Skip to Main Content

This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #30, #31, #42, #50, #51, #61, #71


Learning Objectives

  • List the goals of nursing home (NH) care.

  • Understand the complexity of caring for residents/patients in NHs, including the differences between short and long stayers.

  • Identify the roles and responsibilities of different disciplines in NH care.

  • Describe strategies to improve nursing care.

  • Summarize key ethical issues in NH care.

Key Clinical Points

  1. The goals of NH care are different than traditional medical care in other settings.

  2. NH care is provided by a team of health professionals, all of whom have critical input into the resident/patient’s care plan.

  3. Screening and preventive practices are relevant for many long-stay NH residents.

  4. Several strategies, including collaborative practice among physicians and nurse practitioners (or physician assistants) and innovative use of health information technology, can help improve NH care.

  5. Determination of decision-making capacity, appropriate utilization of advance directives, and proxy decision makers are critical aspects of NH care.

The focus of this chapter is the clinical care of nursing home (NH) residents. Many older people who would have otherwise been in NHs are now residing in assisted living facilities or in their own homes. Management of older people with multiple medical problems and geriatric conditions in the NH setting is challenging for a number of reasons. Although many NHs provide excellent care, the poor quality of care provided in many other NHs has been recognized for decades. Since the Institute of Medicine issued its critical report in 1986 and the mandating of the Resident Assessment Instrument in 1987, the overall quality of care has improved. The Centers for Medicare and Medicaid Services (CMS) has instituted several strategies that are designed to improve the quality of NH care. These include the NH Compare website (, which shows consumers (and NHs) how individual homes perform on surveys and specific quality indicators; the new federal survey process employing the Quality Indicator Survey (QIS;; the Five-Star rating system (; and the new requirement in the Affordable Care Act that all NHs must have a Quality Assurance and Performance Improvement (QAPI) program. Despite all of these efforts, the US Office of Inspector General issued a report documenting the high frequency of adverse events among NH residents during the first 1 to 2 months of admission. The report documented that about one in three residents suffer an adverse events (including medication-related side effects; the quality of care such conditions as falls, electrolyte disturbances; and infections) take place. Thus, much remains to be done to improve NH care in the United States.

Because typical older NH residents suffer from multiple underlying diseases, good medical care is especially important. Despite the logistical and economic barriers that can foster inadequate medical care in the NH, many straightforward principles and strategies can ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.