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Choosing and Paying for a Long-Term Care Facility

Learn about the different types of nursing facilities and how to choose the best option.

Despite significant recent growth in home care and alternative seniors' residences, nearly one of every two women and one of four men over age 65 will enter a long-term care nursing facility (a.k.a. "nursing home") at some time in their lives. Many nursing facility stays are short ones, to allow a senior to recuperate from an illness, injury, or surgery. But many other stays are extended: More than a third of all nursing facility stays last more than a year, and one in ten lasts three years or more.

Many people would prefer to remain outside a nursing facility. However, some seniors, because of their condition, circumstances, or the unavailability of in-home services or affordable assisted living residences, can receive adequate care only in residential care.

Most residents in nursing facilities cannot function without 24-hour monitoring, extensive personal assistance, and nursing care because of illness or physical or mental limitations. Other residents are in relatively good physical and mental health, but too frail to live alone at home. If they had more family or resources, many of these people might be able to make do with home care or living in an assisted living facility. For lack of an alternative, they become nursing facility residents.

Choosing the Appropriate Level of Care

There is a great range in the levels of care available in nursing facilities. Care ranges from intensive 24-hour care for the seriously ill (which is called skilled nursing care) to long-term personal assistance and health monitoring with very little active nursing (often called custodial care). Some facilities provide only one level of care, while others provide several levels at the same location.

Skilled nursing facilities provide short-term, intensive medical care and monitoring for people recovering from acute illness or injury. Other facilities -- called nursing homes, board and care homes, sheltered care homes, or something similar -- provide custodial care, long-term room and board, and 24-hour assistance with personal care and other health care monitoring, but not intensive medical treatment or daily nursing.

Your task is to find a good and affordable nursing facility that provides not just care, but the right type of care. For someone with severe physical or mental limitations, it is crucial to find a facility that provides the kind of attention and care that meets the individual's specific needs. For people who need little or no actual nursing care, the task is to find a facility that provides physical, mental, and social stimulation rather than merely bed and board.

People with Alzheimer's disease have special needs when it comes to residential care. For more information, see Residential Care Facilities for Seniors With Alzheimer's.

Hospital-Based Skilled Nursing Facilities

Hospital-based skilled nursing facilities, also known as extended care facilities, are departments within hospitals. They provide the highest levels of medical and nursing care, including 24-hour monitoring and intensive rehabilitative therapies. They are intended to follow acute hospital care due to serious illness, injury, or surgery.

Unlike other nursing facilities, hospital-based facilities are not for permanent residence, but for a short-term stay until a patient can be sent home or maintained elsewhere. Hospital-based facilities are very expensive (more than $500 per day), but the average stay is generally short (usually a matter of days or weeks) and, for those who qualify, is usually covered by Medicare or private insurance.

Skilled Nursing Facilities

Nonhospital-based skilled nursing facilities (SNFs) provide a relatively high level of nursing and other medical care, as well as personal care and assistance, for people whose illnesses or impairments require close monitoring.

Around-the-clock nursing is available from licensed vocational or practical nurses, with at least one supervising registered nurse on duty at all times. In addition to nursing, most other prescribed medical services can be provided, including various rehabilitative therapies. An SNF is almost always for short-term recovery from a serious illness, injury, or surgery that required hospitalization. A few people may spend months in an SNF, but most stays last only days or weeks.

The cost of SNF care ranges upward from $500 per day. Medicare, Medicaid, and private insurance will pay for SNF care, but only up to specific coverage limits.

Intermediate Care Facilities

Intermediate care facilities (ICFs) provide less nursing and other medical care than SNFs. ICFs are for long-term residents with chronic illnesses or impairments, whose conditions are not as acute as those of SNF residents. Residents in an ICF are usually ambulatory, for example.

Staff is geared as much toward personal care and assistance as to medical care, although there is always a licensed vocational or practical nurse on duty. ICFs generally care for people who need a long recovery period from serious illness, injury, or surgery, but who no longer need the level of nursing care and high-tech monitoring that an SNF provides.

Costs range from $250 to $500 per day. Medicare does not cover ICFs and private insurance coverage is rare, usually requiring prior approval. Medicaid, however, may cover much of the cost of ICF care.

Very few facilities are set up to be ICFs alone; most are part of an SNF or a custodial care facility.

Custodial Care Facilities

Custodial care facilities provide services that are often lumped together under the heading of custodial care: personal assistance and low-level nursing care, but not intensive medical care. Sometimes referred to as "rest homes," these custodial care facilities (CCFs) are considerably less expensive than SNFs or ICFs and, in addition to monitoring residents' physical conditions, they provide social, educational, and recreational activities as well as organized exercise. Because CCFs do not provide extensive medical care, they are appropriate for people whose physical and mental conditions do not require constant attention or intervention.

Because of the limited medical and nursing care they offer, CCFs cost about $100 to $250 per day, considerably less than SNFs or ICFs. However, most residents stay in a CCF for a lengthy period of time, at a cost of $50,000 to $150,000 per year. CCFs come in all shapes and sizes, from five-bed facilities in converted private homes to 100-bed facilities with large common areas and extensive social, physical, and educational activities.

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