skilled Nursing Care in Your Area
It is smart to explore the hospital's recommendations or referrals for skilled nursing, and to also do your own research on facilities in your area. There are tools that can be used with the click of a mouse to determine several factors about a facility and quality of care there. Below are some options for researching nursing and skilled nursing options.
Skilled Nursing Locator - After typing in your zip code or city, the SeniorAdvice.com nursing home locator provides contact information on skilled nursing and nursing home care facilities in your area. The listings will include their amenities and services offered as well as Medicare ratings, when available.
Nursing Home Compare - Developed by the Centers for Medicare & Medicaid Services (CMS), this site uses a five-star rating system to classify the quality of care in each Medicare-participating skilled nursing facility. Although potentially helpful, ratings through Nursing Home Compare should not be the only factor in choosing a facility, as some of the quality ratings criteria are self-reported. By using this website, you'll be certain to select a facility that's Medicare-approved, so it will be eligible to receive payment from Medicare.
Nursing Home Inspect - The same CMS data from above but in an easier format. One can easily compare over 60 thousand nursing home reports from each state in a variety of areas: the number of deficiencies cited by regulators in the past few inspections; the number of serious deficiencies in which patients were put at immediate jeopardy of harm; any fines imposed; and government suspended payments for new patients, which is another type of penalty.
How to Transition to Skilled Nursing Care
If your loved one is about to be discharged from a hospital stay, but still needs medical care, the hospital is responsible for identifying skilled nursing facilities within the geographic region that can meet their needs. It is important to be admitted to a SNF or skilled nursing unit prior to leaving a hospital. This is because bed "openings" and the approval process to receive skilled nursing can take a bit of time depending on the city and demand.
William was overwhelmed when he learned his mother would be discharged from the hospital after a fall. He wanted to make sure he was choosing the right nursing facility for his mother's needs, but he only had 24 hours before her discharge. A Medicare Rights counselor explained Medicare coverage rules for SNFs, how to choose a facility, and how the facilities are rated for quality. With Medicare Rights' assistance, William was able to confirm that his mother qualified for SNF care, select a quality facility, and ensure his mother had a smooth discharge.
"My mother was being discharged from the hospital, and I needed to find her a skilled nursing facility. I really had no idea where to begin and didn't have the ability to do research beforehand. My counselor explained everything to me and helped me understand the rating systems for these facilities. Now my mom is getting the care she needs."
How to Transition out of Skilled Nursing or a Nursing Home
The federal Nursing Home Reform Law (1987) provides that a SNF (or nursing facility) must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless:
- The transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility;
- The transfer or discharge is appropriate because the resident's health has improved sufficiently so [that] the resident no longer needs the services provided by the facility;
- The safety of individuals in the facility is endangered;
- The health of individuals in the facility would otherwise be endangered;
- The resident has failed, after reasonable and appropriate notice, to pay...for a stay at the facility; or
- The facility ceases to operate.
The SNF must give the resident advance written notice of its intention to transfer or discharge the resident. The notice must explain the reason, advise the resident of the right to a state hearing to contest the transfer or discharge, and provide the name, mailing address, and telephone number of the State long-term care ombudsman. If the resident has resided in the facility for 30 or more days, the SNF must generally give the resident 30 days' advance notice of the transfer or discharge. More information about discharges and patient rights can be found online on the Medicare Advocacy Website.
Other Options for Care After a Nursing Home Stay or Skilled Nursing Care
The facility must develop a post-discharge plan of care, developed with the senior and caregiver participation, which will help with the adjustment to a new living environment.
Depending on the senior's capabilities and/or preferences, they can:
- Return home, with or without the support of home care
- Return (or apply to) an independent living community, with or without the support of home care
- Return (or apply to) an assisted living community or residential care home
- Return (or apply to) a nursing home
You can learn more about rights related to nursing home discharge planning at The National Long-Term Care Ombudsman Resource Center.
How are skilled nursing and nursing home facilities regulated?
Both nursing homes and skilled nursing facilities are state regulated by the Department of Health in conjunction with the U.S. Centers for Medicare and Medicaid Services (CMS). Subject to inspections called "surveys," nursing homes are evaluated for any violations or immediate threats to patient safety and satisfaction. Unsatisfactory surveys are remedied by the nursing home administrator by proposing a plan of correction. Failure to improve on any violation could induce fines, reappointing managers, or suspension of new resident admissions or a facility's license, or even revoke a facility's license. Skilled Nursing Facilities are subjected to even more comprehensive evaluations due to the medical staff and more acute care nature of the facility.
How to Visit and Evaluate a Nursing Facility or Skilled Nursing Provider
It is important to take time to visit several facilities if possible and inquire about services and staff prior to your loved one receiving care there. Some things to consider:
- Take a tour. Does the facility have adequate therapy equipment and social activities? Observe common areas, recreation and therapy equipment and other exercise devices - a sign of a good recovery program.
- What is the reputation of the nursing staff? Turnover rate? Check the facility's record with the board of public health or question the facility ombudsman.
- Is the facility accredited? Medicare or Medicaid approved? Accreditation shows that the facility has taken extra steps to comply with The Joint Commission.
- How is the environment? Is it clean? Cheery? Are the furnishings and décor nice? Is the facility operated based on the needs of the staff or the needs of the patient?
- Where is the location? Is the facility close to family? Choose a facility that isn't too far away from regular visitors or family.
- Check reports & violations. See what issues the facility had in the past, if any.
- If possible, ask to speak with current residents to see how they rate the care at the facility.
How can I pay for care at a skilled nursing or nursing facility?
According to a survey conducted by CareScout in June 2017, the national average monthly cost for a semi-private room in a nursing home was $7,148. This is just over $235 per day out-of-pocket. While it is unclear how much more actual skilled nursing services cost, it is somewhere in that ballpark. The costs can add up quickly, especially for stays longer than the average of 28 days.
Medicare is a federal government program for those 65 or older with low income and limited assets. Medicare generally does not pay for long-term care like a stay in a nursing home, but it will pay for acute care like that received in a short stay at a SNF. It may pay for rehab while someone recovers from an illness, injury, or surgery.
Those who qualify for Medicare will be happy to discover that it covers all or part of a stay in a skilled nursing facility up to 100 days. There must be a stay in the hospital prior for at least 3 days, and the following conditions must be met:
- Medicare-certified Skilled Nursing Facility
- Existing medical condition, or as a result of the hospital stay
- Benefit period has not expired (usually up to 100 days)
- Doctors referral or recommendation for skilled nursing care
According to Medicare Interactive, if the above conditions are met, day 1-20 is fully covered by Medicare. A partial daily amount is covered from day 21-100. Beyond 100 days, skilled nursing care must be covered out-of-pocket by the patient, long-term or life insurance, or private funds.
Medicaid is a Federal and State health insurance program for those with low income and limited assets. Administration of the program varies by state, according to the Centers for Medicare and Medicaid Services (CMS). Medicaid may pay for a stay in a nursing home if the individual meets nursing home functional eligibility criteria and has income and assets below certain guidelines. A large number of Medicaid certified nursing homes and SNFs are available in each state. Unlike Medicare, Medicaid has strict eligibility requirements.
Long-Term Care Insurance
Long-term care insurance is a policy that is purchased through a private insurance company. Similar to health insurance policies, the price varies greatly depending on age, general health and amount of coverage needed. Coverage could be denied for people with pre-existing conditions such as Alzheimer's disease or Parkinson's disease. Not all insurance will deny based on these conditions, so it is important to explore different insurance companies.
Aid and Attendance Benefit for Veterans
According to the VA website, the Aid and Attendance benefit (A&A) benefit is a special benefit for war era veterans and their surviving spouses. It is a tax-free benefit designed to provide financial assistance to help cover the cost of long-term care in the home, in an assisted living facility or in a nursing home. This benefit is for those who live in a nursing home or are mentally or physically incapacitated or require the regular attendance of another person or caregiver in at least two of the daily activities of living. To learn more about the eligibility requirements and to apply for these veteran benefits visit VeteransAid.org.
In situations when costs aren't covered through other means, paying via private funds is an option. Sources of private funds for assisted living include retirement accounts and 401Ks, savings accounts, annuities and insurance plans (including life settlements), trusts and stock market investments. Home equity and bridge loans can also be used when transitioning to a nursing home or assisted living facility. Social Security can also be used as a means of paying for a nursing home, and this can be an ideal solution for those who are receiving most of their care through a nursing facility.
It is evident that skilled nursing and a nursing home can be confused because they are very similar. Skilled nursing care can be offered to those of any age, and at various facilities with designated skilled nursing units or in an independent SNF. Nursing home stays are quite a bit longer than care provided by skilled nursing. There is an abundance of resources for those looking to get information about care, financial help and regulations of these services and facilities.