Nursing homes differ by size, religious and ethnic orientation, and philosophy of care. Choosing a home depends on personal preference, your sense of where your relative would do best. For instance, larger homes tend to offer much more in the way of services and a richer variety of staff. They are less homelike, however, getting lower marks on staff/patient rapport. Your choice will also be dictated by the type of residents the home serves. Although the law prohibits discrimination in admission, many nursing homes cater to the needs and comfort of a particular ethnic or religious group – serving familiar foods, celebrating traditional holidays.

Philosophical differences can be important. Does the home believe in separating residents by degree of disability? This may be good if your father is not very impaired and would be depressed by being in close contact with residents who are physically and mentally worse off. It may be bad if he would benefit from being with residents who are more alert. Does the home have a special unit for residents with Alzheimer’s disease? If so, this may be the best place for your mother with dementia.

Consider the location. In general, the closer the better, either to you or to your relative’s hometown. If the home is near the patient’s town, remaining involved in the life of the community may be possible. Your relative’s personal doctor may agree to continue treatment. (Residents always have the right to be treated by a physician of their own choice, though they may have to pay extra for this service.) If the home is close to you, you can visit often. You will be better able to offer your love and attention and also to check up on what is going on.

With these considerations in mind, talk to family and friends who know residents in the homes you are considering. Then visit each place. The first time you go, arrive unannounced. Expect what you see to be disheartening. Only people in the worst physical straits need nursing homes.

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Nursing homes are categorized in two definite ways: by the intensity of services they provide and by their mode of ownership. The first distinction is crucial. Medicaid (or Medicare) will pay for services only in nursing homes classified as offering either skilled or intermediate care.

Skilled nursing facilities provide the most care, including round-the-clock nursing, physical, occupational, and dietary therapy, social services, and recreation. Health-related facilities for intermediate care facilities) are for people who do not need skilled care but do need some assistance in functioning. They offer less intensive nursing and medical care. Multilevel facilities are most common, providing skilled and intermediate care under one roof. The advantage of choosing a multilevel nursing home is that your relative will receive services in the same place (though probably on a different floor or in another building) if there is a change in condition and a different level of care is required.

You cannot choose the level of nursing care when your relative is admitted. The person is placed at the appropriate level by a doctor or nurse certifying eligibility for that particular type. Although the evaluation process tends to differ from state to state, usually a standard preadmission form is required. The person is examined, and points are assigned for degrees of disability. Depending on this «impairment» score, the applicant may be categorized as not needing institutional care, needing a health-related facility, or needing skilled nursing care.

Medicare will pay only for care in a skilled nursing facility, and then only in limited circumstances. Up to one hundred days may be covered if a doctor certifies that the patient requires ongoing nursing care for a condition that was first treated in the hospital and if the nursing home’s utilization review committee does not disapprove the stay. These rules are rigorously applied. Depending on the state, Medicaid is likely to pay for all or most skilled or intermediate care.

(Check with your local office of the aging or the admissions department of the home you are interested in for more information.)

The second nursing home difference, mode of ownership, is less relevant. Proprietary homes are owned and run for a profit. Voluntary homes are owned and run by nonprofit organizations such as church groups. Public homes are owned by the city or state. Recently there has been a tremendous increase in the number of proprietary chains. There is some perception that these institutions, because they are in the money-making business, tend to deliver worse care. But research shows there is no way to predict the quality of care a home offers by its mode of ownership.

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