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Nursing Homes in the US: From Colonies to COVID-19

You’ve likely heard them referred to by a range of names – old-age homes, old folks’ homes, rest homes, and of course, nursing homes. Bridging the gap between homes and hospitals, nursing homes provide specialized care for our aging population. As opposed to assisted living communities, which focus on independent living for seniors of average health, nursing homes provide 24-hour medical care and various rehabilitation services. Many residents of nursing homes require long-term care (such as for chronic illness), while others may take up lodging for short-term recovery.

Nursing Home Environment

Let’s take a look at nursing homes broadly–in terms of origins, policy history, and present standing. Then, we’ll consider the impact of COVID-19, how nursing homes plan to adapt to safeguard residents in the future, and how leaders in the U.S. health industry plan to hold them accountable.


Table of Contents


Almshouses and Convalescent Homes

Despite a long history of senior care, the nursing home as an institution is a relatively modern concept. Historians trace our contemporary facilities to British almshouses. Originating in the early medieval era and established by local churches, this type of community housing was open to the poor, widowed, and aging. In the early days, almshouses were often associated with hospitals of the time. Later versions, such as those established by settlers in the Americas, solely provided food and shelter for older adults, orphans, and those with disabilities.

Nursing homes as we know them today were not conceived until the late 19th century. It was believed that the aging adults would benefit from having their own facilities rather than sharing with those with very different needs (such as the youth, the mentally ill, and alcoholics).

Tollmache Almshouses
The Tollmache almshouse, built in 1870, in Nantwich, Cheshire, UK

Known as convalescent homes, these institutions provided seniors with basic care, hot meals, and shelter. However, unlike the almshouses of old, convalescent homes charged their residents a fee. In the 1930s, the economic depression increased the need for housing assistance in the general population. The 1935 Social Security Act introduced the Old Age Assistance Program (OAA), which provided funding for low-income seniors. The OAA required that recipients reside outside of almshouses, thus triggering a large and lasting migration of U.S. seniors into age-specific facilities.

Visiting Nurses

Another foundational element of our modern senior care system is the visiting nurse. We can trace back the concept of traveling nurses to Phoebe of 50 A.D., who was sent to Rome to help those in need. Though the legacy of nurses spans throughout much of written history, it wasn’t until the late 1800s that the role was professionalized – with nursing schools popping up at hospitals around the country.

visiting nurse

Based on the British model of a district nurse, visiting nurses of the era were fully trained to provide care for those with chronic illnesses, disabilities, or aging-related challenges. Visiting nurses were primarily part of local associations, and the role was seen as a distinct vocation – providing in-home care focused on patients rather than providing assistance to doctors.

Even with the expansion of U.S. hospitals in the 1920s and 1930s, those with chronic illnesses were often seen as a “burden” to hospitals in financial terms. It was then that visiting nurses made a point to galvanize financial support for the chronically ill, aging adults, and low-income individuals. Today, there are upwards of an estimated 4 million adults 65 and up using home health care annually, and with over 200 visiting nurse associations in the U.S., home health care represents the largest portion of long-term care nationally.

Federal Nursing Home Regulation

Specialization and larger budgets first employed in convalescent homes proved beneficial for the lives of older residents. However, a key component to senior health — medical care — was still missing. In 1946, President Truman signed the Hill-Burton Act into law, which helped to improve the standard nursing home model by incorporating medical care. With new, federally regulated nursing homes on the rise, older models were investigated, and many were deemed unsafe.
Faced with increased pressure, nursing homes across the country began to resemble hospitals rather than housing. Modern equivalents to these previous iterations of nursing homes can be found in assisted living and continuing care retirement communities, though they have made significant advancements as well.

In 1971, President Richard Nixon addressed the increasing population of adults over the age of 65 amidst the decline of multi-generational households – which was leaving a large number of U.S. seniors isolated. Nixon directed American’s attention to the growing generational gap, which, in his words, “…denie[d] the country the full value of the skills and insights and moral force which the older generation is uniquely capable of offering.”

His eight-point plan to secure progress for this demographic included greatly improving nursing and service programs and safeguarding senior income. Nixon’s plan led to a greater crackdown on substandard care quality and a greater investment in their lives. The Office of Nursing Home Affairs (ONHA) began performing systematic audits of skilled nursing facilities in 1974.

Nursing Home Reforms

Another triumph for U.S. nursing homes came with the 1987 Nursing Home Reform Act. The NHRA set federal standards for nursing homes, including social, nutritional, pharmaceutical, nursing, and rehabilitation services. It also introduced the Nursing Home Residents’ Bill of Rights, ensuring residents the right to necessary care, privacy, security, participation in their health decisions, dignity, and various freedoms (such as refusal of visitors).

States are responsible for enforcing the guidelines of NHRA, and perform facility surveys every 15 months or in case of complaints. Facilities found to be noncompliant to these guidelines can be subject to federal penalties, withheld funding, or monitoring by the state. The 1998 Nursing Home Initiative, passed under President Bill Clinton, put increased pressure on federal and state regulators to identify and eliminate substandard nursing home practices across the nation.

The Impact of Medicare and Medicaid

Though the possibility of national health insurance and medical insurance for U.S. seniors first hit the Congress floor in 1945, the Medicare and Medicaid programs were not signed into law until 1965. With their instatement came a flood of new federal funding, as well as quality standards set by the U.S. Department of Health, Education, and Welfare (HEW), aided by the senate-appointed Special Committee on Aging.

The programs encountered initial issues as a large number of facilities were found to be delivering substandard care. Later, subsequent amendments gave states the authority to enforce regulations and the HEW the authority to deny funding to facilities that didn’t make the cut. This practice of inspection contingent on funding continues to this day. Currently, Medicare and Medicaid funding applicability for nursing homes depends heavily on facility compliance to the NHRA.

Nursing Homes Today

The most recent survey from the CDC reports approximately 15,600 nursing homes housing over 1.3 million senior residents in the U.S. (many of which are aged 85 and over). Though this only represents roughly 5 percent of our seniors, nursing homes still represent a huge industry in U.S. health care, with over $250 billion in annual revenue.

The majority of nursing homes are private and for-profit, relying heavily on health plans such as Medicare and Medicaid for funding. Daily nursing home rates average $255 for a semiprivate room and $290 for a private room –– comparable to the daily rate for a higher-end hotel. However, the majority of nursing home residents receive financial support from Medicaid. Nursing home residents eligible for Medicaid generally have 100 percent of their bill covered by the program.

Alternatively, the Medicare program is not designed to support long-term care. Medicare will cover 20 days at 100 percent, while requiring partial payment from residents for the following 80 days – for a coverage period of 100 days maximum. Medicare supplemental insurance will cover a maximum of 100 days at 100 percent. For U.S. veterans and their spouses, the VA provides both the Aid & Assistance Program and their own specialized nursing homes, though eligibility may vary.

Though institutions specifically focused on continuing senior health are relatively new, there has been much enhancement to the quality of life in nursing homes. New, innovative practices have been appearing in nursing homes across the nation. Furthermore, the Commonwealth Fund 2007 National Survey of Nursing Homes noted a broad shift in U.S. nursing homes towards a more resident-centered culture. As a result of the departure from the traditional nursing home lifestyle, residents are experiencing better dining options, heightened independence, and more social opportunities.

Some facilities are incorporating activities such as Blackjack, art and music classes, 1950s dance nights, community volunteering (such as baking for local firefighters), gardening and more. What’s more, a 2018 study found the U.S. to be a top “successfully aging society” in terms of productivity, well-being, cohesion, security, and equity. With its early origins in specialized residential eldercare, the U.S. is certainly posed for an innovative future in the field.

The Impact of COVID-19

The influence of the global coronavirus pandemic has had a staggering effect on cultural and social norms, and perhaps more pressingly, the health and livelihood of the world’s inhabitants. It goes without saying that the effects of infection, isolation, and health-care staff shortages would trickle down into nursing homes –– where the majority of the residents are at a higher risk for contracting the virus.

A recent study shows that COVID-19 has more negatively impacted seniors living in long-term care facilities more than any other group. It is likely that the negative impact on these communities is even more severe, as only 19 of U.S. states report COVID-19 deaths as associated with long-term care facilities. Our imprecise view of pandemic-related consequences for those in long-term care homes is furthered by the separate state categorization of long-term care in terms of their proximity to health care. For example, nursing homes versus assisted living facilities are treated differently in some states.

In addition to the major uptick in COVID-related illness and death, pressure on the health-care system has created a staff shortage in nursing homes. Not only has this had an impact on quality of care, but it has also reportedly contributed to increased infection rates. Combined with a significant shortage of personal protective equipment (PPE) reported in nursing homes nationwide, it seems that they, as other long-term care facilities, have experienced the devastating impact of this public health crisis.

Awareness of these issues may have seniors questioning their current or future status in a nursing home. Would I or my loved ones be safe in these facilities? If I need long-term care, can I trust the options available? Likewise, public health advocates and government officials are increasingly voicing their concerns over the current and future conditions of nursing homes, especially now.

Just weeks prior to officially acknowledging its pandemic status, the Department of Justice enacted the National Nursing Home Initiative. The goal of the initiative is to more vigorously investigate problematic facilities in the interest of elder justice. This initiative, incidentally, helped pave the way for accountability from nursing homes neglecting the Centers for Disease Control and Prevention protocol, or otherwise providing inadequate care for senior residents during the pandemic. At the same time, state officials such as New York Gov. Andrew Cuomo and Michigan Gov. Gretchen Whitmer have faced nationwide scrutiny for allegedly neglecting nursing home crises in the face of COVID-19.

One way to inform yourself and your family on current nursing home conditions is by using the Nursing Home Compare website created by The Centers for Medicare and Medicaid Services (CMS). This tool allows you to search facilities by name or location, and delivers an array of critical data –– including penalties, ownership details, and safety measures. The Claude Pepper Center has also made an effort to collect all nursing home data related to COVID-19.

With the increased public consciousness of U.S. health policy and standards, many believe we are in a position to see positive developments in nursing homes in the near future. Many experts believe nursing homes are now at a major turning point. State legislatures across the country are reexamining their long-term care management and passing new bills that benefit the residents of these facilities.

One thing, however, is for sure. The nursing home industry is about to go through some significant changes.

Written By
Amie Clark

Amie has been writing about senior care products and services for the last decade. She is particularly passionate about new technologies that help improve the quality of life for seniors and their families. Seeing her parents and grandparents age made Amie ask herself, “Would this be good enough for my loved ones?” In her spare time, Amie enjoys outdoor adventures and spontaneous road trips. Learn more about Amie here