The Continuum of Care: Nursing Homes

Nursing homes, a ubiquitous institution found in communities large and small across United States, where about 1.38 million U.S. elders reside today, have a short history, but one that holds stories of both tragic and heroic proportion. My Mother-In-Law just passed at the age of 91 in a nursing home. We were able to create a wonderful ending, with a private room large enough to accommodate all the visiting family members, and were catered to by staff and hospice through the last week of Doris’s long life. She was there for seven years.

Before the modern nursing home, aka skilled nursing facility, there was the Old Age Home, and before that, the Almshouse. One of America’s first true old age homes, the Indigent Widows’ and Single Women’s Society, was founded by Quakers in Philadelphia in 1817. Its mission was to provide those with “social standing” a place to live and die with some modicum of respect and comfort, and so avoid the often nightmarish conditions found in the charitable Almshouses, where the poor and those without social standing were sent to die.

Usually operated by charities, almshouses endured a squalid reputation well into the 20th century. An early pension advocate, Abraham Epstein, wrote in 1929 that the Almshouse “stands as a threatening symbol of the deepest humiliation and degradation before all wage-earners after the prime of life.” Frightful conditions in Depression-era almshouses were a driving force behind the Social Security Act in 1935. The belief was that by creating a source of guaranteed income, no American would have to end up on their death bed without a modicum of care and dignity. Supreme Court Justice Benjamin Cardozo (1870-1938), writing for the majority in affirming the constitutionality of the Social Security law, proclaimed that “the hope behind this statute is to save men and women from the rigors of the poorhouse as well as the haunting fear that such a lot awaits them when the journey’s end is near.”

Beyond the personal guaranteed income of Social Security, the creation of government run health insurance systems like Medicare and Medicaid, signed into law in 1965, provided additional impetus to the dramatic growth of the nursing-home industry. Between 1960 and 1976, the number of nursing homes grew by 140 percent, nursing-home beds increased by 302 percent, and the revenues received by the industry rose 2,000 percent.

The 1970s brought widely publicized investigations that uncovered many instances of the poor conditions and substandard care more typical of early 20th century homes for the aged and infirm. Lacking in medical care, proper nutrition, and competent, caring attendants, the offending nursing homes were viewed as warehouses for the elderly or junkyards for the dying. Like their ancestors horrified at the idea of disappearing into an almshouse, elderly citizens of the time feared ending their days in a nursing home, and family members grappled with guilt because they had “abandoned” their loved ones to institutional care.

In 1972 reforms of Social Security, the primary source payments to nursing homes, established a single set of requirements for facilities supported by Medicare and for nursing homes that received Medicaid. Although this limited the ability of most individuals to enter skilled-nursing facilities, it increased the demand for intermediate-care facilities. Other amendments to the Older American Acts in 1973 and 1987 provided and strengthened statewide nursing home ombudsman programs, respectively, giving nursing homes residents and their families stable and secure channels for voicing complaints. These actions, however, did not raise nursing home standards uniformly nor did they eliminate the dread with which older adults faced nursing-home admission.

Yet as the percentage of the U.S. population over age 85 continues to grow, nursing home care is increasingly in the future for many of the oldest Americans. By 2000, nursing homes had become a $100 billion industry, funded largely by Medicaid, Medicare along with families’ private resources. And although only 2 percent of Americans between age 65 and 74 reside in nursing homes at the turn of the century, the proportion of those 85 or older had increased to 25 percent (approximately 5 million Americans are 85 or older).

In December 2012, 1,382,546 people lived in 15,664 nursing homes across the United States, according to the American Health Care Association. Colorado in 2011 had 214 nursing homes, offering 18,682 licensed “beds,” with an average occupancy rate of 83%, or 16, 418 people. A year later, at the end of 2012, there were 19,993 beds in Colorado but only 15,875 residents, a 79% occupancy. These are not robust numbers representing a growth industry.

As a society, many want to take advantage of the coming demand for long term care services, to improve the system of care for the frail elderly. However, financial challenges loom for this nursing home industry that employs over 1.7 million people nationwide. According to the American Health Care Association (AHCA), over the next 10 years reimbursement will fall by $65 billion dollars. There are political pressures to reduce benefits and cut costs. The Republican proposals for block grants would effectively end government over sight that has driven the improved care seniors receive. It’s estimated, again by the ACA, that nursing homes currently are losing $20 per day on each Medicaid patient. If public policy pressures inhibit industry growth by failing to provide incentives to businesses to expand or improve, they won’t, and the demand will be unmet. It’s quite a conundrum.

If you are faced with finding a nursing home for a loved one, it pays to do your homework and explore all options, including various assisted living scenarios. If you’ve done that and your only option is a nursing home, ask people you trust about their experiences. Friends, neighbors, teachers and clergy you know may well have personal experience with nursing homes in the area. Your doctor or hospital social services departments can be valuable sources of information. Online, visit the Eldercare Locator at or call 1-800-677-1116 for more information on long-term care choices in the area. Two great websites to conduct research on nursing homes in your area are: Home Checklist and, You can also contact your local Agency on Aging, known locally as DRCOG, or the Denver Regional Council of Governments.

Robin Avery is a Gerontologist, a Consultant to, and Developer and Operator of assisted living communities, with a Masters Degree from The Naropa University.

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