Nursing home care in the United States includes both long-term residential care and short-term postacute or rehabilitative care. While the number of Americans living in nursing homes for extended periods has fallen steadily over the past decade as an increasing proportion of older individuals remain in their homes or in assisted living facilities, the number receiving short term nursing home care has risen dramatically. In 2008, approximately 1.4 million people lived in a nursing home at any given time. However, over the course of the year, over 3.25 million people spent time in a skilled nursing facility .
Nursing home residents, whether short- or long-stay, tend to be old, female, and have multiple impairments in their activities of daily living (ADLs). Of those in nursing homes in 2008, 16.2 percent were between the ages of 65 and 74, 33.0 percent were between 75 and 84, 32.0 percent were between 85 and 94, and 5.2 percent were 95 years of age or older . In the same population, 8.5 percent had impairments in 3 ADLs, 30.8 percent had impairments in 4 ADLs, and 18.4 percent had impairments in 5 ADLs. Cognitive impairment is also widespread in this population, with 10.4 percent exhibiting severe or very severe impairment, 30.7 percent having moderate or moderately severe impairment, and only 32.0 percent showing no impairment.
Nursing home care represents a substantial segment of health care costs for older individuals: in the US in 2006, $124.9 billion was spent on nursing home care, of which 17 percent was paid by Medicare, 43 percent by Medicaid, 7 percent by private insurance, and 26 percent out of pocket . Long-term patients live at the facility and are often described as receiving custodial care. Room and board costs for this group are generally paid for by Medicaid, long term care insurance, or out-of-pocket by patients or their families. For most short-stay nursing home patients discharged from a hospital setting, the goal is to return to the community. A subset of these patients may be at the nursing home for short-term end of life care and some will require long-term nursing home care. Room and board costs for this group are generally paid by their skilled nursing facility (SNF) benefit, which, in the case of Medicare, covers up to 100 days per benefit period if care needs meet specific clinical criteria.
Physicians providing medical care in the nursing home must be knowledgeable about regulatory, ethical, and epidemiological as well as geriatric issues . For certain conditions, such as heart failure, diabetes mellitus, and chronic obstructive pulmonary disease, medical management is similar to outpatient management. This topic will focus on those conditions in nursing home patients that warrant a particular approach or heightened awareness. Many are geriatric syndromes that comprise constellations of symptoms that may have any of several etiologies.
COMPREHENSIVE GERIATRIC ASSESSMENT
Comprehensive geriatric assessment includes an evaluation of the patient's functional, physical, cognitive, emotional, and psychosocial status. It is a cost-effective intervention that improves quality of life in a variety of settings  and is recommended for use in frail elders by the American Geriatrics Society . The nursing home is an ideal environment in which to carry out comprehensive geriatric assessment since its population is at high risk and its residential character facilitates implementation of recommendations. (See "Comprehensive geriatric assessment".)