The current cohort of older Americans is a more robust group than in the past, and the prevalence of disability related to chronic disease is in decline. Despite improvements in the health of older people as a whole, the overall need for services provided by nursing facilities will rise. In the future, the medical needs of nursing facility residents will likely be more complex and require additional services from primary care practitioners, including physicians, nurse practitioners, clinical nurse specialists, and physician assistants. Nursing facilities already show a trend in the increasing percentage of residents who are not able to perform activities such as dressing and bathing independently. As shown in Figure 21-1, over a 20-year span, residents able to feed themselves declined from 67% to 53% and those able to dress themselves, from 30% to 13%.
Decline in functional status in residents admitted to nursing facilities from 1977 to 1999. (NCHS. National Nursing Home Survey. 1999. http://www.cdc.gov/nchs/nnhs.htm.)
The term nursing facility is inclusive of other commonly used terms, e.g., nursing home, long-term care facility, subacute care unit, or nursing home care unit. Nursing facilities are primarily free-standing in the community or are separate units in hospitals. Patients are usually referred to as residents. On the average, nursing facility residents have a median age of 85, three or more functional impairments, and six chronic illnesses. One-half are cognitively impaired with additional functional impairments and/or chronic illnesses. Most lack sufficient personal and financial support to remain in their homes. Payment for services rendered comes from Medicare Part A, Medicare Part B, Medicaid, Veterans Affairs, private insurance plans including long-term care insurance, and out-of pocket. Skilled nursing facilities (SNF) are subsets of nursing facilities that receive payment for skilled nursing services under Medicare Part A. SNF services include rehabilitation therapies and/or skilled nursing care, such as intravenous therapy, wound care treatment for deep pressure ulcers, or close-monitoring posthospitalization in medically complex residents.
As shown in Figure 21-2, two populations are distinguished by length of stay and goals. Long-term residents stay more than 6 months and are either cognitively impaired, physically disabled, or both. Short-stay residents of less than 3 months duration are recovering from an acute illness, suffering from a terminal illness, or are medically unstable with a limited life expectancy. From 1985 to 2001, when payment structures for hospitalized older adults changed to encourage earlier discharges, trends in admissions demonstrate hospitals released the same percentage of residents to nursing facilities. However, in 1985, 18% of nursing facility residents admitted from hospitals were discharged to the community versus 30% in 2001. Today, more residents are being admitted for rehabilitation following surgery or acute illness and need a higher level of care for a shorter period of time.