My grandmother is losing her way in the Redcliffe Nursing Home at the end of the twentieth century. She is trapped between the summers of 1922 and 1952, a Christmas beetle caught inside the screen and sliding doors of her memory. —Brett Dionysius, Australian award-winning poet and author

Although there are more options than ever before, nursing homes remain the facilities that care for the majority of us as we continue to age. Nursing homes usher many of us to the edge of “that good night” into which Dylan Thomas urged us not to go gently.

If I had to guess, and it’s not that difficult, I would guess that no one “plans” to spend the last days of their lives in a nursing home.  Never the less, sometimes a massive stroke happens and all family care givers work full time, family leave act days have been used, and there is no other choice.

Nursing facility care has radically improved since 1986, when the National Academy of Sciences published a report calling nursing homes “warehouses” for the elderly. The report criticized existing nursing home law, saying that it focused on the capacity of each facility to provide services rather than on the quality of the services received by the residents. That is, the focus was on mechanical aspects of nursing homes—square footage, staffing numbers, kinds of equipment and payments.

Congress responded to that report with the Federal Nursing Home Reform Act of 1987 (NHRA). The act was intended to focus on the needs of individual residents—ensuring that residents are treated as persons rather than as “units of reimbursement.”

The law has changed the nursing home landscape, although there is still much room for improvement. In spite of the NHRA, most nursing facilities remain critically under-staffed.  Adequate staffing is probably the most important factor in quality nursing home care.  Issues surrounding the challenges of sufficient staffing are numerous, and must wait for another column.

Family members are usually distraught, stressed and feeling guilty when admitting a family member to a nursing home. Unfortunately, during that admission procedure, and at other times during your family member’s stay, it is possible to make mistakes and errors that may “haunt” you for a long time. Also, family members need to be prepared to transition from caregivers to care advocates. Without an effective advocate for the nursing home resident, the likelihood of problems caused by the lack of good care will greatly increase. It’s the old “squeaky wheel gets the grease” story.

Remember that the law specifically prohibits nursing homes from requiring a third-party guarantee of payment. You can sign to pay the bills from the resident’s resources, and you can voluntarily sign to assume personal responsibility for the bill. Just make sure you don’t do any of it by accident. Read the contract carefully. It’s probably best to ask your favorite elder law attorney to review the contract before final signing.  The cost for such a review will be much lower than the costs of making a mistake in this critical area.

Furthermore, there has been great progress in removal of the Medicare “Improvement” Standard for nursing home care.  Remember being told “Medicare won’t pay any longer because you don’t need skilled care?”  Under current law, the nursing homes and Medicare are not allowed to use that standard.  A nursing home patient must continue receiving rehab services in order to maintain the strength and abilities they possessed when they were admitted to the facility.  Even so, it’s important to remember that, at best, Medicare can only cover up to 100 days of nursing home care.

The National Consumer Voice for Quality Long Term Care, www.theconsumervoice.org, has replaced the

Citizens’ Coalition for Nursing Home Reform (NCCNHR).  Their website has more information

on long term care issues than you can absorb in one or two sittings. If you must place a family member in a nursing home, or are considering the possibility, I urge you to look at the materials from this group.

I’d also like to recommend a Medicare/Medicaid publication, A Consumer Guide to

Choosing a Nursing Home.  The purpose of this guide is to help prospective residents and their friends and family members navigate consumer information resources, understand the information and make an informed choice.  This Guide can be downloaded from the  www.medicare.gov website, or from the information clearinghouse on www.theconsumervoice.org.  The booklet is also available in Spanish.  Call 800-633-4227 for a free copy.

The magazine  U. S. News & World Reports  publishes annual lists of the “best” of things – colleges, towns, etc.  You can read their report on the best nursing homes in Maryland by entering  “Nursing Home Ratings in Maryland” in your computer browser.    They also provide a report called “How to Choose a Nursing Home.”    We can find out a lot about how facilities are rated, but nothing is better than a personal, hands-on review and your own investigation.

            Thank you so much for reading. Stay well. See you next week