Nursing Home Visit

Nursing Home Visit


A nursing home visit is a family- nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. In performing  home visits, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired outcomes.

  • To give care to the sick, to a postpartum mother and her newborn with the view teach a responsible family member to give the subsequent care.
  • To assess the living condition of the patient and his family and their health  practices in order to provide the appropriate health teaching.
  • To give health teachings regarding the prevention and control of diseases.
  • To establish close relationship between the health agencies and the public for the promotion of health.
  • To make use of the inter-referral system and to promote the utilization of community services

The following principles are involved when performing a home visit:

  • A home visit must have a purpose or objective.
  • Planning for a home visit should make use of all available information about the patient and his family through family records.
  • In planning for a home visit, we should consider and give priority to the essential needs if the individual and his family.
  • Planning and delivery of care should involve the individual and family.
  • The plan should be flexible.

The following guidelines are to be considered regarding the frequency of home visits:

  • The physical needs psychological needs and educational needs of the individual and family.
  • The acceptance of the family for the services to be rendered, their interest and the willingness to cooperate.
  • The policy of a specific agency and the emphasis given towards their health programs.
  • Take into account other health agencies and the number of health personnel already involved in the care of a specific family.
  • Careful evaluation of past services given to the family and how the family avails of the nursing services.
  • The ability of the patient and his family to recognize their own needs, their knowledge of available resources and their ability to make use of their resources for their benefits.
  • Greet the patient and introduce yourself.
  • State the purpose of the visit
  • Observe the patient and determine the health needs.
  • Put the bag in a convenient place and then proceed to perform the bag technique .
  • Perform the nursing care needed and give health teachings.
  • Record all important date, observation and care rendered.
  • Make appointment for a return visit.
  • Bag Technique
  • Primary Health Care in the Philippines

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Thanks alots for the impressive lessons learnt from the principal of community health care and nursing home

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The Nerdy Nurse

Nursing Home Visit – Tips & What To Expect

If you are preparing for your first nursing home visit, read this guide. This is packed with helpful tips so you can be prepared.

Reasons Nurses Do Home Visits

There are lots of reasons that a nurse might visit someone’s home. Before I share some of my tips, it’s important to understand the purpose of the visit. Each type of home visit will have different goals and outcomes, so you’ll do different things when you arrive.

These are the main reasons that nurses might do home visits:

  • Care for a sick patient as a home-care nurse
  • Teach care techniques to a postpartum family
  • Assess the living condition of a patient and/or their family members for upcoming care
  • Teach people about prevention and control of diseases from within their homes
  • To promote the utilization of community services

Nursing Home Visit - Tips & What To Expect

7. Make Another Appointment

Your chances of doing a home visit as a nurse will depend on where you work. Typically, community outreach organizations and home health care agencies will do the most frequent home visits.

How To Decide Whether To Do A Home Visit

If you are a new nurse, you probably won’t be the one making the decision about whether to visit a patient’s home, but it is still good to know how the decision is made.

Typically, these are the main guidelines that health care providers use to decide whether nurses should visit a patient in their home:

  • The needs of the patient and their family – including physical, psychological, and educational
  • Patient and family’s acceptance and willingness to cooperate
  • Patient and family’s ability to recognize their needs and their ability to use the resources for their benefits
  • How many health personnel are already involved in the care of this specific family
  • The policy of the agency in regards to the home visits

How To Do A Home Visit

When it comes time to do your first home visit, just follow these steps in order. This will help you have a pleasant experience and make sure you don’t forget something important.

1. Greet The Patient

Arrive with a smile and introduce yourself. Remember to state where you are coming from and your role in the agency. Make sure you ask them their name and what they prefer to be called (if they have a nickname).

2. Tell Them The Purpose Of The Visit

Go into detail about why you are there and what you are hoping to accomplish. This part should be detailed so that they know what to expect.

3. Assess The Patient

Next you will do a quick observation and assessment. This is a silent and mental one so that you know what you will have to do while on your visit.

4. Set Your Bag In A Clean Place

Make sure your bag is sitting on a table that is lined with clean paper. Then, wash your hands with soap and water. Take out all the tools you will need for your visit so they are easy to access. Put on an apron, close the bag, and you are ready for your nursing care treatment.

5. Perform Your Nursing Care

After you are all prepared, you can do the care which you came to do. One of the most important things you will do on these visits is educate the patient and/or their family. Listen to their questions attentively and answer them the best you can. Direct them to any community services if you cannot help them right away.

6. Keep Excellent Records

Write everything down. Record the date, what you observed, and all the care you gave the patient. Also write down everything you told the family for caring for the patient at home.

If necessary, make an appointment to return and give more care. This is always needed, but don’t leave until you verified whether they need a follow up.

Nursing Home Visit: Final Thoughts

It might be nerve-wracking to think about visiting a patient or their family at their home. If you are really nervous, you can ask a friend or family member to help you prepare. Do a few practice runs as you introduce yourself and go through the motions of the assessment and care.

Set realistic expectations for yourself. If you need notes to remember what to ask, then take them along. Always ask for help when you need it. These can be very valuable and give the education and support that the patient and/or their family

More Nursing Tips

If you enjoyed these nursing home visit tips, then here are some more tips and advice about life as a nurse.

  • How To Get ACLS Certified
  • How To Write A Cover Letter
  • The Best Accelerated Nursing Programs

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About The Author

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Best Visiting Nurse Services

AccentCare is the best visiting nurse service, with performance ratings above industry standards

One day you or a loved one might need a visiting nurse for medical care in your home. In the United States, it’s a relatively common experience. According to the Centers for Disease Control and Prevention (CDC), about 4.5 million Americans are treated in their homes every year by more than 12,000 home healthcare agencies. Many people prefer the ease of having medical care in their own home, rather than having to travel to a hospital or doctor's office.

When the time comes, you’ll need to do some research to find a visiting nurse service that fits your personal needs. With that in mind, we reviewed over 40 home healthcare companies to find the best visiting nurse services available.

Best Visiting Nurse Services of 2024

  • Best Overall: AccentCare
  • Best for Post-Operative Assistance: Elara Caring
  • Best Technology: Enhabit Home Health & Hospice
  • Best for Specialized Care: Interim HealthCare
  • Best for Hospice (End-of-Life Care): ProMedica Hospice
  • Our Top Picks

Elara Caring

  • Enhabit Home Health & Hospice
  • Interim HealthCare
  • ProMedica Hospice
  • See More (2)

Final Verdict

  • How to Choose


Best overall : accentcare.

  • Services offered : Personal care, behavioral health, rehabilitation, medical assistance, hospice and palliative care, care management, health alert systems
  • Number of locations : 260 locations across 31 states

We selected AccentCare as the best overall provider of skilled home health care based on its accessibility (there are over 260 locations) and performance ratings that are above industry standards.

Programs for chronic conditions

Specialized programs, including behavioral health and stroke

Tele-monitoring program for early intervention

Some locations have different names, which can be confusing

Website’s location search page is hard to find

All of AccentCare's agencies are accredited by Community Health Accreditation Partners (CHAP) and have earned an overall 4.6-star quality rating and recognition from the We Honor Veterans program. AccentCare treats over 140,000 patients a year. Along with skilled home health care and private duty nursing, it offers hospice care, personal care services, and care management.

AccentCare also uses technology to supplement visiting nurse home care visits with tele-monitoring that can deliver biometric data (blood pressure, pulse, blood glucose, etc.) in close to real-time to keep the medical support team informed and ready to take action if necessary. AccentCare is the fifth largest provider of skilled home health in the U.S.

Best for Post-Operative Assistance : Elara Caring

  • Services offered : Home health care, hospice care, rehabilitation, recovery care, personal care, behavioral care
  • Number of locations : 200+ locations across 16 states

Elara Caring focuses on recovery and rehabilitation, excelling in nursing, physical therapy (PT) , occupational therapy (OT), and speech therapy . 

Also offers hospice care and behavioral health services

Delivers proactive customized care (CAREtinuum)

Only available in 16 states

Elara Caring's CAREtinuum program, a system that uses predictive analytics to identify patients at risk, sets it apart from other companies for post-operative assistance. For example, Elara’s CAREtinuum Fall Risk Program patients are 72% less likely to return to the hospital due to falling.

Elara Caring offers a wide range of in-home clinical services, treating more than 65,000 patients a day. Along with skilled home health, Elara Caring offers hospice care, personal care, and behavioral care. Its behavioral care supports a wide range of conditions, including depressive/anxiety disorders, schizophrenia, bipolar, and other disorders.

Even though Elara only has locations in about one-third of the states in the U.S., it is the ninth largest provider of skilled home health in the country.

Best Technology : Enhabit Home Health & Hospice

  • Services offered : Home health care, hospice care, post-operative care, transition program from hospital to home, long-term care
  • Number of locations : 355 locations across 34 states

We chose Enhabit Home Health & Hospice for its easy-to-use technology that makes a customer’s online experience simple, with comprehensive information quickly available.

Locations in 34 states

Variety of programs to enhance skilled nursing, including skilled therapy, balance and fall prevention, and orthopedics

Not all locations offer hospice

Website offers Spanish translation, but only portions of the site are available in Spanish

The online software at Enhabit streamlines each step, from referral processing to scheduling to management of physician orders, in order to optimize patient care and attention. This connection between patients, doctors, and in-home care providers makes processes easier and more transparent.

In addition, Enhabit’s web portal provides one-stop access to manage diagnoses, patient history, medications, and plan of care. Enhabit is also able to deliver better care for patients through predictive analysis, to identify potential risks.

Best for Specialized Care : Interim HealthCare

Interim Healthcare

  • Services offered : Home health care, senior care, in-home nursing services, respite care, transitional care; at-home physical therapy, occupational therapy, and speech therapy.
  • Number of locations : 300+ locations across 41 states

We chose Interim HealthCare for its focus on home care for adults or children with special needs due to an injury or illness.

Promotes a more engaged existence at home for patients and their families

Offers caregivers more than 300 continuing education units

Available in nearly 50 states

Independently owned franchises mean inconsistencies in customer satisfaction

Interim HealthCare's services include care for adults and children who are developmentally delayed or need to use a feeding tube. Specialized offerings include home care for arthritis, multiple sclerosis , joint replacement, hypertension , paraplegia and quadriplegia, and traumatic brain injury (TBI).

Interim also offers many specialized interactive online training courses and live webinars for specific needs, such as dementia care. Interim HealthCare University provides extensive training resources available for free to employees, including over 300 lessons for both clinical and non-clinical staff and management in areas such as fall prevention, home care technology, and transitioning from a facility.

Interim’s HomeLife Enrichment program looks beyond basic needs to address the mind, spirit, and family as well as the body. The focus is to add purpose, dignity, and self-worth to basic safety and independence.

Interim HealthCare has a network of more than 300 independently owned franchises (employing nurses, aides, therapists, and other healthcare personnel) serving about 173,000 people every year.

Best for Hospice (End-of-Life Care) : ProMedica Hospice

  • Services offered : Home hospice care, pain management, spiritual support, comforting treatments, bereavement services
  • Number of locations : In 26 states

ProMedica Hospice provides the comfort and quality of life that hospice is known for, with fast and effective responses to patient discomforts such as pain, shortness of breath, and anxiety.

Advance directive not required for hospice care

Fully accredited

Provides employees with training, continuing education, and tuition assistance

Only available in 26 states across the U.S.

ProMedica Hospice has locations in 26 states, offering services such as pain and symptom management therapies. Heartland can provide hospice care in any “home”—including a private home, an assisted living facility, or a skilled nursing center.

While some hospices require a do not resuscitate (DNR) order before providing care, ProMedica (formerly Heartland Hospice Care) doesn’t. In situations where Medicare will be paying for the care, a DNR is not required because the care is considered palliative (providing comfort, instead of a cure or treatment).

ProMedica Hospice develops talent by offering its employees training and education opportunities at many of its locations. For example, its nursing assistant training programs include assistance with the cost of taking a state certification exam.

ProMedica Hospice also offers bereavement services, advanced planning services, and the possibility to grant funds to help offset financial burdens created by terminal illness.

While each visiting nurse service on this list has its strengths, AccentCare is our top pick due to its wide variety of specialized programs and high quality rating. The caretakers at AccentCare are skilled and experienced. Plus, home care visits are supplemented with an advanced tele-monitoring system.

Guide to Choosing a Visiting Nurse Service

When it comes to selecting the best visiting nurse services for you or a loved one, there are several factors you should look for to help inform your decision.

  • Accreditation : Home healthcare agencies and companies must be licensed in order to operate in a state. As you research the best visiting nurse services, ensure that the agency you select is licensed in the state you live. Consult with the Centers for Medicare & Medicaid Services (CMS) or the Joint Commission, which offers accreditation to home health providers.
  • Insurance : Check your available coverage and what potential out-of-pocket costs may be by asking any potential visiting nurse service if it accepts your insurance. Often, services take Medicare, Medicaid, private insurance, or Veterans Administration benefits.
  • Services needed : Depending on your needs, you may require more specialized nursing care. For example, visiting nurse services can be tailored to the patient if they need after-surgery care, rehabilitation therapy, medication administration, or personal care and companionship.
  • Visiting hours : Many visiting home nurses operate between the hours of 8 a.m. and 5 p.m. However, depending on the needs of the patient, in-home hours can often be adjusted. Ask a home healthcare provider if they also arrange for evening or overnight visits, should you need them.

Frequently Asked Questions

What are the duties of a visiting nurse.

A visiting nurse is a skilled medical professional, usually a registered nurse, who oversees all aspects of the medical care you receive at home, as ordered by a physician. This might include evaluating your medical condition and health needs, monitoring your vital signs and assessing risk factors, and administering medication. A visiting nurse is also trained to care for specific conditions such as COPD, diabetes, dementia, and Alzheimer’s. They can change dressings for surgical incisions or wounds and provide hospice care .

When your visiting nurse leaves, they make sure that you and your caregivers have the necessary information and supplies to support the plan of care.

Is a Visiting Nurse the Same as a Home Health Aide?

A visiting nurse is a skilled medical professional, while a home aide typically has limited formal medical training and provides services such as help with personal hygiene, meals, and transportation. A home health aide may stay in your home for several hours providing care, while a visiting nurse will stay for a shorter time to perform specific tasks.

Does Medicare Cover Visiting Nurse Services?

If you have Medicare, home health care, such as that provided by a visiting nurse, is covered 100% by Medicare when your doctor certifies that you meet the required guidelines. If you do not have Medicare, consult with your healthcare insurance to determine your policy parameters for coverage, including necessary copayments, if any.

Hospice (including a visiting nurse, if one is on your team) is covered by Medicare, Medicaid, the Veteran’s Health Administration, and private insurance. Although most hospice care is provided at home, it is also available at hospitals, assisted living facilities, nursing homes, and dedicated hospice facilities.

Always double-check coverage with your insurance provider and ask the visiting nurse service if it accepts your insurance plan.

For this ranking, we looked at more than 40 home health providers. The primary criteria were the number of locations and national footprint, so the ranking would be useful to a large number of people. In addition to reviewing companies' areas of expertise, we also looked at their website interface, navigation, and usability and how they are ranked in areas such as quality care and patient satisfaction by services such as the U.S. government’s Centers for Medicare and Medicaid Services (CMS) Home Health Star and Home Health Compare .

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Centers for Disease Control and Prevention, National Center for Health Statistics. Home health care .

LexisNexis Risk Solutions. LexisNexis Risk Solutions ranks top home health and hospice providers .

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Home Visit: Opening the Doors for Family Health

Chapter 11 Home Visit Opening the Doors for Family Health Claudia M. Smith Chapter Outline Home Visit Definition Purpose Advantages and Disadvantages Nurse–Family Relationships Principles of Nurse–Client Relationship with Family Phases of Relationships Characteristics of Relationships with Families Increasing Nurse–Family Relatedness Fostering a Caring Presence Creating Agreements for Relatedness Increasing Understanding through Communication Skills Reducing Potential Conflicts Matching the Nurse’s Expectations with Reality Clarifying Nursing Responsibilities Managing the Nurse’s Emotions Maintaining Flexibility in Response to Client Reactions Clarifying Confidentiality of Data Promoting Nurse Safety Clarifying the Nurse’s Self-Responsibility Promoting Safe Travel Handling Threats during Home Visits Protecting the Safety of Family Members Managing Time and Equipment Structuring Time Handling Emergencies Promoting Asepsis in the Home Modifying Equipment and Procedures in the Home Postvisit Activities Evaluating and Planning the Next Home Visit Consulting and Collaborating with the Team Making Referrals Legal Documentation The Future of Evidence-Based Home-Visiting Programs Focus Questions Why are home visits conducted? What are the advantages and disadvantages of home visits? How is the nurse–client relationship in a home similar to and different from nurse–client relationships in inpatient settings? How can a nurse’s family focus be maximized during a typical home visit? What promotes safety for community/public health nurses? What happens during a typical home visit? How can client participation be promoted? Key Terms Agreement Collaboration Consultation Empathy Family focus Genuineness Home visit Positive regard Presence Referral Nurses who work in all specialties and with all age groups can practice with a family focus , that is, thinking of the health of each family member and of the entire family per se and considering the effects of the interrelatedness of the family members on health. Because being family focused is a philosophy, it can be practiced in any setting. However, a family’s residence provides a special place for family-focused care. Community/public health nurses have historically sought to promote the well-being of families in the home setting ( Zerwekh, 1990 ). Community/public health nurses seek to promote health; prevent specific illnesses, injuries, and premature death; and reduce human suffering. Through home visits, community/ public health nurses provide opportunities for families to become aware of potential health problems, to receive anticipatory education, and to learn to mobilize resources for health promotion and primary prevention ( Kristjanson & Chalmers, 1991 ; Raatikainen, 1991 ). In clients’ homes, care can be personalized to a family’s coping strategies, problem-solving skills, and environmental resources (see Chapter 13 ). During home visits, community/public health nurses can uncover threats to health that are not evident when family members visit a physician’s office, health clinic, or emergency department ( Olds et al., 1995 ; Zerwekh, 1991 ). For example, during a visit in the home of a young mother, a nursing student observed a toddler playing with a paper cup full of tacks and putting them in his mouth. The student used the opportunity to discuss safety with the mother and persuaded her to keep the tacks on a high shelf. The quality of the home environment predicts the cognitive and social development of an infant ( Engelke & Engelke, 1992 ). Community/public health nurses successfully assist parents in improving relations with their children and in providing safe, stimulating physical environments. All levels of prevention can be addressed during home visits. Research has demonstrated that home visits by nurses during the prenatal and infancy periods prevent developmental and health problems ( Kitzman et al., 2000 ; Norr et al., 2003 ; Olds et al., 1986 ). Olds and colleagues demonstrated that families who received visits had fewer instances of child abuse and neglect, emergency department visits, accidents, and poisonings during the child’s first 2 years of life. These results were true for families of all socioeconomic levels but greater for low-income families. The health outcomes for families who received home visits were better than those of families that received care only in clinics or from private physicians. Furthermore, the favorable results were still apparent 15 years after the birth of the first child ( Olds et al., 1997 ), and the home visits reduced subsequent pregnancies ( Kitzman et al., 1997 ; Olds et al., 1997 ). The U.S. Advisory Board on Abuse and Neglect advocates such home-visiting programs as a means to prevent child abuse and neglect ( U.S. Department of Health and Human Services, 1990 ). Other research shows that home visits by nurses can reduce the incidence of drug-resistant tuberculosis and decrease preventable deaths among infected individuals ( Lewis & Chaisson, 1993 ). This goal is achieved through directly observing medication therapy in the individual’s home, workplace, or school on a daily basis or several times a week (see Chapter 8 ). Several factors have converged to expand opportunities for nursing care to adults and children with illnesses and disabilities in their homes. The American population has aged, chronic diseases are now the major illnesses among older persons, and attempts are being made to limit the rising hospital costs. As the average length of stay in hospitals has decreased since the early 1980s, families have had to care for more adults and children with acute illnesses in their homes. This increased demand for home health care has resulted in more agencies and nurses providing home care to the ill and teaching family members to perform the care (see Chapter 31 ). The degree to which families cope with a member with a chronic illness or disability significantly affects both the individual’s health status and the quality of life for the entire family ( Burns & Gianutsos, 1987 ; Harris, 1995 ; Whyte, 1992 ). Family members may be called on to support an individual family member’s adjustment to a chronic illness as well as take on tasks and roles that the ill member previously performed. This adjustment occurs over time and often takes place in the home. Community/public health nurses can assist families in making these adjustments. Since the late 1960s, deinstitutionalization of mentally ill clients has shifted them from inpatient psychiatric settings to their own homes, group homes, correctional facilities, and the streets (see Chapter 33 ). Nurses in the fields of community mental health and psychiatry began to include the relatives and surrogate family members in providing critical support to enable the person with a psychiatric diagnosis to live at home ( Mohit, 1996 ; Stolee et al., 1996 ). The hospice movement also recognizes the importance of a family focus during the process of a family member’s dying ( American Nurses Association [ANA], 2007a ). Care at home or in a homelike setting is cost effective under many circumstances. As the prevalence of acquired immunodeficiency syndrome (AIDS) increases and the number of older adults continues to increase, providing care in a cost-effective manner is both an ethical and an economic necessity. Nurses in any specialty can practice with a family focus. However, the specific goals and time constraints in each health care service setting affect the degree to which a family focus can be used. A home visit is one type of nurse–client encounter that facilitates a family focus. Home visiting does not guarantee a family focus. Rather, the setting itself and the structure of the encounter provide an opportunity for the nurse to practice with a family focus. A nurse visiting a client in his home listens to the man’s heart while his daughter looks on. Nurses who graduate from a baccalaureate nursing program are expected to have educational experiences that prepare them for beginning practice in community/public health nursing. Family-focused care is an essential element of community/public health nursing. One of the ways to improve the health of populations and communities is to improve the health of families ( ANA, 2007b ). Home visits may be made to any residence: apartments for older adults, group homes, boarding homes, dormitories, domiciliary care facilities, and shelters for the homeless, among others. In these residences, the family may not be related by blood, but, rather, they may be significant others: neighbors, friends, acquaintances, or paid caregivers. Nurses who are educated at the baccalaureate level are one of a few professional and service workers who are formally taught about making home visits. Some social work students, especially those interested in the fields of home health and protective services, also receive similar education. The American Red Cross and the National Home Caring Council have developed training programs for homemakers and home health aides; not all aides have received such extensive training, however. Agricultural and home economic extension workers in the United States and abroad also may make home visits ( Murray, 1968 ; World Health Organization, 1987 ). Home visit Definition A home visit is a purposeful interaction in a home (or residence) directed at promoting and maintaining the health of individuals and the family (or significant others). The service may include supporting a family during a member’s death. Just as a client’s visit to a clinic or outpatient service can be viewed as an encounter between health care professionals and the client, so can a home visit. A major distinction of a home visit is that the health care professional goes to the client rather than the client coming to the health care professional. Purpose Almost any health care service can be accomplished on a home visit. An assumption is that—except in an emergency—the client or family is sufficiently healthy to remain in the community and to manage health care after the nurse leaves the home. The foci of community/public health nursing practice in the home can be categorized under five basic goals: 1.  Promoting support systems that are adequate and effective and encouraging use of health-related resources 2.  Promoting adequate, effective care of a family member who has a specific problem related to illness or disability 3.  Encouraging normal growth and development of family members and the family and educating the family about health promotion and illness prevention 4.  Strengthening family functioning and relatedness 5.  Promoting a healthful environment The five basic goals of community/public health nursing practice with families can be linked to categories of family problems ( Table 11-1 ). A pilot study to identify problems common in community/public health nursing practice settings revealed that problems clustered into four categories: (1) lifestyle and living resources, (2) current health status and deviations, (3) patterns and knowledge of health maintenance, and (4) family dynamics and structure ( Simmons, 1980 ). Home visits are one means by which community/public health nurses can address these problems and achieve goals for family health. Table 11-1 Family Health-Related Problems and Goals Problem * Goal Lifestyle and resources Promote support systems and use of health-related resources Health status deviations Promote adequate, effective family care of a member with an illness or disability Patterns and knowledge of health maintenance Encourage growth and development of family members, health promotion, and illness prevention Promote a healthful environment Family dynamics and structure Strengthen family functioning and relatedness * Problems from Simmons, D. (1980). A classification scheme for client problems in community health nursing (DHHS Pub No. HRA 8016). Hyattsville, MD: U.S. Department of Health and Human Services. Advantages and Disadvantages Advantages of home visits by nurses are numerous. Most of the disadvantages relate to expense and concerns about unpredictable environments ( Box 11-1 ). Box 11-1 Advantages and Disadvantages of Home Visiting Advantages •  Home setting provides more opportunities for individualized care. •  Most people prefer to receive care at home. •  Environmental factors impinging on health, such as housing condition and finances, may be observed and considered more readily. •  Collecting information and understanding lifestyle values are easier in family’s own environment. •  Participation of family members is facilitated. •  Individuals and family members may be more receptive to learning because they are less anxious in their own environments and because the immediacy of needing to know a particular fact or skill becomes more apparent. •  Care to ill family members in the home can reduce overall costs by preventing hospitalizations and shortening the length of time spent in hospitals or other institutions. •  A family focus is facilitated. Disadvantages •  Travel time is costly. •  Home visiting is less efficient for the nurse than working with groups or seeing many clients in an ambulatory site. •  Distractions such as television and noisy children may be more difficult to control. •  Clients may be resistant or fearful of the intimacy of home visits. •  Nurse safety can be an issue. Nurse–family relationships How nurses are assigned to make home visits is both a philosophical and a management issue. Some community/public health nurses are assigned by geographical area or district . The size of the geographical area for home visits varies with the population density. In a densely populated urban area, a nurse might visit in one neighborhood; in a less densely populated area, the nurse might be assigned to visit in an entire county. With geographical assignments, the nurse has the potential to work with the entire population in a district and to handle a broad range of health concerns; the nurse can also become well acquainted with the community’s health and social resources. The potential for a family-focused approach is strengthened because the nurse’s concerns consist of all health issues identified with a specific family or group of families. The nurse remains a clinical generalist, working with people of all ages. Other community/public health nurses are assigned to work with a population aggregate in one or more geopolitical communities. For example, a nurse may work for a categorical program that addresses family planning or adolescent pregnancy, in which case the nurse would visit only families to which the category applies. This type of assignment allows a nurse to work predominantly with a specific interest area (e.g., family planning and pregnancy) or with a specific aggregate (e.g., families with fertile women). Principles of Nurse–Client Relationship with Family Regardless of whether the community/public health nurse is assigned to work with an aggregate or the entire population, several principles strengthen the clarity of purpose: •  By definition, the nurse focuses on the family. •  The health focus can be on the entire spectrum of health needs and all three levels of prevention. •  The family retains autonomy in health-related decisions. •  The nurse is a guest in the family’s home. Family Focus To relate to the family, the community/public health nurse does not have to meet all members of the household personally, although varying the times of visits might allow the nurse to meet family members usually at work or school. Relating to the family requires that the nurse be concerned about the health of each member and about each person’s contribution to the functioning of the family. One family member may be the primary informant; in such instances, the nurse should realize that the information received is being filtered by the person’s perceptions. The community/public health nurse should take the time to introduce herself or himself to each person present and address each person by name. Building trust is an essential foundation for a continued relationship ( Heaman et al., 2007 ; McNaughton, 2000 ; Zerwekh, 1992 ). The nurse should use the clients’ surnames unless they introduce themselves in another way or give permission for the nurse to be less formal. Interacting with as many family members as possible, identifying the family member most responsible for health issues, and acknowledging the family member with the most authority are important. The nurse should ask for an introduction to pets and ask for permission before picking up infants and children unless it is granted nonverbally. A nurse enters the home of a client with a young child. All Levels of Prevention Through assessment, the community/public health nurse attempts to identify what actual and potential problems or concerns exist with each individual and, thematically, within the family (see Chapter 13 ). Issues of health promotion (diet) and specific protection (immunization) may exist, as may undiagnosed medical problems for which referral is necessary for further diagnosis and treatment. Home visits also can be effective in stimulating family members to seek appropriate services such as prenatal care ( Bradley & Martin, 1994 ) and immunizations ( Norr et al., 2003 ). Actual family problems in coping with illness or disability may require direct intervention. Preventing sequelae and maximizing potential may be appropriate for families with a chronically ill member. Health-related problems may appear predominantly in one family member or among several members. A thematic family problem might be related to nutrition. For example, a mother may be anemic, a preschooler may be obese, and a father may not follow a low-fat diet for hypertension. Family Autonomy A few circumstances exist in our society in which the health of the community, or public, is considered to have priority over the right of individual persons or families to do as they wish. In most states, statutes (laws) provide that health care workers, including community/public health nurses, have a right and an obligation to intervene in cases of family abuse and neglect, potential suicide or homicide, and existence of communicable diseases that pose a threat of infection to others. Except for these three basic categories, the family retains the ultimate authority for health-related decisions and actions . In the home setting, family members participate more in their own care. Nursing care in the home is intermittent, not 24 hours a day. When the visit ends, the family takes responsibility for their own health, albeit with varying degrees of interest, commitment, knowledge, and skill. This role is often difficult for beginning community/public health nurses to accept; learning to distinguish the family’s responsibilities from the nurse’s responsibilities involves experience and consideration of laws and ethics. Except in crises, taking over for the family in areas in which they have demonstrated capability is usually inappropriate. For example, if family members typically call the pharmacy to renew medications and make their own medical appointments, beginning to do these things for them is inappropriate for the nurse. Taking over undermines self-esteem, confidence, and success. Nurse as Guest Being a guest as a community/public health nurse in a family’s home does not mean that the relationship is social. The social graces for the community and culture of the family must be considered so that the family is at ease and is not offended. However, the relationship is intended to be therapeutic. For example, many older persons believe that offering something to eat or drink is important as a sign that they are being courteous and hospitable. Because your refusal to share in a glass of iced tea may be taken as an affront, you may opt to accept the tea. However, you certainly have the right to refuse, especially if infectious disease is a concern. Validate with the client that the time of the visit is convenient. If the client fails to offer you a seat, you may ask if there is a place for you and the family to sit and talk. This place may be any room of the house or even outside in good weather. Phases of Relationships Relatedness and communication between the nurse and the client are fundamental to all nursing care. A nurse–client relationship with a family (rather than an individual) is critical to community/public health nursing. The phases of the nurse–client relationship with a family are the same as are those with an individual. Different schemes have been developed for naming phases of relationships. All schemes have (1) a preinitiation or preplanning phase, (2) an initiation or introductory phase, (3) a working phase, and (4) an ending phase (Arnold & Boggs, 2011). Some schemes distinguish a power and control or contractual phase that occurs before the working phase. The initiation phase may take several visits. During this phase, the nurse and the family get to know one another and determine how the family health problems are mutually defined. The more experience the nurse has, the more efficient she or he will become; initially, many community/public health nursing students may require four to six visits to feel comfortable and to clarify their role ( Barton & Brown, 1995 ). The nursing student should keep in mind that the relationship with the family usually involves many encounters over time—home visits, telephone calls, or visits at other ambulatory sites such as clinics. Several encounters may occur during each phase of the relationship ( Figure 11-1 ). Each encounter also has its own phases ( Figure 11-2 ). Figure 11-1 A series of encounters during a relationship. (Redrawn from Smith, C. [1980]. A series of encounters during a relationship [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Figure 11-2 Phases of a home visit. (Redrawn from Smith, C. [1980]. Phases of a home visit [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Preplanning each telephone call and home visit is helpful. Box 11-2 lists activities in which community/public health nurses usually engage before a home visit. The list can be used as a guide in helping novice community/public health nurses organize previsit activities efficiently. Box 11-2 Planning Before a Home Visit   1.  Have name, address, and telephone number of the family, with directions and a map. 2.  Have telephone number of agency by which supervisor or faculty can be reached. 3.  Have emergency telephone numbers for police, fire, and emergency medical services (EMS) personnel. 4.  Clarify who has referred the family to you and why. 5.  Consider what is usually expected of a nurse in working with a family that has been referred for these health concerns (e.g., postpartum visit), and clarify the purposes of this home visit. 6.  Consider whether any special safety precautions are required. 7.  Have a plan of activities for the home visit time (see Box 11-3 ). 8.  Have equipment needed for hand-washing, physical assessment, and direct care interventions, or verify that client has the equipment in the home. 9.  Take any data assessment or permission forms that are needed. 10.  Have information and teaching aids for health teaching, as appropriate. 11.  Have information about community resources, as appropriate. 12.  Have gasoline in your automobile or money for public transportation. 13.  Leave an itinerary with the agency personnel or faculty. 14.  Approach the visit with self-confidence and caring. The visit begins with a reintroduction and a review of the plan for the day; the nurse must assess what has happened with the family since the last encounter. At this point, the nurse may renegotiate the plan for the visit and implement it. The end of the visit consists of summarizing, preparing for the next encounter, and leave-taking. Box 11-3 describes the community/public health nurse’s typical activities during a home visit. Box 11-3 Nursing Activities During Three Phases of a Home Visit Initiation Phase of Home Visit 1.  Knock on door, and stand where you can be observed if a peephole or window exists. 2.  Identify self as [name], the nurse from [name of agency]. 3.  Ask for the person to whom you were referred or the person with whom the appointment was made. 4.  Observe environment with regard to your own safety. 5.  Introduce yourself to persons who are present and acknowledge them. 6.  Sit where family directs you to sit. 7.  Discuss purpose of visit. On initial visits, discuss services to be provided by agency. 8.  Have permission forms signed to initiate services. This activity may be done later in the home visit if more explanation of services is needed for the family to understand what is being offered. Implementation Phase of Home Visit 9.  Complete health assessment database for the individual client. 10.  On return visits, assess for changes since the last encounter. Explore the degree that family was able to follow up on plans from previous visit. Explore barriers if follow-up did not occur. 11.  Wash hands before and after conducting any physical assessment and direct physical care. 12.  Conduct physical assessment, as appropriate, and perform direct physical care. 13.  Identify household members and their health needs, use of community resources, and environmental hazards. 14.  Explore values, preferences, and clients’ perceptions of needs and concerns. 15.  Conduct health teaching as appropriate, and provide written instructions. Include any safety recommendations. 16.  Discuss any referral, collaboration, or consultation that you recommend. 17.  Provide comfort and counseling, as needed. Termination Phase of Home Visit 18.  Summarize accomplishments of visit. 19.  Clarify family’s plan of care related to potential health emergency appropriate to health problems. 20.  Discuss plan for next home visit and discuss activities to be accomplished in the interim by the community/public health nurse, individual client, and family members. 21.  Leave written identification of yourself and agency, with telephone numbers. Characteristics of Relationships with Families Some differences are worth discussing in nurses’ relationships with families compared with those with individual clients in hospitals. The difference that usually seems most significant to the nurse who is learning to make home visits is the fact that the nurse has less control over the family’s environment and health-related behavior ( McNaughton, 2000 ). The relationship usually extends for a longer period. A more interdependent relationship develops between the community/public health nurse and the family throughout all steps of the nursing process. Families Retain Much Control The family can control the nurse’s entry into the home by explicitly refusing assistance, establishing the time of the visit, or deciding whether to answer the door. Unlike hospitalized clients, family members can just walk away and not be home for the visit. One study of home visits to high-risk pregnant women revealed that younger and more financially distressed women tended to miss more appointments for home visits ( Josten et al., 1995 ). Being rejected by the family is often a concern of nurses who are learning to conduct home visits. As with any relationship, anxiety can exist in relation to meeting new, unknown families. Families may actually have similar feelings about meeting the nurse and may wonder what the nurse will think of them, their lifestyle, and their health care behavior. A helpful practice is to keep your perspective; if the clients are home for your visit, they are at least ambivalent about the meeting! If they are at home to answer the door, they are willing to consider what you have to offer. Most families involved with home care of the ill have requested assistance. Because only a few circumstances exist (as previously discussed) in which nursing care can be forced on families, the nurse can view the home visit as an opportunity to explore voluntarily the possibility of engaging in relationships ( Byrd, 1995 ). The nurse is there to offer services and engage the family in a dialogue about health concerns, barriers, and goals. As with all nurse–client relationships, the nurse’s commitment, authenticity, and caring constitute the art of nursing practice that can make a difference in the lives of families. Just as not all individuals in the hospital are ready or able to use all of the suggestions made to them, families have varying degrees of openness to change. If after discussing the possibilities the family declines either overtly or through its actions, the nurse has provided an opportunity for informed decision making and has no further obligation. Goals of Nursing Care Are Long Term A second major difference in nurse relationships with families is that the goals are usually more long term than are those with individual clients in hospitals. Clients may be in hospice programs for 6 months. A family with a member who has a recent diagnosis of hypertension may take 6 weeks to adjust to medications, diet, and other lifestyle changes. A school-aged child with a diagnosis of attention deficit disorder may take as long as half the school year to show improvement in behavior and learning; sometimes, a year may be required for appropriate classroom placement. For some nurses, this time frame is judged to be slow and tedious. For others, the time frame is seen as an opportunity to know a family in more depth, share life experiences over time, and see results of modifications in nursing care. For nurses who like to know about a broad range of health and nursing issues, relationships with families stimulate this interest. Having had some experience in home visiting is helpful for nurses who work in inpatient settings; it allows them to appreciate the scope and depth of practice of community/public health nurses who make home visits as a part of their regular practice. These experiences can sensitize hospital nurses to the home environments of their clients and can result in better hospital discharge plans and referrals. Because ultimate goals may take a long time to achieve, short-term objectives must be developed to achieve long-term goals. For example, a family needs to be able to plan lower-calorie menus with sufficient nutrients before weight loss is possible; a parent may need to spend time with a child daily before unruly behavior improves. Nursing interventions in a hospital setting become short-term objectives for client learning and mastery in the home setting. In an inpatient setting, giving medications as prescribed is a nursing action. In the home, the spouse giving medications as prescribed becomes a behavioral objective for the family; the related nursing action is teaching. Human progress toward any goal does not usually occur at a steady pace. For example, you may start out bicycling faithfully three times a week and give up abruptly. Similarly, clients may skip an insulin dose or an oral contraceptive. A family may assertively call appropriate community agencies, keep appointments, and stop abruptly. Families can be committed to their own health and well-being and yet not act on their commitment consistently. Recognizing that setbacks and discouragement are a part of life allows the community/public health nurse to be more accepting of reality and have the objectivity to renegotiate goals and plans with families. Box 11-4 includes evidence-based ways to foster goal accomplishment. Box 11-4 Best Practices in Fostering Goal Accomplishment With Families 1.  Share goals explicitly with family. 2.  Divide goals into manageable steps. 3.  Teach the family members to care for themselves. 4.  Do not expect the family to do something all of the time or perfectly. 5.  Be satisfied with small, subtle changes. 6.  Be flexible. Changes are sometimes subtle or small. Success breeds success, at least motivationally. The short-term goals on which everyone has agreed are important to make clear so that the nurse and the family members have a common basis for evaluation. Goals can be set in a logical sequence, in small steps, to increase the chance of success. In an inpatient setting, the skilled nurse notices the subtle changes in client behavior and health status that can warn of further disequilibrium or can signal improvement. Similarly, during a series of home visits, the skilled nurse is aware of slight variations in home management, personal care, and memory that may presage a deteriorating biological or social condition. Nursing Care Is More Interdependent with Families Because families have more control over their health in their own homes and because change is usually gradual, greater emphasis must be placed on mutual goals if the nurse and family are to achieve long-term success. Except in emergency situations, the client determines the priority of issues. A parent may be adamant that obtaining food is more important than obtaining their child’s immunization. A child’s school performance may be of greater concern to a mother than is her own abnormal Papanicolaou (Pap) smear results. Failure of the nurse to address the family’s primary priority may result in the family perceiving that the nurse does not genuinely care. At times, the priority problem is not directly health related, or the solution to a health problem can be handled better by another agency or discipline. In these instances, the empathic nurse can address the family’s stress level, problem-solving ability, and support systems and make appropriate referrals. When the nurse takes time to validate and discuss the primary concern, the relationship is enhanced. Families are sometimes unaware of what they do not know. The nurse must suggest health-related topics that are appropriate for the family situation. For example, a young mother with a healthy newborn may not have thought about how to determine when her baby is ill. A spouse caring for his wife with Alzheimer disease may not know what safety precautions are necessary. Community/public health nurses seek to enhance family competence by sharing their professional knowledge with families and building on the family’s experience ( Reutter & Ford, 1997 ; SmithBattle, 2009 ). Flexibility is a key. Because visits occur over several days to months, other events (e.g., episodic illnesses, a neighbor’s death, community unemployment) can impinge on the original plan. Family members may be rehospitalized and receive totally new medical orders once they are discharged to home. The nurse’s clarity of purpose is essential in identifying and negotiating other health-related priorities after the first concerns have been addressed ( Monsen, Radosevich, Kerr, & Fulkerson, 2011 ). Increasing nurse–family relatedness What promotes a successful home visit? What aspects of the nurse’s presence promote relatedness? What structures provide direction and flexibility? The nursing process provides a general structure, and communication is a primary vehicle through which the nursing process is manifested. The foundation for both the nursing process and communication is relatedness and caring ( ANA, 2003 ; McNaughton, 2005 ; Roach, 1997 ; SmithBattle, 2009 ; Watson, 2002 ; Watson, 2005 ). Fostering a Caring Presence Nursing efforts are not always successful. However, by being concerned about the impact of home visits on the family and by asking questions regarding her or his own motivations, the nurse automatically increases the likelihood that home visits will be of benefit to the family. The nurse is acknowledging that the intention is for the relationship to be meaningful to both the nurse and the family. Building and preserving relationships is a central focus of home visiting and requires significant effort ( Heaman et al., 2007 ; McNaughton, 2000 , 2005 ). The relatedness of nurses in community health with clients is important ( Goldsborough, 1969 ; SmithBattle, 2009 ; Zerwekh, 1992 ). Involvement, essentially, is caring deeply about what is happening and what might happen to a person, then doing something with and for that person. It is reaching out and touching and hearing the inner being of another…. For a nurse–client relationship to become a moving force toward action, the nurse must go beyond obvious nursing needs and try to know the client as a person and include him in planning his nursing care. This means sharing feelings, ideas, beliefs and values with the client…. Without responsibility and commitment to oneself and others…[a person] only exists. It is through interaction and meaningful involvement with others that we move into being human ( Goldsborough, 1969 , pp. 66-68). Mayers (1973, p. 331) observed 16 randomly selected nurses during home visits to 37 families and reported that “regardless of the specific interaction style [of each nurse], the clients of nurses who were client-focused consistently tended to respond with interest, involvement and mutuality.” A client-focused nurse was observed as one who followed client cues, attempted to understand the client’s view of the situation, and included the client in generating solutions. Being related is a contribution that the nurse can make to the family, independent of specific information and technical skills, a contribution that students often underestimate. Although being related is necessary, it is inadequate in itself for high-quality nursing. A community/public health nurse must also be competent. Community/public health nursing also depends on assessment skills, judgment, teaching skills, safe technical skills, and the ability to provide accurate information. As a community/public health nurse’s practice evolves, tension always exists between being related and doing the tasks. In each situation, an opportunity exists to ask, “How can I express my caring and do (perform direct care, teach, refer) what is needed?” Barrett (1982) and Katzman and colleagues (1987) reported on the differences that students actually make in the lives of families. Barrett (1982) demonstrated that postpartum home visits by nursing students reduced costly postpartum emergency department and hospital visits. Katzman and co-workers (1987) considered hundreds of visits per semester made by 80 students in a southwestern state to families with newborns, well children, pregnant women, and members with chronic illnesses. Case examples describe how student enthusiasm and involvement contributed to specific health results. Everything a nurse has learned about relationships is important to recall and transfer to the experience of home visiting. Carl Rogers (1969) identified three characteristics of a helping relationship: positive regard, empathy, and genuineness. These characteristics are relevant in all nurse–client relationships, and they are especially important when relationships are initiated and developed in the less-structured home setting. Presence means being related interpersonally in ways that reveal positive regard, empathy, genuineness, and caring concern. How is it possible to accept a client who keeps a disorderly house or who keeps such a clean house that you feel as if you are contaminating it by being there? How is it possible to have positive feelings about an unmarried mother of three when you and your partner have successfully avoided pregnancy? Having positive regard for a family does not mean giving up your own values and behavior (see Chapter 10 ). Having positive regard for a family that lives differently from the way you do does not mean you need to ignore your past experiences. The latter is impossible. Rather, having positive regard means having the ability to distinguish between the person and her or his behavior. Saying to yourself, “This is a person who keeps a messy house” is different from saying, “This person is a mess!” Positive regard involves recognizing the value of persons because they are human beings. Accept the family, not necessarily the family’s behavior. All behavior is purposeful; and without further information, you cannot determine the meaning of a particular family behavior. Positive regard involves looking for the common human experiences. For example, it is likely that both you and client family members experience awe in the behavior of a newborn and sadness in the face of loss. Empathy is the ability to put yourself in someone else’s shoes and to be able to walk in her or his footsteps so as to understand her or his journey. “Empathy requires sensitivity to another’s experience…including sensing, understanding, and sharing the feelings and needs of the other person, seeing things from the other’s perspective” according to Rogers (cited in Gary & Kavanagh, 1991 , p. 89). Empathy goes beyond self and identity to acknowledge the essence of all persons. It links a characteristic of a helping relationship with spirituality or “a sense of connection to life itself” ( Haber et al., 1987 , p. 78). Empathy is a necessary pathway for our relatedness. However, what does understanding another person’s experience mean? More than emotions are involved. A person’s experience includes the sense that she or he makes of aspects of human existence ( SmithBattle, 2009 ; van Manen, 1990 ). Being understood means that a person is no longer alone ( Arnold, 1996 ). Being understood provides support in the face of stress, illness, disability, pain, grief, and suffering. When a client feels understood in a nurse–client partnership (side-by-side relationship), the client’s experience of being cared for is enhanced ( Beck, 1992 ). To understand another person’s experience, you must be able to imagine being in her or his place, recognize commonalities among persons, and have a secure sense of yourself ( Davis, 1990 ). Being aware of your own values and boundaries is helpful in retaining your identity in your interactions with others. To understand another individual’s experience, you must also be willing to engage in conversation to negotiate mutual definitions of the situation. For example, if you are excited that an older person is recovering function after a stroke, but the person’s spouse sees only the loss of an active travel companion, a mutual definition of the situation does not exist. Empathy will not occur unless you can also understand the spouse’s perspective. As human beings, we all like to perceive that we have some control in our environment, that we have some choice. We avoid being dominated and conned. The nurse’s genuineness facilitates honesty and disclosure, reduces the likelihood that the family will feel betrayed or coerced, and enhances the relationship. Genuineness does not mean that you speak everything that you think. Genuineness means that what you say and do is consistent with your understanding of the situation. The nurse can promote genuine self-expression in others by creating an atmosphere of trust, accepting that each person has a right to self-expression, “actively seeking to understand” others, and assisting them to become aware of and understand themselves ( Goldsborough, 1969 , p. 66). When family members do not believe that being genuine with the nurse is safe, they may tell only what they think the nurse would like to hear. This action makes developing a mutual plan of care much more difficult. The reciprocal side of genuineness is being willing to undertake a journey of self-expression, self-understanding, and growth. Tamara, a recent nursing graduate, wrote about her growing self-responsibility: “Although I felt out of control, I felt very responsible. I took pride in knowing that these families were my families, and I was responsible for their care. I was responsible for their health teaching. This was the first semester where there was no a faculty member around all day long. I feel that this will help me so much as I begin my nursing career. I have truly felt independent and completely responsible for my actions in this clinical experience.” This student, who preferred predictable environments, was able to confront her anxiety and anger in environments in which much was beyond her control. A mother was not interested in the student’s priorities. A family abruptly moved out of the state in the middle of the semester. Nonetheless, the student was able to respond in such circumstances. She became more responsible, and she was able to temper her judgment and work with the mother’s concern. When the family moved, the student experienced frustration and anger that she would not see the “fruits of her labor” and that she would “have to start over” with another family. However, her ability to respond increased because of her commitment to her own growth, relatedness with families, and desire to contribute to the health and well-being of others. In a context of relating with and advocating for the family, the relationship becomes an opportunity for growth in both the nurse’s and the family’s lives ( Glugover, 1987 ). Imagine standing side-by-side with the family, being concerned for their well-being and growth. Now imagine talking to a family face-to-face, attempting to have them do things your way. The first image is a more caring and empathic one. Creating Agreements for Relatedness How can communications be structured to increase the participation of family members? Without the family’s engagement, the community/public health nurse will have few positive effects on the health behavior and health status of the family and its members. Nurses are expert in caring for the ill; in knowing about ways to cope with illness, to promote health, and to protect against specific diseases; and in teaching and supporting family members. Family members are experts in their own health. They know the family health history, they experience their health states, and they are aware of their health-related concerns. Through the nurse–family relationship, a fluid process takes place of matching the family’s perceived needs with the nurse’s perceptions and professional judgments about the family’s needs. Paradoxically, the more skilled the nurse is in forgetting her or his own anxiety about being the good nurse, the more likely the nurse is to listen to the family members, validate their reality, and negotiate an adequate, effective plan of care. One study of home visits revealed that more than half of the goals stated by public health nurses to the researcher could not be detected, even implicitly, during observations of the home visits. Therefore, half the goals were known only to the nurse and were, therefore, not mutual. The more specifically and concretely the goals were stated by the nurse to the researcher, the greater would be the likelihood that the clients understood the nurse’s purposes ( Mayers, 1973 ). To negotiate mutual goals, the client needs to understand the nurse’s purposes. The initial letter, telephone call, or home visit is the time to share your ideas with the family about why you are contacting them. During the first interpersonal encounter by telephone or home visit, explore the family members’ ideas about the purpose of your visits. This phase is essential in establishing a mutually agreed on basis for a series of encounters. As a result of her qualitative research study of maternal-child home visiting, Byrd (2006, p. 271) stated that “people enter…relationships with the expectation of receiving a benefit” that may be information, status, service, or goods. Byrd asserted that it is important for nurses to create client expectations through previsit publicity about (marketing) home-visiting programs. Also it is essential to understand the expectations of the specific persons being visited. Family members may have had previous relationships with community/public health nurses and students. Family members may be able to share such information as what they found to be most helpful, why they are willing to work with a nurse or student again, and what goals they have in mind. Other families who have had no prior experience with community/public health nurses may not have specific expectations. Asking is important. A contract is a specific, structured agreement regarding the process and conditions by which a health-related goal will be sought. In the beginning of most student learning experiences, the agreement usually entails one or more family members continuing to meet with the nursing student for a specific number of visits or weeks. Initially, specific goals and the nurse’s role regarding health promotion and illness prevention may be unclear. (If this role was already clear, undergoing a period of study and orientation would be unnecessary.) Initially, the agreement may be as simple as, “We will meet here at your house next Tuesday at 11:00  AM until around noon to continue to discuss what I can offer related to your family’s health and what you’d like. We can get to know each other better. We can talk more about how the week has gone for you and your family with your new baby.” These statements are the nurse’s oral offer to meet under specific conditions of time and place. The process of mutual discussion is mentioned. The goals remain general and implicit: fostering the family’s developmental task of incorporating an infant and fostering family–nurse relatedness. For the next week’s contract to be complete, the family member or members would have to agree. The most important element initially is whether agreement about being present at a specific time and place can be reached. If 11:00  AM is not workable for the family, would another time during the day when you both are available be mutually agreeable? For families who do not focus as much on the future, a community/public health nurse needs to be more flexible in scheduling the time of each visit. The word contract often implies legally binding agreements. This is not true of nurse–client contracts. Nurses are legally and ethically bound to keep their word in relation to nursing care; clients are not legally bound to keep their agreements. However, establishing a mutual agreement for relating increases the clarity of who will do what, when, where, for what purposes, and under what conditions. Because of some people’s negative response to the word contract, agreement or discussion of responsibilities may be better. An agreement may be oral or written. For some families, written agreements, especially early in the relationship, may be perceived as a threat. For example, a family that has been conned by a household repair scheme may be very suspicious of written agreements. Family members who are not legal citizens may not want to sign an agreement for fear that if it is not kept they will be punished. Do not push for a written agreement if the family is uncomfortable. If you do notice such discomfort, this may be a good opportunity to explore their fears. Written agreements are required when insurance is paying for the care provided by nurses working with home health agencies and to comply with the Health Insurance Portability and Accountability Act (HIPAA). Helgeson and Berg (1985) describe factors affecting the contracting process by studying a small convenience sample of 15 community/public health nursing students and 12 client responses. Of the 11 students who introduced the idea of a contract to clients, all did so between the second and the fourth visits of a 16-week series of visits; 9 students did so orally rather than in writing. No specific time was the best. Eight clients were very receptive to the idea because they liked the idea of establishing goals to work toward and felt the contract would serve as a reminder of their responsibility. The very process of developing a draft agreement to present to families provides the novice practitioner with an increased focus of care, clarity of nurse and family responsibilities and activities, and a basis from which to negotiate modifications in client behaviors ( Helgeson & Berg, 1985 ; Sheridan & Smith, 1975 ). The Home Visiting Evaluation Tool in Figure 11-3 lists nurse behaviors that are appropriate for home visits, especially initial home visits and those early in a series of home visits. Nurses can use this list as a preplanning tool to identify their readiness to conduct a specific home visit. Additionally, students and community/public health nurses have used the tool to evaluate initial home visits and identify their behaviors that were omitted and needed to be included on the second home visits. The tool also has been used jointly as an evaluation tool by nurses and supervisors and students and faculty. Figure 11-3 Home Visiting Evaluation Tool. (From Chichester, M., & Smith, C. [1980]. Home visiting evaluation tool [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.)

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reduction in hospital admissions

reduction in mortality

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Discover the benefits.

  • For Patients + Caregivers
  • For Community Providers
  • For Partners

Health care in your home

Old-fashioned house calls by medical doctors, nurse practitioners and physician assistants bring modern medicine to you. Feel better and stay well at home.

Covered by your health plan

The Landmark program works with health plans to improve access to care for patients with multiple chronic conditions. Landmark’s team-based care is available often at no cost to you.

Keep your current doctors

Landmark coordinates its care with your primary care provider, specialists and other community resources. Landmark provides added support to those who need it most.

Available 24 / 7

Our provider-staffed call center answers any time of the day or night. We also provide urgent visits to help you avoid unnecessary trips to the emergency room.

No waiting room

With Landmark house calls, you won’t need transportation to clinics and hospitals, and you avoid waiting rooms and exposure to germs.

Reduced stress

Patients and caregivers enjoy peace of mind with Landmark support. Landmark cares for the whole patient.

Landmark house calls put patients at the center of health care.

Collaborative care for complex patients.

Landmark’s community-based mobile providers bring coordinated care to patients with multiple chronic health conditions. We augment your care in the patient’s home.

Covered by health plans

The Landmark program is included in eligible patients’ health plans to improve care coordination and healthcare access for home-limited patients.

You remain the primary care provider

Landmark care is coordinated directly with you. Our providers reinforce your care plan in the home through physician-led interdisciplinary care teams.

Access our interdisciplinary team

Landmark’s interdisciplinary care team is available to you and your patients, including behavioral health specialists, social workers, palliative care specialists, nurse care managers and pharmacists.

Reduce administrative burden

We can help your highest acuity patients by managing post-acute care, home health orders, face-to-face encounters, and more.

24 / 7 availability

You can reach us any time, including weekends and holidays. We do urgent home visits to intervene if your patient experiences a chronic disease exacerbation.

Landmark supports your patients with complex health and social needs.

Chronic care management.

We’re one of the nations’ leading risk-bearing medical groups. We focus on giving your most complex members care when they need it, right in their home.

Over 250,000 patients across the country

We bear risk for over 250,000 complex, chronic patients, spanning Medicare Advantage, Medicaid, Dual, and Commercial, populations.

Behavioral, social and palliative care

Our team of multidisciplinary clinicians may include behavioral health specialists, palliative care practitioners, social workers, nurse care managers, dietitians and pharmacists.

Urgent in-home visits

One in four of our home visits is urgent. We bring medical care to your members when they need it, to avoid unnecessary emergency room trips and hospitalizations.

Built-for-purpose infrastructure

Our technology platform is designed specifically to support the medically vulnerable, clinically complex population.

Meaningful outcomes

Landmark commonly helps health plans achieve 4- and 5-star performance on Medicare STARS clinical quality of care, while caring for the most complex patients.

Landmark provides care for complex, chronic patients to positively impact access, satisfaction, outcomes and cost.

It was great

Great visit

I gave Dr. Rezo, the Landmark doctor, five stars because she was thorough and professional. I have found that the one hour home visit, which is in addition to an annual physical with my primary doctor, is helpful because the doctor has the time to answer health questions that one's primary doctor just does not have the time for. I have learned valuable information about my health concerns from Dr. Rezo.

Practice health care the way you always wanted — with those who need it most.

Expert insights.

Prioritizing Mental Health as a Universal Human Right image

Prioritizing Mental Health as a Universal Human Right

By: Neltada Charlemagne, DNP, APRN, PMHNP-BC, PHN, BHC

Outsmart Unplanned Medical Costs: 10 Steps for Managing the Unexpected image

Outsmart Unplanned Medical Costs: 10 Steps for Managing the Unexpected

Older adults can safeguard themselves from the physical, mental and emotional toll of unexpected medical costs.

Optum Care Network – Monarch and Landmark Health bring care to you at home. image

Optum Care Network – Monarch and Landmark Health bring care to you at home.

Optum Care Network – Monarch has teamed up with Landmark to deliver in-home medical care to members with multiple chronic conditions.

Have questions about Landmark? We’d love to hear from you.

Why Home Visiting?

The evidence base for home visiting, including its cost effectiveness, is strong and growing. Below are examples of home visiting's demonstrated impact on critical needs and why home visiting is a key service strategy for improving infant, maternal, and family outcomes.

Home visiting has measurable benefits.

By meeting families where they are, home visiting programs have demonstrated short- and long-term impacts on the health, safety, and school-readiness of children; maternal health; and family stability and financial security. Home visitors are able to meet with families in their home and provide culturally competent, individualized needs assessments and services. This results in measured improvements in the following outcomes:

Healthy Babies 

Home visitors work with expectant mothers to access prenatal care and engage in healthy behaviors during and after pregnancy. For example—

  • Pregnant participants are more likely to access prenatal care and carry their babies to term.
  • Home visiting promotes infant caregiving practices like breastfeeding, which has been associated with positive long-term outcomes related to cognitive development and child health.

Safe Homes and Nurturing Relationships 

Home visitors provide caregivers with knowledge and training to reduce the risk of unintended injuries. For example—

  • Home visitors teach caregivers how to “baby proof” their home to prevent accidents that can lead to emergency room visits, disabilities, or even death.
  • They also teach caregivers how to engage with children in positive, nurturing ways, thus reducing child maltreatment .

Optimal Early Learning and Long-Term Academic Achievement

Home visitors offer caregivers timely information about child development and the importance of early childhood in establishing the building blocks for life. For example—

  • They help caregivers recognize the value of reading and other activities for early learning. This guidance translates to improvements in children’s early language and cognitive development, as well as academic achievements in grades 1 through 3 .

Supported Families

Home visitors make referrals and coordinate services for children and caregivers, including job training and education programs, early care and education services, and— if needed—mental health and domestic violence resources. Research shows that—

  • Compared with their counterparts, caregivers enrolled in home visiting have higher monthly incomes, are more likely to be enrolled in school , and are more likely to be employed .

Home visiting is cost effective.

Studies have found a return on investment of $1.80 to $5.70 for every dollar spent on home visiting. This strong return on investment is consistent with established research on other types of early childhood interventions.

Learn more in our Primer and annual Yearbook .

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Stay up to date on the latest home visiting information.

Make the Most of a Nursing Home Visit During the Pandemic

Keep these tips in mind to bring cheer to your loved one.

This article is based on reporting that features expert sources.

The Visitors' Guide to Nursing Homes

Nursing home visits are challenging at any time, and even more so during the pandemic. Most nursing homes now have strict visiting rules in place to protect residents from exposure to COVID-19, such virtual, window or drive-up visits (with visitors staying in their cars). Some nursing homes allow for socially distanced outdoor or indoor visits (although indoor visits are limited to isolated areas designated for family, not visits in the resident's room).

Walking around nursing home grounds in masks due to coronavirus health restrictions.

Getty Images

No matter what form the visit takes, you’ll want to make the most of the time with your loved one. "It is very lonely for seniors in nursing homes today and they crave validation, fond memories of family events and affirmation of their value and dignity," says Teri Dreher, a board-certified patient advocate and owner of a patient advocate company in Chicago.

Prepare for a Good Nursing Home Visit

Do your homework before the visit. To prepare, you can:

  • Find out about the rules and restrictions. Ask what kind of visit is permitted and how much time you're allowed.
  • Consider the time of day. Does your loved one need to stick to a schedule of meals or naps that can’t be interrupted? Does the visit need to be coordinated with the weather?
  • Ask if you can bring along a friend or a family member, such as your spouse, sibling or child. Visits are a great time for older adults to see their grandchildren , even if it's just through a window.
  • Make arrangements for potential challenges. These may include a loved one’s soft voice that you may not hear from 6 feet away in a socially distanced visit or poor hearing that may keep your loved one from understanding you. Nonprescription assistive hearing devices or face masks with a clear “window” (if your loved needs to read lips) can foster better communication.
  • Think about questions you'd like to ask staff during the visit. “Make certain all of your questions for the staff are prepared well in advance before you arrive. Make your questions succinct; thank the workers and always be polite. Health care workers in nursing homes today are under a lot of pressure and have more restrictions on their time,” Dreher advises.

Make Observations

During your visit – whether it’s in person, through a window or via video call – take note of your loved one’s health . “Observation, even if just through a window, can give you some idea of your loved one’s physical condition – for instance, if their clothes are clean, if their hair is brushed or if they’ve lost weight ,” says Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care.

Grant says it’s important to observe the facility (for example, is it clean or does it smell?) and staff behavior. “Are they wearing face masks? Are they washing their hands or using hand sanitizer before and after contact with your loved one?” Grant asks.

She also recommends asking your loved about his or her experience in the nursing home, such as:

  • Are there enough staff to help you when you need it?
  • How do you spend your day? Are you getting outside your room?
  • How have your meals been?
  • Are staff giving you baths or showers and changing your clothes daily?

What to Do Together

The nature of visiting restrictions may determine what you can do. You may be permitted to stroll or roll (if your loved one is in a wheelchair) around the nursing home grounds. If that’s not possible, perhaps you can still:

  • Play a video game (such as a card game) while sitting 6 feet apart. Electronic devices such as iPads can make that work.
  • Listen to favorite music together.
  • Sing songs on a video call.
  • Use a video call to give your loved one a tour of something (your house or yard) or have grandchildren demonstrate an activity they’re involved in (playing a musical instrument, for example).
  • Assist your loved one with errands. Make a shopping list together so you can go out and get needed items.
  • Present your loved one with something special. Find out what’s permitted in advance, and consider bringing some special sweets, a meal from your loved one’s favorite restaurant or meaningful objects (label them first). “Framed pictures of family members, new pajamas, a soft blanket and favorite magazines are nice gifts. Anything you can do to bring love and joy will be very appreciated,” Dreher says.

How do you decide what to do? “Take cues from your loved one and let them guide the visit,” Grant advises. “Remember the visit is about them and their needs.”

What to Talk About

Conversation will take center stage during your visit, even if your loved one isn’t able to chat much anymore. Some guidelines:

  • Express positive emotions. “Tell your loved one how good it is to see them, how much you’ve missed them and how much you’ve thought of them,” Grant recommends. “If they're excited to talk to you, let them lead the conversation.”
  • Keep it light. “Try to keep the visit social and not bring up stressful topics,” Dreher suggests.
  • Be aware of who's steering the conversation. "If they're excited to talk to you, let them lead the conversation. They may just enjoy sharing their thoughts and experiences. Alternatively, if they're quiet or withdrawn, you can lead the conversation, sharing positive experiences and thoughts," Grant advises. "Try to answer the questions they ask and remember to keep the focus on their needs."
  • Reminisce about happy times , such as previous holidays, special milestones or nice things the person has done for you in the past that you still appreciate.
  • Bring your loved one up to date about positive things happening in your life or your family members’ lives. Let your loved one know what’s happening outside of the nursing home walls so they can feel involved in your life.
  • Remind them of things they can look forward to. Having an eye on something positive in the future brings purpose and helps people get through tough times.

If your loved one wants to talk about something serious, listen and show empathy. It could be a helpful cathartic moment for them.

Some Final Advice

Remember that your loved one is in a nursing home because he or she is frail and needs lots of assistance to get through the day. Try to be gentle:

  • Be sensitive to memory changes . If your loved one has any cognitive impairment, don’t press them about people or past experiences if they don’t remember. If they repeat themselves or ask the same questions, be patient.
  • Make a "soft" exit. It can be hard to leave when your visiting time is over. Consider coordinating your visit with an upcoming activity, such as a nap or lunch. Once your loved one is absorbed in what's happening, your departure won't feel so upsetting.
  • Share feedback with staff. Report any concerns to a nurse or go up the chain of command to the nursing director or administrator.

And schedule another visit soon. It will bring meaning to your loved one and give them a reason to keep going, especially during the pandemic.

The Best Ways for Nursing Home Residents to Stay Active

Daily stretching exercise routine for a group of cheerful elderly people at an old age home.

The U.S. News Health team delivers accurate information about health, nutrition and fitness, as well as in-depth medical condition guides. All of our stories rely on multiple, independent sources and experts in the field, such as medical doctors and licensed nutritionists. To learn more about how we keep our content accurate and trustworthy, read our  editorial guidelines .

Dreher is the president of NShore Patient Advocates LLC in Chicago.

Grant is the director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care.

Tags: senior health , nursing homes , caregiving , aging , family health , senior citizens , health , health care , assisted living

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Home Healthcare, Hospice & Community Services Logo

Visiting Nurses

Nursing, Behavioral Health, Home Support, Palliative Care, and Therapy

Continuing the tradition of your visiting nurse.

When a VNA nurse, social worker, therapist, or caregiver arrives at your door, you can expect expert compassionate care. We believe everyone, no matter their station, deserves to live their life at their optimal level of health, well-being, and independence, according to their personal beliefs and choices. People turn to the VNA during times of illness or injury so you can remain where you most want to be — at home.

Whether it takes a few days or a number of weeks, your home care team will be there to provide caring support and assistance. Our staff strives to help you recover comfortably and safely at home, as well as help your caregivers manage your care.

Highly Skilled Care from the Comfort of Home

The kind of care you receive at home is crucial to recovery. Through a combination of evidence-based best practices, a patient-centered team approach, and education for your caregivers, our home health staff members are committed to providing highly skilled care right in your home.

The VNA leverages over 100 years of expert care to offer a wide variety of services to meet the needs of our community.

Signs that might indicate a need for home health care:

  • Change in ability to complete daily living activities
  • Change in appetite, weight loss or difficulty in swallowing
  • Recent hospitalization or surgery
  • Dependence on a caregiver
  • Difficulty managing medications

New medical diagnosis and a need for teaching

Falls or increasing risk of falls

Wound care needs

Difficulty with pain

Difficulty in breath

Specific care offered by our skilled nurses and expert caregivers includes:

Skilled Nursing (assessments, teaching, intervention, etc.)

Physical Therapy

Occupational Therapy

  • Medical Social Work

Home Health Aides

Home Support Providers

Speech Therapy

Palliative Care 

Behavioral Health Care

Fall Prevention

Ostomy Care

Medication Management

Telehealth Visits

Physician-ordered mother and child visits

Frequently Asked Questions

What is the hcs service area.

Some or all of HCS programs are offered in 52 towns in southwestern New Hampshire. Visit our Service Area page for more information.

What is Home Health Care?

Home Health Care encompasses a wide range of health care services provided in the patient’s home with the purpose of maintaining a patient’s optimal level of health, well-being, and independence, according to their personal beliefs and choices. Home care is a collaborative effort involving caregivers, physicians, and an interdisciplinary home care team. It is a cost-effective alternative to extended hospitalization, rehabilitation, or a nursing home stay. Patients are usually more comfortable in their own home and studies have shown patients recover quicker at home.

What are the Medicare criteria for Home Healthcare?

In order to receive home health care services under Medicare, the patient must require:

  • Skilled, intermittent nursing care, physical therapy, or speech therapy
  • Have a physician’s order for home health care
  • AND be homebound. Medicare considers a person to be homebound if leaving the home would require a considerable effort and if they have a condition due to an illness or injury which restricts the ability to leave home except with the aid of devices or assistance of another person. Homebound patients may leave their home if absences from the home are infrequent or for periods of relatively short duration.

What can I expect at an admission visit?

During your first visit, the nurse or therapist will share a lot of information with you. They will also make sure the information we have about you is correct. The first visit may take up to two hours. The nurse or therapist will talk about:

  • Your discharge paperwork and/or doctor’s orders
  • Your role as a patient/caregiver, including payment responsibilities
  • Your “Plan of Care,” including the services you will receive and how often team members will visit
  • Your goals for home care
  • Your medicines, including side effects and how and when to take them
  • Your risk for falling
  • How to contact the office with question or concerns

What is a typical visit like?

Because everyone’s situation is different, there is no typical visit. We work with you and your doctor to design a treatment plan based on your specific situation. The VNA team members spend as much time as they need with every patient to make sure they are getting the care needed to get healthy again.

How often will a clinician visit me?

Your specific needs and your insurance coverage will help to determine how often VNA team members visit you. The total number of visits scheduled depends on your specific needs. VNA team members visit patients an average of two to three times a week. Visits will happen less often as you improve.

How are visits scheduled?

A VNA team member will try to call you on the evening before to schedule a visit for the next day. However, sometimes they may not be able to call until the morning of the visit. We are sorry when we cannot offer more notice. We get new patients added to the schedule every day. Sometimes, they are very sick and require urgent visits. This causes our homecare team members’ schedules to change. They will always try to give you an estimated time when they will arrive. Please answer your phone or return our calls promptly.

Will I have the same nurse and/or therapist all the time?

We understand the importance of building trust with your caregiving team. That is why we try our best to schedule the same team of clinicians to visit your home every time. Changes in time of day, day of week, and after-hours may impact our ability to schedule the same nurse or therapist, so we cannot guarantee the same provider every time.

How can I pay for this?

Home Healthcare, Hospice & Community Services accepts Medicare, Medicaid, and many private insurances. Home Healthcare, Hospice & Community Services does not deny anyone the care necessary for their health and safety solely on the basis of ability to pay. If you do not have insurance coverage, you may be eligible for service at a reduced fee or free care.

How do I make a referral?

If you or someone you know could use the expert skilled care provided by the VNA, please contact us by calling 603-352-2253  or 800-541-4145 or by emailing us at  [email protected] . Please do not email protected health information. You can also view our “ Make a Referral ” page to learn exactly what is needed for a complete referral to any of our programs.

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The Rehabilitation Team at HCS works with your physician and orthopedic specialist to help you recover, improve, and maintain your safety and independence!


Home Healthcare, Hospice & Community Services offers comprehensive services to the residents of southwestern New Hampshire. Services include:

Hospice at HCS

Palliative Care Support

Rehabilitation Therapies

Healthy Starts Program

Nutrition for Seniors


Castle Center Life Enrichment Day Program

Medical Social Work/Outreach

Wellness Programs

Financial Information

Home Healthcare, Hospice & Community Services accepts Medicare, Medicaid and many private insurances. Home Healthcare, Hospice & Community Services does not deny anyone the care necessary for their health and safety solely on the basis of ability to pay. If you do not have insurance coverage, you may be eligible for service at a reduced fee or free care.

For information or to make an appointment, please call 603-352-2253 .

  • Introduction
  • Conclusions
  • Article Information

The group SNF visits (A) captures regular primary care encounters within SNFs, and the outpatient visits group (B) captures visits with primary and specialty care clinicians who are not affiliated with SNFs.

The map for 2022 (D) depicts visits in January through June 2022.

High-use SNFs were defined as those in the top quartile by telemedicine use in 2020 for SNF or outpatient visits (depending on the analyzed outcome) and low-use SNFs as those in the bottom quartile.

eTable 1. Attrition of SNFs and their residents included in the study

eAppendix 1. List of included clinician specialties

eTable 2. List of place-of-service, procedure, and modifier codes to identify telemedicine visits

eTable 3. Characteristics of long- and short-term care residents in SNFs in 2020

eFigure 1. Telemedicine use for outpatient visits in SNF residents across US states in 2019-2022

eFigure 2. Count of SNF and outpatient visits delivered by telemedicine for short- and long-term SNF residents in 2019-2022

eTable 4. Top principal diagnoses groups in telemedicine visits in 2020-2021

eTable 5. Adjusted odds ratios of characteristics of SNFs in the top quartile by telemedicine use for SNF visits in 2020 and 2021

eTable 6. Characteristics of SNF visit providing clinicians in the top decile by telemedicine use in 2020-2021

eTable 7. Characteristics of patients who received at least one telemedicine visit during their SNF stay in 2020-2021

eFigure 3. Proportion of visits delivered by telemedicine in four examined clinical care scenarios for long-term care residents in high- and low- telemedicine use SNFs in 2018-2021

eAppendix 2. Testing of parallel trends for the outcomes before telemedicine expansion

eAppendix 3. Difference-in-differences in visit counts in 2018-2019 vs 2020-2021 in high vs low telemedicine adopting SNFs

eAppendix 4. Difference-in-differences models with a separate term for 2020 and 2021

Data Sharing Statement

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Ulyte A , Mehrotra A , Wilcock AD , SteelFisher GK , Grabowski DC , Barnett ML. Telemedicine Visits in US Skilled Nursing Facilities. JAMA Netw Open. 2023;6(8):e2329895. doi:10.1001/jamanetworkopen.2023.29895

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Telemedicine Visits in US Skilled Nursing Facilities

  • 1 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 2 Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3 Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 4 Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts

Question   How was telemedicine adopted in US skilled nursing facilities (SNFs) during the COVID-19 pandemic in 2020 to 2022?

Findings   In this cohort study of more than 4.4 million residents at 15 434 SNFs, telemedicine visits increased from 0.15% to 15% of routine SNF visits and 37% of other outpatient visits in SNFs in early 2020, before dropping again and stabilizing at 2% of routine SNF and 10% of outpatient visits by mid-2021. Higher telemedicine use was associated with improved access to psychiatry visits in SNFs.

Meaning   In this study, after transiently high use in 2020, telemedicine remained present in SNFs at lower levels by 2022, with higher use associated with more frequent psychiatry visits.

Importance   Telemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs.

Objective   To describe patterns of telemedicine use in SNFs.

Design, Setting, and Participants   This cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020.

Exposure   Telemedicine adoption at SNF after 2020.

Main Outcomes and Measures   Number and proportion of telemedicine SNF and outpatient visits.

Results   Across 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, −0.1% to 14.6%) or new specialist visits (−0.7%; 95% CI, −2.5% to 1.2%).

Conclusions and Relevance   In this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Telemedicine has long been regarded as a promising mechanism to improve access to health care in skilled nursing facilities (SNFs). 1 - 5 Clinicians are rarely on site at SNFs in the evening or over the weekend. 6 - 9 Medical issues that present during these off hours often result in unnecessary visits to the emergency department. 10 Further, SNF residents typically have to leave their facility to access specialty care, making access more challenging for residents with limited mobility. The resulting delays or absence of care contributes to avoidable hospitalizations and emergency care visits. 8 , 10 - 12

Despite recognition of its potential, 3 telemedicine use in SNFs was rare before 2020, and in the Medicare program, it was only reimbursable in rural communities for select types of visits. 4 This changed when Medicare expanded coverage at the start of the COVID-19 pandemic in early 2020. Telemedicine was allowed for any evaluation and management (E&M) visit for SNF residents, with the goals of limiting the spread of COVID-19 and safely expanding access to needed care. 4 , 13 , 14

Little is known about the potential effect of greater telemedicine use in SNFs, 15 - 18 including whether it could potentially alleviate long-standing gaps in access to specialists or urgent care after hours. As policymakers debate the future of telemedicine reimbursement beyond the COVID-19 emergency, understanding patterns of adoption can guide policy and regulations to help telemedicine improve access to care in SNFs.

We examined trends in telemedicine visits for Medicare SNF residents from January 2019 through June 2022. We profiled the characteristics of telemedicine visits in 2020 to 2021, including the SNFs, clinicians, and patients using it, and examined whether higher adoption of telemedicine was associated with relatively improved access to specialists, care over the weekend, and visits for residents with limited mobility.

The study was approved by the Office of Human Research Administration at Harvard T. H. Chan School of Public Health. The requirement for informed consent was waived because the data were deidentified. We followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for cohort studies.

We used 100% fee-for-service Medicare administrative claims and the Minimum Data Set version 3.0 files from 2018 to 2022 to identify short- and long-term SNF residents and their E&M visits and Master Beneficiary Summary files for resident characteristics. We added SNF characteristics from the Centers for Medicare & Medicaid Services Nursing Home Compare 19 data set (January 2020).

We identified postacute (short-term) SNF stays with Medicare Part A SNF claims and long-term care stays using dates obtained from Minimum Data Set assessment records from 2018 to 2022 (through June). Based on a validated algorithm, 20 , 21 beneficiaries were considered long-term care residents from the first SNF stay of which any portion was not covered by a Medicare Part A SNF claim (ie, recorded only in the Minimum Data Set). We excluded beneficiaries who did not have full coverage with traditional Medicare Part A or Part B at any point during their SNF stay. We also excluded SNF stays outside the 50 US states and Washington, DC (attrition is shown in eTable 1 in Supplement 1 ).

The study focused on E&M visits provided in person or via telemedicine for beneficiaries during SNF stays. We identified visits in the Carrier and Outpatient files using the Healthcare Common Procedure Coding System (HCPCS) codes defined as E&M care under the Restructured BETOS Classification System. 22 Evaluation-and-management critical care, hospital inpatient, observation care, and emergency department services were not included, and we limited services to those provided by prescribing, patient-facing specialists, such as physicians, nurse practitioners, and physician assistants (included specialties are listed in eAppendix 1 in Supplement 1 ).

We grouped the E&M visits into 2 mutually exclusive groups: (1) routine SNF visits (BETOS subcategory of E&M visits for nursing home services) and (2) other outpatient visits (all other included visits). SNF visits are federally required at regular intervals for all residents in SNFs serving Medicare patients, almost always happen at the facility, and are often delivered by SNF-affiliated clinicians. Apart from such SNF visits, residents can attend outpatient visits with primary or specialty care clinicians, which usually happen outside the facility and often with an established care clinician from before transfer to the SNF. 23 Because these 2 visit groups are distinct in their clinical purpose, regulations, and reimbursement, we analyzed them separately.

We identified telemedicine visits based on the place of service, HCPCS, or modifier codes recorded on claims (eTable 2 in Supplement 1 ). We extracted the primary diagnosis of each visit and grouped them into clinical domains. 24 Multiple SNF (or outpatient) visits by the same clinician for the same patient on a given day were considered just 1 SNF (or outpatient) visit. In the few cases of both telemedicine and in-person services recorded on the same day (eg, telemedicine visit in the Carrier file and in-person visit in the Outpatient file), the visit was considered telemedicine.

We hypothesized that telemedicine could effectively increase the number of accessible clinicians (especially during off hours), facilitate visits where physical examination is less necessary, and reduce barriers associated with transportation and initiating a new specialist relationship. To test these hypotheses, we examined 4 outcomes: (1) SNF visits on weekends; (2) outpatient visits for patients with limited mobility; (3) new specialist physician visits (identified with HCPCS codes 99201-5); and (4) outpatient and geriatric psychiatrist visits. Because the time of a visit is not captured in claims data, we used weekend dates to capture off-hours care.

We captured beneficiary characteristics, such as sex, age, race and ethnicity, reason for Medicare enrollment, dual Medicaid and Medicare enrollment, and comorbidities (identified with Chronic Conditions Data Warehouse flags) 25 and flagged beneficiaries who had any outpatient COVID-19 principal diagnosis (code U07.1) during their SNF stay. Race and ethnicity were self-reported at the time of Medicare enrollment and were included to identify potential disparities in telemedicine use. Resident mobility was considered limited for residents with total dependence for locomotion as recorded in the first valid Minimum Data Set assessment in the current or preceding year.

We extracted clinician gender, year of graduation, and zip code from the Centers for Medicare & Medicaid Services Provider Data Catalog. 26 We characterized SNFs by the proportion of their residents in 2020 who were dually eligible or of a specific race and ethnicity, urban or rural location, 27 ownership type (for-profit, not-for-profit, government), chain status, Nursing Home Compare 19 star rating, and staffing level (sum of registered nurse and licensed practical nurse hours per resident-day).

Based on highly concentrated telemedicine use for SNF visits across clinicians, we defined high users as clinicians in the top decile by telemedicine. Following a slightly less skewed distribution across SNFs, we defined high telemedicine-use SNFs as the top quartile of facilities by the proportion of telemedicine visits and low telemedicine-use SNFs as those in the bottom quartile. We used the start and end dates of SNF stays to calculate the number of SNF resident-days overall and during weekends, in order to account for differences in length of residence and express the outcomes per resident-year (365 days) or resident-month (30 days).

We compared the characteristics of patients, SNFs, and clinicians with high vs lower telemedicine use in 2020 to 2021. Given a highly skewed distribution of telemedicine use among SNFs and clinicians, we modeled the binary outcome of whether or not an SNF or clinician was a high telemedicine user with logistic regressions. We used stratified logistic regression to quantify resident characteristics associated with any telemedicine use within an SNF, with an offset (natural logarithm of SNF stay duration in days) to account for the higher probability of any visit (including telemedicine) during a longer stay. Given the changing nature of the COVID-19 pandemic, in a sensitivity analysis, we compared SNF characteristics predictive of high telemedicine use separately for 2020 and 2021. Data analysis was done with SAS version 7.15 (SAS Institute). Regression models with SNF fixed effects were run with Stata version 17 (StataCorp). Differences were considered statistically significant with 2-sided P  ≤ .05.

We tested whether higher uptake of telemedicine in SNFs was associated with improved access to care in 2020 to 2021 in 4 scenarios. Using a difference-in-differences approach, we compared high telemedicine-use SNFs in 2020 (for SNF or outpatient visits, depending on the studied outcome) to low-use SNFs. We included only residents in long-term care with at least 60 SNF days in a calendar year, because patients staying at SNFs long-term and receiving their main care there would be expected to be affected by changing care patterns within an SNF the most. We included only SNFs in continuous operation before and during the pandemic, defined as SNFs with 10 or more SNF visits and 10 or more outpatient visits in 2018-2019 and 2020-2021.

We modeled the number of visits per resident within a calendar year using linear regression adjusting for patient characteristics, year, the state where the SNF is located, SNF telemedicine-use category (high or low), and an interaction term between this category and period (2018-2019 or 2020-2021), which captures the difference-in-differences. We weighted the modeled patient-level observations by the numbers of days the resident spent in that SNF that year and clustered model errors by SNF. Parallel trends in the outcomes in high and low telemedicine-use SNFs were tested in 2018 to 2019. We compared the outcomes in 2020 and 2021 separately in a model with 2 interaction terms.

From January 2019 through June 2022, 2 761 128 short- and 2 147 944 long-term care residents (4 463 591 unique beneficiaries) stayed in 15 434 SNFs. In 2020, the mean (SD) age of short-term residents was 79.4 (10.7) years (80.0 [12.2] years for long-term residents; 79.7 [11.6] years overall), 59% were women (63% of long-term residents; 61% overall), and 9.8% were Black (13.4% of long-term residents; 12% overall) (eTable 3 in Supplement 1 ).

Telemedicine visits were concentrated within highest-using SNFs: 50% of telemedicine SNF visits in 2020 to 2021 were provided by the top 18% of telemedicine-using SNFs and 80% of visits by the top 39%. Telemedicine use was even more concentrated among clinicians: 50% of telemedicine SNF visits were provided by the top 7% of telemedicine-using clinicians, and 80% of visits by the top 13%.

Before 2020, telemedicine visits constituted 0.15% of all visits for SNF residents ( Figure 1 ). After an initial increase in early 2020 to 15% of SNF visits and 37% of outpatient visits, the proportion of subsequent telemedicine visits decreased gradually, reaching a plateau of 2% for SNF visits and 10% for outpatient visits in summer 2021 and 2% for SNF visits and 8% for outpatient visits by 2022. Among all SNFs, 823 SNFs (5%) used telemedicine at least once in 2019, 13 920 (91%) in 2020, 12 383 (81%) in 2021, and 9321 (61%) in the first half of 2022.

In 2019, only 3 Midwestern states had more than 1% of SNF visits delivered via telemedicine ( Figure 2 and eFigure 1 in Supplement 1 shows outpatient visits). In 2020, all states used telemedicine for more than 1% and 20 states for more than 10% of SNF visits. By the first half of 2022, only 1 state used telemedicine for more than 10% of SNF visits and 8 states returned to less than 1% of use.

Although the overall trend of telemedicine use was similar for short- and long-term care residents, the proportion of telemedicine visits was slightly higher for long-term care residents ( Figure 1 ). Short-term care residents had a higher absolute rate of telemedicine visits due to overall more frequent visits during their temporary stays (eFigure 2 in Supplement 1 ). COVID-19 was the most frequent diagnosis for telemedicine visits among short-term residents (6.4% of all telemedicine visits) (eTable 4 in Supplement 1 ). Mental health diagnoses were the most common among telemedicine visits of long-term care residents (depressive disorders, 8.2%, and neurocognitive disorders, 7.9% of all visits).

The top quartile (3609) of SNFs used telemedicine for at least 9.8% (median 18.4% in top quartile vs median 1.7% in other SNFs). High-use SNFs were more likely to be situated in the Midwest or West (adjusted odds ratio [aOR], 1.44; 95% CI, 1.30-1.58, and aOR, 1.24; 95% CI, 1.08-1.42, respectively, compared with the South), less likely to be in the Northeast (aOR, 0.39; 95% CI, 0.33-0.45), and more likely to be in nonmetropolitan areas (aOR, 2.06; 95% CI, 1.77-2.40, rural vs metropolitan) ( Table 1 ). 27 These SNFs were also smaller (aOR, 0.68; 95% CI, 0.61-0.76, for ≥121 beds vs ≤80 beds) and served fewer Black residents (8.7% vs 12.7%). Adjusted odds ratios were similar when studying high-use SNFs in 2020 and 2021 separately, except for SNF location (eTable 5 in Supplement 1 ). High telemedicine-use clinicians practiced in more rural areas and served more SNFs (mean 15 vs 10; eTable 6 in Supplement 1 ).

Among SNF residents, 808 530 (25.5%) received at least 1 SNF or outpatient telemedicine visit during their stay (eTable 7 in Supplement 1 ). Adjusting for length of stay, residents younger than 65 years (vs 65-74 years; aOR, 1.26; 95% CI, 1.24-1.28) and with a COVID-19 diagnosis during their stay (aOR, 1.69; 95% CI, 1.67-1.70) were more likely to receive telemedicine visits. Residents in long-term care (aOR, 0.55; 95% CI, 0.55-0.55) as well as older, non-White, dual-eligible residents were less likely to receive telemedicine visits.

We examined the outcomes of high telemedicine adoption in 4 scenarios, corresponding to situations where telemedicine could be expected to increase access to care. Figure 3 shows the unadjusted change in total visits in these scenarios in high vs low telemedicine-use SNFs (the proportion of telemedicine shown in eFigure 3 in Supplement 1 ). Pre-trends were parallel in high- and low-use SNFs for new specialist visits but not the other outcomes (eAppendix 2 in Supplement 1 ). Compared with 2018 to 2019, high-use SNFs in 2020 to 2021 provided more psychiatry visits per resident year than other SNFs (0.03; 95% CI, 0.00 to 0.07), a 20.2% relative increase (95% CI, 1.2% to 39.2%) compared with the 2019 mean in high-use SNFs ( Table 2 and model details in eAppendix 3 in Supplement 1 ), with higher relative increase in 2020 (eAppendix 4 in Supplement 1 ). High-use SNFs also provided more outpatient visits for residents with limited mobility (adjusted difference, 0.18; 95% CI, 0.00 to 0.37), a 7.2% relative increase (95% CI, −0.1% to 14.6%), with a higher increase in 2021. High-use SNFs had fewer SNF visits on weekends (relative change of −20.1%; 95% CI, −29.3% to −11.0%) and no difference in new outpatient visits with specialist physicians (relative change of −0.7%; 95% CI, −2.5% to 1.2%).

To our knowledge, this study offers the first comprehensive picture of telemedicine adoption for SNF residents after policy changes in the COVID-19 pandemic, when telemedicine was rapidly implemented to prevent infection spread during in-person encounters. 28 We found that telemedicine use increased rapidly in early 2020, driven by the highest-using SNFs and clinicians. However, by mid-2021, the share of telemedicine decreased to 2% among SNF and 10% among outpatient visits, consistent with similar trajectories in other settings. 29 , 30 Overall, telemedicine use did not result in a substantially different volume of visits, mitigating concerns that loosening restrictions and regulations might unleash potential abuse and excessive billing. Contrary to previous concerns about the barrier of the start-up investment to enable telemedicine, 1 rapid expansion to the majority of SNFs in 2020 demonstrates that telemedicine could be ramped up without a long and intensive set-up process.

High telemedicine use had a mixed association with changes in care delivery for the 4 scenarios we considered. We found evidence that higher adoption of telemedicine was associated with improved access to psychiatry visits and outpatient care for residents with low mobility. While low-telemedicine SNFs had a large decrease in psychiatry visits in 2020, the level remained steady in high-telemedicine SNFs. Likely, telemedicine helped maintain established patient-clinician connections and expanded access to potential new clinicians, especially amid the long-standing decline in psychiatrist numbers. 31 Despite the potential to improve off-hours care with telemedicine, 32 SNF visits on weekends unexpectedly increased more in low-use SNFs, although nonparallel pre-trends limit the interpretation of this finding. In addition, by 2021 overall telemedicine use for new specialist visits and SNF visits on weekends was relatively low. Additional use cases might still become more prevalent with time if telemedicine becomes a more integral part of care at SNFs.

Taken together, these results suggest that though telemedicine could provide an opportunity to extend the temporal and physical boundaries of care in SNFs, in practice this did not happen consistently. 2 , 18 , 23 One exception may be in rural areas with a shrinking physician workforce, where telemedicine might be the only feasible option for receiving timely care. 18 , 33 We found that clinicians using the most telemedicine were more likely to serve rural areas and visited more SNFs. Access to mental health care was also particularly important as depressive symptoms increased in nursing home residents during the pandemic, likely as a result of restricted visiting and increased isolation. 34 , 35

Telemedicine use was also highly concentrated among a small group of clinicians, suggesting that staff and clinician preferences were likely an important driver in the magnitude of telemedicine implementation. In a small qualitative study, SNF staff deemed that telemedicine visits of routine care were inferior to a physician actually visiting the facility and noted that telemedicine encounters increased staff workload because of new and redundant tasks that were not offset with reduction in other responsibilities. 18 In interviews, physicians practicing at SNFs also noted that while organization resources are critical, staff time to prepare for and facilitate a telemedicine encounter is an even larger bottleneck. 36 Increased workload combined with staffing shortages, preferences of the older patients typically residing in nursing homes, 37 , 38 and a lack of investment in technology 18 , 39 could have led to telemedicine being used only transiently in 2020 to 2021.

Our study has limitations. First, we report telemedicine use only in Medicare fee-for-service beneficiaries, so these results may apply less to residents with different coverage policies, such as Medicare Advantage or Medicaid. Second, we relied on a broad set of indicators in Medicare claims to define telemedicine visits. However, these indicators do not capture the diversity of visit formats, ranging from audio-only calls to technology-facilitated remote physical examinations. We also could not capture other remote services, such as phone consultations directly between a physician and nurse. Third, we are not able to draw causal conclusions of how telemedicine influenced residents’ care and outcomes, as its adoption was most likely nonrandom, particularly in scenarios with existing pre-trends.

This study found that although virtually all policy barriers to telemedicine use in SNFs were removed at the start of the pandemic in 2020, its use remained concentrated in a small proportion of SNFs, especially in 2021 to 2022. We found preliminary evidence that telemedicine adoption might be associated with some changes in patterns of clinical care, potentially leading to improved access to specialty care. Continued reimbursement of telemedicine services in SNFs thus has a potential to improve resident care without substantially increasing its overall volume.

Accepted for Publication: July 13, 2023.

Published: August 18, 2023. doi:10.1001/jamanetworkopen.2023.29895

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Ulyte A et al. JAMA Network Open .

Corresponding Author: Michael L. Barnett, MD, MS, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Kresge 411, Boston, MA 02115 ( [email protected] ).

Author Contributions: Dr Ulyte had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ulyte, Mehrotra, SteelFisher, Barnett.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ulyte, SteelFisher.

Critical review of the manuscript for important intellectual content: Ulyte, Mehrotra, Wilcock, Grabowski, Barnett.

Statistical analysis: Ulyte, Wilcock, Barnett.

Obtained funding: Ulyte, Mehrotra, Barnett.

Administrative, technical, or material support: Ulyte, Mehrotra, Barnett.

Supervision: Ulyte, Barnett.

Conflict of Interest Disclosures: Dr Mehrotra reported grants from the National Institutes of Health (NIH) during the conduct of the study; grants from the Commonwealth Fund; and personal fees from NORC, Sanofi, Commonwealth of Massachusetts, Pew Charitable Trust, and Black Opal Ventures outside the submitted work. Dr SteelFisher reported grants from NIH during the conduct of the study. Dr Grabowski reported personal fees from AARP, the Analysis Group, GRAIL LLC, Health Care Lawyers PLC, the Medicare Payment Advisory Commission, and RTI International outside the submitted work. Dr Barnett reported support from the National Institute on Aging, Agency for Healthcare Research and Quality, and Retirement Research Foundation and personal fees from California Department of Health Services outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grants from the National Institute of Aging of the NIH (P01 AG032952, Dr Grabowski; K23 AG058806 and R01 AG075507, Dr Barnett), a Postdoc.Mobility fellowship (P500PM_203170, Dr Ulyte) from the Swiss National Science Foundation, and funding from the Patrick and Catherine Weldon Donaghue Medical Research Foundation (Dr Barnett).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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The outcomes of nurse practitioner (NP)-Provided home visits: A systematic review

Zainab toteh osakwe.

a Adelphi University College of Nursing and Public Health, 1 South Avenue, Garden City, New York 11530, United States

Sainfer Aliyu

b Washington Hospital Center. 110 Irving Street, NW. Washington, DC 20010, United States

Olukayode Ayodeji Sosina

c Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, United States

Lusine Poghosyan

d Columbia University, School of Nursing, 560W 168th St, New York, New York 10032, United States

With the shortage of primary care providers to provide home-based care to the growing number of homebound older adults in the U.S. Nurse Practitioners (NPs) are increasingly utilized to meet the growing demand for home-based care and are now the largest type of primary care providers delivering home-visits.

The purpose of this study was to systematically examine the current state of the evidence on health and healthcare utilization outcomes associated with NP-home visits.

Five Databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library) were systematically searched to identify studies examining NP-home visits. The search focused on English language studies that were published before April 2019 and sought to describe the outcomes associated with NP-home visits. We included experimental and observational studies.  Quality appraisal was performed with the Kmet, Lee & Cook tool, and results summarized qualitatively. The impact of NP-home visits on clinical (functional status, quality of life [QOL]), and healthcare utilization (hospitalization, Emergency department(ED) visits) outcomes was evaluated.


A total of 566 citations were identified; 7 met eligibility criteria and were included in the review. The most commonly reported outcomes were emergency department (ED) visits and readmissions. Given the limited number of articles generated by our search and wide variation in intervention and outcomes measures. NP-home visits were associated with reductions in ED visits in 2 out of 3 studies and with reduction in readmissions in 2 out of 4 studies.

Published studies evaluating the outcomes associated with NP-home visits are limited and of mixed quality. Limitations include small sample size, and variation in duration and frequency of NP-home visits. Future studies should investigate the independent effect of NP-home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.


Over two million older adults in the United States are homebound and have great difficulty living in their home independently. 1 Homebound older adults have medical and psychiatric illness, higher functional limitations, symptom burden and mortality compared to non-homebound older adults. 1 , 2 , 3 , 4 These individuals also have poor clinical outcomes, including high hospitalization and emergency room visits. 5 , 6 Despite being a fragile population, many homebound patients have inconsistent access to office-based care, often only receiving care for medical emergencies. 5 , 7 Because of their multiple chronic co-morbidities and functional impairments, homebound patients are among the most costly group of patients in the U.S healthcare system accounting for more that 30 percent of Medicare expenditure. 8 , 9 , 10 , 11

A few modes of “home-based” healthcare services have been developed to meet the needs of homebound patients, from home health care which provides episodic skilled nursing, therapy and home health aide services, 12 to the provision of primary care at home. 13 Home-based medical care (HBMC) is one of such services. HBMC provides primary, urgent or palliative care to homebound patients by bringing the provider into the home. 14 Nurse practitioners (NPs) and physicians are the most common providers of HBMC services in the U.S. 15 Common models of HBMC are home-based primary care (HBPC), home based palliative care and transitional care programs. In HBPC, healthcare providers (e.g., physicians, NPs, and physician assistants) and interdisciplinary care team provide comprehensive longitudinal in-home medical care to homebound. 16 , 17 In home-based palliative care, the focus is on symptom control and entails the provision of consultative palliative care in collaboration with the patient's primary care provider. 18 In transitional care programs, patients transitioning from the hospital to the home setting receive transitional care home visits by a master's prepared advanced practice nurses such as clinical nurse specialist, more recent forms of the transitional care programs utilize NPs. 19 , 20 A growing body of evidence has demonstrated that HBMC programs lead to reduction in hospitalizations, 30‐day readmissions, and potentially preventable hospitalizations. 20 , 21 , 22 , 23 , 24

While the outcomes of HBMC have been shown to be positive, there is currently a national shortage of providers in the U.S, 25 in part due to the escalating primary care physician shortage. 26 , 27 As a result, there has been an increasing reliance on other health care providers such as physician assistants and NPs to reduce barriers in access to HBMC. Current evidence points to high utilization of NP-home visits. In 2013, NPs made 1.1 million home visits making them the largest provider of home visits and the most common provider of home visits to rural residents in the U.S. 28 , 29 This number nearly doubled to 2 million NP-home visits in 2016. 30 , 31 Many homebound patients who receive home visits from an NP, physician or physician assistant also receive Medicare Home Healthcare services, which provides skilled nursing, therapy or home health aide services. For decades, long standing federal regulations in the U.S that govern the services that NPs can provide, have restricted the autonomy of NPs in meeting patient care needs of homebound patients who receive Medicare Home Healthcare services. Although NPs were recognized by Medicare and Medicaid as primary care providers, NPs were not been able to order, certify or re-certify Medicare Home Healthcare —a service utilized by about 3 million Medicare beneficiaries each year. 12 , 32

More recently, amidst the COVID-19 pandemic, the Home Health Care Planning Improvement Act (S. 296/H.R. 2150), was included in the Coronavirus Aid, Relief, and Economic Security Act or the “CARES Act” (H.R. 748). 33 This bill now permanently authorizes NPs to order Medicare Home Healthcare services for Medicare patients consistent with state scope-of-practice law governing NP practice. Allowing NPs to order, certify and re-certify Medicare Home Healthcare services increases practice autonomy for NPs and expands access to home healthcare for vulnerable homebound patients. 31 , 32

Despite the growing utilization in the delivery of varied modes of HBMC, very little is known about outcomes associated with NP-provided care. While studies of HBPC report positive outcomes, patient outcomes are not delineated by provider type (physician or NP), making it hard to precisely estimate the impact of the NP role. 21 , 34 , 35 Studies of transitional care have focused on the post-acute care population transitioning from one setting to another, with NPs providing transitional care supplemental to the care delivered by the primary care providers. 20 , 36 Although substantial evidence has shown that NPs provide quality of care similar to that of physicians, 37 , 38 even with medically complex patients 39 most of these studies have focused on acute care 40 or ambulatory care, 41 , 42 and these findings are not generalizable to care provided in a patient's home environment which presents unique challenges. 34

Because NPs are more likely to serve in low income, minority, and rural areas and to accept Medicaid insurance when compared to physicians, 43 increased practice independence for NPs in HBMC has the potential to address physician shortage and extend care to underserved populations in the U.S. Nevertheless, lack of evidence about the outcomes associated with NP-home visits restricts the optimal utilization of the growing NP workforce to meet the increasing demand for HBMC. 44 , 45

The use of NP-home visits has particularly gained national and policy interest. A current Medicare demonstration program, Independence at Home (IAH), tests the effectiveness of delivering primary care in the home by an interdisciplinary team led by physicians or NPs. The IAH demonstration showed that patients who receive HBPC had fewer 30-day readmissions, hospitalizations, and emergency department visits. 46 , 47 In light of IAHs success, there is a clear need to assess and quantify the specific contributions of NPs reflected in patient outcomes. With the growing aging population, the utilization of NPs in the delivery of HBMC is expected to increase. An understanding of the health and healthcare utilization outcomes associated with NP-home visits will inform efforts to expand access to HBMC for vulnerable homebound older adults in the U.S.

Therefore, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, 48 we performed a review of the literature to examine the relationship between NP-home visits and health and healthcare utilization outcomes of homebound older adults.

Search strategy

With the assistance of a medical librarian, searches were conducted in the following electronic databases: PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Clinical Trials to identify studies investigating the outcomes of NP- home visits.  The search procedure developed for PubMed was carefully replicated to retrieve studies from EMBASE, CINAHL and Cochrane. Initially, broad categories of search terms were chosen, including the following: “nurse practitioner”, “advanced practice nursing”, “advanced practice nurse”, “nurse clinician,” in combination with “house,” “home care services,” “home health nursing,” “transitional care,” “house call,” “home visit,” “home based,” “home care,” “home health,” “home healthcare,” “transitional care,” “transitional health care,” “aged,” “middle aged,” “elderly seniors” and “senior citizen.” Medical subject heading (MESH), key words and truncated search terms were used when available to capture all relevant articles in a database. The search was conducted without date restriction. Reference list of included articles were screened for additional relevant articles. The complete lists of search strategies for each database are listed in Appendix A.

Eligibility criteria

To be included in the review, studies must have met the following criteria: target patient population was (a) older adults ≥ 65; (b) the study investigated patient outcomes associated with NP- home visits, (c) qualitative or quantitative study design, and (d) from peer-reviewed journals published in English through April 30, 2019. Excluded from this review were review articles, editorials, case reports or case studies, reports published as abstracts or commentaries . Because we sought to obtain a comprehensive understanding of the current state of evidence about the outcomes of NP-home visits, studies were not excluded based on study design. Studies were also not excluded based on location/country. Relevant articles were imported to Endnote, reference management software (Endnote X9; Thomas Reuters) and duplicates were deleted.

Study selection

Fig. 1 provides the details of the search process. Two reviewers (SA and ZO) independently screened titles and abstracts of articles to determine whether inclusion criteria were met. Full text articles were reviewed independently by the same reviewers (SA and ZO), and references of those articles were searched for potentially relevant publications. All disagreements were resolved by consensus.

Fig. 1

Flow diagram of the process of study selection.

Data extraction

The following information was collected from each study: first author's name, publication year, study design, study objective, number of NP-home visits, characteristics of the study sample, including sample size, mean age and sex of participants, race/ethnicity of sample and study setting (country and/or area in which the study was conducted) and outcome variables. All data were entered in an Excel (Microsoft Corp., Redmond, VA) document.

Quality appraisal

The quality appraisal instrument developed by Kmet, Lee & Cook 49 was used to assess the quality of the selected studies. This is a validated tool containing individual checklists to assess the quality of qualitative and quantitative studies and consists of 14 criteria scored on a 3-point scale (2 = yes, 1 = partially, 0 = no). Following the guidelines of the tool, “non-applicable” was applied when criteria were not applicable to a study design. Items that met the “non-applicable” criteria were marked and excluded from the calculation of the summary score. The scores were then summed and divided by the total number of items to obtain a summary score for each paper. The summary score was then converted into a percentage of the maximum possible score. Studies were determined to be of high quality if they scored > 75%, unclear quality if they scored 55%−75%, and of low quality of they scored < 55%. Two reviewers (SA and ZO) independently appraised each study. Discrepancies were resolved by discussion between the 2 reviewers, and in consultation with a third reviewer (KS).

In total, 566 article titles and abstracts were screened for study relevance. After applying the eligibility criteria and removing duplicates, 484 articles were excluded by reviewing titles and abstracts. The remaining 39 articles were obtained for full text review out of which, 7 peer-reviewed studies of various designs met inclusion criteria and were selected for the review: 2 randomized control trial (RCT), 50 , 51 3 quasi-experimental, 52 , 53 , 54 1 observational study 55 and 1 mixed methods study. 56 A flowchart with details on the literature search and search results is shown in Fig. 1 .

Characteristics of included studies

Table 1 provides a description of each included study. The study samples represent data from 1748 participants who received NP-home visits. Five studies were conducted in the U.S. and the remaining 2 were conducted in Canada, 52 and in the UK. 54 Mean age of study participants ranged from 66.1 to 81.4 years. The model of NP-home visits varied across the included studies; 3 studies were based on HBPC, 52 , 53 , 56 while 2 studies were based on the TCM, 50 , 55 and 1 study was based on an in-home comprehensive geriatric assessment (CGA) program. 51 The in-home CGA is conducted to assess the medical, psychological and functional abilities of older adults. 57 In all studies, the NP role during home visits included medication management, patient education, and coordination of care. The impact of NP-home visits on healthcare utilization (ED visits, hospitalizations, and readmission) was the most frequently reported outcome 50 , 52 , 53 , 54 , 55 , 56 Study period across the included studies ranged from 2 months 52 to 36 months. 51

Summary of Physician Involvement in NP-Home Visits.

Characteristics of included studies.

NP* = Nurse Practitioner.

HBPC†* = Home based primary care.

TCM†** = Transitional care mode.

Participant recruitment varied across studies. Two studies recruited hospitalized patients, 50 , 55 another 3 recruited community dwelling participants. 51 , 52 , 53 In 2 studies, participants had specific diagnosis such as chronic obstructive pulmonary disease (COPD), 54 and post Coronary artery bypass grafting (CABG) surgery. 55 One study specifically utilized NPs with specialty training in geriatrics. 51

Unsurprisingly, we found that most studies conducted in the U.S. reported a physician oversight, 55 consultation 51 or collaboration with the physician for medication management, 50 although only the NP made home visits. Of the 2 RCTs, 1 compared NP-home visits to case management and physician office visits, 50 the second study compared NP-home visits to medical and social services. 51 One of the quasi-experimental studies compared the NP-home visit intervention to participants receiving care in a hospital setting, 54 another recruited patients receiving home care services. 52

Quality assessment of included studies

Based on the quality assessment tool, 4 studies were of high quality, 2 studies were of unclear quality, and 1 study was of low quality. Quality scores ranged from 54%−100% (mean score 77%). Overall, all the articles had clearly stated aims, main outcomes, and findings. Of the 7 studies, three of the studies did not control for potential confounders (42.8%, n  = 7) and one study (14.2%, n  = 7) did not provide a rationale for including the covariates in multivariate analyses.

Impact of NP home-visits on emergency department (ED) visits

One RCT 50 and 2 quasi-experimental studies 52 , 53 examined the effect of NP-home visits on ED visits. Two studies reported a reduction in ED visits. 52 , 53 Coppa et al. tested the impact of NP-home visits on ED visits and reported significant reductions in the ED visits by 35.56% and 23.7% after implementation of the HBPC program after with 6 months ( p  = 0.001) and 12 months ( p  = 0.001) before the program was implemented. 53 Although the patients received NP-home visits, the visits were only supplemental to visits provided by the patient's primary care providers, therefore, patients in the study still received care from primary care physicians. A Canadian study by Tung et al. compared the number of ED visits among home care patients who received NP home-visits with home care patients who received usual medical care from family physician offices or community outreach medical teams. Participants in the intervention group received at least one home visit from the NP for assessment, treatment or a procedure. The authors found that patients who received NP-home visits had less ED visits at 2 weeks ( p  = 0.0005) and 4 weeks ( p  = 0.0055) compared to those receiving usual care. However, there was no significant difference in the number of ED visits between the 2 groups at the 8 week period ( p  = 0.800). 52 Enguidanos et al. conducted a brief transition intervention for older adults using a RCT designed to examine the impact of the NP intervention on 6 month-service utilization among patients enrolled from one managed care medical center. The NP also contacted the patient's PCP when medication problems were identified. Usual care was described as standard medical care combined with case management services. Patients assigned to the intervention group had half as many ED visits compared with the usual care group (mean=0.50, SD=1.2 versus mean =0.99, SD=2.5; P  = 0.096); however the decrease was not statistically significant. 50

Impact of NP home-visits on hospitalizations

Two RCTs reported the effect of NP-home visits on hospitalizations. 50 , 51 Stuck et al. conducted a 3-year RCT to test the effect of annual in-home CGA on the rate of hospitalization among community dwelling older adults, they found no statistically significant difference between participants who received annual in-home CGA from a geriatric specialty-NP and the usual care group. The usual care group received medical and social services. The mean length of stay per hospitalization was 6.3 days in the intervention group and 5.1 days in the control group ( p  = 0.7) . 51 Enguidanos et al. found no difference in days spent in the hospital in patients who received NP-home visits compared to patients who received usual care ( p  = 0.514), patients enrolled in the usual care received all medical services, including disease senior case management. 50

Impact of NP home-visits on readmission

Four studies including 1 RCT, 50 1 quasi experimental study, , 53 1 observational study 55 and 1 mixed methods study 56 evaluated the impact of NP-home visits on hospital readmissions. Hall et al. found that patients who received NP-home visits post CABG surgery had a significant decrease in all-cause hospital readmissions compared to patients who did not receive NP-home visits. Patients in the intervention group received 2 NP-home visits in the first week to 10 days after discharge from the hospital. Each home visit involved physical examination, medication reconciliation and medication changes under the supervision of the operating surgeon. Six of the 156 patients who received the NP-home visits (3.85%) and 18 of the 156 controls (11.54) were readmitted ( p  = 0.023). 55 Coppa et al., also found a 59.42% decrease in readmissions at 6 months ( p  = 0.001) after enrollment in the HBPC intervention led by a NP, however the result was not sustained at the 12 month-interval ( p  = 0.087). 53

Enguidanos and colleagues 50 evaluated the impact of NP intervention on care transitions among older adults and found no change in readmission rates at 6 months following enrollment in the study ( p  = 0.526). Ornstein and colleagues examined the impact of NP-home visits in a transitional care program embedded within a HBPC program; while the 30-day readmission decreased from 16.6% to 15.8%, it did not reach statistical significance. 56

Impact of NP home-visits on quality of life

One quasi-experimental study 54 assessed quality of life. Health related quality of life (HRQoL) was assessed differently in both studies. A UK study by Ansari et al., compared patients with exacerbation of COPD managed at home by an NP to a hospital cohort of patients with COPD exacerbation managed in an acute care hospital. In this study, COPD -specific quality of life was assessed with St George's Respiratory Questionnaire (SGRQ); a disease-specific questionnaire, which measures health status and perceived wellbeing in persons living with COPD. At recovery, the total SGRQ score decreased for patients who received NP-home visits, it did not reach significance ( p  = 0.06), however, improvement in the activity domain was significant ( p  < 0.05).

Impact of NP home-visits on functional status and nursing home admission

The analysis was based on 1 RCT conducted in 1995. 51 In this study, geriatric specialty NPs provided annual in-home CGA with follow up visits to community dwelling older adults 75 years or older . The odds of dependency in basic activity of daily living was significantly lower in the intervention group compared to the control group (adjusted odds ratio, 0.4; 95% CI, 0.2–0.8; p  = 0.02). Additionally, 9 people in the intervention group (4%) and 20 people in the control group (10%) were permanently admitted to nursing homes ( P  = 0.02).

We conducted a systematic review to assess existing evidence about NP- home visits and how they affect the outcomes of older adults. In this review spanning almost 3 decades, we found only 7 published studies. Studies varied considerably in terms of study design, delivery of intervention, and study outcomes. Given the small number of studies and their methodological limitations, overall evidence of the relationship between NP-home visits and patient outcomes is limited. While we attempted to identify the outcomes associated with autonomous NP-home visits, this was particularly challenging, as we excluded studies where the NP and physicians provided home visits to the same patients.

Similar to a systematic review by Stall and Colleagues, 21 which evaluated the outcomes of HBPC, in this review the most common outcomes were related to healthcare utilization (ED utilization, hospitalizations and readmissions). Many of the studies we identified were based on the TCM and largely enrolled a post-acute care population. Although prevention of acute care utilization is an important goal of HBMC. The use of NP-home visits among homebound older adults extends beyond transitional care purposes; to prevent healthcare utilization post discharge, 58 but fill a critical access gap, by meeting the ongoing healthcare needs in the home environment.

In studies examining the effect of NP-home visits on readmissions, 1 high quality observational study 55 found that a home transition program, which involved NP-home visits for patients post CABG-surgery significantly, reduced 30-day readmission. One additional study found a decrease in readmissions at 6 months, yet the results were not sustained at 1 year, 53 the 2 remaining articles found no effect. 50 , 56 Therefore, the results do not conclusively demonstrate that NP-home visits will lead to reductions in readmissions.

Emergency department utilization was another common outcome examined in the reviewed studies. Although results for ED utilization were promising, more evidence is needed to fully understand the impact of NP-home visits on the rate of ED utilization among older adults. Two of the 3 studies in our review showed that use of NP-home visits could lead to reduction in ED visits. One study found decrease in ED visits at 2 and 4 weeks; however this association was not consistently significant at 8 weeks; this study did not control for comorbidities. 52 A second study found reductions in ED utilization at 6 months and 1 year, although it had a small sample size, and there was no comparison group. 53

Overall, research on the effect of NP-home visits on health and healthcare utilization outcomes is limited and inconclusive. Study design and methodological rigor varied across studies; hence, it was challenging to compare outcomes across studies. Most of the studies did not find associations that reached statistical significance, 50 , 52 , 54 , 56 though this may be due to the fact that they were insufficiently powered. Intervention characteristics included in the studies also varied including intensity of home visit, use of specialty NPs across studies, this made synthesis of study measures and outcomes difficult. The comparison groups were inconsistent and none of the studies directly compared NP-home visits to home visits by other healthcare providers such as physicians or physician assistant. Although, the RCTs compared an intervention with “usual care,” specific details of usual care were not clearly provided.

While beyond the scope of this review, analysis of the included studies points to known barriers to autonomous NP-provided care in the home setting prior to the implementation of the CARES Act. Of the 7 studies, studies conducted in the U.S captured the presence of physician oversight, supervision or collaboration although the NPs provided the home visits (Supplemental Table 1). In efforts to examine the unique outcomes of NP-home visits, we attempted to exclude studies that describe NP-home visits that involved physician co-management; this presented a challenge predominantly for studies conducted in the U.S. where state scope-of- practice restrictions on NPs vary across the country and many states require collaboration with a physician. 59 Notably, in this review, studies conducted outside the U.S did not mention any form of physician consultation or oversight.

Strengths and limitations

Findings from this review are supported by rigorous methods including the use of a medical librarian in developing the search strategy, independent selection of studies by 2 reviewers, and quality appraisal conducted by 2 reviewers, and validated by a 3rd reviewer.

This systematic review has certain limitations. First, the paucity of published studies related to NP- home visits limits the ability to draw conclusions. Second, studies that met our inclusion criteria had varied study designs and patient samples, and duration and frequency of NP home-visit varied across studies. Third, our restriction to studies published in English may have also excluded some relevant papers. We may have also missed articles in the literature search due to other variations in terminology describing NPs particularly for studies conducted outside the U.S., where other terms may capture the role of an NP. Finally, there is a possibility of publication bias, as we did not include unpublished findings such as conference proceedings or dissertation results. Notwithstanding these limitations, our findings present the state of the literature assessing NP-home visits and point to important future directions for continued investigation.

Implications for practice and future research

The use of NP-home visits is widely recognized and has gained national interest, 28 , 60 yet few studies have assessed the outcomes of NP-home visits. This is the first study to our knowledge to systematically review the evidence of the impact of NP-home visits on the outcomes of homebound older adults. Our findings indicate that the effect of NP-home visits on health and healthcare utilization outcomes is mixed at best, with only half of the studies reviewed reported positive findings on reducing ED utilization. We identified gaps in the evidence that future research could address.

Future studies should directly compare NP-home visits to home visits provided by other health care providers or teams. While RCTs investigating the effect of NP-home visits may be difficult given the patient population and the complexity of the intervention, researchers should consider observational studies that use robust risk adjustment and modeling approaches to create more defined comparison groups. Future research should also identify larger samples of patients receiving NP-home visits or use large datasets such as nationwide Medicare data to ensure sufficient statistical power to identify associations.

Clinical outcomes were underrepresented in the results generated by our systematic review; the most commonly reported outcomes were related to health care utilization. Although health care utilization (hospitalizations, readmission and ED visits) is an important indicator of high-quality HBMC, 21 other outcomes such as functional status or medication adherence are also important patient outcomes to be evaluated. Future studies should also identify patient-level factors, for example, level of comorbidity that may be associated with likelihood to receive NP- home visits, such studies will inform policy and clinical practice decisions about what subgroups of patients benefit most from NP-home visits. In the U.S, racial and ethnic minorities and rural populations tend to have poorer access, satisfaction, and health outcome;s 61 , 62 researchers should consider subgroup analysis of these understudied groups in future work. Doing so will inform the development of future targeted interventions.

While expanding the independence of NPs in the delivery of HBMC is a topic of ongoing debate 32 ; based on our review, little research informs such discussion. This gap in evidence is critical given the expected increase in the homebound older adults as the current population ages and growing reliance on NP-home visits. Future studies should investigate the independent effect of NP- home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.


We would like to acknowledge Ms. Karen Sorenson, Research and Education Librarian, Albert Einstein College of Medicine, New York for her appreciated assistance with the literature search for this systematic review. We thank Dr. Yamnia I. Cortes for a careful read and helpful comments.

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Russia: Insufficient Home Services for Older People

Gaps in Services Create Risks for Institutionalization, Violate Rights

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A pensioner carries logs in the courtyard of her wooden house where she opened a private museum of the old quarter.

(Moscow) – The Russian government is not providing adequate resources for home-based services for older people , denying some of them the ability to live independent and dignified lives, Human Rights Watch said today.

Despite legislative reform to enhance these services, their funding and delivery appear to be inadequate to meet the needs of older people in Russia. Insufficient services may leave older people with little choice but to live in a nursing home or other institutional setting, rather than guaranteeing their right to live where and with whom they choose within their community.

“There are significant gaps in the services the Russian government provides to older people at home,” said Jane Buchanan , deputy disability rights director at Human Rights Watch. “When older people in Russia don’t get the support they need, they risk having to decide between living in an institution or in undignified conditions at home. This is a decision no one should have to make.”

With its aging population growing, Russia has taken positive steps toward reforming services for older people. In 2013, Russia passed a law to ensure that older people have access to a broader range of home services. Services can include personal support assistance such as delivery of groceries, payment of bills, food preparation, personal hygiene, or medical services, emergency services, or mental health services.

The law, which entered into force in 2015, says that services should be tailored to an individual’s needs with the goal of enabling older people “to remain in a familiar and positive living environment.”

However, Human Rights Watch’s interviews with 20 older people in Pskov and Sverdlovsk regions, as well as with experts and advocates in various parts of Russia, suggest that despite reform efforts, services often do not go far enough to meet the needs of older people to allow them to live at home with dignity.

Under the law, financing and delivery of home-based services is the responsibility of regional governments. Experts and advocates said that funds were often insufficient to cover the real need for home services, rendering the 2013 law ineffective. Social workers, whose jobs include delivering home-based services to older people, often have heavy caseloads that do not allow them to provide comprehensive services, even if provided for by regional or federal norms. In most cases Human Rights Watch examined, social workers were unable to carry out services beyond delivery of food and medicine.

A 93-year-old woman in Sverdlovsk region, who broke her leg two years ago has pain that makes walking or bending it difficult, said that a social service worker visits her twice a week, primarily to deliver groceries and tidy her apartment. But the woman said that she cannot get into the bathtub without help, rarely eats cooked meals, and receives few visits other than from the social worker.

“I don’t leave my apartment,” she said, crying. “I would love to… Two winters I have not been able to go anywhere. I sit here like I am in prison.” Three social workers interviewed said that they each assisted 16 to 19 people a week. Because of that workload, they said, they were unable to spend more than an hour two or three times per week with a client, and typically could only provide the least time-consuming services such as delivering groceries, firewood, water, or taking out the garbage and paying bills.

Social workers said that if a person had higher support needs and required more assistance, such as with cooking, eating, or personal hygiene, they could only ask relatives for help, pay for services, or move to an institution.

The law also requires older people or their legal representative to request services, meaning that unless older people get adequate information about entitlements, they may not be able to get the support that is available. According to Russian government statistics , Russia had 37.3 million people over the government pension age , 60 for women and 65 for men (approximately 25 percent of the population) as of January 2020, up from 20.4 percent increase in 2005. The percentage of older people is expected to continue growing in the coming years.

The Russian government spends significantly less for home-based support services than for institutional living costs: according to government statistics, average spending per person in a nursing home is 35,000 rubles (approximately US$472) a month and 34,095 rubles (US$460) in a psychoneurological institution (PNI), compared with an average of 5,889 rubles (US$79) for home-based services.

More than 278,000 people live in state-run residential institutions for older people and people with disabilities in Russia, but there is no publicly available government data on how many of them are older people. Journalists and advocates have reported extensively on the abuses in these institutions, including inappropriate use of psychotropic medication to control behavior, inadequate medical care, and denial of legal capacity.

The Russian government is collaborating with non-profit organizations to improve and expand the delivery of home-based services in pilot programs in 24 regions, with the goal of eventually expanding those reforms throughout the country. The federal government has allocated 1.8 billion rubles (US$24.8 million) from the federal budget for this and related initiatives each year from 2021 to 2023. Human Rights Watch did not assess the effectiveness of the pilot projects.

However, advocates said that the reform’s success in any given region still largely depends on the financial commitments and interest of regional governments, which means the availability of services varies across regions, sometimes significantly. They also said that longer-term federal funding and legislative reform were crucial to making reforms sustainable.

The Russian Constitution and national laws guarantee the right to health and social security to secure conditions for a dignified life. Russia also has obligations under international law to ensure the rights to an adequate standard of living and to physical and mental health. It should also protect the right of people with disabilities, including older people with disabilities, to live independently in the community with support.

The Russian government should ensure that all older people receive the support they need to live at home, if that is their choice, with dignity and autonomy. It should ensure that regional governments have sufficient funds to provide adequate support services on a long-term basis and improve and standardize training of social workers and other service providers where needed.

Federal and regional governments should improve and expand the types and availability of social services provided to older people and take measures necessary to ensure that sufficient numbers of social workers are available to provide support services for as much time as required. The government should also require service providers to do more outreach to older people to inform them about available services to ensure that those most in need of support can get them.

“Russia has taken important steps toward improving home-based support for older people, but there is a risk that those reforms will exist only on paper if they are not accompanied by better financing and more regulatory reform,” Buchanan said. “The Russian government should increase funding for reform efforts and ensure that older people can fully enjoy their right to live at home with dignity.”

For additional details and accounts by those interviewed, please see below.

A resident of a nursing home opens a bag with sweets.


Between December 2019 and March 2020, Human Rights Watch conducted in-person interviews with 20 people between the ages of 60 and 93 in Pskov and Sverdlovsk. Human Rights Watch also interviewed three social workers and two relatives of older people in those regions. Between December 2019 and July 2021, Human Rights Watch conducted both in-person and remote interviews with 14 experts, advocates for the rights of older people, including those directly involved in reforming long-term care, and journalists.

Human Rights Watch also reviewed laws, regulations, statistics, and policies that pertain to older people and home-based services at both the federal and regional level. Older people and their relatives are identified with pseudonyms to protect their privacy. The research did not include documenting conditions in residential institutions.

On July 19, Human Rights Watch sent questions to the Ministry of Labor and Social Protection of the Russian Federation, the Pskov Regional Committee for Social Protection, and the Sverdlovsk Regional Ministry of Social Policy.

In a July 29 letter to Human Rights Watch, the Pskov Regional Committee provided its official website address and said that any information not published on it is “for internal use only and is not public.” The letter provided no further information. The other agencies have not yet responded.

Institutional Settings for Older People

Russia’s changing demographics have prompted the government to reform its policies for long-term care. The changes include increasing the support and services available to older people, increasing the participation of nongovernmental organizations in delivering services to people at home, and increasing access to medical services for older people.

As of January 2020, 278,900 people lived in the country’s 1,249 state-run residential institutions. Of these, 78,500 people live in residential institutions for older people and people with disabilities, nursing homes, while 157,500 live in psychoneurological institutions (PNIs) for people with psychosocial, developmental, and intellectual disabilities, and a smaller number in small group homes or gerontological centers.

Maria Sisneva, director of the advocacy group Stop PNI, said that the government does not publish data on ages of people living in residential institutions. She estimates that the average number of older people in PNIs has increased in recent years, typically making up 30 to 50 percent of residents. Advocates and experts told Human Rights Watch that older people in PNIs are most frequently segregated in so-called “mercy wards,” highly restricted parts of the facility for people who are deemed to have higher physical or psychosocial support needs.

Experts say that there is also a growing number of private nursing homes. While some are registered, registration is not required, and those that remain unregistered have virtually no government or independent oversight. In 2020, some experts estimated the number of beds in unregistered private nursing homes to be as high as 30,000. Media outlets have reported on numerous fires and other deadly incidents in private, unregistered nursing homes.

Media reports and advocates say that residential institutions for older people and people with disabilities in Russia are rife with human rights abuses. Psychoneurological institutes widely employ chemical restraint, the use of medication, particularly psychotropic drugs, to control behavior without a therapeutic purpose, and physical restraints, for example tying a person to a bed or other furniture to restrain them. And they provide poor quality medical treatment and very little physical or cognitive rehabilitation of any kind.

These institutions often lack sufficient transparency to allow more effective monitoring to prevent abuse. Organizations including Human Rights Watch have documented that many PNI residents have been stripped of their legal capacity by a court, in many cases without being in the courtroom, as Russian and international law require. In many cases, the institution itself assumes legal guardianship, making it even harder for residents to report abuse.

Staff ratios are typically extremely low, with advocates and journalists citing an approximate ratio of one staff person to 20 to 30 residents, many of whom have high support needs.

Advocates who have visited institutions said that older people in these institutions were rarely dressed in anything but a hospital gown, and typically remained in their beds all day, including for meals.

“[Staff] at least organize concerts and dances for the younger people, but older people [in the PNIs] are simply living out their days,” Sisneva said. “They are not given anything to do.”

Advocates and experts say that the situation in nursing homes, where most older adults are not under guardianship, was typically not as dire as in PNIs, but a lack of transparency and low staffing ratios often led to human rights violations, including the inappropriate use of psychotropic drugs to control behavior, inadequate or inappropriate medical treatment, and lack of sufficient support and engagement.

The Covid-19 pandemic highlighted the lack of transparency: the government did not publish regular and timely information about nursing home infections and deaths despite widespread accounts by media outlets and advocates about the spread of the virus.

A Human Rights Watch investigation into Russian institutions for children with disabilities in 2014 found numerous rights violations, including physical and psychological violence, neglect, poor nutrition, lack of health care, and the use of physical and chemical restraints, among other abuses.

Gaps in Home Services for Older People

Many older people Human Rights Watch interviewed said they did not want to live in a nursing home or PNI and preferred to live in their own homes. Two had lived in a nursing home but had decided instead to live in the community. But interviews with older people, advocates, and experts indicated that in some places, government-subsidized support services are insufficient to support older people living in the community, particularly those without relatives or others able to provide support.

The government began an effort to reform support services with Federal Law 442 On the Foundations of Social Services for Citizens of the Russian Federation . The law, which entered into force in 2015, applies to those who have “fully or partially lost the ability or opportunity to care for themselves, to move about independently, or to provide for their basic needs due to illness, injury, age, or disability.” In contrast with previous regulations, the new law called for both home and institutional service providers to create an “individualized program” to support the needs of older people and people with disabilities.

Under the law, home-based services include, among other things, personal assistance, emergency assistance, socio-medical assistance, such as administering medication or assisting with injections, and socio-psychological support, such as counseling or other psychological services. While all these services can be crucial to independent living, Human Rights Watch focused on access to personal assistance, which according to Russian government statistics is the service that older people use most frequently.

The legal framework for determining eligibility is based on financial means, which can be problematic, Human Rights Watch found. Under the law, the government must cover the costs of services for those who fall below a certain financial eligibility threshold, which differs among regions. People with incomes above that threshold must partially or fully pay for services. Income is calculated on a household basis, meaning the income of any family members living with the older person is taken into consideration. Government guidance encourages service providers to prioritize providing free services to older people who live alone.

But determining eligibility for free services based on family income assumes that the older person will have access to an adequate share of that income, which may not be the case. It can also reinforce or create situations in which older people are dependent on family members financially and for assistance, rather than treating the older people as individual, autonomous rights holders. Instead, the government should determine eligibility for free services based on individual income, Human Rights Watch said.

Older people, social workers, and advocates said that older people often do not receive home-based services that allow them to live in the community comfortably and with dignity. They said that social workers most frequently provide only very basic services such as delivering groceries and medicine and, in rural areas, firewood and water, or help with paying bills. But if an older person requires more support, such as with hygiene, cooking, eating, or assistance leaving the house, the government often does not provide these services.

“Nikolai P.,” 70, who lives alone in an apartment in Pskov region, had his first stroke in the late 1990s. He has limited use of his legs and one arm and can stand for only brief periods while using his stronger arm to support himself with a cane. A social worker visits him briefly three times per week to deliver groceries and firewood. But since he is over the regional income threshold, he has to partially pay for services. He said he was unable to afford some services that he needs, such as for preparing meals.

“I almost never [eat a cooked meal],” he said.” Sometimes I boil some pelmeni [dumplings], but it’s difficult to stand. How can I simultaneously stir the pot and hold myself up with one leg? If I were a tightrope-walker maybe I would be able to balance on one leg like that.”

He pays the social worker 1,400 rubles (US$19) monthly to deliver groceries, dispose of garbage, and help pay bills. “I need more services,” he said. But if he paid more out of his monthly pension of 19,000 rubles (US$257), he said, after he pays for utilities, food, and other necessary goods, he would have difficulty buying medicine, on which he spends 5,000 rubles (US$67) per month. “[The social worker] just told me to pay, or nothing. They told me to hire somebody myself, because ‘These are our rates.’”

“Elizaveta N.,” 84, who lives in Sverdlovsk region and is now blind, remained active until her late 70s and had sufficient eyesight to confidently leave her apartment by herself until 2018. Her daughter and son live in Moscow. Her grandson lives in the same city as she does and has three young children and a business, leaving him little time to help her. Her social worker visits twice a week to deliver groceries and medication, and to take out the garbage. The social worker vacuums twice a month.

“I could do with some walks [outside]... She [the social worker] doesn’t have time. She has to look after 18 people, that’s nine people per day,” she said. Responding to a question about how her life had changed due to the lack of sufficient services to support her, she said, “I’m socializing less, there are fewer calls, I rarely go out.”

The social workers told Human Rights Watch that if an older person required a higher level of support, they often were forced to go to a nursing home if they did not have relatives who could or would support them.

A social worker in Pskov region described one client who had had a stroke:

“She had difficulty moving around and she could talk, but [with difficulty]. She lived in a free-standing house and would have had to be visited every day so they could heat the stove, bring firewood, and bring water. She couldn’t even walk… If she at least was walking it would have been possible [to live independently at home]. But if a person is bedridden, there is no other option [than a nursing home].… They don’t want to go [to a nursing home] but need forces them to.”

Regional Disparities in Financing, Standards

Experts and advocates said that a major problem for expanding home-based services is the fact that they are largely financed and regulated by regional governments. The federal government creates a model list of personal assistance services that must be provided, including delivery of groceries, firewood, and other goods, help preparing food, help paying bills, and cleaning services. But regional governments are then responsible for determining the final list, and the rates, frequency, and duration, as well as oversight, setting staff workload, and funding.

Russia has high levels of regional inequality compared with countries with similar economies, and home-based services therefore may differ widely from region to region due to budgetary discrepancies. Experts said that regions cut back on spending by limiting the frequency or amount of time a social worker is allowed to spend on providing services.

“The trick is that the standards for delivering social services are set by the regions,” said one expert familiar with the home-based service system. “The standards establish the quality and frequency of the services. For example, they may say, ‘At most two times per week.’ But this means that vital needs are not covered. Regions do this because they do not have enough money.”

Regional regulations outlining caps on services indicate that it would most likely be difficult for an older person with high personal support needs to remain in their home, particularly without significant additional private or family assistance. In St. Petersburg , for example, regulations recommend that social workers can change a person’s diapers and feed them only 156 times a year.

In Pskov region , clients in houses without running water can receive only seven liters of water a month. In Khabarovsk region, social workers can support people unable to eat on their own to eat meals only twice a week. In contrast, in Moscow, city authorities said that eligible older people have a right to up to five hours of personal assistance at home per day.

Social Workers’ Workload, Training Needs

According to Russia’s state statistics office , the number of social workers in the country decreased from 172,526 in 2013 to 135,983 in 2017. The average number of clients a social worker serves increased, from 6.5 a day in 2011 to 8.4 in 2017. Social workers interviewed said that as a result, they had only limited ability to take on extra tasks for clients with higher support needs. This undermines their capacity to deliver on the federal law’s requirements for an individualized approach to supporting older people.

“[The individual plans] are more or less all the same,” said a social worker in the Pskov region. “It’s groceries, payment [for utilities], and other things like bringing them newspapers or medicine. In theory, there are a lot of services, but I just [can’t] do some things. I say right away that I can’t cook for them, wash floors, or clean. If they want that, they have to hire somebody or ask a neighbor. When would we have time for this?”

A social worker in Sverdlovsk region said, “I mostly bring groceries. Sometimes I cook for them but it’s not like I can spend three hours cooking meat, I can just boil them some [frozen] dumplings or make some tea. People can be visited twice per week, five times per week if they want. But never for more than an hour.”

“Social workers [in Russia] do not deliver support services, they primarily deliver groceries,” said Irina Grigorieva, a professor of sociology who researches aging at St. Petersburg State University. While federal statistics were not available on the quantity of each type of service distributed, some regional government data indicates that grocery delivery takes up most of social workers’ time. In Moscow , for example, delivering groceries and other key goods made up 60 percent of services.

Experts also pointed to the lack of federal training standards for social workers, which, when compounded with the large number of people they are expected to assist, meant they are often ill-equipped to take on the more complex support services.

“In Russia there is no system for training social workers, more than half of the regions don’t have access to social services training,” said another expert involved in long-term care reform. “Social workers have very low motivation. They need to reach as many people as possible and so they take ‘easy’ [cases], rather than more ‘challenging’ ones.”

The social worker in Sverdlovsk region echoed this in her comments about working with people with intellectual disabilities such as dementia: “We don’t take those [people]. … They should hire a home aide, there are no state home aides, that’s not our job.”

Asked what could be done to improve quality of assistance for people at home, she said, “We need fewer clients so that the quality of support would be higher, and also less paperwork… If the ‘lying down’ clients [those who cannot walk] had home aides, and I only had 12 clients, that would be quite manageable.”

Some regions appear to have taken positive steps toward ensuring that social workers have more capacity to support the needs of older people. According to the Moscow city government, all grocery delivery and utility payments were outsourced to professional companies as of January 2020, which allowed social workers more time for other tasks. A June 2020 news release said that “a number of services, previously provided only for a fee can now be provided free of charge (apartment cleaning, changing bed linens, accompanying [an older person] for a walk, etc.).”

Regions participating in the pilot programs to improve and expand at-home services have also passed relevant legislative amendments to, for example, increase cooperation between healthcare and social protection systems, tailor social service programs to individual needs, and expand the types of home-based services available.

Lack of Information for Older People and Family Members

Human Rights Watch interviewed older people and family members who seemed unaware of the existence of state-provided home services or believed they were ineligible, particularly if they lived in more remote rural areas. They expressed little trust in the government to provide such services and were wary of involving social workers rather than family members or neighbors in helping them.

Federal Law 442 states that social services should be delivered on a “declarative” basis, meaning a person in need of support (or their representative) must reach out to the local provider to request services. Advocates and experts have lobbied for an alternative system in which social workers, medical professionals, or others would identify or seek out those in need of support and connect them with the relevant services.

A social work expert said that in some cases social workers do reach out proactively to find in need of these services. The expert said this was typically related to the need to fill government quotas rather than an effort to comprehensively assess need in a given area: “Each locality has a quota, or a set number of clients whom social workers should be supporting, and for most part [this number] does not change. When people die, they [social workers] go looking for people to fill the rolls.”

“Alexander” and “Svetlana” O., 83 and 82, respectively, worked on a collective farm in a remote village of Pskov region until their retirement. Due to work-related injuries and arthritis, both can only walk for brief periods with the help of a cane. Walking and standing are painful. Their great-grandson, who is in the 10th grade, brings them firewood and water. They have never requested government assistance. When asked why, Svetlana said, “Who [would we ask]? You can’t get it. Who wants to travel out to us? [Look at] the road.”

“Anastasia F.,” 60, in Pskov region, has diabetes which has left her unable to walk without a cane. In 2019, she lived on a pension of 8,806 rubles (US$120) per month, which was the minimum pension in Pskov at that time, making her eligible to receive free services. However, she said that she feared involving the state in her life because she is currently responsible for her 15- and 16-year-old nephews while their father, her brother, is in prison, and she did not want to risk having social services remove them from her care. “I’m afraid to complain anywhere,” she said.

Relatives of older people similarly expressed disbelief that the government would provide adequate support services, or simply did not know that such services existed.

For example, “Agafya L.,” 60, supports her 95-year-old stepfather, who is blind, full-time. When asked if she had considered reaching out to the government social services provider for help, she said, “Older people, myself included, don’t know where to reach out to for help… I have been caring for him for five years, and these are blacked-out… years of my life. I can’t sleep. I don’t have any days off.”

“Lydia P.,” 50, in Pskov region, supports her 80-year-old father, who has dementia, limited mobility, and needs help with personal hygiene and eating. She also cares for two adopted children, including one with a disability. When asked whether she would consider reaching out for state support for her father, she said, “From where? Nobody is interested. I know that because of my own experience with social workers [for the adopted children] … I understand perfectly well that if they won’t help a child, why would they help an older person?”

Older people and their relatives also expressed a fear of stigma associated with seeking services, expressing a perception that those who received help from the state were often those whose children or relatives did not care sufficiently about them to help. The social worker in Pskov region said, “Let’s say their son doesn’t help them, they are embarrassed. They don’t want to admit that they need help.”

“Polina Z.,” 80, in Pskov region, has severe asthma and is limited in her ability to take care of her home. When asked whom she would ask for help, she said, “I would reach out to my children, there’s nobody else.”

International and Russian Law

Older people with disabilities have the right to live independently in the community and to home and community-based support under the Convention on the Rights of People with Disabilities (CRPD), which Russia ratified in 2012. Support includes “access to a range of in-home, residential, and other community support services, including personal assistance necessary to support living and inclusion in the community, and to prevent isolation or segregation.” These supports should be available to anyone with a disability on an equal basis, meaning it should not depend on the level of support a person requires.

The Russian Federation is also a party to the International Covenant on Economic, Social and Cultural Rights, by which it has undertaken to realize the right of everyone to social security; an adequate standard of living, including adequate food, clothing, and housing; and the highest attainable standard of physical and mental health. To realize these rights, governments should determine the nature and scope of problems, adopt properly designed policies, and ensure the relevant budget support.

The Russian Constitution provides for the right to “social security guarantees,” “state support to older people and people with disabilities,” and the right to health and medical assistance.

Under Federal Law 442 , social services should be “based on human rights and respect for individual dignity, humane, and not denigrate a person’s honor or dignity.” The law calls for services to be delivered without regard for sex, race, age, nationality, language, or place of residence. Services should be located near the users of the service; be sufficient to meet the needs of citizens; and have sufficient financial, technical, personnel, and other resources. The stated goal of the law is to allow for people “to remain in a familiar and positive living environment.”

Enabling people to live with dignity and as full members of society goes beyond meeting basic survival needs. While some regions are attempting to provide some support for older people’s access to social and public spaces and participation in the community, for example a companion when visiting theaters and organizing physical and cultural activities, these services are limited and not available across all regions.

To ensure that older people have access to support services that enable their participation in society on an equal basis with others, such services should be included on the federal government’s minimum list of services. Older people should be involved in the design of these services so they can determine what aspects of life and society they wish to participate in.

Federal Law 181 On Social Protection of People with Disabilities in Russia entitles people with disabilities who require assistance to medical and household services at home and in residential facilities. Under the law, social protection for people with disabilities is aimed at ensuring their equal participation in public life.

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Nurse criminally charged in death of care facility resident

Prosecutors say nurse refused to let the staff call 911, by: clark kauffman - march 22, 2024 6:07 pm.

nursery nurse home visit

Marvin ‘Pete’ Jacobs died Feb. 19 at the Fonda Care Center in northwest Iowa. According to state inspectors, he died after the care facility staff failed to suction his airway. (Facility photo via Google Earth; inset photo courtesy of the Jacobs family)

A nurse who allegedly failed to suction the airway of a U.S. Army veteran in an Iowa nursing home has been criminally charged in the man’s death.

Becky Sue Manning, 69, of Lake View, is charged with felony wanton neglect of a health care facility resident. According to prosecutors, Manning, a licensed practical nurse, refused repeated requests to provide physician-ordered care for a resident of the Fonda Specialty Care nursing home while working there in 2023 as an employee of the GrapeTree Medical Staffing temp agency.

Manning has yet to enter a plea in the case. She was arrested Thursday and released from jail on Friday on a $10,000 bond. Her lawyer could not be reached for comment Friday night.

According to state inspection records, Marvin “Pete” Jacobs, 87, died Feb. 19, 2023, while sitting in his room at Fonda Specialty Care. Jacobs had undergone a tracheostomy, and because his airway tended to become clogged, the staff kept a suctioning machine by his bedside.

On that afternoon, an aide later told inspectors, Jacobs was sitting in his recliner when another worker said Jacobs appeared to be “in trouble” and instructed her to get a nurse right away. Jacobs was pointing at his neck, gasping for air, and mouthing that he could not breathe, the aide told inspectors.

The aide said she left the room to get the only nurse on duty — alleged by prosecutors to be Manning — and was absent for a few minutes. The worker who remained in the room later told inspectors Jacobs grew “really pale” and was gasping, so she, too, left the room and approached Manning and said, “Would you please suction him? He needs to be suctioned.”

When Manning entered the room, Jacobs was pale, but soon turned purple and then blue, the aide later reported. Manning allegedly took his vital signs and told the aide Jacobs was having a heart attack. The aide explained to Manning that Jacobs had been signaling he couldn’t breathe, at which point Manning allegedly said, “Just a minute,” and left the room. The suctioning machine sat idle on Jacobs’ nearby dresser.

According to inspectors, the nurse alleged by prosecutors to be Manning told inspectors the “staff wanted me to suction him (and) I told the staff no. I was told that I would not have to do anything with the tracheostomy.” Manning allegedly said she first left the room to get supplies so she could check Jacobs’ blood pressure, pulse and oxygen levels and that when she returned, he was clammy and had an irregular pulse.

“I told the staff that I needed to go back to the nurses’ station and find out if the resident was a full code or DNR,” Manning allegedly told inspectors, referring to do-not-resuscitate orders that some residents have in place.

She reportedly told inspectors that while she was checking on that, one of the aides approached her and said she was needed right away in Jacobs’ room. “I went back into his room and he had no blood pressure, no pulse, and no respirations. I pronounced him deceased,” Manning allegedly told inspectors.

Manning reportedly acknowledged to inspectors that her fellow workers had each told her Jacobs needed his airway suctioned and that he had been pointing to his neck and mouthing that he couldn’t breathe. According to the inspectors, she allegedly said that despite her colleagues’ comments, it never occurred to her to suction Jacobs’ airway.

Pocahontas County prosecutors allege that no fewer than four workers asked Manning to suction Jacobs’ airway and that the staff had alerted Manning to the fact that Jacobs was asking to be suctioned and that, in their professional opinion, he needed to be suctioned right away.

Prosecutors also allege Manning prevented the staff from calling 911 when it became apparent Jacobs couldn’t breathe.

The Iowa Department of Inspections and Appeals fined Fonda Specialty Care $10,000 for the death, then reduced that penalty 35%, to $6,500, due to the lack of an appeal in the case.

In its written response to DIA’s findings, the facility’s owners, Care Initiatives of West Des Moines, said it does not admit to any statements, findings or conclusions by the state inspectors and added that it “will continue to provide care and services” for respiratory patients, including airway suctioning.

Jacobs grew up in northwest Iowa, was the varsity catcher of the 1953 Auburn Tigers state baseball championship team, and a 1954 graduate of Auburn High School. From 1955 to 1957, he served in the U.S. Army while stationed in Korea. After his discharge, he and his wife, Darlene, raised three sons in northwest Iowa. Over the years, he worked as a farmer and served as a partner and owner of the Mill City Loader Corporation.

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site. AP and Getty images may not be republished. Please see our republishing guidelines for use of any other photos and graphics.

Clark Kauffman

Clark Kauffman

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing.

Iowa Capital Dispatch is part of States Newsroom , the nation’s largest state-focused nonprofit news organization.

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Nursing Home Costs in 2024

W ondering what you can expect to spend on nursing home care ? That’s a complex question, as several factors can impact the cost of a nursing home stay, including location, duration of stay, and care services required, among others. According to Genworth’s estimates, the median cost of a private room in a nursing home is $330 per day or $10,025 per month in 2024. Semiprivate rooms are more affordable, with a median cost of $294 per day or $8,929 per month 1 . That adds up to an annual cost of $107,146 for a semiprivate room or $120,304 for a private room. Nursing home costs will also vary greatly by location. In 2024, monthly median costs for a semiprivate room range from $5,483 in Texas to $19,267 in Alaska.

Regardless of the cost of nursing care, there are many ways families can make this necessary care more affordable. Let’s get into what you can expect to spend and how most families go about paying for nursing home care.

National Median Costs of Nursing Home Care in 2024

Nursing home costs will depend on many factors, such as your location, the provider you choose, how long you plan to stay, and whether any type of special services are needed. In some cases, facilities’ rates are all-inclusive, while others may charge additional fees for certain services, including physical therapy , speech therapy, and memory care .

Rates have climbed considerably in recent years, a trend that looks to accelerate over the next several years. In fact, if projections hold, the monthly cost of a semiprivate room in a nursing home will be over $10,000 by 2030, an increase of about one-third. For private rooms, expected annual costs already have passed the six-figure mark. Here’s a look at the past, present, and projected annual costs side by side:

Nursing Home Costs By State

Along with the type of room you choose, the state you receive care in while impacting nursing home costs; it is much more affordable in some states than others. Here’s a look at the estimated median monthly costs for nursing home care in semiprivate and private rooms around the country. 1

In every state, the cost of both types of rooms in nursing homes rose between 2015 and 2021, and for some states, the increases have been dramatic. Minnesota, which already had a median cost on the higher side of the national average, also saw the largest increase both for semiprivate and private rooms. Genworth provides a look at each state’s compound annual growth rate from 2015 to 2021 for the cost of semiprivate and private rooms in nursing homes. In other words, this is an estimate of how much each state’s nursing home prices were rising each year for that period 2 :

Watch the video below with Jeff Hoyt, our editor-in-chief, for more information on the cost of nursing homes.

What Is a Nursing Home?

Before jumping into the costs of nursing homes, let’s first answer the question: What is a nursing home? Nursing homes provide nursing care for seniors around the clock, with 24-hour medical care available. This type of care is also referred to as skilled-nursing care and convalescent care . While seniors typically transition into a nursing home permanently, some homes also provide short stays for those in need of rehabilitation after an injury, illness, or surgery that may require skilled nurses and/or therapists.

FYI: Not all nursing homes are created equal. Use our senior living amenities checklist to find the exact benefits you need.

Whether you need these services on a part-time or full-time basis, nursing home care comes at a premium price compared to other health care options. However, it also provides older adults with all of the valuable services they need concerning medical care, socialization, rehabilitation, and housekeeping services in environments designed to offer the comforts of home.

You can watch our video below to learn more.

Cost of Nursing Homes vs. Assisted Living

Assisted living costs  continue to rise, though assisted living communities are much more affordable than nursing homes. The estimated median cost of assisted living facilities is $181 per day, which equates to $5,511 per month, or $66,126 per year–depending on your state of residence. While this represents an increase over the past few years, assisted living is far more affordable than semiprivate or private rooms in nursing homes. It’s important to note that these figures don’t take into account specialized care, such as  memory care , or considerations for disabilities.

Cost of Nursing Homes vs. In-Home Care

In some cases, individuals and families may choose skilled in-home nursing care , which is typically provided by a registered nurse or certified therapist who can administer medication and monitor their vitals regularly. However, the more intense the medical care required, the more expensive it will be. For example, typical homemaker companion services cost about $195 per day , home health aides cost $213 per day, and for a 10-hour workday, a typical registered nurse would make around $400. Though, in most cases, these types of services are not needed all day, or even every day.

Are Nursing Home Costs Tax Deductible?

In most cases, out-of-pocket nursing home costs are tax deductible under itemized medical expenses. If you, your parent, spouse, or another legitimate dependent is in nursing care primarily for medical care, expenses related to medical care, lodging, and meals are deductible. However, seniors in nursing homes for personal reasons, rather than medical, will only be allowed to deduct costs associated with actual medical care, not including meals and boarding costs. Visit our guide to health care tax deductions to learn more about ways to deduct medical expenses.

How to Pay for Nursing Home Costs

Nursing care costs can be paid for privately, but you can also fund your care in other ways, including through health insurance, life insurance, long-term insurance policies, savings, reverse mortgages, and local or regional agency assistance.

Payment options

Medicare coverage for nursing home costs, medicaid coverage for nursing home care, veterans benefits for skilled nursing care, private pay, annuity (savings), life insurance, long-term care insurance, renting out a property, bridge loan, reverse mortgage loan.

Medicare will only cover skilled nursing care expenses in very specific situations and is not designed to pay for nursing home or custodial care costs long term. One such situation is when a senior has been hospitalized and released but still requires a bit of specialized care. Medicare will help pay for short-term stays in nursing homes if they:

  • Were admitted to the hospital for a minimum of three days as an inpatient.
  • Have been admitted to a Medicare-certified facility within 30 days of the hospital stay.
  • Need skilled care like physical therapy, speech therapy, and other types of rehabilitation.

Those who meet all of these conditions under original Medicare will qualify for assistance as follows.

  • Up to 20 days of nursing care is 100 percent by Medicare.
  • After day 21 and up to day 100, patients will pay a copay that is up to $200 per day.
  • After 100 days, all Medicare coverage ends, and all payments are the patient’s responsibility.

Medicaid is an excellent option for low-income older adults. This coverage assists individuals with many types of medical care, including doctor’s visits, hospital stays, and long-term care services such as those received in a skilled nursing facility. Often, this program covers 100 percent of these costs, but there may be copayments for certain beneficiaries. For those who qualify for Medicaid, this is the best choice for nursing care coverage.

Veterans with service-related injuries and disabilities can receive full coverage from the Department of Veterans Affairs for long-term care services at specified locations or through certain providers approved by the department. Long-term VA care includes 24/7 nursing care, physical therapy, help with daily tasks, comfort care, and pain management. Those without service-related disabilities may also qualify for VA benefits if they meet certain qualifications. However, depending on the veteran’s household income, there may be copayments required. Visit our guide to Veteran senior care to learn more about the various types of senior housing.

It’s common to pay for nursing home care privately at first, then move to Medicare or another funding source later. The main benefit of paying privately is flexibility. With Medicare and other taxpayer-subsidized programs, seniors have fewer choices because nursing homes can limit the number of publicly-funded enrollees. So, it’s important to know the accepted payment setups before deciding to move into a given facility. Sources of private funds could be savings or money from cashing out IRAs and other investments. People also borrow from life insurance policies, sell their homes, and get reverse mortgages, as explained below.

Pro Tip: Are you trying to get your finances in order to afford nursing care? Read our guide to finances for seniors for all our tips and expert advice on making the most of your money.

When planning for long-term care, a person with savings can buy an annuity. The underwriter receives a lump sum of cash and then issues regular monthly payments to the individual after retirement. The individual can use these payments for a nursing home, a car payment, or anything else. The main advantage of having an annuity is financial discipline. The annuity forces savings to be stretched out over time and regular payments are guaranteed. Additional advantages of annuities are listed below.

  • Savings put into an annuity are shielded from consideration on applications for government aid.
  • A person who lives a long life could draw more from the account than they put into it.

The main disadvantage of annuities is that value is lost in commission and annual charges. Also, penalties are charged if funds are withdrawn early.

>>Read More: Annuity Calculator

A whole life insurance policy (but not a term life insurance policy) can be tapped for long-term care payments. However, this, of course, reduces the financial benefit for heirs. Three approaches are:

  • Surrendering a policy
  • Selling a policy
  • Converting life insurance to “life assurance”

First, a whole life insurance policy can be surrendered to the provider. This means that the agency buys the policy back from the policyholder. However, usually, they’ll pay just 50 to 75 percent of the face value. If you’re looking for affordable life insurance plans, check out our guide for the best cheap life insurance in 2024.

Similar terms are offered for the second approach: selling the policy to a “life settlements” company. Again, the typical offer is about 50 to 75 percent of the policy’s value. The life settlements company continues to pay the policy’s premiums until the policyholder passes away. The company then receives the financial payout. Life insurance conversion to “life assurance” is a third option designed specifically to pay for long-term senior care. Like life insurance , life assurance includes a savings guarantee plus an investment portfolio. Life insurance conversion accounts might give less for senior care but preserve a death benefit (inheritance). The advantages and disadvantages vary from person to person. Meeting with a financial advisor could be worthwhile.

>>Learn More: Life Insurance Calculator

When a person is planning well in advance to pay for senior care, buying long-term care insurance can be a smart move. It offers more freedom of choice compared to using Medicare and other public programs for nursing home payments. People buy policies that pay anywhere from $2,000 to $10,000 per month. To guard against dramatic market changes, inflation protection can be included with monthly premium payments. It’s important to know that long-term care insurance policies vary in terms of when they’ll pay benefits. Generally, to receive payments for nursing home care or assisted living, a person must need help in at least two activities of daily living. A doctor’s statement documenting this need is required as part of the claim. Visit our list of the best long-term care insurance plans to learn more.

Did You Know? One way to cut down on nursing home costs is to age in place with a medical alert system. Check out our best medical alert system guide to help you make an informed decision.

>>Read About: Long Term Care Calculator

When a senior leaves their old home empty after moving to a nursing home, renting it out with careful management could be a valuable income source. Turning a home into a rental might become a permanent source of income for the family or just a temporary source of income until the home is sold. Ideally, any rental arrangement will be made when the homeowner is still a competent decision-maker. For a loved one to take over, that person will need legal guardianship or power of attorney over the homeowner.

Bridge loans can cover people’s living expenses as they await a property sale, pension payout, or another virtually guaranteed source of income. A bridge loan is a short-term loan, but often the first payment isn’t due until 90 days after signing. Typical loan lengths vary from three months to two years.

While a bridge loan can help during a pending home sale, a reverse mortgage loan helps keep the home until the second spouse moves out or passes away. The loaned money can help pay for nursing home care. The advantage of using a reverse mortgage loan for nursing home payments is that it covers two housing costs at once. However, when the second person no longer lives in the home, loan payments become due. Heirs often opt to sell the property rather than maintain payments.

FYI: One of the best ways to manage your budget is to use an app. Check out these 5 best budgeting apps for seniors .

How Can I Find Nursing Homes Near Me?

You can explore an array of nursing homes and skilled care providers with ease by using our comprehensive nursing home directory . Our database allows you to search by ZIP code or state and then lets you narrow down your search by specific needs or preferences.

What is a nursing home

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Healthcare in Moscow – Personal and Family Medicine

Emergency : 112 or 103

Obstetric & gynecologic : +7 495 620-41-70

About medical services in Moscow

Moscow polyclinic

Moscow polyclinic

Emergency medical care is provided free to all foreign nationals in case of life-threatening conditions that require immediate medical treatment. You will be given first aid and emergency surgery when necessary in all public health care facilities. Any further treatment will be free only to people with a Compulsory Medical Insurance, or you will need to pay for medical services. Public health care is provided in federal and local care facilities. These include 1. Urban polyclinics with specialists in different areas that offer general medical care. 2. Ambulatory and hospitals that provide a full range of services, including emergency care. 3. Emergency stations opened 24 hours a day, can be visited in a case of a non-life-threatening injury. It is often hard to find English-speaking staff in state facilities, except the largest city hospitals, so you will need a Russian-speaking interpreter to accompany your visit to a free doctor or hospital. If medical assistance is required, the insurance company should be contacted before visiting a medical facility for treatment, except emergency cases. Make sure that you have enough money to pay any necessary fees that may be charged.

Insurance in Russia


Travelers need to arrange private travel insurance before the journey. You would need the insurance when applying for the Russian visa. If you arrange the insurance outside Russia, it is important to make sure the insurer is licensed in Russia. Only licensed companies may be accepted under Russian law. Holders of a temporary residence permit or permanent residence permit (valid for three and five years respectively) should apply for «Compulsory Medical Policy». It covers state healthcare only. An employer usually deals with this. The issued health card is shown whenever medical attention is required. Compulsory Medical Policyholders can get basic health care, such as emergencies, consultations with doctors, necessary scans and tests free. For more complex healthcare every person (both Russian and foreign nationals) must pay extra, or take out additional medical insurance. Clearly, you will have to be prepared to wait in a queue to see a specialist in a public health care facility (Compulsory Medical Policyholders can set an appointment using EMIAS site or ATM). In case you are a UK citizen, free, limited medical treatment in state hospitals will be provided as a part of a reciprocal agreement between Russia and UK.

Some of the major Russian insurance companies are:

Ingosstrakh , Allianz , Reso , Sogaz , AlfaStrakhovanie . We recommend to avoid  Rosgosstrakh company due to high volume of denials.

Moscow pharmacies

A.v.e pharmacy in Moscow

A.v.e pharmacy in Moscow

Pharmacies can be found in many places around the city, many of them work 24 hours a day. Pharmaceutical kiosks operate in almost every big supermarket. However, only few have English-speaking staff, so it is advised that you know the generic (chemical) name of the medicines you think you are going to need. Many medications can be purchased here over the counter that would only be available by prescription in your home country.

Dental care in Moscow

Dentamix clinic in Moscow

Dentamix clinic in Moscow

Dental care is usually paid separately by both Russian and expatriate patients, and fees are often quite high. Dentists are well trained and educated. In most places, dental care is available 24 hours a day.

Moscow clinics

«OAO Medicina» clinic

«OAO Medicina» clinic

It is standard practice for expats to visit private clinics and hospitals for check-ups, routine health care, and dental care, and only use public services in case of an emergency. Insurance companies can usually provide details of clinics and hospitals in the area speak English (or the language required) and would be the best to use. Investigate whether there are any emergency services or numbers, or any requirements to register with them. Providing copies of medical records is also advised.

Moscow hosts some Western medical clinics that can look after all of your family’s health needs. While most Russian state hospitals are not up to Western standards, Russian doctors are very good.

Some of the main Moscow private medical clinics are:

American Medical Center, European Medical Center , Intermed Center American Clinic ,  Medsi , Atlas Medical Center , OAO Medicina .

Several Russian hospitals in Moscow have special arrangements with GlavUPDK (foreign diplomatic corps administration in Moscow) and accept foreigners for checkups and treatments at more moderate prices that the Western medical clinics.

Medical emergency in Moscow

Moscow ambulance vehicle

Moscow ambulance vehicle

In a case of a medical emergency, dial 112 and ask for the ambulance service (skoraya pomoshch). Staff on these lines most certainly will speak English, still it is always better to ask a Russian speaker to explain the problem and the exact location.

Ambulances come with a doctor and, depending on the case, immediate first aid treatment may be provided. If necessary, the patient is taken to the nearest emergency room or hospital, or to a private hospital if the holder’s insurance policy requires it.

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The best things to do and places to visit in Moscow, Russia

Updated On 14th October, 2021

While Moscow isn’t always at the top of everyone’s Europe bucket list , it’s certainly one of the best places to visit in Europe if you’re looking for a more alternative adventure! In this blog post I plan on sharing some of the free things to do in Moscow, as well as the best places to visit in Moscow, so that you can enjoy some of the best things to do in Russia! 

Moscow, the capital of Russia, sits in the European part of the country. It’s an incredibly beautiful city, which I personally found to be more beautiful than Saint Petersburg (which is often people’s preference). The capital is certainly a lot busier, and less laid back than Saint Petersburg , but it’s a much more colourful and vibrant city, full of stunning and unique architecture.

Visiting famous landmarks such as The Kremlin and St Basil’s Cathedral, enjoying some of the green space in Gorky Park, watching a ballet in the Bolshoi Theatre… these are just a few reasons that you should visit Moscow! On top of that, because of visa restrictions (we’ll get onto that later), it’s also one of the most unique destinations in Europe. 

There is a common misconception that Moscow is a dangerous city, but now that I’ve visited, I don’t believe this to be true. I would say the same rules apply here as to other large cities: avoid walking in dark areas alone at night, keep an eye on your belongings on public transport, and be streetwise. There’s no reason to avoid visiting this energetic city and miss out on these amazing things to do in Moscow! 

It would take months if you wanted to truly explore Moscow because it’s a huge city, but I’m going to share some of my favourite things to do in Moscow and places to visit in Moscow so that you can prepare for your upcoming adventure! Even if you’re only there for a few days, you should be able to fit in these highlights from my trip. 

Other blog posts you might be interested in...

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Where is Moscow?

If you’re wondering ‘Where is Moscow, Russia?’ then you’ve come to the right place! Moscow in in west Russia, the European part, and it’s the capital city. 

How do you get to Moscow?

Getting a visa for moscow:.

To get into Russia, you need to get a visa. The processing time is approximately 20 days, and you’ll need to have your fingerprints taken at a visa centre in London , Edinburgh or Manchester. You can find out more about getting a visa for Russia here.  

Getting to Moscow:

Once you’ve got your visa, the easiest way to get to Moscow from the UK is by flying. Direct flights between London and Moscow take just under four hours, and with an airport layover you’re looking at a 6-7 hour trip. You can also fly in from many other major European and international cities. 

Top tip: Check out flights to and from Copenhagen on  Skyscanner here.

Check out how to pack a weekend away in a carry-on suitcase here.

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16 best places to visit in Moscow...

1. st basil’s cathedral.

The most iconic building in Russia and one of the most iconic buildings in the world. St Basil’s Cathedral is one of the best places to visit in Moscow, if not the best! 

St Basil’s is situated on Red Square, where you’ll also find many other popular places to visit in Moscow. In my opinion this still stands out against them all. There’s something about the multi coloured domes against the Moscow skyline that I found quite spectacular. 

Although I’d already been in Russia for several days, it wasn’t until I was at this amazing piece of architecture that I really felt I was in Russia.

The cathedral was built by order of Ivan the Terrible, and apparently after the architect completed it, Ivan blinded him so that he could never build anything more beautiful. Whether or not this story is true, it certainly adds a bittersweet feeling as you stand admiring the beauty of St Basil’s Cathedral.

Inside is a museum displaying many historic items once used at the cathedral, which costs 700 rubles to enter. In my opinion it’s worth the entry fee, as simply seeing the ornate interior walls is a spectacle in itself.

The best things to do in Moscow: my favourite places to visit in Moscow

2. The Kremlin

This historic fortress that sits on Red Square is probably the largest landmark and one of the most popular places to visit in Moscow. It’s the official residence of the President, although he doesn’t actually live there. It’s been rebuilt many times since it was first constructed in 1147 out of wood, before Ivan III the Great ordered it to be made from stone, which is the Kremlin you’ll recognise today. 

The best things to do in Moscow: my favourite places to visit in Moscow

This place is huge, and there’s quite a lot to see. The first problem I had was finding where the entrance was. Even though I had a pre-booked ticket, I was then told I still had to visit the ticket office to exchange it for another ticket. I also needed my passport, so make sure you have yours if you plan to visit the Kremlin. After a lengthy queue I finally had a ticket I could use to enter the Kremlin, and had to go through security. The security here is thorough, so make sure you don’t take too much in with you. I had my pockets full, and it was a nightmare emptying them and explaining each item, before I was finally allowed in. Once inside you can pay for extra tickets to visit the various museums, however there’s also quite a lot to see simply on the grounds if you don’t want to spend too much. 

See more tips for travelling on a budget here. 

There’s so much to see here, including The Assumption Cathedral, Ivan the Great Bell Tower Complex, the Grand Kremlin Palace, the Armoury Chamber and Diamond Fund. There is also the Tsar Cannon (a huge artillery cannon), and the Tsar Bell. The Tsar Bell is the largest bell in the world. An incident with a fire and water being poured over the bell caused it to crack and for a slab to break off from it, which can now be seen propped up next to it.

The best things to do in Moscow: my favourite places to visit in Moscow

As you walk around the grounds you’ll hear the sound of whistles. The guards patrolling the area will blow a whistle at anyone walking where they shouldn’t. Even if it’s just on the grass, or towards more restricted areas. This can sometimes be funny to watch, as often the tourists will be in a world of their own whilst a guard is blowing a whistle at them. Sometimes a guard will be stood face to face with a tourist angrily blowing their whistle before the tourist realises they need to get back onto the main path.

This is perhaps one of the more unusual places to visit in Moscow! Gum is a huge department store situated on Red Square. It’s an interesting department store to walk around, with several levels, although the shops inside are certainly quite pricey. It’s a beautiful building when it’s lit up at night, and it seems to fit in nicely amongst the other famous sights on Red Square. Even if you don’t plan to buy anything here, one of the best things to do in Moscow is to take a quick look inside, although bear in mind there are usually security checks before entering.

4. State Historical Museum

The large crimson building on Red Square is now the State Historical Museum. It was originally the first pharmacy in Russia, and later a University before finally becoming the museum it is today.

Unfortunately I didn’t go inside as my time was limited and there was so much else I wanted to see, but if you have the time I think it would be one of the best things to do in Moscow. There are items dating back to the 6th century, and maybe even further. There’s also a library inside storing many ancient manuscripts and the largest coin collection in Russia. 

The best things to do in Moscow: my favourite places to visit in Moscow

5. Bolshoi Theatre

Bolshoi means big in Russian, so it roughly translates to large theatre. The Bolshoi Theatre is one of the foremost ballet companies in the world. The exterior of the building is an impressive sight, one of the most beautiful places to visit in Moscow, and it’s certainly worth admiring from the outside. There are guided tours of the interior, but if you really want to experience the theatre, one of the best things to do in Moscow is to watch a ballet here.

I was torn between booking a seat, but the ballets were very expensive. I’d have liked to have seen “Swan Lake”, (as at least I may have recognised some of the music). Unfortunately there were no performances on the days I was in Moscow, so I decided to pass. But if I return to Russia, then watching a ballet will be on my list of things to do.

The best things to do in Moscow: my favourite places to visit in Moscow

6. Sparrow Hills

If you want a good view of the city, then Sparrow Hills is one of the best places to visit in Moscow. It’s a bit of a trek outside of the centre, but if you have the time then it offers an escape from the hustle and bustle of the busy city. There’s a viewing platform here which gives you fantastic panoramic views of Moscow.

Nearby you’ll see the magnificent Moscow State University building, which is one of the seven sisters of Moscow.

7. Seven Sisters

Whilst in Moscow, you’ll no doubt notice these magnificent soviet skyscrapers dotted around the city. At the time of construction they were the tallest buildings in Europe, Moscow State University being so until 1997. There are, as the name suggests, seven in total, which are: Hotel Ukraina, Kotelnicheskaya Embankment Apartments, the Kudrinskaya Square Building, the Hilton Moscow Leningradskaya Hotel, the Ministry of Foreign Affairs, Moscow State University, and the Red Gates Administrative Building.

If you visit Sparrow Hills, then you’ll come across Moscow State University, but I’m certain as you explore the city, you’ll see more of these giants against the Moscow skyline. One of the best things to do in Moscow is to see if you can locate all seven as you wander round the city! 

The best things to do in Moscow: my favourite places to visit in Moscow

8. Nikolskaya Street

The start of this street is found by Red Square. It’s one of the most prominent pedestrianised streets in Moscow, filled with shops, restaurants and bars, so one of the best places to visit in Moscow if you’re looking for a bite to eat or some souvenirs!

What makes this street extra special are the thousands of bright lights in the sky above. After dark it looks simply magical with the many colourful lights overhead as you walk beneath them. One of the best things to do in Moscow is to visit Nikolskaya Street after dark and see them for yourself. It almost feels like Christmas in London!

There is another street nearby which also features similar lights, “Kuznetskiy Most”, which is also quite beautiful, but I thought “Nikolskaya Street” was ever slightly more impressive.

The best things to do in Moscow: my favourite places to visit in Moscow

9. Izmailovo Kremlin and Izmaylovskiy Bazar

Did you know that The Kremlin in Red Square is not the only Kremlin in Moscow? Kremlin actually means a type of fortress, so there are many in Russia.

The Izmailovo Kremlin is a fairly new addition to the city, having been built in 2007 as a cultural centre. With its multitude of colours and historic style, it has a real fairytale feel to it. There are several small museums here for you to explore, devoted to subjects such as Russian folk art, vodka and bread (yes, bread). Visiting these is definitely one of the more unique things to do in Moscow! 

It’s a little way out of the centre, but it’s an interesting place to visit in Moscow to see something a little bit different, and it won’t be as overcrowded with tourists. 

Next to the Izmailovo Kremlin is the best market in Moscow for souvenirs. You’ll find good and poor quality items, but you’ll certainly pick up a bargain if you take your time and haggle for a good price. Many of the items here you’ll get for half the price you would in souvenir shops in the city centre. It’s here that I picked up several Matryoshka dolls for a very good price. I think I’d have paid more than double, or possibly even triple if I’d have bought them elsewhere.

The best things to do in Moscow: my favourite places to visit in Moscow

10. Izmailovsky Park

Not too far from Izmailovo Kremlin you’ll find this huge park, one of the prettiest places to visit in Moscow. It’s easy to get lost here, so try to make sure you keep track of where you entered if you plan to go back the same way. There’s a lot to see in this park, a round pond, ferris wheel, playgrounds and sports grounds, shooting galleries, cinemas and a skate park.

There are often festivals, concerts and exhibitions at the park, on top of firework displays and dance parties.

The main reason I chose to visit the park was to find the painted trees. A local artist “Yevgenia Khlynina” has been painting on trees in this park, and one of the best things to do in Moscow is to explore the park looking for them. One of the most famous pieces of hers is the “Hedgehog in the Fog” from a famous soviet cartoon.

The best things to do in Moscow: my favourite places to visit in Moscow

11. Gorky Park

The most famous park in Moscow is named after the writer “Maxim Gorky”. Although it’s likely you’ve heard it mentioned in the song “Wind of Change” by “The Scorpions”. 

There’s lots to do and see in the park with sports facilities and exhibitions. During the summer months this is one of the best places to visit if you’re looking for things to do in Moscow; there are often open air concerts and an open air cinema. There are many statues and sculptures in the park, including a small sculpture park area which features many interesting pieces.

One piece of advice: don’t visit Gorky Park or any other parks on 2nd August if you’re in Russia. 2nd August is Paratrooper day, which usually encourages a lot of drinking in the park, which is not always very welcoming.

The best things to do in Moscow: my favourite places to visit in Moscow

12. Arbat Street

One of the oldest and busiest streets in Moscow, and the most famous pedestrian street in the city. Arbat is one of the most popular places to visit in Moscow. There are several shops including many dedicated to souvenirs, but although these will have a good range of goods, they will be quite expensive . You may see street performers and buskers, and there are often poets reciting famous works, if not their own works.

It’s within walking distance from the Kremlin, which should only take around 10 minutes.

There are actually two streets with this name, Old Arbat Street and New Arbat Street. Old Arbat Street is where you’ll find the pedestrianised area. New Arbat Street is a separate street which runs alongside a main road, filled with many bars and restaurants.

The best things to do in Moscow: my favourite places to visit in Moscow

13. Metro station art

The best way to get around Moscow is by using the metro, and the metro is a tourist attraction in itself.

Although I obviously didn’t visit every metro station, I believe that every single station is unique in its own beautiful way. Many of the stations I passed through were impressive, quirky or simply jaw dropping. You’ll more than likely pass through many of them on the way to other sights, but I’d recommend the following:  Komsomolskaya, Novoslobodskaya, Mayakovskaya, Teatralnaya, Arbatskaya, Prospekt Mira and Ploschad Revolutsii (be sure to pet the dog statue for good luck).

There are of course many others for you to explore, but these are the ones I considered to be some of the most impressive places to visit in Moscow (even if they’re only metro stations!).

The best things to do in Moscow: my favourite places to visit in Moscow

VDNKh is an exhibition centre with many monuments and museums. Now that it’s combined with the Botanical Garden and Ostankino Park, one of the best things to do in Moscow is to spend the day at this recreational centre enjoying a mix of nature and culture. The most popular museum in the complex which you shouldn’t miss on your trip to Moscow is the Museum of Cosmonautics.

15. Lenin's Mausoleum

Despite requesting to be buried with his mum in St Petersburg, it is at the foot of the Kremlin on Red Sqaure that you will find Lenin’s Mausoleum, where Vladimir Ilych Lenin has been frozen in time since 1924. It’s only open for a few hours a few times per week. Photography is not allowed, and you should line up on the western corner of the square (near Alexander Garden) to wait you turn to see the embalmed body. 

16. Novodevichy Convent

Novodevichy Convent, on the UNESCO World Heritage List, is one of the most beautiful places to visit in Moscow. Located south west of the centre you’ll find this stunning monastery. Inside you’ll find a cathedral and several churches, surrounded by high walls and 12 towers.

Where are your favourite places to visit in Moscow?

What about the best things to do in Moscow? Anything you’d add?

Love as always and happy adventuring…

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I’m Spike! Solo traveller, cultural explorer and world adventurer! With 57 countries under my belt, I live and breathe travel. I never plan to stop exploring new destinations and experiencing new cultures.

Did you find this post helpful? I’d love you to share it for me.

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The best places to visit in Moscow




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More from our inbox:, orwell in a honda, lessons from covid, diversity in college: more financial aid is needed.

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To the Editor:

Re “ Covid Funds Shrinking, Paid Family Caregivers Face Big Cutbacks ” (news article, March 5):

The story of Kacey Poynter and her son, Sonny, puts a spotlight on the precarious state of family caregiving in America. Indiana’s decision to slash funding for its attendant care program threatens to throw families like Ms. Poynter’s into financial turmoil and disrupt the critical care their loved ones require.

Indiana is just the latest state grappling with this issue. The bigger picture reveals a fragmented system struggling under the weight of insufficient federal investment. The influx of federal pandemic funds offered temporary relief, allowing states like Indiana to expand caregiver support programs.

However, family caregivers were hurting far before the pandemic, with 19 million people reporting high levels of emotional stress. Now, as these funds dry up, states and family caregivers are left scrambling.

To ensure that family caregivers can continue providing vital care for their loved ones, Congress must invest in our nation’s care infrastructure. This includes allocating sufficient funding for home- and community-based services, as well as a national paid family and medical leave program.

Additionally, swift implementation of the National Strategy to Support Family Caregivers , released by the Biden administration in 2022, is essential to recognize the irreplaceable role that caregivers play in our society.

By investing in family caregivers in Indiana and in every state, we’re investing in a stronger future for all families.

Jason Resendez Washington The writer is the president and C.E.O. of the National Alliance for Caregiving.

“ Staffing Shortages at Nursing Homes Persist ” (front page, March 1) reinforces the urgent need for the U.S. to develop a coherent approach to the long-term care needs of our aging population.

The pandemic underscored problems in nursing homes that had long been apparent. It also highlighted a longstanding bias toward institutional care for low-income people. Medicaid, the largest source of funding for long-term services, is required to pay for nursing home care, but not for home- and community-based services.

A National Academy of Social Insurance report , “Social Insurance During the Pandemic: Successes, Shortcomings and Policy Options for the Future,” examines the devastating impact of Covid-19 on our nation’s nursing home residents and staffs. Residents of color were disproportionately harmed; their mortality rates were significantly higher than those of white residents.

Congress needs to consider reforms to increase nursing home staffing and improve pay and working conditions. Congress might also consider expanding the Medicare-funded graduate medical education programs to include nurse training. This would help subsidize the cost of such training and address the nursing shortage in nursing homes.

As your article notes, many experts believe that our current approach to long-term care is “fundamentally broken.” It is time for a national solution.

William J. Arnone Washington The writer is C.E.O. of the National Academy of Social Insurance.

Re “ Watch the Way You’re Driving. Carmakers Are Watching, Too ” (front page, March 12):

I was driving on Interstate 95 in Connecticut recently when a car entering the highway cut me off. I swerved into the left lane, causing my car to fishtail before I regained control. My quick action averted a serious and possibly fatal accident.

That swerve is an example of the kind of noncontextual information that auto insurers are gathering from stealth computer programs in cars like my 2023 Honda Civic. Had I activated “Driver Feedback,” that incident could have led to higher insurance rates for me — instead of for the driver who nearly caused an accident.

In 2024, Big Brother sneaks into the back seat of our cars and watches every move we make. The view from there, however, is not always accurate.

Betty J. Cotter Shannock, R.I.

After reading this article, I feel as if I hit a big pothole going 50 miles an hour. I have questions: What is the car company’s cut for providing information to the insurer? If the insurer charges 21 percent more, as happened to a driver quoted in the article, does the car manufacturer get 10 percent of that?

To generate even more revenue, I suggest that car companies force us to watch commercials (like when you’re filling up at the gas station) on the large screens that are in every car now. Enjoy your drive!

Brant Thomas Cold Spring, N.Y.

Re “ Four Years On, Covid Is Here to Stay ,” by Daniela J. Lamas (Opinion guest essay, March 11):

In her wonderful article, Dr. Lamas beautifully described how she is no longer mortified by Covid but carried its grave lessons forward. As an infectious diseases specialist, I have had similar experiences.

Ignorance is not bliss. To dispel any magical and potentially costly thinking, I want to elaborate on three important lessons.

The first lesson is that science and cooperation prevailed. Let us celebrate and remind ourselves that through mutual respect and a common goal, we were able to tame a deadly virus.

The second lesson is that straightforward and practical infection-control measures such as distancing and quarantining were effective and bought us the time needed to develop a vaccine.

Finally, the third lesson is that the vaccine worked.

Like it or not, Covid is here to stay. We will all need to boldly accept this fact. We need not be fearful, though, because we now understand it and have hopefully learned at least three critical lessons that will prevent Covid from resurging and causing another deadly pandemic.

Prescott Lee Boston

nursery nurse home visit

Can You Create a Diverse College Class Without Affirmative Action?

The Supreme Court effectively ended race-based admissions preferences. But will selective schools still be able to achieve diverse student bodies? Here’s how they might try.

Re “ Can You Create a Diverse College Class Without Affirmative Action? ” (The Upshot,, March 9):

The analysis in your piece shows that highly selective colleges might achieve racial diversity using race-blind approaches if they put extensive weight on socioeconomic factors.

Our own analysis produced similar findings. But we also show that such a change would require a substantial increase in financial aid so that low-income students could afford to enroll. For all but perhaps a dozen or two institutions that have very large endowments, that is likely more than they can muster.

In fact, financial aid already falls $10 billion short of what low-income students at selective colleges need. The logic is simple: Swapping out 35 percent of high-income students for lower-income students, as in one of your simulations, would be very expensive. The newly selected students would need tens of thousands of dollars in financial aid per year.

Increasing the enrollment of lower-income and Black, Latino and Native American students at selective colleges is an important goal that institutions should prioritize. But the cost would be substantial. Insufficient financial aid is a problem across higher education, one that makes using income-based admissions preferences like those described in the Upshot analysis an uphill climb.

Phillip Levine Sarah Reber Dr. Levine is a professor of economics at Wellesley College and a nonresident senior fellow at the Brookings Institution. Dr. Reber is a senior fellow in economic studies at Brookings.

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The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Centers for Medicare & Medicaid Services

Press Releases CMS Announces New Guidance for Safe Visitation in Nursing Homes During COVID-19 Public Health Emergency

  • Nursing facilities

Today, the Centers for Medicare & Medicaid Services (CMS) issued revised guidance providing detailed recommendations on ways nursing homes can safely facilitate visitation during the coronavirus disease 2019 (COVID-19) pandemic. After several months of visitor restrictions designed to slow the spread of COVID-19, CMS recognizes that physical separation from family and other loved ones has taken a significant toll on nursing home residents. In light of this, and in combination with increasingly available data to guide policy development, CMS is issuing revised guidance to help nursing homes facilitate visitation in both indoor and outdoor settings and in compassionate care situations.  The guidance also outlines certain core principles and best practices to reduce the risk of COVID-19 transmission to adhere to during visitations.

“While we must remain steadfast in our fight to shield nursing home residents from this virus, it is becoming clear that prolonged isolation and separation from family is also taking a deadly toll on our aging loved ones,” said CMS Administrator Seema Verma. “With the Trump administration’s unprecedented efforts to bolster testing resources and deploy infection control support, we believe nursing homes should be able to resume visitations reuniting residents with their families within the recommendations outlined in our guidance.”

The vulnerable nature of the nursing home population, combined with the inherent risks of congregate living in a healthcare setting, have required aggressive efforts to limit COVID-19 exposure, including limiting visitation.  As a result, in March 2020 , CMS issued guidance instructing facilities to restrict visitation except for certain compassionate care situations.  In May 2020, CMS released Nursing Home Reopening Recommendations , which provided guidance on visitation as nursing homes progress through the phases of reopening.  In June 2020, CMS also released a Frequently Asked Questions document on visitation, which expanded on previously issued guidance on outdoor visits, compassion care situations, and communal activities.

In the revised guidance issued today, CMS is encouraging nursing homes to facilitate outdoor visitation because it can be conducted in a manner that reduces the risk of transmission.  Outdoor visits pose a lower risk of transmission due to increased space and airflow. The guidance released today also allows for indoor visitation if there has been no new onset of COVID-19 cases in the past 14 days and the facility is not conducting outbreak testing per CMS guidelines.  Indoor visitation is subject to other requirements as well as indicated in the guidance.

The guidance also clarifies additional examples of compassionate care situations.  While end-of-life situations have been used as one example, there are other examples including: 

  • When a resident who was living with their family before recently being admitted to a nursing home is struggling with the change in environment and lack of physical family support.
  • When a resident who is grieving after friend or family member recently passed away.
  • When a resident needs help and encouragement with eating or drinking, previously provided by family, is experiencing weight loss or dehydration.
  • When a resident who used to talk to others, is experiencing emotional distress, seldom speaking, and crying frequently (when he/she had rarely cried in the past).

For additional details on the revised nursing home visitation guidance released today, visit here:

The full list of CMS Public Health Actions for Nursing Homes on COVID-19 to date is in the chart below.

Get CMS news at , sign up for CMS news via email and follow CMS on @CMSgov

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CMS News and Media Group Catherine Howden, Director Media Inquiries Form 202-690-6145

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New York State Senator Patricia Canzoneri-Fitzpatrick

( R, C ) 9th Senate District

Statement From Senator Canzoneri-Fitzpatrick On 4 Year Anniversary of Deadly COVID Nursing Home Order

Patricia Canzoneri-Fitzpatrick

March 25, 2024

  • Coronavirus; COVID-19; Seniors; Nursing Homes; Adult Care Facilities

It has been 4 years since the executive order that placed COVID-positive patients into nursing homes, which caused a disastrous ripple effect that led to the death of thousands of senior citizens.

It has been 4 years since the executive order that placed COVID-positive patients into nursing homes, which caused a disastrous ripple effect that led to the death of thousands of senior citizens — and kicked off a devastating, traumatic saga for surviving family members. Let us never forget that New Yorkers were not allowed to visit, much less properly grieve, their deceased loved ones. To this day — four years later — we are STILL waiting for the results of the investigation. Across two administrations, there has been no accountability for the deadly mistakes that were made. Grieving relatives will not forget the devastation that was unduly placed upon their families, and we as legislators will not rest until the deceased and their families are given justice.

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Senator canzoneri-fitzpatrick and green acres mall donate to hewlett house in recognition of women's history month.

March 26, 2024

Senator Canzoneri-Fitzpatrick with Geri Barish of Hewlett House and Jill Bromberg of Green Acres Mall

Senator Canzoneri-Fitzpatrick & Senate Republican Conference Unveil Legislative Package to Prioritize Housing


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Senator Canzoneri-Fitzpatrick Calls on the Legislature to Stop Law Breaking Criminals Who Are Squatting in People's Homes

An amendment that would help homeowners by making “squatters” who inhabit a home without permission subject to a theft crime within the penal code

2023 Women of Distinction Honoree

Ways we can make every day earth day, 2023 legislative questionnaire, hands off home rule.

Nursing home co. Petersen Health likely to break up in bankruptcy sale

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  1. Nursing Home Visit

    The home visit is a family-nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. In performing this activity, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired outcomes.

  2. Home care visits: how they work, and what to expect

    A home care visit is when a professional carer comes to your home, often for between 30minutes to a few hours a day, to provide support with day to day tasks. This can range from personal care such as washing and dressing, to more practical task such as cooking meals or getting you moving. Its often referred to as hourly care, or domiciliary ...

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    Set Your Bag In A Clean Place. 5. Perform Your Nursing Care. 6. Keep Excellent Records. 7. Make Another Appointment. Your chances of doing a home visit as a nurse will depend on where you work. Typically, community outreach organizations and home health care agencies will do the most frequent home visits.

  4. Best Visiting Nurse Services of 2024

    AccentCare treats over 140,000 patients a year. Along with skilled home health care and private duty nursing, it offers hospice care, personal care services, and care management. AccentCare also uses technology to supplement visiting nurse home care visits with tele-monitoring that can deliver biometric data (blood pressure, pulse, blood ...

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    4. Clarify who has referred the family to you and why. 5. Consider what is usually expected of a nurse in working with a family that has been referred for these health concerns (e.g., postpartum visit), and clarify the purposes of this home visit. 6. Consider whether any special safety precautions are required.

  6. Landmark Health

    Landmark partners with health plans to bring medical, behavioral health, and palliative care, along with social services, to patients in communities across the U.S. Our mobile providers visit patients in their homes through in-person house calls and telemedicine visits over video and phone. View Our Locations.

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    How does the nursing home check to make sure it doesn't . hire staff members with a finding or history of abuse, neglect or mistreatment of residents in the state nurse aid registry? What are the nursing home's policies and procedures on . prohibiting and reporting abuse and neglect? What training does the nursing home have in place to keep

  8. Nursing Home Visits: Tips and Regulations

    Generally, nursing home visits are allowed, though some nursing homes may have specific visiting hours. Because seniors in nursing homes were disproportionately affected by COVID-19 at the height of the pandemic [1], nursing homes were often closed to visitors to protect staff and high-risk residents, according to Centers for Disease Control ...

  9. PDF Nursing Home Visitation Frequently Asked Questions (FAQs)

    Nursing Homes. 4. Can visits occur in a resident's room if they have a roommate? A: Yes. Ideally an in-room visit would be conducted when the roommate is not present, howeverif that is not an option and as long as physical distancing can be maintained, then a visit may be conducted in the resident's room with their roommate present.

  10. CMS Updates Nursing Home Guidance with Revised Visitation

    Mar 10, 2021. Home health agencies. The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), issued updated guidance today for nursing homes to safely expand visitation options during the COVID-19 pandemic public health emergency (PHE). This latest guidance comes as more ...

  11. PDF How to Safely Conduct Visits to Nursing Homes

    of the visit. Do not conduct visits in common areas (except those areas dedicated for visitation). Increase air-flow and ventilation. Clean and sanitize the visitation area after each visit. Provide reminders in common areas (e.g., signage) to maintain physical distancing, perform hand-hygiene, and wear well-fitting masks. Other Recommendations:

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    Home visitors provide caregivers with knowledge and training to reduce the risk of unintended injuries. For example—. Home visitors teach caregivers how to "baby proof" their home to prevent accidents that can lead to emergency room visits, disabilities, or even death. They also teach caregivers how to engage with children in positive ...

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    For information or to make an appointment, please call 603-352-2253. Home Healthcare, Hospice & Community Services continues the tradition of your visiting nurse. Home Healthcare at HCS provides nursing, palliative care, and rehabilitative therapies.

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    In children under five years, it is plausible that nurse home visiting could lead to fewer acute care visits and hospitalization by providing early recognition of ... Hollenbeak C. S. Cost-effectiveness of postnatal home nursing visits for prevention of hospital care for jaundice and dehydration. Pediatrics. 2004; 114 (4):1015-1022. doi: 10. ...

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    By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40).

  18. The outcomes of nurse practitioner (NP)-Provided home visits: A

    The use of NP-home visits is widely recognized and has gained national interest, 28 , 60 yet few studies have assessed the outcomes of NP-home visits. This is the first study to our knowledge to systematically review the evidence of the impact of NP-home visits on the outcomes of homebound older adults.

  19. Nursing Visits

    To learn more about our skilled nursing visits, call us at 415-449-3700 or fill in the form below. "Seniors At Home is always my top recommendation when a patient needs home care because of their reliability, consistency, and wide scope of care. Families thank me for referring them to Seniors At Home.". Mary, Medical Social Worker, San Rafael.

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    The Russian government spends significantly less for home-based support services than for institutional living costs: according to government statistics, average spending per person in a nursing ...

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    A nurse who allegedly failed to suction the airway of a U.S. Army veteran in an Iowa nursing home has been criminally charged in the man's death. Becky Sue Manning, 69, of Lake View, is charged with felony wanton neglect of a health care facility resident. According to prosecutors, Manning, a licensed practical nurse, refused repeated ...

  22. Nursing Home Costs in 2024

    According to Genworth's estimates, the median cost of a private room in a nursing home is $330 per day or $10,025 per month in 2024. Semiprivate rooms are more affordable, with a median cost of ...

  23. Healthcare in Moscow

    These include 1. Urban polyclinics with specialists in different areas that offer general medical care. 2. Ambulatory and hospitals that provide a full range of services, including emergency care. 3. Emergency stations opened 24 hours a day, can be visited in a case of a non-life-threatening injury.

  24. The best things to do and places to visit in Moscow, Russia

    1. St Basil's Cathedral. The most iconic building in Russia and one of the most iconic buildings in the world. St Basil's Cathedral is one of the best places to visit in Moscow, if not the best! St Basil's is situated on Red Square, where you'll also find many other popular places to visit in Moscow.

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    Two former officials of a veterans' nursing home in Massachusetts that had a deadly outbreak of COVID-19 settled their cases Tuesday to avoid prison, according to the state attorney general.

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    The influx of federal pandemic funds offered temporary relief, allowing states like Indiana to expand caregiver support programs. However, family caregivers were hurting far before the pandemic ...

  27. Department of Community Health Nursing Home Medicaid Rates Effective

    255.28. 178.64. YES YES. 00143382A Berrien Nursing Center 00143393A Twin Oaks Convalescent Center 00143415A Union County Nursing Home. 222.74 276.11 285.08.

  28. CMS Announces New Guidance for Safe Visitation in Nursing Homes During

    Today, the Centers for Medicare & Medicaid Services (CMS) issued revised guidance providing detailed recommendations on ways nursing homes can safely facilitate visitation during the coronavirus disease 2019 (COVID-19) pandemic. After several months of visitor restrictions designed to slow the spread of COVID-19, CMS recognizes that physical separation from family and other loved ones has ...

  29. Statement From Senator Canzoneri-Fitzpatrick On 4 Year Anniversary of

    It has been 4 years since the executive order that placed COVID-positive patients into nursing homes, which caused a disastrous ripple effect that led to the death of thousands of senior citizens — and kicked off a devastating, traumatic saga for surviving family members. Let us never forget that New Yorkers were not allowed to visit, much less properly grieve, their deceased loved ones. To ...

  30. Nursing home co. Petersen Health likely to break up in bankruptcy sale

    Nursing home co. Petersen Health likely to break up in bankruptcy sale. By Dietrich Knauth. March 22, 2024 9:27 PM UTC Updated ago. A plaque is displayed at the entrance of the U.S. District ...