No fewer than one in five Marylanders over 60 will live an average of almost three years in half a room in a building filled with sick or confused people. The stay won't come cheap: The basic rate, without any extras, normally runs at least $100 a day.
It's a stay few plan or even think about until they have to. Most choosing a nursing home -- often children, spouses or other relatives of the elderly -- must decide on one quickly, out of necessity, amid an emotionally wrenching crisis.
But it's vital to set aside time to take a hard look at nursing homes -- to visit, ask lots of questions, keep detailed notes, inspect records -- to ensure good care in a pleasant environment.
* What type of care is needed? "Skilled care" is intensive care under the supervision of doctors and nurses or rehabilitation such as physical or speech therapy. "Intermediate care" means limited nursing care as well as help in taking medication, bathing, dressing and getting around. Getting a bed can depend on what kind of care is needed.
* Can you find a nursing home near your home? Few things are more important to a patient than frequent visits from relatives and friends.
* Is the nursing home approved for Medicare and Medicaid programs? Most nursing home residents exhaust their assets in less than a year and then must rely on Medicaid to foot most or all of the nursing home tab.
Medicare, the federal medical and hospital insurance system for those over 65, pays only in rare cases, accounting for less than 2 percent of nursing home care in Maryland.
* What extra charges are likely? Basic rates normally covers room, meals, housekeeping, linen, general nursing care, recreation and personal care. Many homes charge separate fees for physician visits, drugs, tests and services such as phone calls and haircuts.
* Can you visit the home? Call the administrator and arrange for a meeting, a tour and time to poke around, observe and chat with residents and staff. Meet the directors of nursing and social services. Be observant and keep detailed notes.
* Is the home clean, brightly lighted and free of strong chemical and deodorant odors often used to cover up smells because linens and clothes haven't been changed promptly?
* Are patients dressed, groomed and talking? Do they appear comfortable and cared for and participate in regularly scheduled recreation and activities? If most appear docile, it could mean they're sedated with drugs.
* Can residents walk outside in good weather?
* Are many patients wearing restraints? If so, ask why. Such restraints should be used only with a doctor's written order.
* What kinds of care are provided to meet the patient's specific needs, such as Alzheimer's disease, other illnesses or physical disabilities?
* Are rooms bright and decorated with pictures on walls? Is there adequate space for personal belongings, clothing, a television and radio?
Are phones provided? Is theft a problem?
* Are bathrooms spotless and accessible to handicapped residents? Does each bed have a curtain or screen for privacy? Does each resident have a call button within reach? Do staff members respond to calls promptly?
* Do employees show respect for residents or treat them condescendingly or harshly? Are enough nurses on duty? Maryland law requires nursing homes to have a registered nurse on duty during the day seven days a week and a licensed nurse at all times. What is the ratio of nursing staff to residents? The more RNs, the better the care may be. What is the staff turnover rate?
* Are the dining room and kitchen clean and pleasant? Do residents appear to enjoy the food? Do those who need help eating get it? How many meals a day are served? Are snacks available? Will the home provide for special diets such as low-cholesterol, diabetic or low-salt? Nursing home residents complain more about the food than anything else.
* Are emergency exit doors well-marked, unobstructed, unlocked and accessible to handicapped residents? Are fire, evacuation and disaster plans posted?
* Does a resident council meet regularly? Request a copy of the residents' rights policy.
* What physician services are available? Does the home keep records of contacts with the attending physician or the patient's doctor? Is a staff physician readily available at all times? The law requires either the patient's physician or one from the nursing home to visit at least once a month during the first 90 days to evaluate the patient's condition and review medications. Thereafter, a doctor must visit every other month. The nursing home must have a doctor available by phone or on-hand 24 hours a day.
* Does the home have arrangements with a nearby pharmacy to deliver medications and with a nearby hospital to transfer residents in emergencies?
* What deficiencies have state inspections revealed? All Maryland nursing homes must be licensed by the state and meet standards for patient care, safety personnel and physical environment. Investigative teams survey each of the state's estimated 220 nursing homes at least twice a year and conduct an annual survey and follow-up visits. Deficiency lists based on these inspections are available at the county's Department of Aging or at the state Office of Licensing and Certification. (Addresses and phone numbers appear below).
After attempting to answer these questions and narrowing the possibilities to a few nursing homes, go back for a second, unannounced visit on weekends or evenings, when fewer staff are on duty. See if the second visit changes your initial impressions.
Review finances carefully and consult an expert or a lawyer specializing in Medicaid if needed. Most nursing home patients start as "private-pay" residents, then must turn to Medicaid for help. But don't wait to go broke before applying for Medicaid, or you might not get it in time to pay the nursing home bill.
Medicaid rules are extremely complicated, with many exceptions.
Generally, to qualify, applicants must have monthly income from all sources less than the nursing home bill and no more than $2,500 in assets. Some assets, including a house, if the patient may return to it, may be exempted.
After admission to the nursing home, regular visits from vigilant family members who know what to look for will go a long way toward ensuring quality care, while boosting the patient's spirits.
Some nursing homes suggest family members not call or visit for the first few weeks to allow residents to adjust. Ignore this advice; visit and call as often as possible and encourage other family members to do so.
If you have complaints or concerns, go to the charge nurse first. If health is threatened, to the administrator, who must respond to your complaint within four working days. If your complaint remains unresolved, contact the county Aging Department, the state Office on Aging or the Office of Licensing and Certification Programs.
For more information, contact the following agencies:
* Anne Arundel County Department of Aging, 101 Old Solomons Island Road, Annapolis 21401; 222-7011.
* Office of Licensing and Certification Programs, 4201 Patterson Ave., 4th Floor, Baltimore 21215; 764-2770.
* Maryland Office on Aging, 301 West Preston St., Room 1004, Baltimore 21215; (301) 225-1100 or (800) 243-3425.