Bruce C. Vladeck

The continuing paradoxes of nursing home policy.

FEW INDIVIDUALS CHOOSE TO LIVE IN A NURSING HOME rather than in their own home. Many older people and their families fear nursing homes; advocates for younger disabled people lobby for alternatives. Only a small fraction of practicing physicians and nurses work in nursing homes, not all as a first choice. Hospital administrators, who rely on nursing homes as a destination for patients who cannot be discharged to home—and in many instances, as a source of admissions as well—tend to not understand them very well. State and federal budgetmakers believe they cannot live without nursing homes, yet fund them reluctantly. For 30 years, public policy toward long-term care has attempted to minimize the number of people residing in nursing homes. Yet every day 1.5 million individuals in the United States are living in nursing homes, half of whom will never again live anywhere else. More than 1 in 3 US residents who reach age 65 years will spend some time in a nursing home before they die. Nobody, it seems, loves nursing homes very much, but nursing homes are as necessary as they are misunderstood. The confusion about nursing homes arises because many clinical practices and public policies about long-term care are unclear and frustrating. In the patchwork of US health care delivery and financing, nursing homes sit squarely atop 2 of the most problematic seams: the disjunction between Medicare and Medicaid and the disjunction between episodic acute care and long-term care. As a result, facilities referred to as “nursing homes” are generally individual facilities with 2 entirely separate—and often conflicting— clinical missions, serving 2 very different kinds of patients (or, as Zweig et al demonstrate with the case of Mrs R when she begins her nursing home stay for rehabilitation and continues as a long-term stay resident, the same person under very different clinical and financial circumstances), under radically different sets of payment rules and incentives of Medicare and Medicaid.