Whippersnappers in the Nursing Home

Abstract

Dr. Jeff responds: Nursing homes have always served a wide variety of residents whose functional deficits require institutional care. Some exist only to care for children who are too medically complex to be at home. Although most states have home care programs and group homes to support developmentally disabled adults in the community, the aging of family caregivers of those individuals may lead to early nursing home placement. In the 1980s and 1990s, some nursing units and even entire facilities were created to serve a growing HIV-disabled population, which was generally quite young. Fortunately, as antiretroviral drug regimens have transformed the natural history of HIV/AIDS, the number of such patients requiring long-term care has declined. Nevertheless, most nursing homes maintain their self-image as geriatric care centers. With the aging of the population and the expansion of community-based programs to maintain higher-functioning patients at home, this demographic profile might have been expected to compound itself. It hasn’t. One reason for this has been the rapid expansion of subacute programs in nursing homes. Driven by the reality that reimbursement rates for subacute care are dramatically higher than for maintenance long-term care while dramatically lower than hospital care, many younger patients who would never have been considered candidates for nursing homes are coming (often very much against their will) to renamed “nursing and rehabilitation centers.” Many of these patients would previously have received care in the hospital, hospital-based acute rehabilitation units, or specialized rehabilitation hospitals. Some, particularly patients requiring ventilators, might otherwise have been referred to long-term acute care facilities. Others are chronic mental hospital patients or developmentally disabled individuals whose medical complications justify transfer into the federally reimbursable skilled nursing system (despite preadmission screening and resident-review regulations). The known risks of diabetes mellitus and cardiac complications in patients treated with antipsychotic medications may be accelerating this process. Others are dying patients whose insurance provides limited terminal care benefits. Many elective or semi-elective surgical procedures, such as the rapidly increasing number of joint replacements, include planned, prebooked stays in a nursing home afterward. It should be emphasized that all these admissions are driven by financial considerations, not by any evidence that skilled nursing facilities provide superior care or better outcomes than other care sites. Admissions to skilled nursing facilities are a consequence of our national “whack-a-mole” approach to health care cost reduction and the lack of any comprehensive health care planning.