One of the more rewarding periods of my life involved the management of several nursing homes. Recruited by a friend because of my experience in the pharmacy business, I found the challenges related to long-term care facilities both demanding and sometimes frustrating. As more Americans reach the point in life where they need managed care, the growth in nursing home residents has created a number of opportunities and challenges.

The Conflicts Between Care and Profits

The majority of nursing facilities in the country are run as for-profit businesses. There are two basic categories of these facilities. First, some nursing homes are modern, up-to-date operations that cater to residents with very good insurance and the ability to pay high monthly fees.

Other homes serve residents who rely on state and federal reimbursements for their primary revenue. Each of these operations charges the government a daily rate per bed occupied. Called a reimbursement, the nursing home is paid monthly for the total beds occupied during the previous billing period. The rates paid vary by state and, within the states, by the level of care necessary for each patient under care. There is also reimbursement for such things as prescription medicines and certain services.

We operated a mix of these homes, and I found the biggest challenge was in providing adequate care to patients while still generating an acceptable profit. The state and federal governments are frequently seeking to control their total costs, especially with the growing senior population.

At the same time, the costs for managing nursing homes continue to rise. The pressures on such costs come from:

• Personnel - The single biggest cost for all nursing homes is the staff they require. Providing round-the-clock care is an expensive proposition. Although a range of skills is needed, a large number of the employees are attendants. Unfortunately, most of these workers are paid only minimum wage and possess only basic skills. This reality means there is frequent turnover and, worse, a constant struggle to keep concerned, empathetic personnel on board. Without adequate and professional staff, the care of each patient tends to suffer.

• Compliance - The states oversee the nursing homes in their jurisdiction. Each state maintains a staff of inspectors, and they visit homes to ensure compliance with a large number of standards. There is a basic conflict in the fact that state regulations impose ever-higher standards while the reimbursements are lowered or increased very slowly. This creates a tendency for management to look for ways to cut corners and often affects the overall quality of care.

• An Older Population - Many elderly patients now live longer than ever before. As they spend more years in nursing homes, their health creates special medical needs, ranging from managing bed sores to dealing with the increased number of Alzheimer’s cases. These conditions require more skilled nursing personnel and incur other costs.

Issues Beyond Financial Concerns

I found that many children and family members of the elderly resented the fact that they had to place their loved ones in a nursing home. This often created contentious situations, where the demands for care were unrealistic. On the other hand, we found many of our residents never got visitors and had no one to help them with little tasks, even during holidays and special times.

While we always tried to make sure all our residents received personalized care and the attention they needed, it was depressing for everyone to see residents sitting depressed and without visitors. The sense of abandonment many feel in nursing homes creates a constant need to focus on the morale and overall mental health of the residents and staff.

If you have ever been in a nursing home, you are aware of one of the biggest problems we constantly battled. While it may seem a small issue, maintaining a fresh and inviting atmosphere is a major challenge for nursing homes. Because many residents are incontinent, there is an unpleasant smell unique to many facilities. Fighting that smell is a major management problem. At the same time, its presence or absence is a ready indicator of management’s overall level of professionalism.

Selecting a Home and Maintaining Care

My experience in the nursing home industry taught me some key things related to the care of loved ones. These include the following:

• It is important to carefully evaluate any home before allowing your loved one to be placed in it. Check for state inspection records – they are easy to obtain. Also, visit with the management and assess their commitment and professionalism. Also, take time to walk around and watch how the caregivers are conducting themselves.

• Visit your loved ones regularly once they are admitted. Make your visits irregular and unannounced. When you do visit, take time to ask how things are going and watch for any changes in mood or attitude. Also, it is helpful to check for bedsores and to watch for any changes in weight.


These are just the first of a number of simple steps you can take to ensure that the facility serving your loved one provides the expected and needed level of care.