New York Times: Nursing Homes That Belie The Bad Image


Published: October 5, 2009

I have often said in no uncertain terms that I never want to be placed in a nursing home unless it is to recover from a treatable illness or injury. I have heard so many horror stories of neglect, mistreatment, understaffing, poorly trained attendants and even corruption. I shared the common perception of a nursing home as the last place you go before you die, and this was not how I wanted to spend my last days.

Skip to next paragraph Then last spring, after I had made similarly disparaging remarks in a public forum, I was invited to tour one of the largest nursing homes in Florida, now called Miami Jewish Health Systems. I was delighted to discover an example of a home where one could not only benefit medically and emotionally but also enjoy one’s last days.

This is an all-purpose, nonprofit facility that evolved through visionary leadership and generous donations from community members to become one of the top-ranked centers in the nation. Many of its features, especially the caring and respect devoted to each resident by well-trained personnel, could serve as a model for nursing homes throughout the country.

It is one-stop shopping, complete with an acute-care hospital, short- and long-term skilled nursing care, in-patient and out-patient rehabilitation services, a memory and dementia clinic, psychiatric treatment, a pain center, recreational and entertainment activities, respite care for caretakers, spiritual and religious services, assisted living quarters, hospice care and even treatment for children with cerebral palsy.

The Miami Model

Of course, there are other well-run facilities throughout the United States, like the Hebrew Home at Riverdale in the Bronx. But many nursing homes, even those that lack the space and finances to provide soup-to-nuts care, could learn from the 20-acre facility in Miami, where the ill and infirm of every ethnicity and religious persuasion spend days, weeks, months or years.

There I met Annabe Schwartz, a 94-year-old widow, meticulously groomed and well dressed, who sat in her wheelchair surrounded by plants and pictures she had chosen.

“I love this place,” she told me. “It’s my home.” Although she said she was estranged from her family, at the Miami home she said she felt cared for, appreciated and respected, with prompt attention to her medical needs.

Staff members trained in gerontology greet each resident by name and with a smile, know each one’s medical and personal histories and seem to enjoy taking care of older people, even those who can at times be cantankerous.

The Miami home has 492 beds, 300 of them for long-term care for people who are chronically ill and no longer able to live independently. Eighty-five percent of patients are covered by Florida’s Medicaid program, which pays $205 a day for each, or $75 less than the actual cost of care, which must be raised through contributions and foundation grants.

In an article last April in The Journal of the American Medical Association, a group of researchers concluded that a large percentage of patients throughout the country lacked continuity of care — contact with the same physician both in and out of the hospital. Far too often, once patients leave the hospital, their care lacks coordination and follow-up, leading to frequent and costly returns to the hospital — a problem the Obama administration will have to solve if it is to contain the costs of care for the growing aged population. This kind of coordination is a hallmark of the Miami home.

Ideally, most long-term nursing care would be provided in the patient’s home, the most economical solution and the stated preference of 9 in 10 older Americans. For example, as reported recently by AARP, Florida spends about $5,000 a year to help one older person remain at home through its community care program and $8,000 for Medicaid home services; the average annual cost of a Florida nursing home is $65,000.

Still, if a nursing home is an inevitable destiny for you or a loved one, it is possible to find a good one. In her enlightening book “Taking Charge: Good Medical Care for the Elderly and How to Get It” (Old Mission Press, 2006), Jeanne M. Hannah, a Michigan lawyer whose mother died of neglect in a nursing home, wrote, “There was a pervasive attitude among the caregivers I encountered in the long-term care facility that the patients were old and were going to die anyway, that caring for them — changing diapers, hand-feeding — was something that the workers did, not because they liked to do it, wanted to do it or were even particularly good at it, but because they needed the minimum wages that are paid for these unpleasant jobs.”

Ms. Hannah found that in her mother’s nursing home there were not enough aides to help patients with activities like feeding, that aides lacked adequate training and supervision and that medical attention by doctors and skilled nurses was brief and infrequent.

“Unless your loved one is in a most unique facility,” she concluded, “it will be up to you to monitor her care and assist with her care.”

A Checklist for the Search

Ms. Hannah and her co-author, Dr. Joseph H. Friedman of Brown University School of Medicine, listed five main steps they regarded as essential in seeking out a nursing home.

Investigate deficiencies. Quality standards have been established by the federal government and state health departments. A nursing home that fails to comply with a standard or regulation is issued a deficiency citation, and information about these deficiencies can be found on the Medicare Web site Nursing Home Compare, at

Choose quality over location. “Location is not the best reason for selecting a facility,” the authors wrote. “Your primary consideration should be high quality of care,” which includes the highest possible staffing levels and, ideally, direct connection with a hospital. Here again, the Medicare Web site can help.

Monitor the care. Don’t assume you can depend on the facility to make sure the patient receives proper care. Visit often at various times, including nights, weekends and holidays, when the staff members on duty may not be the most experienced. Make sure medications are given at the right times and check on the amount of food and fluids the patient is actually consuming, since malnutrition and dehydration are common hazards in nursing homes and can be fatal.

Assist at meals. For patients not adept at feeding themselves, arrange to have someone come in to assist with eating, especially at the noontime meal, the main one in nursing homes.

Hire a geriatric care manager. If no one nearby is able to assist a nursing home patient, consider hiring a professional who can serve as family liaison. A geriatric care manager is trained in gerontology and can visit the patient, evaluate and monitor the situation, and arrange medical and other appointments. The National Association of Professional Geriatric Care Managers maintains a directory, searchable by ZIP code, at its Web site,