Why Home Care Can’t Compare to Skilled Nursing Facilities

Most newly admitted nursing home residents could not be safely and cost-effectively diverted to home- and community-based services (HCBS) because many of them have health issues, such as dementia and stroke, that require high levels of care, according to a Canadian study in the July issue of JAMDA.

Only about one in 20 nursing home residents could reasonably be returned to the community, despite the high occupancy rates of nursing homes north of the border, the study authors conclude.

Though conducted in Canada, this study may point to an even greater need for support in communities and nursing homes in the U.S., according to John Morley, M.D., editor-in-chief of JAMDA.


“What the study shows, which is exactly what we’d see in the United States, is that most people cannot survive at home, even with strong support from their relatives,” Morley told Skilled Nursing News.

The study may be of interest to U.S. skilled nursing providers and advocates, coming as the industry considers whether potential Medicaid cuts would incentivize more home care, drawing residents away from SNFs.

The large demand for long-term care is driven by the prevalence of dementia among newly admitted Canadian nursing home residents, who as a result have high care needs and show a slow and steady decline in physical and mental function over time. Many have also suffered from stroke, which causes similar effects.


There may be an opportunity to divert some nursing home residents — for example, younger male patients who are less likely to have dementia or stroke but more likely to have other chronic diseases such as diabetes and cancer. Many of these enter nursing homes directly from homes without home care supports, so increased community supports may make it possible to keep them in the community. This effort is best made before the patient is placed in a nursing home, the study’s authors claim, because after this it is difficult and unlikely for the person to transition out of LTC.

However, in addition to this effort to keep patients in the community, additional nursing home supports are needed.

“Given the long wait lists in many jurisdictions for nursing home beds, and the reported shortcomings in care provided to residents, further investments in the nursing home sector may be warranted,” the study reports.

Due to the growing demand for care of those with LTC needs, “it may be useful to think less about LTC beds, and more about what it would take to create LTC ‘spaces.’ Such LTC spaces can occur across multiple settings in the community, including private homes, supportive housing…and in specialized units,” the report states.

“I would assume that the United States is much worse at providing good community care than Canada,” Morley said. “If anything, the study is underestimating how bad things are in the community. This paper points very much to the need for a robust Medicaid for older people to allow them to get adequate quality of life towards the end of their life.”

Written by Elizabeth Jakaitis

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