A nursing home is a long-term-care facility primarily for elderly persons who are sick, frail, or who have functional limitations and have no alternative source of care. About 23,000 long-term-care institutions function within the United States, housing more than 1.5 million persons, 85% of them over 65 years old. The level of care provided in these facilities ranges from highly technical care for extremely ill people to assisted living, which includes supportive, but not skilled, care. Much of the direct care of patients is provided by certified nursing assistants who are supervised by professional nurses.
Since the 1960s the number of residents in nursing homes in the United States has more than doubled. Factors that have contributed to this growth include an increase in people age 65 or older; separation of the elderly from their families; and, since 1965, the availability of federal and state reimbursement for nursing home care for people who cannot otherwise afford it, primarily from Medicaid. By the late 1980s, private-pay patients were contributing more than half of total long-term-care facility expenditures. Private long-term-care insurance options increased somewhat during the 1980s, offering some protection against the potentially catastrophic costs, which can be as high as $50,000 per year for those not eligible for public financing.
Both federal and state agencies regulate standards of care. Standardized patient assessment and care planning procedures were implemented in the early 1990s as one of several reforms in the Nursing Home Reform Act of 1987. These procedures are aimed at ensuring that all nursing home patients receive active treatment and not just custodial "warehousing." Recognizing that nursing homes serve as residences as well as care facilities, this legislation also required that facilities ensure a patient's privacy and personal autonomy. The requirements must be observed by facilities that receive federal reimbursement. As a result of these reforms the widespread use of physical restraints and medication to control patient behavior has been significantly reduced.
The structure of the nursing home industry reflects the competitiveness of the current health care marketplace. Freestanding, single-service nursing homes are being replaced by continuing care campuses, which include independent living units and progressive levels of care. These facilities provide the resident with the security of knowing that different levels of care are available without having to relocate. Specialty care units, such as those designed for dementia care or physical rehabilitation, reflect increased expectations for appropriate treatment.