nursing home care in the united states nursing home care in the united states as of 2017, approximately 1.4 million americans live in a nursing home, two-thirds of whom rely on medicaid to pay for their care. residential nursing facilities receive medicaid federal funding and approvals through a state health department. these facilities may be overseen by various types of state agency (e.g. health, mental health, or intellectual disabilities). part of a series onliving spaces mainhouse (detached) • apartment • housing projects • human outpost • tenement • condominium • mixed-use development (live-work) • hotel • hostel (travellers' hotel) • castles • public housing • squat • flophouse • green home • shack • slum • shanty town issuesaffordability • executive housing • environmental planning • fair housing • healthiness • homelessness • housing discrimination • home ownership • luxury apartments • ownership equity • rent • subprime lending • subsidized housing • sustainable development • vagrancy society and politicshousing subsidy • rent control • real estate economics • redlining • right to housing otherassisted living • cottage homes • foster care • group home • halfway house • homeless shelter • hospital • nursing home • orphanage • prison • psychiatric hospital • residential care • retirement home • residential treatment center • retirement community • supportive housing • supported living housing portal nursing homes have traditionally been large institutions. smaller community versions were developed around the 1970s. some "community living" (cl) groups advocated for a different type of care and funding, which resulted in the creation of assisted living facilities. efforts to promote community-based long term services and supports (ltss) are led by groups such as the consortium of citizens with disabilities which represents over 200 national disability organizations. history in the united states, the national social insurance program medicare, was established by the u.s. federal government in 1965, which guaranteed access to health insurance for americans aged 65 and older. this program prompted many new nursing homes to be set up in the following years, although private nursing homes were already being built from the 1930s as a consequence of the great depression and the social security act of 1935. medicaid, the nation's poverty program, often funds programs such as nursing beds as residents may be "impoverished" to access the facility. in 1987, a report examined the nursing home problem in wisconsin which involved 4,000 people, 80% under 65 years of age with an average of 110 patients per facility. 5% had developmental disabilities. they reported that 13 large institutions were certified as snfs (skilled nursing facilities), that all were "absolutely inappropriate" placements for the developmental disabilities' clients (the federal gao then reported a need to upgrade services in the homes, including day services), and the facilities resembled institutions of other types such as willowbrook where abuses had been uncovered. board and care homes were the subject of exposés for lacking medical personnel at the time of the 1990s reviews. nursing home reform nursing homes have been the subject of decades of efforts by states and at the national levels to reform health and residential care for "frail" elders, especially those with lower incomes in the us. regulations have been added to assure that basic good care (i.e., humane, accepted good human standards) will take place in these facilities (e.g., personnel, education, activities and services, ancillary and professional services, advocacy and reviews). a major nursing home reform initiative occurred in 1996 when the health care financing administration studied its own facilities and reported to the us congress on the effectiveness of its current system and certification of nursing homes. by 1998, the president announced new steps for federal oversight including monitoring of poor performance, collection of new fees, and increased focus on nutrition and basic personal care like pressure sores. by 2000, minimum staffing ratios and implementation of nursing home quality of care were introduced. these actions followed the omnibus budget reconciliation act of 1987 the centers for medicare and medicaid services in the department of health and human services now publish the "nursing home data compendium" annually, which show various statistics related to nursing homes and residents, as well as health deficiencies and substandard care. the results of the 2015 edition were generally positive, showing a decrease of substandard care reports from 4.4% in 2008 to 3.2% in 2014, reversing a previously increasing trend. intermediate care facilities intermediate care facilities (small) were developed by the state categorical systems (intellectual disabilities, mental health) in the 1970s, as a reaction to exposes on institutional conditions resulting in required active treatment in institutions and the new building of community facilities recommended under 16 in size. these facilities, which resembled homes in their smaller sizes (e.g., 4–6) are operated by community services management (sometimes civil servants) and are separately regulated. all need a state health department approval for federal medicaid and medicare. nurses may be hired as a staff supplement, as may be therapists (e.g., speech, occupational therapists), adult day who may be civil servants or ba/aa human services personnel, or clinic services (e.g., psychologist, audiologist). conversion of group homes or community residences into intermediate care facilities was of great concern due to its "overly medical" nature and requirements not meeting the community needs of the population group. regulations in the u.s. centers for medicare and medicaid services ensures that every medicare and medicaid beneficiary receives health care, both within health care settings such as nursing homes, and among health care settings during care transitions. the states in the us have health departments also responsible for oversight of the facilities and regulation. home and community services are new developments in the 1970s in the us for long-term services and supports (ltss) populations and parallels the move to ambulatory versus facility care which was a us hospital and institutional (e.g., nursing facilities) to community transition. ltss services have diverse oversight and regulations, and these vary by facility type, by population group, and by financing as well as traditional regulatory agencies. the ltss movement was involved with increasing autonomy and control of services which was recommended in professional texts, national forums, research studies and state directives in the 1980s and 1990s. to ensure that nursing homes meet the necessary legal standards, the authorities conduct inspections of all nursing home facilities; as often as quarterly. surveyors conduct on-site surveys of certified nursing homes on average every 12 months to assure basic levels of quality and safety for beneficiaries. the authority might also undertakes various initiatives to improve the effectiveness of the annual nursing home surveys, as well as to improve the investigations prompted by complaints from consumers or family members about nursing homes. alternative care models other fields have introduced new community care models into fields dominated by the hospital and nursing care industries, such as assisted living facilities, program of all-inclusive care for the elderly (pace) from the 1990s, or service-enriched housing from the 1970s. in recent years, there has been a general movement toward implementing alternative care models. some have tried to create a more resident-centered environment, so that they should become more "home-like" and less institutional or "hospital-like". in these homes, units are replaced with a small set of rooms surrounding a common kitchen and living room. the staff giving care is assigned to one of these "households". the reason, in part, is because the population is aging, and over half of the people in nursing homes are over age 85. residents have more choices about when they wake, when they eat, and their schedule for the day. they also have access to pets. the facilities utilizing these models may refer to such changes as the "culture shift" or "culture change" occurring in the long term care, or ltc, industry which includes the ltss industry termed long term services and supports in the community. sometimes this kind of facility is called a "greenhouse". most residential care models are considered to be community services operated by community agencies rather than nursing facilities; an example of different kinds of "community-based care" are "alzheimer's demonstrations" which originally included: mobile day care, rural geriatric dementia evaluation, el portal services for latinos, client advocates, and al-care services for clients who live alone (starns, karner and montgomer, 2002). task-oriented care in 1953, a leading american nurse educator, eleanor lambertson, proposed a system of team nursing to overcome the fragmentation of care resulting from the task-oriented functional approach. team nursing would ideally respond to the needs of both the patient and the staff. the team leader's function is to stimulate the team to learn and develop new skills. the team leader instructs the team members, supervises them, and provides assignments that offer them potential for growth. team nursing is characterized by the following: direct patient care accomplished by a specific group of nurses and allied health care workers accomplished by using the nursing process comprehensive, holistic nursing care when the team functions at a high level of efficiency composed of a team leader who coordinates patient care and supervises team members, who are responsible for total care given to an assigned group or number of patients requires cooperation and effective communication with all staff members basic to team nursing are the team conference, nursing care plan, and leadership skills. the conference is led by the team leader, and all personnel assigned to the team should be included. the team leader should discuss the needs of the patients, establish goals, individualize the plan of care for each patient, instruct the team members, and follow up on all directions previously given to the team. the nursing care plan is a written guide that organizes information about a patient's health. it focuses on the actions that must be taken to address the patient's identified nursing diagnoses and meet the stated goals. it provides for continuity of care by a constantly changing nursing staff. the team leader starts the care plan as soon as the patient is admitted to the medical treatment facility. in response to changes in the patient's condition, and evaluation of goal achievement, the nursing care plan is updated and revised throughout the patient's hospital stay. eleanor lambertson describes reform of the hospital nurse within the context of hospital management in which nursing facilities are considered independently managed entities without a hospital-physician structure. the "functional approach" is also the common term used for community programs which are homes (not operated by nurses), and operated by other than nursing personnel; and most recently was reviewed as one of three community approaches (also, competency-based) related to self-determination theories in the field of intellectual disabilities field (wehmeyer, et al., 2003). resident-oriented care with resident-oriented care, residents are able to make more choices and decisions about their lifestyle. their families are more involved in the residents care, and employees have a greater degree of participation with the residents. resident-oriented care combines the clinical models of care with a flexible social models. nursing facilities that implement this approach to elder care strive to respond to each resident's spiritual, physical, and emotional needs. every member of a facility's team, care for the residents, from administrators to the nurse aides. for example, all call lights are answered immediately. whoever is close when the call is placed, responds - even if this is a member of the administration. facilities long term care originally loosely regulated, convalescent or rest homes may include foster group living, room and board facilities, and group care which may often be private, for-profit based on social security and social security disability insurance. facility personnel long-term care personnel (ltc) who work in facilities are now considered part of the new workforce funded through the federal government and its medicaid and medicare programs which are undergoing change in conjunction with the patient protection and affordable care act of 2010. the institute on community integration at the university of minnesota with the lewin group, has been providing online education for the direct support professional who also work in facility-based programs not just in the new community long term services and supports (ltss) intermediate care facility personnel many intermediate care facility personnel may be civil servants in states who have been part of the deinstitutionalization movement in the us. otherwise, these are government contracted facilities from categorical departments (e.g., intellectual and developmental disabilities) who